Would Bill Clinton Have Gotten Two Stents Under ObamaCare?

President Clinton went to his cardiologist at 11:30 a.m. on February 11, 2010 — with several days of chest pressure (angina). He was immediately admitted to a hospital and had two stents placed in his coronary arteries. This restored blood flow to his heart muscle and relieved his chest pain. He left the hospital for home at 6 am the next day, ready to return to his busy lifestyle, including helping the Haitian relief efforts.

The Clinton episode could not have occurred at a more instructive time. That very day, a Wall Street Journal story implied that stents for coronary artery disease may be “unnecessary” or produce results that are no different than management by medication alone, especially in light of the findings of the COURAGE trial study, published in 2007.  Yet many in the Pay-for-Performance movement ignore the most important results of the study: Stents reduce chest pain faster, return people to active, productive lifestyles and overall make people happier. Sadly, ending suffering in patients is not necessarily viewed as a desirable or necessary result when it costs more money and there is no change in the death or heart attack rate. 

It is worth noting that many reputable academic cardiologists have questioned the conclusions and the quality of the COURAGE study. One glaring problem is that 33% of people in the “Optimum Medical Therapy” (OMT) study group were allowed to cross into the group of patients receiving a stent but were analyzed as if they had no stent! The lead investigator, Dr. William Boden, published a Powerpoint on COURAGE that elucidated the real motivating factor of committee use of such studies: to save money for third party payers. In the WSJ article he is quoted as projecting an $8 billion savings of annual medical spending in the country. In his presentation, he states: “Cost-effectiveness analysis can help allocate resources rationally.” He points out that stents cost $299,000 per Quality Adjusted Life Year (QALY) gained. In fact, Dr. Boden apparently has influenced Blue Cross Blue Shield in New York where stress tests and 12 weeks of drug therapy will be required prior to receiving a stent.

Bill Clinton must not have gotten the memo. If Blue Cross rules applied to him he would have endured an unnecessary stress test and undergone 12 weeks of drug therapy prior to getting the stents that relieved his chest pain. 

Even without ObamaCare, comparative effectiveness guidelines are being imposed on the health care system. Such Washington, D.C.-based committees as the Ambulatory Quality Alliance, the National Quality Forum, and the Federal Coordinating Council for Comparative Effectiveness and others have already begun using cost to determine when treatments like the one Clinton received will be approved. Since the Bush administration, committees like these have carefully laid the ground work for Pay for Performance (PFP) programs that claim to improve “quality and efficiency.”

They started by forcing hospital compliance with guidelines under Medicare. For instance, they withheld incentive payments from hospitals if they didn’t report on their compliance rates on giving patients with heart attacks beta-blockers within 24 hours.  Sadly, they had to end this particular goal when they discovered four years too late that some patients were entering shock and dying when inappropriately given the drug — merely so the hospital could get a good score and avoid a financial penalty.

Even without ObamaCare, the PFP model is envisioned for nearly every medical decision doctors make.

As an American physician, I make this medical recommendation to you: Choose not to suffer for the benefit of others. Treat your pain and return to beneficial activities you choose. That will benefit others far more than any centrally-planned medical economy.

Comments (15)

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  1. Virginia says:

    It’s interesting that politicians in both the U.S. and Canada seem to bypass “normal procedure” when undergoing surgery for a life-threatening condition.

  2. Tom H. says:

    Great post, David. The answer is: If his name were Joe Clinton instead of Bill Clinton, he would not get the stents under ObamaCare.

  3. Larry C. says:

    Good post. And I think you are right. Money concerns are going to trump health concerns once the government gets even more involved than it already is.

  4. Bruce says:

    The answer is “no.” He wouldn’t get the stents. Unless he pulled rank.

  5. Vicki says:

    If he were Joe the Plumber, the answer would be “no.”

  6. Nancy says:

    This is one of your best posts. Thanks, Dr. McKalip.

  7. artk says:

    The COURAGE study looked at people with stable angina, which is chest pain after exertion or no pain at all. Clinton wouldn’t have even been included in the study. First, he already had severe enough coronary artery disease to have already had a quadruple bypass. Second, apparently he was pain free for some time and this angina just came on, no exertion, it just happened. Its simply untrue to say that this study said Clinton shouldn’t get a stent.

    I can’t understand the mendacity of some people to willfully misinterpret serious medical research for political purposes.

  8. David McKalip says:

    While clinton’s chest pain may not have been the subject of the COURAGE study (A point we could argue and one I don’t agree with), that is not the point.

    Government and corporate bureacrats are using the study (as indicated in the WSJ piece) as a cover to deny stents to people who don’t jump through certain hoops.

    That is the problem with government committees and bureaucrats – they don’t understand clinical science or flaws of certain studies. They use these studies like blunt instruments to force everyone into the same category – like a sledgehammer.

    I discussed this issue with reputable practcing cardiologists who agreed with my assesment.

    I am not the one misrepresenting pieces for political purposes — it is being done hundreds of times a day in Washington D.C. to create pay for performance that hurts patients.

  9. David McKalip says:

    Furthmore, the COURAGE study DID include patients with prior CABG surgery.
    Also, chest pain is chest pain. The interpretation of “stable” can be subjective even among the cardiology community.

    What bureacrat at Blue Cross Blue Shield is going to make the judgement on whether the Chest pain is “stable”. Did they go to medical school?

  10. David McKalip says:

    Here are the inclusion criteria for the COURAGE study. Note that CABG is in there.

    Speaking of “mendacity”, what is your name “artk”? I have given mine.
    David McKalip

  11. artk says:

    “What bureacrat at Blue Cross Blue Shield is going to make the judgement”

    That’s the health care system that being defended as being superior in all way to every other system in world. You think it’s bad now, just keep fighting for the myth of “consumer directed” high deductible health care where middle class people will have to choose between rent and preventive care.

  12. Linda Gorman says:

    Consumer directed high deductible health care is hardly a myth. An estimated 8 million people had HSA qualified high deductible policies in January, 2009. The policies have existed only since December, 2003.

    Many of those policies cover preventive care; in any case, as their premiums are considerably lower than traditional policies with low deductibles, people can generally use the money they save in premiums for direct purchase of preventive care. By using cash they can often get care for less thanks to the cash discounts that many physicians offer.

  13. Joe S. says:

    Linda, I think the actual figure is twice that number. That is, 16 million people or more have CDHC accounts. About half are Health Saving Accounts and the rest are Health Reimbursement Accounts.

  14. John Goodman says:

    It is not my opinion that the US system is superior to the systems of other countries in every way.

    Check through the list of NCPA publications. We were praising medisave accounts in Singapore long before MSAs and HSAs became available in the United States. We have always argued that South Africa’s Medical Savings Accounts (also adopted before we got ours) are superior to the US version because they are much more flexible.

    We have argued that tax subsidies for health insurance in Chile and Australia are better than the US practice of giving no tax relief to people who buy insurance on their own.

    And I believe we have made it clear that, despite the faults of the system, the Swiss practice of encouraging long term, personal and portable insurance is admirable, and the Swiss system is certainly superior to Medicaid and Medicare.

    On numerous disease-specific issues we have always acknowledged the ability of the US government to screw things up as badly or even worse than the governments of other countries.

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