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June 15, 2010

President Bill Clinton at AHIP

Filed under: Healthcare — Steve Krupa @ 4:02 pm
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This was my third time seeing Citizen Bill Clinton speak publicly. The first was at the American Red Cross Centennial Ball in October, 2005, a few months after the disaster that was/is Hurricane Katrina; the second was on-site in New Orleans, along with Bush Sr., in May of 2006.(1)  Over the past four years, and much to his credit, Clinton has honed a consistent message, one he is assured to deliver, regardless of his audience’s predilections.

AHIP (America’s Health Insurance Plans) is a collective voice for almost 1,300 health insurance companies, a lobbying group that holds an annual convention and trade show designed to address the pressing issues of and the new technologies/businesses in the health insurance market.  AHIP states that one of their major policy goals is to expand access to high quality, affordable coverage to all Americans, yet it is clear that the AHIP collective was one of the many losers in the recent policy debate regarding PPACA (re: our new healthcare reform law), with their only major policy win being, in my view, the elimination (delay) of the “public option” from the enacted law.

It’s a nice position in life to get paid handsomely to address former foes.  No doubt many members of the AHIP collective had much to do with President Clinton’s own form of healthcare reform failing in the first half of his first term (1992-94).  Putting its primary content aside for just a moment, Clinton’s speech was peppered with two wheedling, audience-specific themes: the first, an invocation of thanks to the AHIP collective for supporting healthcare reform, or the rhetorical equivalent of praising someone for handing over their wallet while being held at gunpoint; and the second, a win-one-for-the-Gipper pep talk praising AHIP’s members as the chosen few who know that improved healthcare quality and lower healthcare costs can coexist, a sentiment that I know from first hand experience many of the AHIP collective struggle to affirm.(2)(3)  By injecting these two themes into what was essentially a speech outlining Clinton’s view of the world’s humanitarian challenges, the ex-president succeeded, brilliantly I believe, in conveying the following message, like it or not: we are committed to making things more equal in the world (the US included); healthcare reform is one step in that direction; and, as part of the process, we are offering you a second chance to re-build your industry around the needs inherent to this objective.  There was no gloating, just a warm embrace and a subtle nod or two – folks please get with the program and get it together – all this for the standard public appearance fee of the popular ex-President, which sources state range in the area of $150,000.

It’s also a nice position in life to do what you want to do and talk about what you want to talk about.  In terms of air time, Clinton’s cajoling served as mere tasting notes to a speech primarily concerned with his current world view and its alignment with the work of his William J. Clinton Foundation (a nongovernmental organization with over 1,100 staff and volunteers in over 40 countries).  A few notable points from his speech, titled Embracing Our Common Humanity, include:

  • The belief that the past decade of crises and changes in the US economic system, up and to the recent (current) recession, has alienated white non-college educated males in the US, who as a group are struggling for hope and optimism and are one of the primary sufferers of the massive unemployment trend.
  • That there is an underlying fear that America, a historical underdog turned post-WWII perennial favorite, may not be winning anymore, as developing countries like Brazil, Russia, India and China challenge our economic supremacy and terrorism challenges the capabilities of our military.
  • That the world is an incredibly interesting place where we continue to advance beyond our imaginations, noting in the years since his first taking office as President: the evolution of cell phones from a 5 lb device to today’s smart-phones accessing a pervasive Internet; and the advancement in genetic engineering to our current realization of synthetic organisms (to list just a few).
  • That despite the world’s being an incredibly interesting place, we still have trouble dealing with three major problems: (a) instability; (b) inequality and (c) climate change (and here I note that these three challenges line-up with many of the Clinton Foundation’s programs including his work to rebuild (or build) Haiti and to reduce global greenhouse gas emissions, the latter of which he believes is a cause to the current climate change).

With respect to healthcare reform specifically, Clinton acknowledged that the law is a vague beginning that is reliant on a second phase of specific programs.  These programs will have to address the real issues of cost and quality that he knows AHIP’s members understand, but that are not clearly understood by the public at large.  According to Clinton, making the new healthcare law work requires innovation, an American specialty that will bridge the gap between “what the government can provide and what the private sector can [currently] produce.”


(1) For a transcript of Clinton’s May 2006 speech in New Orleans, click here, and for a transcript of George H.W. Bush’s speech at that same event, click here. Both are short, sweet and excellent, with Bush Sr. winning over the day despite Clinton’s rock star status with the Tulane student body.

(2) The belief that quality healthcare can be delivered at a lower cost is one that many people, not just insurance executives and underwriters, struggle with, especially consumers (patients). Generally, many patients find evidence-based medicine terms like “quality guidelines” and “quality standards” confusing and continue to believe that more and newer care is best. Patients are also reluctant to believe that their doctor could provide anything but sound medical advice.

(3) The vast majority of the new businesses exhibiting at AHIP have as their very purpose improved quality and lower cost.  Our insurers’ skepticism resides in a history of failed attempts at accomplishing this objective on a broad scale.  As I have noted many times in this blog, this objective can be met within subsets of the healthcare economy today. Broader deployment is the challenge and necessity presented by PPACA, a law that will financially bankrupt the US without massive improvements to the cost-quality relationship in healthcare.


February 12, 2010

Clinton’s Stent(s) and True Comparative Effectiveness

Filed under: Healthcare — Steve Krupa @ 8:51 pm
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It’s ironic to me that on the same day (11-Feb-2010) Bill Clinton underwent surgery to place two stents in one of his coronary arteries Keith Winstein published an article in the Wall Street Journal titled A Simple Health-Care Fix Fizzles Out which explores, among other things, the idea of Comparative Effectiveness, and whether it is or ever will be effective at reducing health care costs.  His article discusses the COURAGE study which concluded (an abstract of the study is available here) that stenting patients with stable coronary artery disease (CAD) did not reduce the risk of: (1) death, (2) myocardial infarction (heart tissue dies because it is starved for blood, similar to a heart attack), or (3) other major cardiovascular events (like a stroke) when used as an addition to optimal medical therapy (drugs); or, in other words, if your medical objective is to manage (1), (2) and (3) above, drugs alone work as well as and maybe better than drugs plus stents (and, by the way, no one gets just stents, they always get the drugs too).

The Wall Street Journal article’s point, however, is the stent procedure, which costs about $15,000, continues despite its apparently dubious medical efficacy for this class of patient.

So, let’s start with some math (I am using Winstein’s numbers here).  The 1 million stent implant procedures done in the US per year cost $15 billion (about $15,000 each).  About 1/3 of those are performed on patients with stable CAD, so adherence to the study’s findings could yield an annual savings of $5 billion.  Compare this to the $200 billion or so it will cost to insure the uninsured in the US and you would be about 2.5% there.  Hey, it’s a start.

Let’s now take the case of Bill Clinton, or anyone else for that matter, who showed up at the doctor with chest pain and got his stents right away.   It has not been reported whether Clinton is a stable CAD patient or not, but his symptom, i.e., his chest pain, is the same symptom demonstrated by stable CAD patients.  According to the output from COURAGE, the protocol for treatment should be drugs for 12 weeks and then a follow-up set of stress tests to determine if the stents are needed.

Winstein goes on to express some perfectly valid reasons why the results of the COURAGE study are largely ignored in practice.  Here’s a short list, containing the usual suspects:

1.  Doctors:  Cardiologists make more money putting in stents.

2.  Payers:  Health insurers don’t monitor stent usage because they pass the cost on to their customers anyway

3.  Patients:  they have no incentive to decline costly care

These reasons point to one of the many problems with the healthcare system, namely the lack of financial accountability, similar to lessons on moral hazard we all learned during last year’s banking crisis.  When we talk about healthcare on this blog, we’re going to come to this moral hazard issue often, it’s imbedded in all that is wrong with the healthcare system.  But I believe the problem with the COURAGE study lies in its inadequate endpoints.  They are primarily clinical and they are economically incomplete and therefore they are not sufficient for a Comparative Effectiveness study.

I would argue that Bill Clinton did not get his stent to avoid a heart attack in the FUTURE.  He got it to reduce his chest pain today.

For Comparative Effectiveness to be a useful economic tool the studies have to measure true economic variables.  One of those variables is patient demand, and I believe if a patient believes his chest pain will diminish from a stent procedure he will see that as the optimum treatment versus drugs alone even if the odds of having a heart attack in the future are not changed.

So, I am a believer in Comparative Effectiveness in theory, but a skeptic that medical trials alone will guide the way.  As a result, I believe innovation requires the deployment of science that brings together clinical realities and market economics to determine the most cost effective approaches to meeting the needs of the patient.  If we couple this with a financial system that includes true consumer financial accountability we will move toward having one of the key components to a value-based purchasing market for healthcare.

Stay tuned…

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