My Michael Moore Moment

In his recent movie, “Sicko,” the controversial director Michael Moore turned his attention to healthcare, specifically the difficulties in access to care faced by many Americans. I have reservations about Michael Moore’s tendency to overshoot his target and suspect that some parts of his documentaries are too contrived to be taken at face value. Nevertheless, this time he has definitely picked a topic of interest to ACR members, and indeed all healthcare professionals. The striking number of physicians in the theater when I saw “Sicko” supports that conclusion.

As ACR president, I am made aware of the concerns of ACR members through the numerous e-mails that stream in to our staff, the ACR list serve, and me personally, in addition to phone calls, letters, and encounters with colleagues in professional settings. On many topics—such as our educational meetings, our journals, and the Research and Education Foundation—the messages from ACR members are overwhelmingly positive and enthusiastic.

However, there is also palpable concern—and occasionally outright anger—about many aspects of the environment in which we care for our patients. Arguably, one could link many of our greatest challenges under the theme of “access to care,” and if I were a film director in the genre of Michael Moore, I would already have enough material to create my own documentary: “Sicko Rheum.”

It’s easy to list numerous access-to-care issues that have become areas of focus for our ACR staff—especially those who work with the Committee on Rheumatologic Care (CORC) and the Government Affairs Committee (GAC)—and for the CORC, GAC, and ACR Regional Advisory Council volunteers. These include absurd cuts to bone densitometry reimbursement, arbitrary and cynical denial of coverage by payers across the country for everything from anti-cyclic citrullinated peptide tests to medications to occupational or physical therapy, and the shortage of rheumatologists. And once more (when this column was written), we are facing the 500-pound gorilla of an impending 10% cut in Medicare payments that, if implemented, would threaten access to care for a large segment of the population and the viability of many rheumatology practices.

Stranger than Fiction

My personal Michael Moore moment occurred this past fall while rounding as attending physician on our rheumatology consult service. The case of “Mr. Wolverine” was especially interesting—high fevers, inflamed joints, occasional rashes, leukocytosis, and prominent elevation of acute phase reactants—the diagnosis was adult-onset Still’s disease. Our understanding of Still’s disease as an autoinflammatory, cytokine-driven disorder has advanced dramatically in recent years, thanks to brilliant research by ACR members such as Virginia Pascual, MD, of Baylor Institute for Immunology Research (Texas), and her colleagues, who have convincingly implicated interleukin 1 as a key mediator and therapeutic target in Still’s. While treatment approaches are evolving and several choices are reasonable in such a patient, use of the interleukin-1 receptor antagonist is emerging as a compelling option, notwithstanding the lack of definitive controlled trials which are very difficult to accomplish in rare conditions.