Looking back, historians may mark 2010 as the most significant year for U.S. medicine in decades. The health care reform legislation signed into law by President Barack Obama on March 23 profoundly changes the way care is provided. And even if opponents succeed in repealing the legislation, the debate itself will shape the way we think about the issue for years to come.
The law didn't come out of nowhere. Stresses and discontents in health care have been building for decades. Costs are rising at the same time that budgets are getting leaner. Most sophisticated tests are forcing doctors and patients to decide whether and how to treat diseases that previously went ignored. And new research calls old guidelines into question.
Such tensions are reflected in nearly all the stories that surfaced this year as the most viewed by readers of Medscape, WebMD's site for health care professionals. Here's the list:
1. Cuts Loom in Medicare Reimbursement
The conflict over health care stems largely from a gap between the care we expect and the care we can afford. That gap is now threatening to undermine Medicare, which is scheduled for a 25% cut in reimbursements if Congress doesn't act soon. It could force many doctors to drop Medicare -- which would send shockwaves throughout the system since Medicare patients make up about a third of 70% of physicians' practices. Almost no one wants to see the cuts take place, but the Congressional Budget Office estimates that keeping reimbursements at current levels through 2020 will cost $276 billion. Under pressure to reduce the national deficit, Congress so far hasn't been able to agree on a source for that much money. Throughout 2010, it kept delaying the cut with a series of short-term fixes. What's likely to happen next? More delays. With the Republicans controlling one chamber of Congress and the Democrats the other, gridlock could doom long-term "doc fix" legislation for the coming year.
Whatever else you might say about health care reform, it's a big deal. The most comprehensive overhaul of the nation's health care system at least since Medicare, the Affordable Care Act seeks to dramatically expand the number of people who can afford health care. It does that by subsidizing the cost for those who can't afford it, penalizing those who refuse to buy it, and limiting the cases in which insurers can deny coverage. Among scores of other provisions, it boosts pay for primary care doctors, encourages compensation based on quality of care, and bars co-payments for most preventive services. As the law is implemented, questions about these and other provisions are cropping up. For starters, do we have enough doctors, nurses, and other health care workers to care for an estimated additional 32 million insured? Also, who will make up the difference if fewer co-payments are collected? These questions and more are certain to arise as legislators critical of the law attack it with renewed vigor.
3. New Guidelines for Prostate Cancer Screening
The advent of better tests -- such as prostate-specific antigen (PSA) screening -- can in some cases save lives with early treatment. But these tests can also pose new dilemmas, as the American Cancer Society (ACS) emphasized on March 3 when it updated its prostate cancer screening guidelines. The test picks up benign disease as well as cancer, and it can't distinguish between aggressive and mild forms of the disease, the ACS pointed out. In some cases, it has led to expensive and invasive treatments in patients who might never have experienced symptoms. So the ACS is calling on physicians to spend more time counseling patients about their options (despite the difficulty of billing for such counseling). The PSA controversy intensified when the scientist who discovered PSA in 1970, Richard Ablin, PhD, of the University of Arizona College of Medicine in Tucson, Arizona, said categorically that the test should not be used to screen all men older than 50. That's a direct contradiction of the ACS guidelines. Controversy about the value of PSA testing continued when results of studies on both the effectiveness of the test and on chemoprevention were reported.
4. Revised Diabetes Guidelines
Screening technology popped up in the news again in December 2009 when the American Diabetes Association published new clinical practice recommendations. Although published late last year, it has been among the top read topics on Medscape in 2010. The guidelines promote the use of the hemoglobin A1c test as a faster, easier diagnostic test that could help reduce the number of undiagnosed patients and better identify patients with prediabetes. A1c measures average blood glucose levels for roughly the past three months. Previously it was used only to evaluate diabetic control with time, but because it doesn't require fasting, A1c testing will encourage more people to get tested, leading to treatments and lifestyle changes that could prevent the worst effects of the disease, the American Diabetes Association said.
Prevention guidelines also made headlines when a large study found that calcium supplements taken without vitamin D may increase the risk for heart attack as much as 30%. Researchers reported the finding online July 29 in BMJ, based on their analysis of 15 trials with up to 11,921 participants. Most guidelines for osteoporosis recommend the supplements, despite relatively small benefits in bone health, but the senior author of the study says that in most cases, "discontinuation of calcium would seem appropriate." The study raised many questions, such as why calcium could have this effect during a relatively short period of time. Pending further research, some experts advised eating foods high in calcium rather than taking supplements.