In my recent column about Michael Moore's movie Sicko (7/10/07 OT), I wrote that the film might influence the way the nation discusses health care reform. I thought the movie did an effective job of telling stories that would get people thinking about the big picture when it comes to the goals and design of our health care system, and yes, now there is evidence that Sicko did indeed get people thinking and talking.
In a national survey, almost half the people familiar with the movie said they had discussed the US health care system with a co-worker, friend, or family member.
As part of a tracking poll on the run-up to the 2008 election, pollsters working for the Kaiser Family Foundation asked a nationally representative sample of 1,500 adults about Moore's movie. Only 4% of the respondents said they had seen the movie, but in a testament to the power of “free media” (news stories and features about the movie and its content), more than 10 times as many people said they had read or heard about the movie.
What's more, many of the people who didn't actually see it still said the movie affected their opinions about the health care system. Forty-three percent of those who had seen or heard about the movie said they were now more likely to think there is a need to reform the US health care system. Still, a slightly larger share (49%) said their opinions about the need for reform had not changed.
Similarly, more than a third (37%) said they were more likely to think other countries have a better approach to health care than we do in the US; while almost half (43%) said the movie had not changed their views of how the US compares with other countries.
In my view, the film did a good job grappling with the broad values-based questions of health care: What do we want, and what do we expect of each other in order to get it? However, I thought the movie missed the boat when it came to some of the specifics.
According to the Kaiser Family Foundation poll, slightly more than a third (36%) of respondents who had seen or heard about Sicko thought it accurately represented the problems with the US health care system, while almost as many (33%) thought Moore overstated the problems. Many (22%) didn't have an opinion on the accuracy of the movie.
Now remember, about 90% of the people responding to that last question had not seen Sicko. They were basing their opinions on what they had heard or read about the movie. And those stories about the movie were very different than the movie itself. In the interviews I saw, Michael Moore was full of bluster and argument, in contrast to his mild, even gentle, demeanor through most of the movie.
And news stories tended to focus on the accuracy of specific statements in the movie, whereas I felt the movie was less about discreet facts than it was an examination of the underlying values of the health care system—and the contrast with the basic values and assumptions that underlie some other nations' systems.
We are so deeply immersed in media these days that even our perceptions of a media production are shaped more by second-hand reports than by direct experience.
Of course, 4% of the US adult population, the number who told pollsters they had seen the movie, adds up to millions of people. But 42% of the adult population, the number who had read or heard about the movie, is a truly gigantic number. Moore certainly achieved his goals of making media waves.
The final question in this poll put the power of the movie and the media in perspective. Respondents were asked, “Which of the following has recently had the biggest impact on your opinions about the issue of health care?” Almost two-thirds said the biggest impact came from their personal experiences. Only 2% credited Sicko.
Nine percent cited what they've heard or read about proposals from presidential candidates. The rest said it was something else or all three of the listed factors.
We may depend on media reports for our knowledge of events across the wide world, but what happens to us or our family and friends hits hardest.
And one more result you'll probably enjoy: Four out of five respondents said they have a favorable opinion of doctors.
View to the Future
Are payers—government and private—trying to force small oncology practices out of business?
The sources interviewed for this article believe the financial hardships experienced by small oncology practices are an unintended consequence of payers' attempts to reduce their drug spending. That said, indications suggest that both government and private payers consider that some retraction of oncology services is acceptable.
From the federal government's perspective, there is at least one thing to like about the MMA: more services for less money.
At the request of Congress, the Medicare Payment Advisory Commission studied the effects of Medicare payment changes on oncology services in 2005. Because the changes were so new, MEDPAC's January 2006 report said it was difficult to assess the impact on patient satisfaction, quality of care, or physician practices.
But one effect was easy to see: “Medicare paid less for chemotherapy drugs in 2005 than the previous year, although the volume of drugs provided to beneficiaries, measured by quantity and drug mix, increased.”
By the following year, MEDPAC had data to be more specific. In its January 2007 report, the Commission analyzed trends for all drugs, including cancer therapies. Total Part B drug spending, taking into account price and volume changes, fell from $10.9 billion in 2004 to $10.1 billion in 2005—a decrease of nearly 8%.
“ASP resulted in substantial price savings for Medicare on nearly all drugs, and those payment rate changes drove decreased spending,” the report said.
John P. Whitecar Jr., MD, an oncologist in Mississippi, agrees that the payment system for oncology drugs and services needed to be changed, but that the federal government should expect to reduce its drug costs when the demand for services is growing makes him scratch his head.
“The fact is that the number of people entering into the Medicare population continues to increase,” he said. “More and more of them are living longer, and how you can expect that not to cost more defies reality to me.”
MEDPAC's reports are influential because the commission advises Congress. In content and tone, its 2007 report gave Congress no reason to be alarmed about the effect of the reimbursement changes. Among its findings:
- ▪No evidence of access problems for Medicare beneficiaries in any part of the country for physician-administered drugs. Medicare patients without supplemental coverage may be more likely to receive chemotherapy in hospital outpatient departments than physician offices. Whether that is good or bad, MEDPAC said, depends on whether you believe the worries of office-based oncologists or the bragging points of hospital-based physicians.
- ▪A wide range of staffing changes to reduce costs. Larger practices hired pharmacists to better control drug costs and hired social workers to help patients find ways to pay for their treatments; other practices reduced staff or froze salaries.
- ▪Larger practices adapting more easily than small practices. MEDPAC heard reports of practices that no longer provided drugs in the office but did not have first-hand evidence. A practice consultant interviewed by MEDPAC reported that several solo practice physicians had been on the verge of bankruptcy but returned from the brink, courtesy of the consultant's help in obtaining drugs at lower prices and improving their coding.
- ▪Various coping strategies. Most practices are working to become more efficient by finding better drug prices and managing their drug inventory. Some are increasing revenue by charging for more services, breaking up services into separate visits, and hiring financial advisors to help patients with cost-sharing responsibilities.
- ▪Infusion centers closing. Two oncology practices interviewed by MEDPAC reported they had closed or were planning to close at least one satellite office because of the Medicare reimbursement cuts.
Meanwhile, private payers are eager to follow Medicare's happy example. In an interview earlier this year, Tom Baker, Senior Vice President of Strategy and Analytics at the Zitter Group, said private payers in general think oncologists have simply been making too much money.
“If an oncologist calls and says, ‘Hey, I can't make money doing this,’ the payer doesn't care,” he said.
Whether that hard line means payers want oncology practices to curtail the scope of operations remains to be seen. Loretta Goodson, practice administrator at Northeast Georgia Cancer Care, said Blue Cross and Blue Shield of Georgia appeared not to be worried that the practice might have to close some of its satellite sites.
“They said the standard of care is for [rural patients] to travel to see a specialist,” she said. “They didn't seem affected that our patients would have to travel 60 miles.”
Many oncologists are lobbying their Congressional representatives—or asking their patients to do so. Dr. Whitecar believes his patients' appeals helped influence his US representative to sign on as a co-sponsor of a legislative proposal that would increase reimbursement rates. Meanwhile, one of Dr. Rafique's patients is related to his U.S. representative—and she is trying to get the two together to talk.
At Community Oncology Alliance, a not-for-profit organization that advocates for oncology practices, Mary Kruczynski, the Director of Policy Analysis, and others have been lobbying Congress for the past four years. Their current goal is a legislative victory in 2008.
“I think we're going to have a crisis situation by next year if we don't get some relief, whether the Administration gives it or whether the Congress gives it,” she said. “We're hoping that we are going to have some relief. It's up in the air.”