I am a physician, financial planner, educator, and I love to tell great stories. The world is too complicated and doesn’t have to be that way. The goal for this blog is to bring simplicity to the two subjects I know best – financial planning and medicine.
My background - Med School at University of Mississippi and residency at the Medical College of Virginia. I taught at the University of Florida and worked in various emergency departments in the Jacksonville area.
In trying to find a financial planner, I went back to school for fun and found another passion. I founded Life Planning Partners, Inc. in 2004 and felt like I haven’t had a job since. I began sharing stories on the interplay of my two professions and am grateful for audiences all over the country who want to hear my message about medicine, money, and keeping it simple. Please join the conversation.

2/03/2012 @ 11:04AM3,947 views

The ACA and the Power of the Breast Lobby

Breast cancer is a devastating illness that strikes down wonderful women in their prime through no fault of their own. We lose our mothers, friends, and sisters after watching them go through agonizing treatments. I have worked with cancer patients and have been with many dying people, yet it did not prepare me for the senseless death of my college roommate from breast cancer at the age of 42, leaving behind her husband and three beautiful young children. It is very emotional.

The best treatment for any cancer is prevention. A good example is the use of a vaccine for cervical cancer. Breast cancer prevention will happen one day, and until it does, we will need to focus on early detection through screening and improving treatment. As I have discussed in the past, prevention and screening are a significant part of the ACA. Because of the ACA, insurance is required to cover all U.S. Preventive Services Task Force (USPSTF) Grade A and B recommendations, which are services expected to have substantial to moderate net benefits. So where does breast cancer screening fit in this realm?

In this country, screening protocols are decided based on effectiveness, and each group determines effectiveness in their own way. Data and studies abound supporting any and all positions on the breast cancer screening question. One thing that is not considered is cost, mainly because our society does not allow overt rationing.

Although the institutions that determine these protocols have good intentions, all have inherent interests and biases, which may bring the objectivity of their recommendations into question. For example, with our fee-for-service system, providers get paid more to do more, and some of these organizations represent the providers. Reading their guidelines, you’ll notice many of these organizations recommend more aggressive screening protocols. On the flip side, other organizations may have a vested interest in keeping costs down, and their protocols are less aggressive. And of course, especially with the non-profits such as Komen, there are passionate people involved who have been profoundly affected by their experience with the disease, and their emotions play deeply into the decisions those organizations make.

What is happening now?

The power of the “Breast Lobby” is huge, and they spend a lot of their donor’s money on lobbying activity. In November, 2009, the USPSTF released updated guidelines on breast cancer screening protocols. The new recommendations changed the screening guidelines in women under 50 significantly. The Breast Lobby kicked in, and within a month, the USPSTF had to “update the language” to a less restrictive stance. Still, the recommendation for breast cancer screening in women under age 50 is Grade C, which means “Clinicians may provide this service to selected patients depending on individual circumstances. However, for most individuals without signs or symptoms there is likely to be only a small benefit from this service.”

As I stated earlier, the ACA requires coverage for all preventive services considered Grade A and B. A line had to be drawn somewhere. So what happened with breast cancer screening? Because of the power of the Breast Lobby, the law was changed to specifically allow coverage for screening mammograms under age 50, even though it is not Grade A or B. Men, just so you know, prostate cancer screening is not Grade A or B, and will not be included in your coverage. The Prostates need a better lobby. The best answer though is that politics and medical care decisions should not go hand in hand. We should have an independent organization made up of all constituents to decide these important matters.

Although I am not fond of the way England runs their health care system, they have one great component – the National Institute for Health and Clinical Excellence, or NICE. This organization rationally determines screening protocols based on the best available evidence. Once NICE determines the protocol, providers and patients all get on board. My favorite part – cost is part of the equation. We are an innovative country and are very good at adapting ideas from others. Creating something NICE here would improve care and help us utilize our health care dollars more efficiently. And with the “Third Way,” people can buy coverage not covered by the NICE people.

What is really the right answer? In my Quest for Simplicity, I would love to see organizations come together to agree on one protocol based more on evidence and less on emotion and payer structures. All these great people joining together could improve outreach, treatment and research, and eventually cure this horrible disease. In the meantime, let’s continue to push for less political and more evidence-based ways to provide good health care in a cost effective way.

I appreciate all feedback, especially when it comes from the desires to make the world a better place. It would be great if you could post your comments on this site for the world to see. Other places to reach me – Twitter @CarolynMcC or at Carolyn.mcclanahan@gmail.com.

Addendum: Wow, shortly after posting this article, there is a news release that Komen has reversed their decision on funding Planned Parenthood. We are in a new world – electronic mobs move fast and change can occur so quickly. Wouldn’t it be great if we could change to taking politics out of health care decisions just as quickly? Scary and exciting how fast the world can stand up now.

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Well, breaking news is that Komen will restore the funds to Planned Parenthood. The outcry was too much for them. That’s good, but I am still waiting for when all women with breast cancer will have access to treatment, not just a screening mammogram to let them know they have the cancer.

I am also concerned about how now insurers are denying breast cancer survivors post treatment follow up with their medical oncologists, assigning that task of follow up to primary care providers. I know how primary care providers do not feel they have the expertise to follow cancer patients, especially in the 10-15 minutes per patient they are allowed per visit in most circumstances. This is one area I am highly critical of the NHS/NICE protocols, because that is how they restrict their cancer patients. It saves a lot of money on specialist fees, but studies have shown that there is considerable divergence of opinion between primary care physicians and oncologists when faced with identical case presentations, and the oncologists are more accurate on cancer issues. They, and their patients, have better outcomes when the oncologists follow the cancer survivors. Saving money is important, but not when it costs quality years of life for patients.

Much as I deeply appreciate NICE, I still hope that any system of coverage we might ultimately put in place will retain considerable flexibility for individual cases with special needs. Not everyone responds to the standard of care.

Once we have a national system for electronic medical records it will be possible to track outcomes on a scale that is impossible today. With a coherent national system of record keeping we might obtain the evidence we need to determine efficacy of treatments we offer out of idiosyncrasy and tradition, not evidence, today. I don’t think most people realize how much data we lose because of the fragmented, opaque non-system of health care delivery we permit now, and how much treatment is only based in opinion, and “that’s how we do it here”. We could be doing a much better job.

We are pretty much close to being on the same page on all of this. Being from the finance world, we have to decide how much we can afford and find the most cost effective way to provide the best care possible.

I dream of what can be accomplished in patient care, research, patient safety, and cost efficiency with the use of a single nationalized electronic medical record. A leader who promises us that vision would be one I would highly consider following. It would be a good start to a great health care system.

To be able to determine the best, if there is one best, screening and care requires there be multiple protocols available or else how pick from many. A govt selection of one best would eliminate the opportunity for knowledge gained from use of differing protocols as the govt run system would only allow one. Politics, and thus lobbying, always enters a govt selection. You mention, “A line had to be drawn somewhere.” Why? Only because govt is intruding upon the rights of the individual and their doctor to select what they believe is the best for the individual patient. That is the essence of why so many are against a massive govt controlled health care system. By the govt selecting the one “best” protocol, as the British NICE does, the incentive to find other perhaps better ways is minimized or eliminated. The govt will already have the selected best in place, why fight city hall? Finding out which is best takes time, maybe years or more. Utopia would have one answer for all problems. That assumes the best has already been found. As a doctor you know different treatments at times may be called for a patient depending upon their individual needs. I found and wrote about that in my personal case when I stumbled upon a paper on how socialized health care in Finland handled a 100% bicep tear like mine a couple years back. Here in the USA, I had three repair procedure options and the US system acted within a week. In socialized care the choices were not there and the average time for surgery wasn’t a few days, it was 35 weeks! And that delay caused problems that the paper discussed eliminated the gold standard in care! The paper wasn’t knocking the lower care system, just dryly mentioning it in a medical paper as how the govt run system works. I respect and appreciate your opinions and writing. I do find humor in the call to get politics out of healthcare. That’s simple reduce govt influence in health care. The ACA greatly increases govt role in healthcare and may make become a total takeover. You mention as an example the Komen Foundation reversing their decision on Planned Parenthood as the example of how great it would be to quickly get politics out of healthcare but miss the irony that it was politics (politically correctness) that pressured the decision.

#1. There should be a base system (for everyone) that costs no more than what taxpayers are paying now. For people with money, they can buy additional care to cover services that are not covered by the basic system (your biceps tear.) Many people in THIS COUNTRY wouldn’t even get to see a doctor for their biceps tear currently. The base system doesn’t have to be government run, but it does need one entity paying the bills. #2 If we are using taxpayers money to provide care to the country, it needs to be used efficiently and effectively. Set a screening standard, and if the people with money want something outside the screening standard, let them pay for additional coverage to pay it. #3 The government doesn’t have to set the standard. In fact, NICE is made up of a bunch of non-government people. #4 People with money, good education, and good health care have no complaints with the current system (I think you might fit in that category.) The rest of the people have poor access to care, or can’t afford the care. How do you propose we take care of the 50 million uninsured? Realize that this group are the ones WITH JOBS who don’t qualify for Medicaid or other social services – our waitresses, yard care people, beauticians, etc. #5 Komen decision was political on both sides. If we had a good health care system, Komen and Planned Parenthood wouldn’t even be needed.

It would be wonderful if more people in the world would look at the problem from views other than their own back yard. Win-win situations are more likely to be found using this method.

Today’s outstanding announcement of patients growing new heart muscle in heart attack damaged areas of the heart shows exactly why a “best” protocol should not be selected and mandated to be followed, whether by a gov’t board or a non gov’t group approved by the gov’t. If a “best” protocol had already been selected there would be no opportunity for approval or way to see how a variety of protocols worked and in the case of heart attack treatment this new finding about stem cells would not have had a path to come about. There are likely many different protocols being tested. This one seems to have great results so far. However, being different than the approved “best”, by definition it and other potentially promising ones would have been discouraged or eliminated. I believe this to be hugely significant. There would be no way for a new protocol to come to life. After all the creator of the gov’t health care plan himself, President Obama, has said a single payer govt system is where this needs to go and is headed.

A base system could be created allowing individuals to pick their coverage as they see best. Why one plan for all as a base? Does single young woman need the same coverage as an elderly man. If the gov’t decides it, then providing different coverages for different people would be both discriminatory and possibly violate equal protection under the Constitution! If the gov’t needs to be involved then let it provide vouchers to a certain dollar amount for insurance then let private industry come up with offerings to compete in and fit the market. Isn’t that similar to what the elected representatives have? A gov’t based and mandated system likely won’t cut costs or be efficient. Look at the US Postal Service!

That is all I really intended but I don’t want to ignore your listed questions so here are some positive thoughts in reply.

On your list, #1, I disagree many people in this country would not get to see a doctor for an injury as significant as a 100% bicep tear. Emergency rooms are busy with much less significant issues than that!

#2 Efficiency and gov’t are not things routinely that go hand in hand. The reason is the gov’t is not generally designed for efficiency, the private sector is. If one wants an efficient process then let private companies compete to find efficiency so they can survive and maybe prosper in the competitive marketplace.

#3 If NICE is made up of non government people great. It does not change the fact the system is approved by gov’t even if outsiders might have input. Remember when outsiders gave input early on, our President shrugged it off and said, “We won!” and then ignored all input.

#4 Not sure I fit in category of having no complaints with the current system. Actually I have input that says I am not satisfied with it. I happen to believe as my Grandfather taught me that all the progress in the world is the result of dis-satisfied people, of which I am one on this topic. It would be a much better, lower cost system if a few things happened first. a) Get rid of third party providing insurance. Have the individual involved in the selection of their plans, if desired. b) Let insurance be sold across state lines to encourage greater competition. c) Lesson the mandates so plans that meet individual needs can be developed. d) Change tort laws so doctors are not so scared of being sued and put out of business causing them to practice defensive medicine. e) Could add more but trying not to be too long. Vouchers mentioned above could help the truly needy to get insurance. Those that decide not to have insurance will be at risk through choice. However if we could get a more competitive consumer driven system the costs may lower and more would choose to spend dollars for it. I guess you could say I am pro choice on healthcare.

I am 100% in agreement that things should be looked at from views other than their own. Not doing so is exactly how the US gov’t got into the Affordable Care Act on Christmas Eve with the aforementioned comments such as the President’s “We won”. He and many others were not willing to listen to others views. Even the President’s own website for comment only offered a drop down for message of support, no drop down for message of opposition or message of different input. How telling was that on “The People’s” government website?

Yes, everyone can see a doctor in the emergency department. It is a government law by the way. So a person goes to the emergency room with a biceps tear. As an emergency physician, I would see them and we would arrange follow up with an orthopedist to see them. However the orthopedist is not required to follow up with them, and if the patient does not have the ability to pay, they would get no further care. And, they would begin receiving mounds of bills from their ineffective visit to the emergency department. This is not efficient and leaves people with problems much greater than a biceps tear in dire need of quality care.

I would love to know your answer on how we would provide care to the 50 million uninsured. And also, if we had no government involvement at all, who would regulate the insurance companies and make certain they do the right thing? I can give you hundreds of instances of insurance companies not doing the right thing. They currently ration our care, and I would profoundly prefer an independent objective board over a completely corporate board rationing our care.