Comparative Effectiveness

IN THE STATES: Comparative Effectiveness in Minnesota

Meredith Hughes — Thu, 12 Nov 2009 19:49:00 -0500

What is comparative effectiveness research? If you need a reminder: comparative effectiveness means comparing two or more treatments for the same health problem to see which one works best for patients. The question has popped up quite a bit since comparative effectiveness research showed up in the economic stimulus package alongside other common sense health reforms, such as health IT adoption. Comparative effectiveness is about giving doctors and patients more information and facts for decision-making, not about taking away their autonomy.

Here's a real world example that's worth noting. The Institute for Clinical Systems Improvement (ICSI) in Minnesota is an example of an independent (private), non-profit organization that works to assemble and disseminate comparative effectiveness research. Clinicians in ICSI review medical literature and make recommendations about the most cost effective treatments based on the best available evidence. HealthPartners Medical Group, the Mayo Clinic, and Park Nicollet Health Services jointly founded ICSI in 1993. ICSI is made up of 57 member organizations and is funded by seven Minnesota and Wisconsin health plans. (The research funded by the federal stimulus bill looks at effectiveness, and doesn't make recommendations based on cost.)

ICSI maintains a list of evidence-based health care guidelines to encourage member organization to adhere to the best clinical practices. When better evidence comes along, previous guidelines get retired to make way for higher standards of care. For example, the most recent ICSI report updated care guidelines in several categories:

Obesity Guidelines. Because obesity presents such significant health concerns for the U.S., the Prevention and Management of Obesity in Mature Adolescents and Adults Guideline workgroup revised this document in 2008 to provide a more multi-faceted approach. It updated information on body mass index (BMI) and co-morbid conditions to include approaches to weight loss for each BMI category. Content and clarifying language were added to the waist circumference annotation. Conclusion grading worksheets on physical activity and low carbohydrate diet were incorporated into the related annotations, and one on surgical approaches to weight loss was added to the guideline.

Preventing Chronic Disease Through Primary Care. The guideline defines strategies and programs providers, communities, payers and employers can offer to support patients to make essential changes in four behaviors that contribute to roughly 40 percent of all deaths in the U.S. -- poor nutrition, physical inactivity, smoking and hazardous alcohol consumption. As a result, its recommendations are being used to address conditions like prediabetes, and are seen as a preventive component of care in health care homes.

Surgical Protocol: Before, During, and After an Operation. ICSI significantly revamped this protocol to describe all the steps performed throughout the pre-, intra- and post-operative periods of surgery. The protocol outlines the processes involved in obtaining patient consent, and verifying and marking the surgical site. It addresses the prevention of site infection for numerous surgical procedures, starting with the preoperative evaluation and surgical planning and proceeding through the perioperative period.

Guidelines and protocols describing the best standards of care are the primary goal of ICSI, though they also provide support for member institutions through strategic initiatives such as DIAMOND (Depression Improvement Across Minnesota, Offering a New Direction). DIAMOND is a collaborative care model that emphasizes depression detection and treatment. The program has six components:

A checklist that helps the care team detect and monitor symptoms of depression (ICSI discovered that most primary care physicians only pick up about half the cases of major depression in their patients)
A way for the care team to monitor the depressed patient
A proven medical guide to know how best to change or intensify treatment
Tools to keep a patient who is getting better from falling back into major depression
A care manager to educate and help the patient reduce depression symptoms and improve functioning
A psychiatrist to review patient cases with the care manager and consult with the primary care physician on any recommended changes in treatment

ICSI member organizations Community-University Health Care Center, Family HealthServices Minnesota, HealthPartners, Mayo, and SuperiorHealth Center launched the DIAMOND program in just 10 primary care clinics in early 2008, and by September, the program had spread to approximately 30 clinics serving 1,000 patients. According to ICSI, after six months in the program 47 percent of depression patients were in remission, and an additional 12 percent showed significant improvement.

ICSI's experience in Minnesota shows us that comparative effectiveness research can be a great tool for health care quality improvement. By working together and committing themselves to the most up-to-date, evidence based treatment guidelines, ICSI member organizations are able to provide high-quality, patient-centered care.

QUALITY: Americans Want Evidence-Based Medicine

Paul Testa — Fri, 18 Sep 2009 17:13:00 -0400

Nearly a third of health spending provides no added clinical value to patients. Half or less of what physicians do is backed up with valid scientific evidence. On average, patients get the recommended care just over half the time.

For health policy wonks, these facts are well accepted and treated as crucial components to the case for health reform. But for average Americans, many of these figures would come as a surprise according to recent polling done by the Campaign for Effective Patient Care, in conjunction with Lake Research Partners.

The findings are compiled in a report written by our colleague, Shannon Brownlee, a fellow at New America and the author of the excellent book on our health care system: Overtreated.

The poll surveyed 800 Californians who voted in the last year's election. A brief summary of the findings is available here and toplines are available here. Below are some of the highlights that caught our attention:

65 percent of those polled think their own care is evidence-based, but only 51 percent believe the care others receive is backed by science.
A majority of those surveyed think both overtreatment (54 percent) and undertreatment (59 percent) are serious problems.
80 percent feel it is a serious problem when doctors provide unneeded medical treatment, and 80 percent are more likely to support reforms when they learn about failures of the current system.
Nine in ten of those polled would require doctors to disclose the existence or absence of scientific evidence supporting the effectiveness of treatment.
72 percent of California voters want heath-care reform to ensure that payment is not related simply to the number of services provided but to whether patients receive the treatments that scientific evidence indicates are best for them.

The poll confirms that American's strongly support evidence-based medicine. It is the job of lawmakers to dispel the false rhetoric of rationing and explain how health reform will deliver better care based on better science.

HEALTH REFORM: Good Value Doesn't Mean Rationing

Health Policy — Mon, 20 Jul 2009 20:55:00 -0400

Leif Wellington Haase, the director of New America's California Program and the author of "A New Deal for Health: How to Cover Everyone and Get Medical Costs Under Control," shares his thoughts in this Sunday's New York Times Magazine article on health care spending and rationing.

So long as U.S. medical costs have gone up rapidly, and in particular since the early 1970s, policy analysts, health economists, and medical ethicists have debated the balance between extending an individual life and paying, in effect, for better health for the many. The proliferation of medical technologies, some of which can extend a lifespan by a limited amount but at an enormous marginal cost, has revived this discussion.

It is an important debate, one joined this past weekend by Princeton philosopher Peter Singer in the New York Times Magazine, in an article titled "Why We Must Ration Health Care." The Australian-born Singer, best known for his controversial views on euthanasia and abortion, breaks no new ground here. Victor Fuchs (Who Shall Live?), Henry Aaron (Can We Say No?), Daniel Callahan (False Hopes), David Kindig (Purchasing Population Health), and others have laid the groundwork both for making ethical choices at the margins of modern medicine and constructing a rational framework for making choices among these competing goals.

It's useful to be reminded of the trade-offs associated with the record of medical success that, in part, has made the question of how to finance health reform so vexing. But it is critical to realize that the debate over rationing is largely a red herring. It is mostly irrelevant to the ongoing political and policy debate over comprehensive health reform -- how to expand coverage and keep down costs. Were we trying to halve U.S. spending on health care, it might be relevant now. But we aren't, and it isn't.

To take only the most obvious examples, studies of regional variations in U.S. medical care show that up to one-third of medical spending may be wasted -- some $700 billion a year that doesn't have any positive impact on health. Perhaps hundreds of billions are spent on unnecessary administrative costs by insurers and doctors. Simple steps, such as preventing avoidable hospital-acquired infections through better hand-washing protocols could save lives and save billions of dollars. And the existing practice of reimbursing doctors and other providers on a fee-for-service basis, rather than paying for episodes of care, results in unfathomably higher costs with no discernible improvement in health outcomes.

These systems failures are the main obstacles to getting value for the massive amounts we spend on medical care. Until we tackle them in earnest, it makes no sense to get distracted by largely philosophical arguments over potential restrictions on access to care and patient choice. The current health reform debate is not about rationing. It's about saving money, improving quality, and covering all Americans.

To be sure, it is prudent to make plans for the handful of new high-cost medical procedures and drugs that are coming to market and can impact medical spending in their own right. That's one big reason behind the push to study the comparative effectiveness of treatments, routine in other countries, that was included in the stimulus package this spring and in most comprehensive health reform proposals.

It makes sense to think about ways to reduce our indiscriminate spending on treatments of little additional worth, as with many other ways to increase the value of U.S. medical spending. But we shouldn't confuse seeking better value and health outcomes for our dollars with largely philosophical issues. Raising the spectre of rationing in this way is confused at best and intentionally distorting at worst.

One final thought: it is worth noting that Britain's National Institute of Clinical Excellence, like other bodies charged with reviewing the effectiveness of treatments, recommends expanding the use of new procedures and drugs far more often than it recommends not paying for them. Explicit rationing is used far, far less in most developed countries with dramatically lower levels of health spending than some opponents of expanding access to health insurance would have Americans believe.

HEALTH CARE: How Do We Decide What Matters?

Meredith Hughes — Fri, 17 Jul 2009 16:37:00 -0400

When it comes to health benefits, what is most important to you? Are there certain benefits that are absolutely necessary? Are there some that you could do without?

That's exactly what the Center for Healthcare Decisions wanted to know. They recently released the report "What Matters Most: Californians' Priorities for Healthcare Coverage."

Understanding public priorities for health care benefits is a big deal for lawmakers. Currently, Congress is charging ahead toward health care reform, and figuring out how to design minimum benefit standards for health plans is part of their agenda. A minimum benefits package will make sure Americans have insurance that means something, that they will get the care they need, not a bunch of runarounds and denials of coverage. One way lawmakers can connect with American values on health care is to understand what the American people want in their health benefit package.

Data for the Center for Healthcare Decisions report comes from California residents who were randomly surveyed over the phone or participated in group discussion sessions. Survey respondents were given a series of hypothetical health care vignettes, and asked to rank the importance of coverage for the condition or person in the vignette. Respondents were also asked if they were willing to pay more in their own premiums to cover the condition. For example, how important is it to cover a 24-year-old woman's asthma medications, so she is able to lead a more normal, active life? Should we cover the price of cholesterol medication for a woman who would rather take pills than follow her doctor's advice and change her diet?

Benefits essential for saving lives, curing illness and disease, enabling those suffering from illness to remain contributing members of society (to work and provide for their families), preventing new illness, and controlling serious or debilitating physical pain, received the highest priority, according to the study. People also gave the highest priority to treatments proven to be effective by medical evidence.

Medical problems that did not have as serious an impact on quality of life were less likely to get coverage. For example, let's say a 32-year-old man was in a bike accident and has knee problems. Some respondents were told this man now has trouble walking, and suffers from chronic knee pain. They ranked this priority of treatment, on average, as 7.9 on a scale of 1 to 10, and 90 percent of people approved coverage for his knee surgery. Another group of respondents were told the man has no pain, but has difficulty playing soccer. They ranked this at only a 5.6 on the priority scale, and only 63 percent approved coverage for his surgery.

Problems that were given lowest priority for coverage:

Were unsightly but not physically harmful
Delay or prevent individuals from pursuing recreational activities
Treatments that are requested by patients for convenience or to feel reassured
Are not medically significant or would resolve over time without treatment

We do have limited resources in health care. This doesn't mean the solution is denying care. In fact, many health systems have been able to utilize resources more wisely, providing more necessary care and less wasteful care. This makes patients healthier while lowering costs. (Check out our Health CEOs for Health Reform series for more info.) Successful health reform is going to include changes that maximize quality and minimize cost. We need to spend smarter, utilizing tools such as comparative effectiveness research to determine what treatments are most helpful to patients.

But we do have to make some tough choices about health care, and that ultimately means understanding what people value and want from their health care system, as well as what they need to stay healthy.

HC4HR: Merck Promotes Quality and Value for Patients With Diabetes

Meredith Hughes — Thu, 16 Jul 2009 13:00:00 -0400

When she spoke to us at the Health CEOs for Health Reform event recently, Merck's Senior Director of Public Policy, Jane Horvath, presented her response to two very important questions. Why does Merck, one of the world's largest pharmaceutical companies, believe that delivery system reforms are possible? And what has Merck done that demonstrates that change is possible?

To learn about Merck's pilot plan to promote value and quality in health care, check out the video below, or keep reading.

Better Diabetes Management

Earlier this year, Merck (a pharmaceutical company) and CIGNA (one of the largest health insurers in the U.S.) announced a partnership based around an innovative claim: they could lower costs while improving health care quality. If you've been following our other posts on the Health CEOs for Health Reform and what they've accomplished, this idea may sound familiar.

As a part of the deal, Merck agreed to offer Januvia and Janumet, two oral diabetes medications, at a discounted price if patients showed improvement while taking them. These drugs, in conjunction with diet and exercise, help patients to manage their blood sugar levels. If Cigna reviews the A1C lab results of patients with type 2 diabetes at the end of the year and find values have improved, Merck will increase the discounts on these drugs. (In a lab test, A1C levels can indicate a patient's average blood sugar levels over time.) This doesn't just apply to drugs produced by Merck. Any patient taking an oral anti-diabetic medication who shows improvement will trigger a discount for Cigna.

Comparative Effectiveness Research

Merck and Cigna's deal is performance based -- the better patients taking drugs do, the cheaper the pills. Adherence is a big deal for diabetics. Even the smallest slip up in following through with treatment can have serious health consequences down the road. Simpler (and cheaper!) prevention and disease management strategies such as exercise, diet, and taking medication on time can help protect diabetics from more serious (and costly) health complications such as heart or kidney disease, stroke, or nerve damage. Cigna told Reuters, "medicine adherence programs have helped diabetics reduce emergency room and other hospital visits by 50 percent for those reaching blood-sugar goals, and reduced diabetes-related costs by 24 percent."

According to Horvath, Merck decided a number of years ago that it should support comparative effectiveness research. CER is "an effective and rational tool and information set by which to optimize coverage policy and treatment decisions," said Horvath. By offering discounts on drugs that work, Merck is promoting a health care system that rewards quality, value, and well...health. In a press release, both Merck and CIGNA agreed that "aligning all of the incentives behind improving the health of individuals is one of the most effective ways to achieve long-term health improvement."

QUALITY: IOM Panel Lists 100 Priorities for Comparative Effectiveness Research

Meredith Hughes — Wed, 01 Jul 2009 20:50:00 -0400

Earlier this week, we discussed the Federal Coordinating Council for Comparative Effectiveness Research's recommendations for comparative effectiveness research. Recently, an Institute of Medicine panel released a similar report, which offers a comprehensive list of 100 health issues ranked according to priority.

Comparative effectiveness research gives doctors and patients access to verified, scientific information on best treatments that they otherwise could only get through their best guesswork.

"Health care decisions too often are a matter of guesswork, because we lack good evidence to inform them," Dr. Harold C. Sox, a co-chairman on the panel and the editor of The Annals of Internal Medicine, told the New York Times. "For example, we spend a great deal on diagnostic tests for coronary heart disease in this country, but we lack sufficient evidence to determine which test is best," he added in a press release.

Here is a rundown of the some health issues that were flagged as top priorities for the Administration, specifically, the HHS:

Compare the effectiveness of treatment strategies for atrial fibrillation (the most common kind of abnormal heart rhythm) including surgery, catheter ablation, and pharmacologic treatment (aka drug therapy).
Compare the effectiveness of the different treatments (hearing aids, cochlear implants, or rehabilitation methods such as sign language) for hearing loss in children and adults, especially individuals with diverse cultural, language, medical, and developmental backgrounds.
Compare the effectiveness of various screening, prophylaxis, and treatment interventions in eradicating methicillin resistant Staphylococcus aureus (MRSA—a dangerous, common hospital acquired infection) in communities, institutions, and hospitals.
Compare the effectiveness of management strategies for localized prostate cancer (e.g., active surveillance, radical prostatectomy [conventional, robotic, and laparoscopic], and radiotherapy [conformal, brachytherapy, proton-beam, and intensity-modulated radiotherapy]) on survival, recurrence, side effects, quality of life, and costs.
Compare the effectiveness of various strategies (e.g., clinical interventions, selected social interventions [such as improving the built environment in communities and making healthy foods more available], combined clinical and social interventions) to prevent obesity, hypertension, diabetes, and heart disease in at-risk populations such as the urban poor and American Indians.
Compare the effectiveness of imaging technologies in diagnosing, staging, and monitoring patients with cancer including positron emission tomography (PET), magnetic resonance imaging (MRI), and computed tomography (CT).

Over at Gooznews.com, Merril Goozner pointed out a "sleeper" towards the top of the list, (number five to be precise)...

"Compare the effectiveness of dissemination and translation techniques to facilitate the use of CER by patients, clinicians, payers, and others."

Given that Congress will probably insert language in health care reform legislation stipulating no one should ever be bound to actually use the findings of comparative effectiveness research (why that's like EVIL BIG GOVERNMENT coming between YOU and YOUR DOCTOR), it's probably a good idea for someone to study how to "disseminate and translate" this information so that parts of the health care system might actually put it to use.

A summary of all 100 items is attached below.

QUALITY: Report Details Recommendations for CER Money in Stimulus

Meredith Hughes — Tue, 30 Jun 2009 18:31:00 -0400

Remember that $1.1 billion in the economic stimulus package (aka the American Recovery and Reinvestment Act) dedicated to comparative effectiveness research? Though many of us have had a lot on our minds lately with health care on the Hill, others have stayed focused on how to best use those stimulus funds. This week, the Federal Coordinating Council for Comparative Effectiveness Research, an independent advisory committee, released recommendations.

Comparative effectiveness research provides insight into the best treatments based on real world data. The Council's goal is to create a solid foundation of research that both patients and clinicians could use to inform their treatment decisions.

Health care is a large, diverse field, so the Council also had to come up with a framework for prioritizing research areas. To be considered, a research topic has to meet certain criteria:

Does it fit with the definition of CER?
Is it going to provide useful information to patients, clinicians, and stakeholders?
Does it respond to the needs expressed by patients, clinicians, and stakeholders?
Is it feasible to research? (Can we actually produce something valuable in a reasonable amount of time?)

High priority CER research topics had:

a large potential impact (looking into health conditions that are particularly widespread, burdensome, or costly)
high variability or uncertainty in clinical practice
the potential to positively effect diverse and/or large populations (priority populations include racial and ethnic minorities, persons with disabilities, persons with multiple chronic conditions (including co-existing mental illness), the elderly, and children)
the potential to lay a strong foundation and get the ball rolling on future research
the potential to affect areas that other organizations are unlikely to address

According to the report, "the primary investment for this funding should be data infrastructure. Data infrastructure could include linking current data sources to enable answering CER questions, development of distributed electronic data networks and patient registries, and partnerships with the private sector."

The Council's recommendations are directed specifically at the Office of the Secretary of HHS. The Council expects the Agency for Healthcare Research and Quality (AHRQ), which received $300 million of the $1.1 billion, and the National Institutes of Health (NIH), which received $400 million, to fill in the gaps in translating and distributing the findings of CER to the right places. Thus "dissemination and translation of CER findings, priority populations, and priority types of interventions" are a secondary priority for CER investment.

The Council prioritized transparency and public input in their recommendations; they held numerous public listening sessions, collected feedback through their website, and heard testimony from doctors, patients, and stakeholders.

The full report is available here.

HEALTH IT: Redrawing the Cancer War Battle Plan

Joanne Kenen — Thu, 21 May 2009 16:07:00 -0400

Hundreds of thousands of patients undergo cancer treatment each year, using all sorts of combinations of drugs and treatments and therapies. Not all are in clinical trials—but many of them have something to teach us. We linked to Gooznews touching on this topic a few months ago. Now Merrill Goozner has a longer analysis at Science Progress of how, in part because of advances in health IT, we could tap this untapped pool of knowledge:

A redrawn battle plan—one that focuses on turning the treatment system into a research and learning system that can teach oncologists the best use of the weapons they already have—is long overdue...

…Many of the nation’s 30,000 oncologists are engaged in what could be described as an unobserved and uncontrolled science experiment, especially when it comes to treating the 560,000 Americans who die each year from the more than 100 forms of the disease. As these patients’ cancers advance, their physicians try regimens they read about in journals or hear about from colleagues. The outcomes are never gathered. The data is never analyzed. And the findings are never disseminated.’

The economic stimulus package should help us expand our use of HIT. Goozner says we also have to encourage doctors and scientists to be more accepting of retrospective analysis of treatment data, not just the proverbial gold standard of double-blind clinical trials. But we should be able to harvest some of that knowledge and disseminate findings much more quickly than we do today. The National Cancer Institute has already begun creating that learning system through the Cancer Biomedical Informatics Grid, known as caBIG. The goal: not just broad findings about this drug or that, but fine analysis of which subgroups of dozens of kinds of cancers respond best to which specific treatments or combination of treatments. And rather than limiting and impersonalizing choices, this could move us toward “personalized” medicine.

QUALITY: Comparative Effectiveness, What's the Debate?

Paul Testa — Thu, 07 May 2009 20:21:00 -0400

A piece in Thursday's New York Times suggests that the battle lines are being drawn (again) on comparative effective research (CER). For the New England Journal of Medicine, it's not even a debate.The nation's preeminent medical journal has three articles published this week that come out strongly in favor of comparative effectiveness research.

Addressing concerns that CER creates barriers to medical progress, Alan M. Garber and Sean R. Tunis argue, in fact the opposite is true. While not a panacea, CER is "key to individualized care and innovation, not a threat." Noting that doctors often lack information on what works best for who, Garber and Tunis assert:

[F]ar from impeding personalized medicine, CER offers a way to hasten the discovery of the best approaches to personalization, providing more and better information with which to craft a management strategy for each individual patient.

Jerry Avorn wonders "what's the objection" to "conducting well-designed research to determine what works?" Dispelling some of the attacks made on CER funding during the economic stimulus debate, Avron argues that advocating ignorance is not just bad politics, it's bad policy:

Given the quality and cost crises we face, preserving ignorance would have been a poor strategy for improving the effectiveness, safety, and affordability of health care. Although CER dodged a barrage of well-coordinated bullets this time, the debate is bound to continue. To engage in it responsibly, we must stay focused on the methodologic, practical, and ethical issues we will face in the new era of CER, while avoiding the disinformation and distractions that seek to equate generating new knowledge with denial of care

Knowing is half the battle. The other half, Aanand D. Naik, and Laura A. Petersen argue, is implementation. CER needs to focus not just on what works, but how we translate research into everyday practice:

An implementation research and development program designed for this purpose could fulfill three important objectives: it could accelerate the translation of evidence into everyday care, enhance the opportunities for doctors and patients to define value (balancing expected benefits with costs) on the basis of their understanding of local contexts and constraints, and allow providers and patients to communicate with researchers and policymakers about clinically important issues earlier in the research process.

HEALTH POLITICS: The World's Best Health Care ... Oh Never Mind

Health Policy — Wed, 06 May 2009 19:49:00 -0400

Well if the Republicans hadn't figured out that the American people are clamoring for health reform, their message guru Frank Luntz is back on the scene to remind them. The Politico's Mike Allen today has a piece on the confidential 26-page report to Capitol Hill Republicans coaching them on how to use language to stop "the Washington takeover of Health Care." The Politico article doesn't specify who asked Luntz to do this or who paid, but it's an interesting read—both about how conservatives perceive health reform and how large swathes of the public is demanding change. We especially liked the part about how health care reform is "inevitable."

Allen writes:

"You simply MUST be vocally and passionately on the side of REFORM," Luntz advises in a confidential 26-page report obtained from Capitol Hill Republicans. "The status quo is no longer acceptable. If the dynamic becomes ‘President Obama is on the side of reform and Republicans are against it,' then the battle is lost and every word in this document is useless."

'We don't think the document is useless at all. It previews what we can expect to hear from a least some conservative Republicans (we know others are still engaged in bipartisan dialogue). Luntz counsels them to stop talking about tax credits and free markets and deregulation and instead to humanize the conversation. He also recommends using the same old scare tactics about "Big Government" and "Rationing" to slow down the push for comprehensive reform that will cover all Americans. At least he's not advising them to keep talking about how we've got the best health system in the world—even Luntz's own polling shows that only two percent of the public still buys that one.

Here's a sampling of his message on stopping "the Washington Takeover of Health Care." We also provided some reality checks.

Luntz: Republicans should remind Americans that "One-size-does-NOT-fit-all."

Reality Check: President Obama and congressional Democrats are promoting a reformed health care system with numerous choices of affordable, high quality health care plans, including the option of letting people keep the health care they have now, the hospital they have now, the doctor they have now.

Luntz: Republicans should ask Americans if they'd rather keep paying for their current health care, or if they really want to pay less but get less.

Reality Check: Right now people are paying more and more and more and more and they are getting less and less and less and less, and as our "Cost of Doing Nothing" research has shown, it's only going to get worse. As numerous polls by the Kaiser Family Foundation have shown, Americans are really worried about the cost of care and whether they will be able to afford it in the future.

Luntz: Make Americans worry about waiting "weeks for tests and months for treatments you need."

Reality Check: When was the last time Frank Luntz tried to schedule a doctor's appointment? Haven't any of his friends or relatives—even ones with good insurance—had to wait weeks or months for an appointment, a diagnostic test, even a biopsy? Maybe he should read today's San Francisco Chronicle story about women who had to wait up to 300 days for a mammogram, until a bunch of reform-minded people teamed up to cut the waits and improve access for the mostly poor women who use the public hospital. Imagine how much more efficient we could make health care if we had a system that stopped cost-shifting, covered everyone, valued wellness, and rewarded quality.

Luntz: Reform could lead to rationing and government denying treatment.

Reality Check: Wrong "R" word. Reformers don't want rationing. They want research so doctors know what treatments are actually best for patients, when it's worth spending money on a new treatment, and when we can spend less for good or better health. As Obama told the New York Times Sunday magazine recently, good scientific research will help doctors and other providers "say to patients, you know what, we've looked at some objective studies out here, people who know about this stuff, concluding that the blue pill, which costs half as much as the red pill, is just as effective, and you might want to go ahead and get the blue one. And if a provider is pushing the red one on you, then you should at least ask some important questions."

Luntz: Convince the public that we can bring down costs by reducing WASTE, FRAUD, and ABUSE.

Reality Check: We're all for ending waste fraud and abuse. That's why we want to overhaul the health care delivery system so we pay for high quality of care, not high quantity of care. Why we want a simpler system, with our doctors less buried in paperwork from insurers. That's why we want to stop spending hundreds of billions on health care that doesn't make us any healthier. And speaking of fraud, here's the latest story we've come across on Rick Scott, former CEO of Columbia/HCA and current poster-person for "Conservatives for Patient Rights" This one's in his one-time home town paper, and it's headlined "New voice in health debate left Nashville in disgrace.