Sicko's Critique By Dr. Sanjay Gupta, CNN Is Entirely Misplaced

Funny how a little conflict of interest can show up a person who's so well thought of for years. I've avidly watched Dr. Sanjay Gupta on CNN and affiliated stations, and found him to be very informative, articulate, engaging and interesting. He is all that, but I also ascribed honesty and sincerity to his earnest doctor's persona.

Then I saw Dr. Gupta's 4 minute "fact check" report on "Sicko." Some aspects of the report struck me as strange and unbalanced even the first time. But I paid more attention to it after seeing Sicko creator Michael Moore's outburst on Wolf Blitzer's CNN show, followed by Moore's rebuttal on his website. Subsequently, I saw the Moore-Gupta exchange on Larry King Live, then the actual movie "Sicko," and finally Moore's second rebuttal, this time of Gupta's statements made on Larry King Live.

In these situations you normally expect both sides to be at least partly right. But here's the thing - none of Gupta's substantive corrections or criticisms was valid. Worse, when the facts were starkly laid out in Moore's first rebuttal Gupta only acknowledged one mistake and managed to cover himself on Larry King with his debating skills, glibness, and "running out the clock" in the limited air time.

You can follow the successive links to see the whole story, but here are Gupta's key distortions:

• He accuses Moore of cherry-picking numbers from several data sources. I can see that Moore used the most authentic sources and the latest data where available, and going to other sources on a sliding scale when the ones higher up on the list did not have the information.
• Gupta said that Moore "did indeed fudge his numbers." You call it fudging or "cherry-picking" when the numbers you choose are more favorable to the case you're trying to make. In the main example Gupta gave, it was just the opposite. Moore says US healthcare at $7,000 per capita is much more expensive than Cuban healthcare at $251. Gupta says Moore cherry picked and fudged by taking this number of $251 instead of the BBC figure of $229. This is (a) a trivial difference, (b) Moore had picked the more authentic data source, and worst of all (c) the $229 number was making Moore's case even stronger, so he actually gave detractors the benefit of doubt by quoting the higher figure.
• Gupta quibbled with Moore's statement of US per capita healthcare expenses of nearly $7000 , claiming it was "actually $6,098." Well, Gupta's figures are for 2004, while Moore used the more current 2006 estimates from the US Dept. of Health Services. Gupta made the ridiculous point that the 2006 number was a "forecast." If you haven't noticed, 2006 is already gone, so while it's an estimate that may land up, say, a hundred dollars higher or lower than this estimate, the $7,000 figure is a lot more valid than the $6,098 Gupta touted. I want to ask Gupta, if the US authorities said they were really really sure only about numbers of 30 years ago, would he have espoused using those 1977 numbers for comparison, or the current official estimates?
• Gupta pointed out that Canada scored lower than the US in wait times to see the doctor. Talk of focusing on a glass being 20% empty. That same source said that New Zealand, UK, Germany and Australia (all with universal coverage) scored higher than the US in this six-nation study.
• Gupta showed that industry expert Paul Keckley (whose links and Repub affiliations weren't disclosed) dissing the Europeans because 15-20% of people will purchase services outside of the government system. He exaggerates the numbers, but even so this means that 80-85% of the people are happy enough not to look outside the government system, even for any supplemental care.
• Gupta made a big deal of Cuba at 39th place being behind the US in 37th place in WHO rankings. But the film clearly showed this, and irony of the point being made was clear - even a miserable place like Cuba coming anywhere near the US in healthcare comparisons is a shame.
• Gupta also deliberately mis-ascribes the claim to Moore that healthcare in the other countries is "free." Anyone can see Moore means that patients don't get billed so they are not inhibited from going to the hospital/doctor. The film spent several minutes addressing the issue and claim about "drowning in taxes" and Gupta wrongly implied that the film glossed over this aspect.

The list goes on. Did Sicko have any notable omissions? Sure it did, and I'll mention them in a subsequent post. But even here, Moore may have wanted to concentrate on the two issues that most bothered him, without the distraction of the other things that are wrong with US healthcare.

The point is, Gupta's original piece unfairly criticized "Sicko" on nearly all counts, and this does not stem from honest mistakes. He seems to have ended up defending his healthcare industry as a partisan while in the garb of an impartial journalist. CNN deserves credit for at least giving Moore's outburst coverage in their subsequent shows, and some additional time on Larry King Live to make his case. But while the casual watcher may be taken in, the errors in Gupta's initial report and his subsequent stance should be clear to those looking at it in some depth.

Dr. Sanjay Gupta may refuse to retract his story and unconditionally apologize. CNN should then do so on his behalf. That'll be the right thing to do, though I doubt it'll happen.

Moore Bites CNN Back

I'll talk more about "Sicko" after seeing it, but here was an interesting explosion on Wolf Blitzer's CNN program by Michael Moore yesterday. Moore reacted angrily to Dr. Sanjay Gupta's four minute long fact-check segment on "Sicko" that preceded Moore's interview.

I like Sanjay Gupta and his programs, as well as Wolf Blitzer who I think of as the-man-who-rarely-smiles. But I can see why Moore was angry because at least some (if not all) of Gupta's critique was shoddy and inaccurate.

For example, he needlessly contested Moore's assertion that per capita US healthcare expenditure is $7000 a year saying it is actually $6,098. Even the 2004 figure as reported by OECD is $6,102 and the US Health Department's (HHS) estimates for 2006 exceed $7,000. More seriously, Gupta misquoted the movie as claiming Cuba spent only $25 per capita on healthcare (10% of the actual figure) while Moore fumes that the movie said $251. I just saw Gupta on TV admitting at least to this mistake, while needlessly losing grace by asking why it wasn't $229. (Well, duh, the lower number would just strengthen Moore's claim that Cuban care is much cheaper, so what is Gupta's point?)

As promised by Moore on the CNN program, he posted a strong rebuttal to Gupta's critique on his own website. But even if they've been sloppy, you've got to give CNN credit. They had interviewed Moore live so that his comments and outburst could not be edited, and then have been reporting on the story and the exchange since then on their news channels. Tonight, they've called Moore to Larry King Live for a full interview, with Sanjay Gupta in attendance. This should be interesting.

In a broader context CNN strengthens its centrist credentials with both the left and the right wings complaining that it leans towards the opposite side.

Two Doctor Stories, And Takeaways

Some doctors are very good and others are not. It pays to pick your doctors carefully, and also to do your own research. This was reinforced when we spent time with Anita's brother Prakash and his family this past July 4th holiday.

During our chats Prakash and his wife Shabnam mentioned two health-related incidents, one relating to Shabnam and the other to their son Rishi that I'd like to share.

Some time back Shabnam developed a recurrent redness in one side of the white of her eye that would last for days. A Costco optometrist advised her to get this checked out by a large and flourishing ophthalmic practice that this Costco store worked with. Over the next year till recently Shabnam went to this practice seven times and was seen by three ophthalmologists. Each of them had a different diagnosis and prescribed a different (costly) treatment. Nothing helped.

Then Prakash who is a business professor with no medical background looked up the internet and found the answer - she has occular rosacea, a common condition for people with acne, and that she now manages with simple home treatment. I typed "redness eye" without quotes in the search box of http://www.webmd.com/ and it popped up right away.

The other incident relating to their son Rishi was also ophthalmologist related, and more disturbing. Rishi was a few months old when Prakash and Shabnam noticed in the mornings that he'd have excessive mucus in one inner corner of his eye that they'd clean up. On their pediatrician's recommendation they took him to an ophthalmologist. The ophthalmologist diagnosed 9 month old Rishi with a blocked tear duct and urged them to let him immediately operate on Rishi under general anesthesia. He said the procedure becomes more complicated after 12 months of age.

Prakash wanted to double check, and looked up on the internet as it existed then in 1996. He came across a Canadian website with discussions by doctors that said this blocked tear duct problem is common in infants, and frequently resolves by itself. Moreover, the doctors advised against surgery till at least 18 months of age. Prakash and Shabnam never went to that ophthalmologist again, and sure enough, Rishi's problem permanently cleared of its own by his first birthday. His parents are relieved that they didn't blindly go by the doctor's recommendations.

I've myself always relied on strong word of mouth by patients or doctor friends when choosing our doctors. I almost always end up with great doctors and recommend this practice. And as Prakash's stories show, it can help a lot to look up the internet to check on what your doctor says.

Cover Story Covers Up The Main Point

What do the Bush Administration's attempts to link Saddam's Iraq with 9/11 and the BusinessWeek cover story of June 18, '07 have in common? Both mislead Americans.

The BusinessWeek story and research by Michael Mandel is titled, "The Real Cost Of Offshoring." The rub is in the subtitle that says "U.S. data show that moving jobs overseas hasn't hurt the economy. Here's why those stats are wrong."

Anyone reading this and the text of the story would naturally think that offshoring (or some part of it) hurts the US economy, and stopping this offshoring will improve the economy. But the reverse still holds true.

All the article says is that the GDP growth is not being properly measured because of a "phantom" factor, so the growth may be half a percent less than calculated. This "would wipe out as much as 40% of the (reported) gains in manufacturing output."

What should have been emphasized is that cutting back on offshoring may protect specific manufacturing or service jobs, but it will make the overall US economy even less competitive and hence further reduce or even reverse GDP growth. UK under the much maligned and under-appreciated Tony Blair serves as a good counter-example. Its much fuller embrace of globalization and unrestricted offshoring of services has contributed significantly to its economic well-being and ten years of uninterrupted positive quarterly growth.

But BusinessWeek insinuates to the contrary. So people will draw the wrong conclusion about the many forms of offshoring, including international medical travel. Here's what I politely wrote to BW:

"Readers may draw the wrong conclusion from your June 18, 2007 cover story, 'The Real Cost of Offshoring.'

"Even if all the calculations and analyses are correct, it does not mean that putting the brakes on offshoring will improve the US economy, or even jobs and worker welfare in the long or medium term. On the contrary, in a globally competitive economy failure to embrace the efficiencies of globalization will make Americans worse off.

"Author Michael Mandel and economist Susan Houseman probably agree with this, but it needs to be stated explicitly."

I doubt they'll publish this.

You Don't Get What You Pay For (QED)

This is somewhat new. Past studies have repeatedly shown US Healthcare to cost much more and yet deliver lower overall quality than in other developed countries. But now this Pennsylvania government survey as reported in the New York Times shows the same disparities among US hospitals themselves.

The hospitals with the highest costs for procedures like heart bypasses had worse outcomes and mortality rates than those that charged less than half as much. The high priced hospitals argued that their results were skewed by some very expensive procedures but even this doesn't explain most of the discrepancy.

The study hopefully also looked at median costs instead of mean costs. The former, which is what the patient at the 50th percentile or in the middle of the group would pay, removes the distortions of a few extreme payments and addresses the objections of the higher-cost hospitals. Most studies now also make so-called "risk adjustments" so that hospitals handling more complicated or difficult cases are fairly evaluated and compared.

As mentioned in an earlier post hospitals tend to be rewarded rather than penalized for their mistakes resulting in additional or extended treatment. I'm hoping these reports make Americans more savvy healthcare consumers who don't keep buying the "you get what you pay for" line. The same goes for insurers or employers who may be bearing most of the costs for their members or employees. In addition to improving domestic pricing and practices it will be a further impetus to medical tourism.

If They Don't Have Bread, Let Them Eat Hay

When a woman is dumping her boyfriend she may break it like good news, saying she'll always cherish him, and loves him enough to set him free. That's my reaction on seeing a WSJ report on Rudy Giuliani's healthcare proposals.

Though he'll release details later this summer, he wants to "free" tens of millions of Americans from employer based insurance and move them to the individual market "to give them more coverage choices." Mirroring GWB's "ownership society" he tells Americans "It is your health, you should own your own insurance."

At present it's the 60% of Americans covered by employer insurance who are the best off, and polls show they like their employers to use their collective purchasing clout to arrange insurance. Instead, Rudy is extending GWB's approach by wanting them to shop for their own care. According to another WSJ report this approach as it applies to the much hyped Health Savings Accounts (HSAs) is already starting to falter.

Of course, more choice to consumers can work well if it is structured properly, as in Edwards' or even Romney's plans where insurers cannot refuse insurance coverage or charge higher rates from sicker patients, and yet the overall pool of members remains viable because everyone including the healthy are forced to buy insurance. But Rudy opposes such compulsory insurance coverage.

Even worse, Rudy doesn't address the biggest problem of how to take care of the 47 million uninsured. Delinking insurance from employers and making it portable does little more than scratch the surface, and Rudy is silent about subsidizing or paying for coverage of those who cannot afford it. The tax breaks he offers for individual coverage have little meaning, especially for those who pay little or no taxes. And as I mentioned in an earlier thread, even for those who do, you get at most a $31 tax break for every $100 you spend on healthcare, so how will you come up with the remaining $69?

His "market forces" argument also is meaningless when you among other things (a) disallow the government from using its purchasing power to negotiate drug prices with companies who have monopoly power in selling them (thanks to their government enforced patents - they find no irony in the strong government role in enforcing these); (b) let providers like physicians restrict their own supply way below free market equilibrium; and (c) let hospitals maintain non-transparent pricing and quality information while gouging payers and patients who come their way and cannot switch in the midst of their treatment.

The way he lauds the "free market" over anything the government does makes me want to ask him why he doesn't urge everyone to buy their own weapons under the 2nd Amendment for self-protection and do away with the police force.

So why has Rudy come up with such a bad plan? He may figure this appeals to the fiscally conservative Right who want to minimize government spending and taxes no matter what, plus those Republicans who blindly (and wrongly) believe unrestricted private activity is always better than governmental involvement. He can also attract a lot of contributions from the healthcare industry players. This can increase his chances of winning the Republican nomination, and he can then change his tune (say to something like the Romney plan with greater government spending) well before the General Elections.

Will such a "bait and switch" strategy work? And will Rudy address some of the glaring deficiencies when he reveals the details of his plan later this summer? I don't know, but as of now I find it to be the worst of those put forth by the Presidential hopefuls.

Murder On The Healthcare Express

In Agatha Christie's classic "Murder On The Orient Express" the famous detective Hercule Poirot is unable to solve a murder because the clues point to twelve people on the train. So he cannot identify the killer among them. Turns out that all twelve were involved.

This helps us understand the state of US healthcare. Okay, so it's not really murder of healthcare. Just a trillion dollars of annual extra spend (or half the US total) compared to say, France or Germany for same or worse care. As my article implies, roughly a third of the trillion dollars go to extra profits or earnings above "free market rates" to providers - drug companies, doctors, hospitals. The remaining two thirds of a trillion dollars is the inefficiency or "lose-lose" costs of keeping the current system in place.

How does this relate to the novel? If the high US healthcare prices were due to one factor unfairly enriching just one player, then that factor would have quickly been singled out and eliminated amidst the full glare of media and political spotlight. Instead we have multiple factors at play that enable each industry player to blame others and thus all can get away with "reasonable doubt."

Then of course with about $300 billion in excess rents at stake it is a no-brainer for the industry players to collectively plunk, say, a mere billion dollars annually to buy off (or "influence") policy makers. This helps to maintain the status quo or even alter it to further benefit the players. It's no accident that the drug benefit for seniors (Medicare Part D) costing about $43 billion annually are largely a giveaway to drug companies and private insurers with far less value to the seniors who are the professed beneficiaries. And Paul Krugman in one of his several articles describes how positive government involvement such as a VA (veteran's) health system built up in the Clinton era is stymied by business interests and their Conservative allies.

Lest all this is too general, let me recap some activities by industry players contributing to high US healthcare prices:

• Trial lawyers and the ABA styming tort law reforms and capping of malpractice damages.
• Drug companies overcharging for drugs by mislabelling government negotiations as "price controls" and taking advantage of a system where patients pays a fixed deductible. So patients don't care about prices, even when drugs have only marginal extra benefit.
• Doctor bodies controlling the physician pipeline to ensure that there's a shortage of doctors, instead of letting free market forces determine the supply.
• Hospitals consolidating to gain monopoly pricing power, and refusing to provide transparent pricing. In the process they often charge outrageously ($10 for an ibuprufen or aspirin pill or $75 for a box of tissues.)
• Private insurers opposing a competing public plan. I'm all for private insurance, but why not allow competition without unfair subsidies by a government institution? (P. 4 of 7 of John Edwards' plan envisages this.)

That's only five activities and players. Apparently you don't need twelve like in the novel to get away with it.