Friday, August 21, 2009

Grading papers again: Caesar Rodney Institute op-ed on health care reform plays fast and loose with the facts

Two important issues before we start a very long post.

I am a believer in free markets, but I am also a believer in intellectual honesty and factual accuracy. That's why it is incumbent upon me not to give any organization--especially one that pretends to libertarian leanings in its boilerplate--a pass on shoddy work.

Second: I am going to do something here that some people might consider exceptionally insensitive. I am going to take issue with a cancer survivor's account of her experience with health care, and her conclusions about what that means. I do not assert that she is intentionally misrepresenting her own experience: I am quite sure that's how she remembers it. But when you begin using your own anecdotal experiences to attempt to sway a public policy debate, and when you do so in the service of a non-partisan think-tank, then you have chosen to lay that all on the table.

The document in question is Thoughts on Nationalized Healthcare by Joanne Butler, published by the Caesar Rodney Institute on June 25, 2009.

This will take awhile, because a thorough debunking is always more difficult than unsubtantiated allegations.

The piece begins:

With all the churning going on about President Obama’s health care plan, I can’t help but wonder if his plan had been in place in 2002, whether I would be alive today or not. Lest you think I’m being unduly dramatic, you should know that seven years ago I had a malignant polyp removed from my colon.

Good opening: gripping writing. I am a cancer survivor, but would Obamacare have killed me?

Let's look at the narrative of Ms Butler's experience:

What was unusual was that I was in my forties, and the ‘best practices’ indicate that a person’s first colonoscopy occurs at age 50 — at the earliest.

Because my maternal grandfather died of colon cancer, my Mom drilled the warning signs into my brain long ago. When I started having problems, I did what the preventive care people say you should do, and called my doctor. When I told him about my grandfather, he said that I should have a colonoscopy right away. ‘I know your health insurance doesn’t cover colonoscopies at your age,’ he said, ‘but I will talk to them and get them to pay for it.’

He had that conversation, and shortly thereafter I had the procedure that saved my life.

Let's hit that sentence in bold again:

I was in my forties, and the ‘best practices’ indicate that a person’s first colonoscopy occurs at age 50 — at the earliest.

This both is and is not true, but in order to parse it you have to understand that there is a difference between a preventative colonoscopy and a diagnostic colonoscopy. Ms. Butler is correct: virtually every health insurance plan--public or private--only pays for routine preventative colonoscopies beginning at age fifty.

But diagnostic colonoscopies are recommended and routinely approved for patients as young as teenagers who either have symptoms of significant colorectal problems or a family history of colorectacl cancer or malignant polyps.

Here, to give an example, are the Medicare guidelines for approval of diagnostic colonoscopies that have been in place since 1998:

Indications and Limitations of Coverage and/or Medical Necessity
A. The following are Medicare-covered indications for Diagnostic Colonoscopy:
1. Evaluation of an abnormality on barium enema or other imaging study, which is likely to
be clinically significant, such as filling a defect or stricture
2. Evaluation of unexplained gastrointestinal bleeding:
a. Hematochezia not thought to be from rectum or perianal source,
b. Melena of unknown origin; after an upper GI source has been excluded,
c. Presence of fecal occult blood.
3. Unexplained iron deficiency anemia.
4. Examination to evaluate entire colon for synchronous cancer or polyps in a patient with
treatable cancer or polyp.
5. In patients with Crohn’s colitis and chronic ulcerative colitis: colonoscopy every one or
two years with multiple biopsies for detection of cancer and dysplasia in patients with:
a. Pancolitis of eight or more years duration; or
b. Left-sided colitis of 15 or more years duration.
6. Chronic inflammatory bowel disease of the colon if more precise diagnosis or
determination of the extent of activity of disease will influence immediate management.
7. Clinically significant diarrhea of unexplained origin with additional symptoms (e.g., with
weight loss).
8. Intraoperative identification of the site of a lesion that cannot be detected by palpation or
gross inspection at surgery (e.g., polypectomy site or location of a bleeding source).
9. Treatment of bleeding from such lesions as vascular malformation, ulceration, neoplasm,
and polypectomy site (e.g., electrocoagulation, heater probe, laser or injection therapy).
10. Removal of foreign body.
11. Excision of colonic polyps.
12. Decompression of acute nontoxic megacolon or sigmoid volvulus.
13. Balloon dilatation of stenotic lesions (e.g., anastomotic strictures).
14. Palliative treatment of stenosing or bleeding neoplasm.
15. Marking a neoplasm for localization.


C. Effective 01/01/98, Medicare covers screening for colorectal cancer. Medicare allows a
Screening Colonoscopy every 2 years for beneficiaries that are at high risk. Follow-up testing
performed every 2 years would be allowed for these individuals under the screening colonoscopy
code G0105 (See NCP GI-008). The high-risk diagnosis codes are:
1. a close relative (sibling, parent, or child) who has had colorectal cancer or an
adenomatous polyposis (V16.0, V19.8);
2. a family history of familial adenomatous polyposis (V19.8);
3. a personal history of adenomatous polyps (V12.72); or
4. a personal history of malignant neoplasm of the large intestine (V10.05)
5. a personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus
6. a personal history of gastrointestinal cancer (V10.00, V10.03, V10.04, V10.07)
7. inflammatory bowel disease, including Crohn’s Disease, and ulcerative colitis (555.0-
555.2, 555.9-556.3, 556.8, 556.9, 558.2, 558.9).

Ms. Butler demonstrates in her sentence that she had a family history and physical symptoms, the combination of which was significant enough to convince her physician that a diagnostic colonoscopy was necessary. Why then did he say:

‘I know your health insurance doesn’t cover colonoscopies at your age,’ he said, ‘but I will talk to them and get them to pay for it.’

First, let's allow that none of us can accurately present the wording of a quotation from seven years ago, although I am (again) certain that this is the way Ms. Butler recalls it.

But what the doctor was trying to communicate is the fact that under virtually all insurance plans--again, public and private--a diagnostic colonoscopy is considered a surgical procedure and all such procedures require pre-approval.

In this case we can be a little more specific. During 2002 Ms Butler was a Federal employee, working part of the year for the USDA and part of the year for the Social Security Administration. As such, she qualified for the Federal Employee Health Benefit [FEHB] as her health insurance.

One of the larger insurance companies providing coverage under FEHB was--surprise, surprise--Blue Cross Blue Shield. Note what it says about colonoscopy in the 2003 Blue Choice handbook [I cannot find 2002 online, but I doubt seriously this part changed]:

Services requiring our Your primary care physician has authority to refer you for most services. prior approval For certain services, however, your physician must obtain approval from us. Before giving approval, we consider if the service is covered, medically necessary, and follows generally accepted medical practice.
We call this review and approval process pre-certification. Your physician must obtain pre-certification for the following services:

1. Air ambulance,
2. All inpatient admissions,
3. All referrals to non-participating providers,
4. Ambulatory surgery,
5. Chemotherapy & radiation treatment,
6. Colonoscopy & endoscopy procedures,
7. Diabetic equipment,
8. Home health care....

In other words, according to the Blue Choice guidelines for FEHB policies around that time all diagnostic colonoscopies required pre-certification, and still do.

The physician did nothing unusual here, asked for no exceptions to policy, sweet-talked no insurance company bureaucrats. He simply arranged the pre-certification as physicians do for millions of essential routine diagnostic procedures every day.

But Ms. Butler [who, you need to recall, either then or soon thereafter, went to work for the Social Security Administration] now makes an unusual comparison:

Now imagine what would have happened if my doctor had to convince some federal medical panel to approve my colonoscopy. If we use the Social Security Disability Insurance system as a model, it would go like this:

Step 1: My doctor files a petition form with a low-level intake specialist/bureaucrat, whose job it is to keep the flow of petitions down. Not surprisingly, the intake specialist denies the request.

Step 2: My doctor files an appeal with another bureaucrat, who also says ‘no.’ Due to the huge volume of requests, intake specialists never meet with doctors; instead, they rely on an allowances manual to make their decisions. (Meanwhile, several months have gone by, and that polyp has gotten bigger.)

Step 3: I get out my checkbook and hire an appeals specialist, who prepares a more elaborate, legalistic appeal. I’m willing to spend the money because I need the colonoscopy, and if the federal medical board does not grant me a waiver to get a colonoscopy, it’s illegal for me to get it privately. If I don’t hire the appeals specialist, my case would be closed at step 2. As a last resort, I might consider going overseas (if I can afford it) for the procedure.

By step 3 a year — or two — has gone by, and the malignancy has grown and perhaps spread to other organs. By the time I get to the step that allows me to get a colonoscopy, would I be in hospice? That’s not a bet I’m willing to take. Would you?

We are now into the realm of nothing less than fantasy and intellectual dishonesty.

If we use the Social Security Disability Insurance system as a model

Why would we use such a process as a model, even if the current plans involved setting up such a day-to-day review board? The SS Disability Insurance system is a system designed to evaluate claims for long-term and permanent disability, and whether the claimant should be entitled to monetary benefits for a long time--or even the rest of his/her life. It has nothing to do with approving procedures, and nothing within this incredibly slow, cumbersome system is designed or intended to deal with time-sensitive medical situations like potential cancer. But even here we will discover that Ms. Butler has consciously distorted the practice of the system which employed her at the time of her illness.

I get out my checkbook and hire an appeals specialist, who prepares a more elaborate, legalistic appeal.

Sounds horrible, right? In fact, most people use an attorney or an appeals specialist from the very beginning with Social Security Disability because the system works so poorly. But the overwhelming majority of people who provide that appeals service do not actually charge you anything up front--they are directly paid by the Social Security Administration if they win the claim. Yes, their fee comes from a percentage of your benefits, but spare me the tear-jerker image of the person wasting away from cancer having to get out my checkbook.

Oh, and Ms. Butler knows this, as evidenced by her own job description of what she did for the Social Security Administration:

For the Chief Administrative Law Judge, was the team leader responsible for design & execution of new statutory program to qualify non-attorney representatives to receive their representational fees directly from their client's lump-sum payments.

Then there is this:

if the federal medical board does not grant me a waiver to get a colonoscopy, it’s illegal for me to get it privately.

Really? In what world? Maybe in Canada, and Canadian courts have recently put a giant knock into that theory as well. This sentence is neither part of the Social Security Disability Insurance process nor any health insurance reform proposal that has been placed on the table by any legislator with the possible exception of single-payer, which is not being debated, as some of you may have noticed.

Can you make a slippery slope argument that the current proposals will eventually lead to single-payer, and that such is part of the President's and Democratic Congresscritters' agendas? Sure. But if you are going to do so, please do so directly and not suggest that your little nightmare fantasy has anything to do with what's currently being debated.

Then there's this interesting paragraph:

Make no mistake: any system of health care involves rationing — that includes the system that we have today, and any new system concocted in Washington. As I see it, President Obama would use a federal health practices board as one way to limit access to care. Diktats from the board will make doctors reluctant to prescribe procedures or medications for fear of being disciplined, struck off from participating in federally-approved plans, and losing income. Thus, the government will intrude in that most personal of conversations, those between a doctor and his/her patient.

Begging the question, Ms. Butler, but if you admit that the current system of health care involves rationing, exactly where is that awareness in the rest of your paragraph?

In your own story a health insurance bureaucrat was empowered to intrude in that most personal of conversations, those between a doctor and his/her patient.,

So for a Federal Employee whose FEHB benefits guaranteed her she could not be turned down for coverage for any pre-existing condition, this is an interesting position to take.

We should also note that while Ms. Butler champions a free-market approach to health care, she apparently has no problems with rigorous Statist intervention in international trade, as evidenced by her work for both the Clinton and Dubya administrations at the USDA:

Member of interagency trade retaliation team -- devising lists of products that the USA would raise tariffs on as a result of a favorable WTO decision. Member of interagency team that traveled to Brussels to attend a World Customs Organization plenary session; I was the technical expert responsible for advising the head of the delegation on the scope agricultural tariff definitions and harmonization. Authored a comprehensive study of the South African processed food distribution network; involved extensive research and in-country travel; work product used by U.S. exporters interested in South African market. Went to Capitol Hill frequently to meet with members and staff regarding trade barriers.

Ironically, i agree with Ms Butler's assessment that many politicians supporting the current health insurance reform plans have, as their ultimate goal, a single-payer system with the elimination of primary private health insurance.

But this Caesar Rodney Institute op-ed is neither responsible nor factually accurate, and it is certainly not non-partisan, especially when it is written by an individual who describes herself on her own profile as a member of the Rapid Republican Responders, a group self-described as:

The Republican Rapid Responders is an informal group of experienced GOP campaigners who can quickly deploy to provide grassroots support for national and state GOP candidates and organizations.

The group was formed in early 2004 by a small number of highly motivated GOP loyalists wanting to help ensure the re-election of President George W. Bush.

The group has grown to become a GOP "strike force” of over five hundred grassroots campaigners who volunteer on their own time going door-to-door on behalf of Republican candidates.

The group’s experience -- from the 2004 Presidential election and the 2005 Virginia Gubernatorial race to the 2006 Mid Term elections and the 2007 elections in Virginia, Louisiana, Kentucky and Mississippi --has demonstrated that the Republican Rapid Responders is an effective grassroots volunteer resource for GOP nominees for state and national offices in future campaigns including the all important 2008 election.

I have no problem whatever with the Caesar Rodney Institute championing conservative principles and free-market values, but as for their claim that

Individuals who support the Caesar Rodney Institute span the political spectrum from neo-liberal to conservative, populist to libertarian and independent.

I'm still looking for that neo-liberal support base.

Truth in advertising: I have vigorously defended CRI for its publication of Delaware State Employee salary data, with names, and continue to do so. When CRI does it right, I will say so. But I will not be silent when they publish low-quality material.

After all, if you are really a think-tank, what else have you got except facts and ideas?


Anonymous said...

First of all that woman is a complete and total liar. If we had a single payer system in 2002, she and her doctor would have decided due to the family history she should have the test. What is wrong headed is that this woman wants us to believe the for profit Blue Cross (her choice as a federal employee) a for profit health care provider refused to do it. Exactly the point!

How I know she is a liar is that my father was diagnosed with colon cancer when I was 38. When I told my doctor he immediately said, "due to your family history, you should be checked at least every 5 years and made an appointment for my test". I have had the test every 3-5 years since. When I turned 65 and Medicare kicked in my tests were covered 80% and I paid the 20% out of pocket.

Here is the question for CRI! Why shouldnt all federal employees be covered under the same plan as the american people? Are you federal employees willing to give up your "menu" of for profits, and join the rest of the american people in a program that is not FOR profit, but non-profit? Do you not understand the insurance companies are stealing 30% of your premium to cover, CEO's, shareholders, advertising, and other waste and fraud that is harder to detect because there is no "standard" for care? What the gubmint must do is set rates for certain procedures. Use technology to put our health care records on line, so no matter where you go, any doctor, hospital etc can see your file immediately? Got a living will, it would be on file and if are involved in an accident, or unable to speak, your medical has all your information, no guesswork? Are you aware that Doctors for single payer are sick and tired of spending 40% of their time doing paperwork. The single payer system is not GOVERNMENT RUN, its GOVERNMENT ADMINSTERED, meaning there is no "panel" who determines what procedure your DOCTOR and YOU decide upon. There is no panel in medicare or medicaid now!

CRI just another local group of liars and deceivers who want to make sure no real reform takes place, and this president loses the issue, so they can regain power in 2010. Rush Limbaugh just stated that on his news/lies program.

If you want the truth about how Canadians like their health care, google it. HR 676 is not modeled after Canada or England (which truly is a socialized medical program, same with VA).

If you want to keep paying these for profits, while premiums are skyrocketing covering basic medical and you continue to pay for mental, dental vision, long term, nursing home care etc...only those medical issues are covered by HR 676. And we dont need one red cent more to enact it.

Anonymous said...

Great blogging. I guess between Canadian doctors (who would like to get paid more) and partisan cancer survivors - the CRI and the rest of the right-wing industrial complex has all the dodgy anecdotal evidence it needs to pronounce judgement on health care reform.

G Rex said...

That's a lot of blogspace used just to talk about somebody's ass. That said, I'm over 40 and it's time to get a checkup.

downwithabsolutes said...

JFC, Steve, this is some tremendous blogging. They should have asked me and I could have told them about the difference between preventive and diagnostic. I paid health insurance claims for years and anyone with the crudest knowledge of health insurance should have known that.

Here's my issue with CRI: When I first heard about them through a friend, I was told they were just going to be a repository for impartial facts: like publishing data bases of salaries and state department budgets. Now it's clear to me that this "think tank" has an ideological bent that is more than simply interested in presenting unblemished facts and statistics. They're most certainly a right-wing think-tank that is employing questionable intellectual means to disseminate their information. I don't mind that they are a right-wing think tank, but they sold themselves as something wholly different (IMO) when they launched the thing several months ago. Where they make the leap from publishing state employee salaries to advance transparency to bitching about how Obama's health care plan is socialism and pure evil, I have no clue.

Perhaps it's just early on and they have yet to refine their message or delivery system.