Here's $142M we'll be wasting on pseudoscience in the new US Budget

After much unnecessary drama and 6 months late, Congress finally passed a budget last week funding the government for the fiscal year that started in October 2017. While much of the news is good, or at least not too bad, the 2,232 page budget contains lots of goodies for special interests.

I downloaded the whole thing so you don't have to.

One of the worst pieces of wasteful spending is tucked away on page 934: $142,184,000 for the National Center for Complementary and Integrative Health. Incredibly, this is a 9% increase over the NCCIH's 2017 budget of $130.5 million. Is this because they've discovered new and effective treatments? Alas, no.

NIH has been spending money on so-called alternative medicine since 1992. Over the years, the budget has increased from just $2 million to the very hefty $142 million this year. NIH has now spent a total of $2.366 billion dollars on its alternative medicine center.

The NCCIH started as an "office," funded by a $2 million earmark by former Senator Tom Harkin, who later elevated it to a National Center called NCCAM. On Harkin's retirement in 2015, his buddies renamed it as NCCIH, adopting the buzzword "integrative" as a jazzier word than "alternative." It's a classic (and sad) example of how once something gets started by Congress, it grows relentlessly, creating its own constituency of people and industries who consume the funding and clamor incessantly for more.

What have we learned for our $2.4 billion? Have new cures been developed, new medicines been discovered? Has NIH provided good scientific evidence that any of the "alternative" methods–which include acupuncture, homeopathy, naturopathy, Ayurveda, therapeutic touch, reiki, aromatherapy, and others–actually work? The answer to all these questions is no.

On the other hand, the real work of biomedical research, funded by the rest of NIH, has yielded tremendous progress on a wide range of diseases. These include cures that we could only have dreamed about 10 or 20 years ago, such as this amazing stem cell cure of a 7-year-old boy with a devastating skin disorder, or this leukemia treatment reported in 2013.

After 26 years and $2.3 billion spent trying–and failing–to prove that alternative medicine works, it's long past time to end this nonsense and shut down NCCIH, as I and many other scientists have been saying for years. That $142 million could be used far more effectively studying real treatments for real diseases, rather than imaginary treatments that have failed, time and again, to prove their merits.

$142 million. To those who argue that it's only a small percentage of the NIH budget, I would point out that a typical NIH research grant is under $500K. This means we could fund at least 300 additional biomedical research projects every year if we got rid of this giant special-interest earmark that has utterly failed to produce anything useful.

Instead, someone in Congress managed to sneak in the largest budget increase that NCCIH has seen in 15 years. What a waste.

Dr. House Was Right

I’m a big fan of the show House, which ran on the Fox TV network for 8 years and is now on Netflix. Gregory House, masterfully played by actor Hugh Laurie, is an brilliant doctor who diagnoses patients whose bewildering symptoms have stymied other doctors. He’s also unbelievably rude: he insults and harrasses his patients and his fellow doctors alike, but they tolerate him - usually - because he’s almost always right.

I doubt that any real doctor is as rude as House. But like any group of professionals, doctors vary widely in their people skills. Recently, though, Medicare has started using patient satisfaction as a component of how it pays hospitals. In response, some doctors now try harder to give patients what they want, rather than what they need, as described last year by Kai Falkenberg at Forbes.  On Medscape recently, William Sonnenberg wrote that “patient satisfaction is overrated” and said of Press Ganey, a company that runs patient satisfaction surveys:

“Press Ganey has become a bigger threat to the practice of good medicine than trial lawyers.”

You can find Medicare's hospital survey online. Dr. House would fail, big time.

What’s wrong with giving patients what they want? It turns out that patient satisfaction is tied to higher costs and, even worse, a higher death rate. A large survey covering 52,000 patients, published by a team led by Joshua Fenton at the University of California-Davis  found that the most satisfied patients not only spent about 9% more than average, but had a 26% higher death rate. From the study: “The most satisfied patients had statistically significantly greater mortality risk compared with the least satisfied patients.”

For patients who think a nice doctor is a good doctor, this might come as very disappointing news. Was the effect due to patients already in poor health, who might be more inclined to like their doctors? No: when the researchers excluded the sickest patients and looked only at the healthier ones, the risk of dying was even higher. (It’s important to note here that this is relative risk; only 3.8% of patients died during the six-year followup to the study.)

Over at The Daily Beast last week, Daniela Drake summarized this trend as “You can’t Yelp your doctor.” (Not that Yelp isn’t useful for finding a good pizza place.) And yet, as Scott Hensley reported on the NPR blog Shots, online ratings of doctors are becoming very popular, even though they don’t measure how good a doctor is at diagnosing and treating illness.

This study has implications for so-called “alternative medicine” as well. Patients who frequent alternative providers such as acupuncturists, homeopaths, and naturopaths often report high levels of satisfaction, as if satisfaction correlated with better care. Now we have a large study showing that this is simply not the case.

It makes sense that patient satisfaction is related to cost: patients often demand treatments that they don’t need, and “Patient requests have also been shown to have a powerful influence on physician prescribing behavior”, as Fenton and colleagues reported. It is less clear why the most satisfied patients died at higher rates.

Obviously, doctors don’t need to act like Dr. House to be effective. But doctors need to be able to tell patients things they don’t want to hear. Just because you want an antibiotic for your sore throat or your child’s ear ache doesn’t mean you should get one.  The UC Davis study demonstrates that using patient satisfaction surveys to adjust reimbursement rates, as Medicare is currently doing, is a recipe for higher costs and lower quality of care.

Given a choice between a friendly doctor who gives me what I want and a brilliant doctor who gives me what I need, I’ll take Dr. House.

Alternative medicine quacks show their greedy side

Congress is on holiday this month, but the lobbyists are baiting their hooks, planning their strategies for how to get more money for themselves.

A growing lobby is Complementary and Alternative Medicine (CAM) providers, who have discovered a new opportunity to extract even more money from patients than they do already. They want the government to force insurance providers to pay for quack treatments, regardless of whether or not the treatments work. Any attempt to require evidence, they argue, amounts to discrimination.

Discrimination? Yes! We must not allow the government to exclude health care providers just because those providers don't cure anything.  The CAMmers argument boils down to this: we have patients who want our services.  The patients like us. In some cases, thanks to lobbying at the state level, we even have state-approved licenses. Therefore insurance companies must pay for our services.

Neat.

To be specific, the CAMmers are lobbying furiously to try to protect a special clause in the Affordable Care Act (Obamacare) that promises them a fertile new ground for making money from vulnerable patients.

The strategy is simple: require the government to fund any treatment that a patient wants, and dress this up as "patient choice."  Then if insurance companies resist paying for ineffective treatments, accuse them of discriminating against the poor, hapless "integrative medicine" providers.

Thus through a diabolical twist of illogic, if Obamacare doesn't cover homeopathy, or naturopathy, or acupuncture, or magnetic energy healing, or any other so-called alternative therapy, it's discrimination.

The mind boggles.

Why is this an issue now?  Because, unbeknownst to most people outside the Washington beltway, two pro-CAM lobbying groups slipped a clause into the ACA, section 2706, that attempts to force insurance providers to cover a wide range of quack practices.  This section requires that insurers

"shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider's license or certification under applicable state law."

Sounds harmless, right?  Well, no.  This language was added to the ACA by Senator Tom Harkin, after heavy lobbying by the American Chiropractic Association and the Integrative Healthcare Policy Consortium.  In fact, it is virtually certain that lobbyists wrote the section, and Harkin simply inserted it into the law. The IHPC is a lobbying group dedicated to obtaining more government money for homeopathy, naturopathy, chiropractic, acupuncture, and a raft of other ineffective medical practices.

Section 2706 opens the door to anyone who provides what they claim is health care - no matter how ridiculous the claim - to file a lawsuit claiming discrimination if an insurance company won't pay for their services.  You could start offering dried bird poop for arthritis, call it "avian nature therapy," and if an insurer won't pay for it, you can sue.

Some in Congress have realized how truly bad an idea this is, and just a few weeks ago, a new bill was introduced to get rid of it, HR 2817.  The American Medical Association supports the new bill. This has some CAM proponents alarmed.

Over at the Huffington Post, John Weeks, an outspoken apologist for questionable medical practices, offers the predictable, whining claim that this is all about "discrimination" by legitimate health care providers (the big, bad AMA) against poor, defenseless integrative medicine providers.

Make no mistake: this is all about greed.  The CAM industry sees Obamacare as a chance to reap huge profits, by forcing insurance companies to pay for ineffective treatments, including many that are wildly implausible.

Homeopaths, naturopaths, acupuncturists, reiki practitioners, energy healers, and other CAM practitioners don't want to subject their methods to rigorous tests of effectiveness.  They know that their methods have failed scientific scrutiny, time and time again.  So now they want to force health care providers to pay for anything the patient wants. "Our patients believe us," they argue, "so pay us."

Forcing health care providers to pay for anything a patient wants, even if it doesn't work, is guaranteed to drive up costs, without any benefit to patients.  Let's ditch this bogus "discrimination" clause in the ACA, and insist that all medical care be held to the same high, scientifically rigorous standards.

Maryland legislature scores one for science

Just one month ago, I wrote a post entitled "Naturopathic shenanigans in the Maryland State legislature," about the efforts of naturopaths to get a new law passed in the state of Maryland that would license them to practice medicine.  This effort to get a set of pseudoscientific practices certified as "medicine" has been pursued by naturopaths across the U.S., and Maryland is just one of their latest targets.  I was dismayed when I learned that laws had been introduced in both houses of the Maryland legislature to give naturopaths what they wanted.

Well, the votes just came in, and the law was unanimously defeated in committee in both the House and Senate.  Without knowing precisely what happened (or if any of them read my article, either here or on the Forbes magazine site) I cannot explain why the legislators voted as they did, but after my previous article I want to give them a rousing cheer of approval.  Hurrah!  Sometimes lawmakers get it right, and when they do, they deserve our applause.

Naturopathic shenanigans in the Maryland state legislature

Quacks never give up.  In their never-ending quest to make money from bogus treatments, they try all kinds of strategies to convince people that what they're selling really, really works, despite the evidence to the contrary.

One strategy is creating a legal licensing system.  If the government licenses your profession, it must be legitimate, right?  Legislators wouldn't approve a licensing system for nonsense, would they?  Of course not!

So it's strange that the Maryland legislature is considering a bill in its upcoming session to allow naturopaths to practice medicine in the state of Maryland.  

Some of you might be wondering, what the heck is a naturopath?  As Peter Lipson explained recently in his Forbes column, naturopaths are little more than fake doctors, whose practices are a modern-day version of folk medicine.  When naturopaths got licensed in Minnesota, PZ Myers suggested they be called "witch doctors."  Too harsh?  Well, one thing is clear: naturopaths are trying to get licensed in multiple states (Lipson described their efforts in Michigan) as a route towards legitimacy.

There's an easy way to become legitimate: practice science-based medicine.  This would be awfully difficult for naturopaths, whose practices include homeopathy, colloidal silver treatments, and chelation therapy, to name but a few.

When the naturopaths tried this in Massachusetts 10 years ago, my colleague Kimball Atwood put together detailed testimony describing many of the unscientific and downright dangerous practices of naturopaths.  I encourage anyone to read his full testimony or his series of blog articles.  Here, though, is a brief sample of the erroneous claims made by naturopaths, courtesy of Dr. Atwood:

• "... that hydrogen peroxide dissolved in a bath can provide vital oxygen through the skin of a patient suffering from an acute asthma attack [5]; 
• that balloons inflated inside the nose can cure learning disorders [8];
• that strokes in progress can be reversed by cold compresses applied over the carotid arteries [9]; 
• that vitamin C is an effective treatment for approximately 100 conditions, including glaucoma, male infertility, and AIDS [12]; 
• that high blood pressure and coronary heart disease should be treated with unproven herbs and chelation therapy [17]."

The numbers refer to citations that Dr. Atwood provides for each of his points.

Among other things, the proposed new law (House bill 1029 and its companion Senate bill 783) specifically authorizes hydrotherapy, stating: 

"A license authorizes a licensee to ... administer or perform hot or cold hydrotherapy, naturopathic physical therapy, electromagnetic energy, colon hydrotherapy ... for the purpose of providing basic therapeutic care."

[Aside: I have no idea what it means to "administer electromagnetic energy"; perhaps you simply shine a light on the patient?  I suspect the legislators who are sponsoring this bill haven't a clue either.]

Hydrotherapy doesn't sound so bad until you learn what naturopaths do with it.  According to the naturopathic organization's own experts, 

"One technique is to lower your body temperature, with a cold bath for example, as much as possible without inducing shivering as soon as possible after a stroke has occurred, or is suspected to have occured.... Another hydrotherapy technique with a similar rationale is to soak the feet in a hot foot bath, as soon as possible after the stroke has occurred, while applying a cold compress to the neck, face and scalp. If this technique can be applied as a stroke is happening, it may even abort the stroke."

Again, quoting Dr. Atwood: "All strokes are potentially life-threatening, and are considered to be medical emergencies that require prompt and expert evaluation and supportive care. The treatments described above will do nothing to improve the outcomes of strokes, but are certain to delay competent diagnosis and treatment. 

Most disturbing, perhaps, is that the new Maryland bill would require physicians to violate medical ethics.  The AMA code of ethics states that

"It is unethical to engage in or to aid and abet in treatment which has no scientific basis and is dangerous, is calculated to deceive the patient by giving false hope, or which may cause the patient to delay in seeking proper care."

By adding a naturopath to the Maryland State Board of Physicians, and by requiring them to license naturopaths to practice medicine, the legislature is forcing physicians to act unethically.

So if you live in Maryland, take a few minutes and write to your state representative telling him or her not to support this quack bill.  Heck, contact them even if you don't live in Maryland, and tell them you were thinking of moving but now you want to move to Virginia instead. 

Questionable for-profit cancer center profits from alternative therapies

It sounds like a crazy conspiracy theory: a secretive businessman founds a for-profit medical center to treat cancer.  His hospitals offer conventional treatments but also sell highly questionable, unscientific treatments to vulnerable patients. These treatments help to increase profits.  The businessman uses the profits from his cancer hospitals to support his favorite right-wing causes.  Patients have no idea that the fees they pay for treatment help support these causes.

It may sound unbelievable, but it's true.  Most of this story was described in a lengthy exposé just published in the Washington Post on Christmas day.  The Post revealed that Richard Stephenson, the founder of a large for-profit cancer center, is also one of the primary funding sources for Freedom Works, a right-wing Tea Party organization that played a major role in the 2012 elections.  As the Post story described him:

[Stephenson is] "a reclusive Illinois millionaire who has exerted increasing control over one of Washington’s most influential conservative grass-roots organizations."

Among other examples, the Post describes how

"more than $12 million in donations was funneled through two Tennessee corporations to the FreedomWorks super PAC after negotiations with Stephenson over a preelection gift of the same size....  The origin of the money has not previously been reported."

What the Post story didn't explain was the source of Stephenson's millions: Cancer Treatment Centers of America (CTCA), a private, for-profit company with five cancer hospitals scattered around the U.S.  Stephenson is the founder and chairman of CTCA.

For-profit hospitals present a big ethical problem, even when they provide proper care.  The problem is that motivation to increase profits may work against the interest of patients.  I don't want to debate that here, because CTCA has another, more serious problem.  Alongside standard, science-based cancer therapies, CTCA also offers an array of questionable, unscientific therapies, which it proudly labels as part of its "integrative cancer treatment."  CTCA advertises many such treatments, including:

• Acupuncture
• Acupressure
• Chiropractic
• Naturopathy 
• Homeopathy
• Mind-Body medicine (including Reiki and Qi Gong)

None of the treatments in this list has any scientific support showing that they provide a benefit to cancer patients.  Some of them carry a real risk of harm, as I've written about previously.  Acupuncture carries a risk of infection and chiropractic treatment has a risk of stroke - very small risks, admittedly, but no risk is acceptable when the benefit is nonexistent.  (See Science-Based Medicine for a summary of the science behind these and other alternative therapies.)

CTCA makes multiple unsupported, unscientific claims for its alternative treatments, such as:

• "Naturopathic medicine can help reduce these [cancer-related] symptoms, strengthen the immune system and support the healing process throughout your brain cancer treatment." 
• "Acupuncture may help to alleviate [cancer] treatment-related side effects, such as nausea and vomiting." 
• "When used during your leukemia treatment, our chiropractic care services can help correct bone, muscle and joint problems and restore nerve function." 

These are just a few examples. These claims, and CTCA's marketing of the therapies involved, present a huge ethical problem.  Cancer patients are facing some of the most difficult decisions in their lives, often while suffering through painful treatments, not to mention the fear that their cancer will kill them.  When a cancer hospital offers an "integrative" treatment with the promise that it may help, the patient is highly likely to try it, regardless of the cost.  These are extremely vulnerable patients, and CTCA is taking advantage of them to sell ineffective therapies.  CTCA and its owners, including Richard Stephenson, are profiting from their unsuspecting patients.

Offering treatments that are little more than snake oil to cancer patients is ethically indefensible.  Believers in acupuncture, naturopathy, Reiki, and homeopathy will argue that they are not unethical, because the treatments work.  This argument, though, flies in the face of overwhelming evidence to the contrary.  Those who argue that these therapies really work only demonstrate that they are unqualified to offer medical care.

Cancer Treatment Centers of America presents a very welcoming, positive picture of itself through its website, and much of what it describes is accurate.  However, its errors of omission are huge: nowhere does its website say that CTCA is a for-profit center, nor does it tell you that its founder is a major donor to right-wing political organizations.  And most critically for patients, CTCA offers a palette of pseudoscientific treatments, making medical claims that are not supported by any evidence and that in some cases violate basic principles of physiology and biology - although the website claims that its integrative treatments are "scientifically-based supportive therapies."

Let's put aside the right-wing propensities of its owners and simply focus on the science and the ethics of CTCA's "integrative" therapies.  Even if the treatments were free, there is no justification for offering treatments based on pseudoscience.  In the context of a for-profit hospital, where every treatment provided adds to the bottom line, the practice of pushing illegitimate treatments onto cancer patients is even more reprehensible.

[Note: the publisher of Forbes magazine, Steve Forbes, is a board member for Freedom Works.  In case it's not obvious, I don't speak for Forbes and they don't endorse the content of my blog, which appears both here and on the Forbes site.]

[Note 2: for a more detailed, critical look at some of CTCA's offerings and its claims, see this post by Orac at Respectful Insolence from mid-2010.]