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The Attack On Health IT And Comparative Effectiveness Research: A Warning For What Lies Ahead



March 4th, 2009
by Linda Bergthold

Few of us could have predicted (or were ready for) the firestorm of opposition that provisions in the stimulus bill related to electronic health information or comparative effectiveness research created a few weeks ago.

Oh, we might have thought that privacy issues related to electronic health records (EHRs) might be of concern. Or the fact that electronic health information systems or comparative effectiveness research were not as “job creating” as money for road building (even though they are predicted to create 200,000 or more jobs). But did we anticipate adequately that these two provisions would be so commingled, misunderstood, or hysterically misrepresented in the media as they were?

The tactics used to attempt to defeat these two provisions are instructive, because they will be used in much greater measure when the real health reform legislation becomes public. In President Barack Obama’s February 28 video address, he acknowledged the coming opposition. I offer a few suggestions for how to fight back, and I hope you will contribute your comments as well.

Tactics That Almost Worked: Lies, Repetition, And Speed

Outright Lies. It may have started with the reemergence of an annoying critic of the Clinton health reform plan, Betsy McCaughey, and an editorial she wrote for Bloomberg News titled “Ruin your Health with the Obama Stimulus Plan”. McCaughey, a former lieutenant governor of New York and an adjunct senior fellow at the Hudson Institute, had misrepresented health reform before. In a widely panned article in the New Republic  in 1995, which was eventually repudiated by that publication, she made claims about the Clinton health reform bill that were simply untrue. Her claim to fame was the fact that she had combed through every word of that very long piece of legislation, something almost no one else had done quite that thoroughly.

But, as Ezra Klein points out in his blog posting titled “Lies, Damn Lies and Betsy McCaughey”, “McCaughey, it turned out, isn’t a very good reader.” She misrepresented and misinterpreted key elements of the Clinton plan, but she ended up a media queen, and her accusations were repeated and asserted as facts, over and over again, by the right wing.

This recent controversy was fed by yet another inaccurate article by McCaughey for Bloomberg News a few weeks ago. Among other inaccuracies, she claimed that the National Coordinator of Health Information was a new bureaucracy. (It is not. Former President George W. Bush initiated it in 2004.) That electronic health information would force doctors to do what the federal government thinks is appropriate and effective. (The stimulus bill does no such thing. ) That the Federal Council for Comparative Effectiveness Research would slow the development of new technologies and treatments. (Not. )

McCaughey claimed that information generated by comparative effectiveness research would dictate to Medicare a new cost effectiveness standard. (The Stimulus Bill avoids using the terminology of cost effectiveness and an earlier statement released by the Senate Finance Committee stated that comparative effectiveness information should not be used for coverage decisions in Medicare.) And that the elderly would bear the brunt because Medicare pays for treatments deemed safe and effective. (Medicare pays for treatments that are reasonable and necessary. The Food and Drug Administration [FDA] deals with safety and effectiveness.) And the list of inaccuracies goes on.

Repetition And Speed. The lies are not what is so interesting about this latest dust-up. What is instructive and interesting is the way in which this misinformation made its way so rapidly through the body politic and into the blogosphere, much like radioactive dye that is used in PET scanning to highlight heart disease. McCaughey’s comments were almost instantly picked up by Rush Limbaugh, Fox News, the Drudge Report, the Wall Street Journal, and local radio talk show hosts around the country (such as Ronn Owens at KGO in SF).

The misrepresentations were then echoed but not refuted very effectively by either David Axelrod or David Gregory on NBC’s Meet the Press  and in the New York Times, which also repeated the claims:

But critics say the legislation could put the government in the middle of the doctor-patient relationship. Bureaucrats “will monitor treatments to make sure your doctor is doing what the federal government deems appropriate and cost-effective,” Betsy McCaughey, a former lieutenant governor of New York, wrote on Bloomberg.com. Rush Limbaugh broadcast the charges to millions who listen to his radio talk show.

By providing links to McCaughey and Limbaugh, the Times attributed credibility to their claims, in a style very common among journalists today. Make a statement, provide a quote, make another statement, provide another quote. Voila. You are being fair and balanced. Analysis or critical deconstruction be damned.

The Attempt To Fight Back

By the time these claims that comparative effectiveness research and health information technology (IT) would destroy American health care as we know it had circulated on blogs, radio, and some cable TV, too many people had bought into it to really refute it effectively, although several entities did try. The Washington Monthly’s “Political Animal” blog  issued a strong rebuttal. Keith Olbermann of MSNBC’s Countdown program did a serious rant on the subject, outing McCaughey for taking money from pharmaceutical manufacturers, whose interests were to destroy the legislative language.

Media Matters exposed the Wall Street Journal’s treatment of the subject, in which they picked up the McCaughey lies verbatim. I myself phoned into the Ronn Owens radio program and made a valiant attempt to set the record straight (to no avail, I might add), and I blogged on Huffington Post about it, attempting, with a bit of irony, to defuse the most offensive of the attacks.

But the combined efforts of a few lefty blogs and one lefty cable TV show most likely did not persuade the Americans who were first hit by McCaughey and Limbaugh. The flood of e-mail and calls to legislators surprised even the Republicans. And had the Democratic staff not understood exactly where this was coming from, and had the speed with which the legislation passed been slowed down, there is no telling what might have happened to the funding for health IT or comparative effectiveness research. As Billy Tauzin, the head of Pharmaceutical Research and Manufacturers of America (PhRMA), was quoted in the Los Angeles Times’ article, “I hope it is a clear warning. There are a lot of beehives out there. You don’t just go around punching them.” ( (By the way, I have absolutely no idea what he is talking about, unless he is characterizing Republicans as a bunch of angry bees just waiting to sting us all to death!)

Preparing For The Next Round

Who won this round? Obviously the Democrats did. And policy folks like myself who believe that comparative effectiveness research and electronic medical records are way past due for implementation in American health care. But we weren’t nearly swift enough or strategic enough to stop the flood of abuse these two programs took in a very short timeframe. We will need more than the blogs and Keith Olbermann next time to fight back. Next time the strategy will be to slow things down long enough to kill the program with a thousand cuts.

There are several ways that lies and repetition can be countered. One is to be the first to set the agenda. Another is to find credible spokespeople to communicate that agenda. And still another is to anticipate the opposition and organize a way to refute it quickly.

During the Obama campaign for the presidency, the campaign made a valiant and sophisticated effort to set the agenda and refute the lies being circulated.  There was infiltration of Google search pages and a Web site called “Fight the Smears” that actively fought back against every ridiculous attack and lie, although in some quarters, it was “don’t confuse me with the facts,” and the lies continued to circulate.

There was also a blog team that I worked with that anticipated the attacks on Obama’s health care plan, and we posted on hundreds of blogs in battleground states, providing supporters with ammunition to fight back. We also wrote letters to the editor and opinion pieces, and we commented on hundreds of articles that misrepresented Obama’s health care program.

Our work was made much easier by John McCain’s own health reform ideas, because we were able to set the agenda early on as to the tax implications of his proposals and the dangers they posed for ordinary Americans. Senator McCain never recovered the momentum on health reform and almost stopped talking about it by the end of the campaign.

During the Clinton health reform period, not enough consultation was done with communications experts about how to set the agenda and refute the attacks. “Harry and Louise” took over, and the rest of the game was playing catch-up. This time it is not impossible to anticipate what the major attacks will be. Whatever Obama and the Democrats propose will be called “socialism” or “government takeover”. Ironically, the same voices calling for nationalization of the banks and the credit industry today will lead the way with little obvious sense of their own contradictions. Pointing out those contradictions in advance can help to serve as an “inoculation” against the power of their arguments.

The president is clearly the most effective communicator in his administration, and his willingness to set the agenda, anticipate the attacks, and create a structure (war room? Web site? new blog team? effective surrogates?) to carry his message will be absolutely critical to the passage of any health reform legislation. It is very easy to scare people with lies. It is much, much harder to educate them with facts. But effective persuasion does not depend entirely on facts. It also depends on credibility, honesty, simplicity, repetition, and organization. Obama and his team are masters of all of these techniques, and as they analyze what almost happened with health IT and comparative effectiveness research, they can raise the volume and get ahead of the inevitable tsunami to come.

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9 Responses to “The Attack On Health IT And Comparative Effectiveness Research: A Warning For What Lies Ahead”

  1. EMims Says:

    This is exactly the widespread commentary that continues to muddy the waters of legitimate health care reform. While internists such as myself almost daily wonder when the axe of mandated IT will fall upon our necks, with no forseeable financial or structural support prior to it’s expected implementation, we have partisan artillery laying dense clouds of flak that ultimately serve only to ground the entire process.

    I don’t really blame you, Linda. To do naught opens the doors to unopposed policy manipulation. However, you lessen your effect on the unaligned reader by clouding your rebuttals to Ms. McCaughey with replies that reek with bias.

    acavale’s post should be the driving point derived from this particular thread. If HCR insists that EMR is the key to efficiency, then the cost of that efficiency should not be placed on the caregiver’s shoulders. In an arena where we are expected to see 30+ patients a day simply to sustain a viable practice, while our peer subspecialists easily see half as many patients with twice as much reimbursement for precedurally-oriented care, it is no wonder that only 2% of primary care graduates are choosing to not subspecialize.

    IT is a good thing. EMR should be a good thing for patient care. However, from a practical standpoint, it’s already turning into a thoroughbred racehorse expected to run with almost no preparation. He’ll look great coming out of the gate, but with no good trainer, no endurance and no proper nutrition, he’s going to break his legs long before even the first quarter-mile is complete. Sadly, like any competitive breed, he will not stop running even if he knows his legs are breaking.

    If you are going to support this particular “form” of reform and fight against those that oppose it, please try not to lose sight of the real people counting on you and those like you to effect beneficial change.

  2. Linda Bergthold Says:

    There is a great article in the New York Times today about the use of evidence and how important it is that both doctors AND patients rely on evidence for appropriate treatment.
    http://well.blogs.nytimes.com/2009/04/02/the-ideology-of-health-care/#comment-276489

    The whole purpose of comparative effectiveness research is to provide the kind of evidence that can improve treatment. Not because the government dictates to the doctor, but because research lays out the options. However, it is not just evidence that we need. It’s compliance — by doctors and of course by patients. This article points out the lack of evidence for using antibiotics to clear up sinus infections. But how many patients, after suffering for a week with a painful sinus infection, can resist asking for an antibiotic? And how many doctors can resist giving one?

  3. Deborah Mihm Says:

    Linda, you might enjoy this 1995 letter to the editor in the Washington Times about Betsy McCaughey:

    Birthing pains: Paying for mothers’ hospital stays; [2 Edition]Washington Times. Washington, D.C.: Nov 3, 1995. pg. A.18 Full Text (216 words)
    Copyright Washington Times Library Nov 3, 1995

    In her Oct. 24 Op-Ed article, “Don’t send babies home so soon,” New York Lt. Gov. Betsy McCaughey blasts health management organizations for ordering women to leave the hospital after childbirth within one day. She wants Congress to pass a law requiring insurers to cover hospital stays of at least 48 hours.

    In support of this, she approvingly cites the socialized health insurance systems of Canada, Japan, Great Britain and Germany, which pay for new mothers to stay in the hospital from 2.5 to seven days. While those countries control health care costs more aggressively than does the United States, she writes, “even they draw the line at discharging newborns too early.”

    Two years ago, this same Betsy McCaughey wrote an influential article in the New Republic trashing President Clinton’s health care plan for its supposed rationing of care, crushing government regulation, price controls and lack of patient choice. Now she’s telling us that countries with systems similar to the dreaded Clinton model handle childbirth more humanely than our free-market system does. She even favors government intervention (gasp!) to correct this.

    Being in government for one year and facing the real-life problems of our health care system must have corrupted Ms. McCaughey’s thinking. Look out, Betsy, it’s a slippery slope to socialized medicine.

    DEBORAH MIHM

    Chicago

  4. Michael Millenson Says:

    Linda, it’s interesting to me that your excellent post, and other comments, have left out one glaring fact: the silence of the conservative policy community. After all, comparative effectiveness research was first brought to prominence in a Health Affairs article by Gail Wilensky, PhD, a long-time Republican government official and political adviser — including to John McCain. The IOM committee that recommended a separate federal agency was bipartisan; this was not some idea hatched by Tom Daschle.

    So where were the Republican policy wonks? Or, more effectively, perhaps they could have reminded John McCain of what his own plan said (and maybe reminded a few other Republicans, as well) and shown that this was a non-partisan issue.

    In the Sherlock Holmes story, The Hound of the Baskervilles, the key is the “dog that did not bark.” So, too, here. And if our conservative friends dare not raise their voices at this very, very early point to combat the no-nothings in their own party, what about later on down the road.

  5. ccarlson Says:

    I agree that the articles/responses are fairly typical of the “Libaugh” portion of the right in this country, but I don’t think that concerns about the sharing medical IT information should be so easily dismissed. Whether it’s a government bureaucracy or the private HMO establishment, the question of who has access to the information they gather and disseminate is a valid concern. The questions are multiple, starting nwith who whoever holds the databank will sell it to in a privately run health care system? Will insurance companies have access? How will affect insurance for participants in a system whose bottom line is profitability? And on from there. Also, the Clinton Administrations main problem was not that they needed to manage the dialogue better, but that their process was not inclusive when it came to public advocacy groups, They did not generate trust with a less than transparent process. Good for efficiency of constructing a plan, but fatal in terms of gaining public support. There is a lot of potential criticism of what emerges from the Obama White House that is not and shouldn’t be tossed off as hysterical and merely problems of the need for better management of the dialogue. The ones cited may not qualify as that, but there is more to come. Also, “reliable sources” like the New York Times have time and again dismissed the critiques of “political or medical outsiders” in the case of CFIDS and GWI by supporting the Harvard or Yale “experts” who are very ones of who have blocked or delayed effective treatment of diseases like these and currently Lyme and Morgellons, by claiming for years the victims are suffering from psychosomatic effects, not chronic physical conditions. They need to be challenged! CFIDS and GWI are now finally recognized as real physically-based ailments, but insurance companies escaped, in each case, one to two decades of costs which would have been incurred by paying for treatment. We don’t need to fear government involvement in health care as much as we need to fear good old private enterprise.

    ccarlson

  6. acavale Says:

    I read this morning’s article in the WSJ and actually happened to agree with the premise. Clearly she quotes a Congressional testimony of an individual from the CBO so you cannot call her observations “lies” since they were not hers. This is where having a neutral perspective is very valuable. I cannot understand why you cannot agree with the assertion that the cost of obtaining health insurance is not as big a burden as it is made out to be – companies get a full write off on these costs, employees are not taxed on this as income; it is a win-win situation for both parties as far as taxation issues are concerned. And if this was any news, HR departments of large corporation almost always get great deals from insurance companies. In my view, the rhetoric about insurance costs affecting competitiveness of large corporations is just that, and nothing more.

    Because of your strong views and biases, you are unable to look objectively at what is presented as factual data and what is an opinion. I took Mr. Obama on his word that this would be a “post partisan” administration. So far I can only see extremely partisan actions and words.

    And the administration is yet to address the enormous costs of implementing health IT extensively and everybody that is pushing this IT agenda has over-projected the expected savings. The public has a right to know exactly how much these projects will cost and how much they will save. It is a totally different matter if the administration comes out and says that the cost and potential upheaval is acceptable in order to improve efficiency and increase data exchange, but it has to be honest that cost savings will be negligible for the near future.

  7. Linda Bergthold Says:

    Thank you both for your comments. I do not claim in this blog to be a neutral observer. I am a partisan in terms of my support for health IT and CER, as well as the President who is supporting those ideas. As for the difficulty of implementing Health IT in a sustainable way, I have no doubt it will be very very difficult. However, it is extremely important to point out lies and distortions as they appear in the press about these efforts.. Today, the Wall Street Journal published an article by a woman who is known for her distortions. She claims the cost of health benefits has no impact on American corporations’ competitiveness. It is this type of off the wall journalism, if you can call it that, which we need to counter.

  8. acavale Says:

    Dr. Bergthold: Reviewing your previous experience in health policy matters, it seems obvious to me that you are far from a neutral observer. So, while agreeing with you that scare tactics employed by people like Ms. McCaughey are unacceptable, I would like to point out a Centrist’s view in all these matters regarding health care “reform”. By the way, I had never read or heard about any of the articles or blogs you mention (even though I consider myself a keen health policy observer). Perhaps you are lending some degree of legitimacy and publicity to these ?marginal articles.

    Anyway, with regard to the two issues you point out – EMRs and Comparative Effectiveness Research, I would like to throw some light from a practicing clinician’s perspective. This might perhaps help sway your mind away from blanket endorsement of such ideas.

    First, I am a 7-year EMR user and usually a resource for most local physicians looking for advice. Obviously this puts me in the camp of believers in health IT. However, there is a huge amount of resistance to more florid use of IT in the physician community for several reasons – 1) unbearable cost with no option of passing costs onto customers (as would be routine in any other business/profession);
    2) CCHIT requirements which not only add significantly to EMR costs but some of which are unacceptable to most physicians;
    3) total lack of interoperability with unacceptable costs associated with trying to connect to other computer systems;
    4) lack of any method of financial incentive from either governmental/private payers;
    5) unacceptable loss of productivity in converting from paper-based to electronic practice (like trying to change tires while driving a car-stopping it for a tire-change being unacceptable).

    Second, comparative effectiveness research, while sounding very nice in political talk, can potentially be very harmful to providing individual-specific care to patients. Agreed that there is no specific language in the recently passed law (I believe you on this). However, official recommendations/research studies published by a federal agency carrying out such “research” would automatically be implemented as “standards” by all payers, including Medicare. Anybody involved with appealing denials of investigations and/or treatments by payers on the basis of not conforming to the “reasonable and necessary” criteria can tell you that it is just a matter of time when every treatment plan will have to meet “criteria” set by a “federal health board”. In other words, there would be no such thing as physician-patient relationship or individualized/personalized medical care.

    My biggest fear is that such comparative research would be in the hands of those ivory tower academics, who have no touch with reality and perhaps have never once stepped in and involved themselves in day-to-day community medical practice. This would be a full blown disaster, no matter how many tactics are employed to sell such an idea, even if it comes from a great orator such as our President! The best ideas usually sell themselves (just like to Honda commercial).

  9. danzigcom Says:

    Great post Linda. As reform moves forward, the special interests will pull out the stops and checkbooks (even in this economy) and take advantage of receptive new media, and understaffed, overmatched old media. You are right, the administration’s messages must be credible, simple, and communicated tirelessly through every conceivable channel. Additionally, congress must hear the voices of Americans from every political persuasion who are at risk or suffering from inadequate health care coverage.

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