Of the clinical indicators by which physician organizations and health plans are rated by HEDIS, many are based on good evidence in the peer reviewed medical literature or based on common sense such that randomized trials would be unethical. However, the following guidelines, about one-third of the HEDIS quality measures, are highly questionable:

• Immediate beta-blocker pills for heart attack patients: In 1999, a HEDIS report extolled the value of this quality measure: “One shining example is use of beta blockers after a heart attack. Since 1996, plans' combined performance on this measure has jumped from 62.5 percent to almost 80 percent. Considering the amount of attention given this measure in the last two years, it could be argued that HEDIS has done more to elevate awareness of beta-blocker use as a proven and relatively inexpensive way for physicians and health plans to save lives than did all of the relevant clinical guidelines that preceded it.” However, in 2007, HEDIS quietly withdrew this quality measure saying widespread achievement of near maximum use of beta-blockers in post-MI patients and little variance among health plans resulted in it having little value as a quality measure to differentiate health plans. Then, in December 2008, the American Heart Association and American College of Cardiology withdrew this guideline with a euphemism indicating that the guideline was never valid: Guideline deleted because of “Increased complexity of decision making and controversy about the magnitude of net benefit.” A New York Times article indicated that the Centers for Medicare and Medicaid Services (CMS) sent hospital administrators around the country received “a short, unceremonious e-mail” withdrawing this quality indicator a month later. However, a search of the CMS website for “beta-blocker and heart attack” is negative.

• This uncontrolled vaccination experiment may result in an epidemic of adults getting severe chicken pox in 10 – 20 years.

  Vaccination against chicken pox (varicella) for children: Immunity from varicella vaccination lasts no more than 5 years compared with lifetime immunity from having chicken pox (usually a mild uncomplicated early childhood illness). The older the age of acquiring chicken pox the worse the complications and the higher the risk of death. This uncontrolled vaccination experiment may result in an epidemic of adults getting severe chicken pox in 10 – 20 years.

• Treatment of depression with antidepressant medication: The efficacy of selective serotonin uptake and release drugs (SSRIs, the most widely prescribed antidepressants) is not more than placebo. They clearly increase suicidal attempts and may cause some suicides. Non drug treatments like aerobic exercise, stress management techniques (yoga, meditation, etc.), communing with nature, and gardening are not mentioned in the HEDIS guidelines.

• Breast cancer mammography screening: Controversy abounds in interpreting mammogram screening trials.  The most rigorous trial of all, a Canadian study, found no reduction of breast cancer deaths in premenopausal or postmenopausal women compared with self exam and yearly clinician exam. Benefits of the mammogram are under serious debate currently in the UK.

• 	The “Dr. Dean Ornish Program” including a similar diet, reduces adverse cardiovascular events by > 50% in 5 years compared with < 30% with pills.

  Blood cholesterol screening and drug treatment to lower low density lipoprotein (LDL) cholesterol: A trial of treatment of hypercholesterolemia with Mevacor (a statin drug) in subjects eating the American Heart Association diet compared with a “portfolio diet” (i.e., fruits, vegetables, almonds, soy protein foods, oats, barley, etc) alone showed no significant difference in lowering of LDL cholesterol. The “Dr. Dean Ornish Program to Reverse Heart Disease” including a similar diet, reduces adverse cardiovascular events by > 50% in 5 years compared with < 30% with pills.

• Treating stage 1 high blood pressure (systolic BP 140 – 159 or diastolic BP 90 – 99) with drugs: Published trials have not shown that drug treatment of mild hypertension saves lives or reduces adverse events. The widely reported ALLHAT trial comparing 4 blood pressure lowering drugs for stage 1 hypertension showed that subjects taking water pills (thiazide diuretics) had fewer adverse clinical outcomes than those on the newer patented meds. However, none of the 15 placebo-controlled randomized trials of thiazide diuretics involved exclusively stage 1 patients. Five of those 15 trials showed no benefit with thiazides, and The Oslo trial, combining stage 1 and 2 hypertension subjects, reported a significant INCREASE in deaths with thiazides at 10 years (14 versus 3).

• For type 2 patients with no symptoms of diabetes, a more aggressive diet and exercise prescription would be a reasonable alternative to drugs.

  Treating people with type 2 diabetes who have no symptoms (frequent urination, excessive thirst, blurry vision etc.) with blood sugar lowering drugs: Of at least 15 complications of diabetes studied in the largest type 2 diabetes trial, only one was significantly benefited with drugs. Patients on sugar lowering drugs required fewer laser treatments for diabetic eye disease.  However, drug treatment increased weight and episodes of hospitalization due to diabetic coma (hypoglycemia). For type 2 patients with no symptoms of diabetes, a more aggressive diet and exercise prescription would be a reasonable alternative to drugs.

• Flu shots for healthy adults 50 – 64 years old: Over 90% of the 36,000 deaths per year from complications of influenza are in the elderly (> age 65). One-third of people 50 – 64 years of age have chronic diseases that place them at increased risk for the complications of flu. There is no evidence that vaccinating healthy people 50 – 64 reduces the morbidity or mortality from the complications of flu. 

"Until we really start talking about WHY the current system behaves as it does, why it rewards who it rewards and excludes who it excludes, until we speak plainly about who's benefiting from the status quo (and someone is clearly benefiting), we'll never really get anywhere."