Thursday, April 17, 2014

Another chapter in the never endling clash between the collective and the individual regarding health care

The following comments were inspired by this insightful and very well written commentary by Margarit Gur-Arie entitled "Is the Nuremberg Code Obsolete?" After reading about where the cronies at IOM and the ideologues at Hasting Institute want to take us, I have to shout "It sure as hell better not be obsolete and do you people even know anything about the events that took place in Europe (or Macon county,Alabama for that matter)  in the 20th century and why we have the Code in the first place."

One of the more troubling developments in recent years in medical care is the seemingly increasing acceptance of the notion of the importance of the health of the collective even if sometimes to the determent of the welfare of the individual and that the latter seem to exist for the welfare of the former.

One of the latest twists here is that some are arguing that certain types of clinical research can be done without getting consent of the participants or even informing them about what it going on.

Quoting Gur-Arie:

" The Office for Human Research Protections (OHRP) held a public hearing in August 2013 regarding the nature of informed consent for randomized clinical trials...., two very distinct opinions regarding consent emerge from reading the various testimonies before the committee. The traditional opinion argues that there is a difference between treatment and research and that informed consent is required for both, including study of “standard care” interventions, CER and QI; that randomization always deprives research subjects of the judgment of their physician and that these issues are governed by law (e.g. the Constitution and such). The progressive view, presented by testimony from members of the Institute of Medicine (IOM), its Clinical Effectiveness Research Innovation Collaborative (CERIC), NIH and other research establishments, posits that randomization of “standard care” interventions poses no additional risks to patients, since doctors’ decisions are essentially like flipping a coin anyway, and therefore patients in this new learning system may be subjected to randomized CER and QI experiments without explicit consent and with minimal, if any, information (e.g. “something posted on the door”)."

 Related is this Hasting Center  report which speaks of   (with my bolding):

"The obligation of patients to contribute to the common
purpose of improving the quality and value of clinical care
and the health care system.
Traditional codes, declarations,
and government reports in research ethics and clinical ethics
have never emphasized obligations of patients to contribute
to knowledge as research subjects. These traditional presumptions
 need to change. Just as health professionals and
organizations have an obligation to learn, patients have an
obligation to contribute to, participate in, and otherwise facilitate learning.
This obligation is justified by what we call a norm of
common purpose. This norm of common purpose is similar
to what John Rawls calls the principle of the common good."

Wow, here is a group composed mainly of several ethicists from Johns Hopkins who presume to define an obligation for everyone and redefine the ethics of medical research, a goal they openly admit to in the first paragraph of their report.Everyone has an obligation to work for the common purpose of better health care.

Once all the health care providers and all the patients work together to participate in and gather the data about various medical tests and treatments the very smart people will be able to analyze it all and determine what is best for the collective. Utopian health care is within the reach of the  very smart people with ideas.

Thursday, April 10, 2014

More internists are failing the MOC exam-why could that be? Resistance to ABIM's MOC grows.

Why are more internists failing the Maintenance of Certification (MOC) exam? Kevin Pho on his medical blog offers two suggestions. See here. One reason is what I call the economically driven bifurcation of internists into hospitalists and officists and the disuse atrophy of hospital care skills in the office bound docs and the lack of familiarity with the preventive care changes and routine treatment of non acutely ill patients on the part of the hospitalists. If you don't treat respiratory failure,sepsis and acute heart failure on a regular basis you might just not do as well on the boards. The second reason Pho suggested is that the hassle factor in office care is now so high , with insurance,computer,and quality measures documentation  ever increasing that the fire in the belly to try and keep up with everything may be burning too low to try and keep current on conditions  you no longer are called upon to manage.

The suggestion that there should be one test for the hospital based internist and another for the officist has some merit but what about the dwelling number of dinosaurs who still try to do both. Of course that group is rapidly dying out.

And the more I read and hear about the absurd hoops internists are expected to jump through to try and satisfy the ever onerous non-test aspects of the ABPM's MOC process, the happier I am that I retired.See here for a great presentation of the clown-designed MOC program authored by the leadership at the American Board of Internal Medicine (ABIM).

I am pleased to see that there is at least some organized,as well as much unorganized, effort to resist or maybe even boycott the latest MOC affront imposed by the well paid folks at ABIM. See here and here. Further, mega kudos to Dr. Paul M. Kempen for his efforts to resist the MOC movement. Read what he has to say here. See here for Dr. Wes Fisher's comments re the big business that testing physicians has turned into.

Also of interest are the questions posed by Dr. Marc S. Frager to Dr. Richard J. Baron as well as Dr. Barron's reply.See here.

If you want to sign a petition to urge the ABIM to rescind their latest edicts regarding MOC ,go here

It is easy to find much anger and indignation directed towards the ABIM and recent revelations about possible conflicts of interests regarding its leadership has fanned the flames even more.

Friday, March 21, 2014

Adam Smith's Men of Systems and the progressive medical elite

Adam smith spoke of the men of system- men with a dangerous mixture of hubris and naivete  who presumed to know what is best for every one  and how to plan to bring that optimal state into being.

The following commentary highlights the views of some physicians who might be considered the medical men of system.

The following quote from Drs Don Berwick and Troyen Brennan in their appropriately named book, "New Rules" captures the essence of the fundamental nature of how men of system would arrange medical care.
"Today, this isolated relationship[ he is speaking of the physician patient relationship] is no longer tenable or possible… Traditional medical ethics, based on the doctor-patient dyad must be reformulated to fit the new mold of the delivery of health care...Regulation must evolve. Regulating for improved medical care involves designing appropriate rules with authority...Health care is being rationalized through critical pathways and guidelines. The
primary function of regulation in health care, especially as it affects the quality of medical care, is to constrain decentralized individualized decision making


Dr. Robert Berenson strikes a  seemingly different but clearly related note in a commentary in the Annals of Internal Medicine , 1998,pg 395--402.  in which he promotes the health of the collective rather than the individual patient :

"We propose that devotion to the best interests of each individual be replaced with an ethic of devotion to the best interests of the group for which the physician is personally responsible."

Berenson recommends a replacement of the fiduciary duty of the physician to the patient with a duty to a group while Berwick and Brennan talk about dissolution of the physician patient relationship and moving the locus of medical decision making  away from the physician and his patient to a reliance of authoritarian rules.

More recently Berenson has this to say:

 "we ought to consider setting all payer-rates for providers." He continues "but the country's antigovernment mood renders such a discussion unlikely,at least for now"

A series of articles in JAMA in 1994 (Rationing Resources while improving Quality) by Dr. David Eddy also recommended a utilitarian type medical care structure in which funds would be  spent on medical tests and treatments that were most likely to benefit some majority subset so that in the aggregate there would be a greater good for the greatest number.

Dr. John Benson is the former CEO of ABIM and ABIMF and had this to say recently on the ABIMF's website:

"  ABIM could require candidates to achieve a perfect score on questions related to costs and redundant care as a requirement for admission to secure exams for initial certification or MOC."

So for candidates for certification or the Maintenance of Certification to even that the test they would have to recite,perfectly, the catechism of the brainchild of ABIMF ,the Choosing Wisely guidelines.

This alone, in my opinion,should qualify Dr. Benson for membership,along with the aforementioned doctors,in the Medical Men of System hall of fame.  

The recommendations of Berwick,Brennan,Berenson and Eddy were met by some vocal resistance as least as documented by letters to the editors in JAMA and the Annal of Internal Medicine . These authors were advocating a paradigm shift ,arguing for a 180 degree reversal of traditional medical ethics for which , I believe, physicians at the time were not ready and I hope are not ready now but...

But there is another way to gather support for a sea change in medical ethics and practice behavior,one that will also bring about greater concern for the collective and aggregate outcomes and that will to a large and ever increasing degree move the locus of medical decision making from the individual dyads to a central decider .

This other way is to nudge physicians and later shove them a bit into the acceptance of the notion that physicians have a duty to work for social justice and to act as stewards of the nation"s finite medical resources.To strive for social justice is a political position, one that does not necessarily have any professional links. To declare, or assert gratuitous , as was done the in the  publication known as the Medical Charter that physicians have an obligation to strive for social justice represented a audacious move,one that I am afraid has been at least nominally successful.

To close with a quote from Adam Smith's "Theory of Moral Sentiments" :

"The man of system, on the contrary, is apt to be very wise in his own conceit; and is often so enamored with the supposed beauty of his own ideal plan of government, that he cannot suffer the smallest deviation from any part of it. He goes on to establish it completely and in all its parts, without any regard either to the great interests, or to the strong prejudices which may oppose it. He seems to imagine that he can arrange the different members of a great society with as much ease as the hand arranges the different pieces upon a chess-board. He does not consider that the pieces upon the chess-board have no other principle of motion besides that which the hand impresses upon them; but that, in the great chess-board of human society, every single piece has a principle of motion of its own,"

Thursday, March 06, 2014

Breaking news-OBM discovers economics prinicple of "incentives matter"

Several of my favorite economists have said that the real good stuff in economics is revealed in the econ 101 courses. One of the secrets revealed is that "incentives matter".

Milton Friedman said most of economics could be boiled down to two thoughts; 1) there is no free lunch 2)demand curves slope downwards which simply means people tend to buy more if something costs less and tend to buy less if something costs more.

Another principle is that generally supply curves slope upward which means that someone will tend to supply more of something if the price increases and tends to supply less if the price is lower.

The Chicago economist Casey Mulligan has been making that point for some time  in regard to certain aspects of Obamacare.Obamacare provides subsidies for folks when their income falls below a specified threshold.If they work more and earn more and exceed that threshold  they loose that subsidy.Hence the incentive to work less.In other words, less labor will be supplied if the effective pay is less which is what happens when someone works more and loose a subsidy so your net income falls. As Mulligan says you can decrease employment by changes in the supply side as well as by changes in the demand side.

The downward sloping demand curves notion enters into the Obamacare employment issue as well. If an employer has to provide health insurance or be fined if he employes more than 50 people the incentive is to keep his employee count under that number because the cost of hiring the 51th person is too high. He will tend to hire fewer employees when the cost of hiring increases.

See here for a WSJ article on Prof.Mulligan and his work and comments and how OMB finally caught on.

Wednesday, March 05, 2014

Are the Choosing Wisely leaders becoming impatient with the rank and file docs?

 At least one of them seems to be according to this commentary by the former CEO of ABIM and ABIMF., Dr. John Benson Jr. who is referred to by some as the "father of ABIM". With the respect that designation would imply I think it prudent to take what he has to say seriously.

Basically what he had to say was that the rank and file docs do not seem to be getting the message and more forceful "educational" methods need be employed.

Such as :
 "...hard choices and penalties must go beyond training the next generation"  and

" ABIM could require candidates to achieve a perfect score on questions related to costs and redundant care as a requirement for admission to secure exams for initial certification or MOC."

Yes, the former CEO of ABIM and ABIMF is really saying that candidates for  maintenance of certification (MOC )would have to take a pre-test of Choosing Wisely type material  (and not get any wrong answers) before they could even take the certification exam.


 " CMS, which has the ultimate negotiating position in the form of reimbursement for Medicare services, could only accept negotiated bundled charges. It could also refuse payment for non-compliance with the Choosing Wisely recommendations."

So if you do not comply with our "recommendations" CMS should not reimburse.

 Good grief, it sounds like Dr. Benson thinks the ABIMF Choosing Wisely wisdom should basically be determinative in regard to what sorts of health care we all should and should not have. The adjectives grandiose and hubristic seem to mild to characterize these proposals.I wonder what non-internists physicians think about a small group of internists who believe they should be in charge of so much,or for that matter internists actually in practice.

The Choosing Wisely campaign is spearheaded by the ABIMF which it seems to me to be basically the folks at ABIM. The two legal entities have the same CEO and President. See here for the IRS form 990 for 2011 for ABIMF The foundation at that time had net assets of $ 68,871,66.  Its stated goals are " to catalyze improvements in health care by advancing medical professionalism: In regard to professionalism  as elucidated in the Physician Charter  the foundation's website states the following: :

"The fundamental principles of the Physician Charter are the primacy of patient welfare, patient autonomy and social justice. The Charter also articulates professional commitments of physicians and health care professionals, including:
  • Improving access to high-quality health care,
  • Advocating for a just and cost-effective distribution of finite resources, and
  • Maintaining trust by managing conflicts of interest."
If you think Benson's recommendations are just talk, think again.The ABIM and ABIMF are well funded , have the support of at least one very rich foundation (RWJ) and have so far at least nominally brought about a sea change in medical ethics.I say nominally because I hope many docs have not received the memo.Once the majority of physicians believe their ethical duty is to be stewards of a collective medical resource,patient advocacy and duty to the individual patient will be down the memory hole and as far as physician behavior goes it will be how high to jump and when as the instructions come forth from the medical progressive elite.

Monday, March 03, 2014

Is this what ABIMF"s Choosing Wisely is really all about?

Dr. John Benson Jr, Emeritus President  of the American Board of Internal Medicine Foundation,makes it clear  what direction he wants the Choosing Wisely  (CW)  Campaign to go. See here for his comments.

 Dr. Benson begins his policy prescription with a gratuitous assertion which seem to be a favorite technique of the folks at ABIMF. (Their mother-of-all gratuitous assertions was that physicians were stewards of medical resources.)

 "The prospect of health care consuming 20% of the GDP by 2020 is unconscionable so corrective actions have enormous urgency."  

This recent commentary from The NEJM seems to share some of Dr. Benson's views which is basically "If you people do not do what we know is right someone needs to make you do it". He speaks of penalties.
He wants the CMS to enforce the  Choosing  Wisely 's wisdom.The NEJM article speaks of linking compliance with MOC ( Maintenance of Certification)as well as tying CW recommendation to CMS actions.

Quoting Dr. Benson:

"The time is well past exhortation. The issue has been recognized for decades. Hard choices and penalties must go beyond training the next generation. 2020 is closing in." ( He does not explain the ominous reference to the year 2020).

He continues

" CMS, which has the ultimate negotiating position in the form of reimbursement for Medicare services, could only accept negotiated bundled charges. It could also refuse payment for non-compliance with the Choosing Wisely recommendations."  (note the current President of ABIM and ABIMF is Dr. Richard Baron who left a post at CMS through the revolving door to assume his duties at ABIM and ABIMF)

and it gets worse

" ABIM could require candidates to achieve a perfect score on questions related to costs and redundant care as a requirement for admission to secure exams for initial certification or MOC."

So, a candidate for ABIM certification would have to properly quote the Choosing Wisely catechism before he even gets to take the certification of MOC examination.

Quoting the NEJM article by Dr N.E. Morden and her co-authors from Yale and Harvard:

"..physician-endorsed low-value labels will probably be leveraged to these purposes. [cost containment and quality measures]...We believe that if such efforts are designed and applied carefully they should be embraced as a promising method for reducing low-value services."

...linking the lists ( of tests and procedures not to do ) to specialty specific maintenance of certification act activities such as practice audits and improvement tasks could also advance their dissemination and uptake at very low cost."

"...Choosing Wisely items should also be incorporated into quality-measurement efforts such as center for Medicare and Medicaid Services Physician Quality Reporting  ...linking low vale service use to financial incentives ( translate penalties )  .. should accelerate ...into practice changes."

Remember the CW campaign,which was very low key in 2009. was just to get a dialogue going   so that  the physicians could explain to their patients how at least some of these tests and treatments really don't need to be done because they may be wasteful and sometimes harmful. In 2012 the program was ramped up as the ABIMF "invited various medical professional societies to take ownership of their role as "stewards of finite health resources". And now , in 2014 the movement to give the CW recommendations teeth is ramping up.

The coercive recommendations of Benson and the authors of the NEJM article are in the tradition of those who believe that medical care is too important ( and complex) to be left to the short sighted individual patient and her knowledge and wisdom challenged physician health care provider.They seem to march to the drum beats orchestrated by  Dr. Don Berwick (the temporary head of CMS) and  Dr.Troyen Brennan (the current executive VP of CVS Caremark) who said in their book, New Rules:

"Today, this isolated relationship[ he is speaking of the physician patient relationship] is no longer tenable or possible… Traditional medical ethics, based on the doctor-patient dyad must be reformulated to fit the new mold of the delivery of health care...Regulation must evolve. Regulating for improved medical care involves designing appropriate rules with authority...Health care is being rationalized through critical pathways and guidelines...

Berwick and Brennan must be pleased as largely through the efforts of ABIMF and ACP much has been accomplished   in the reformulation of  traditional medical ethics. They have shaped the narrative to emphasize the bogus stewards-of- resources concept while letting the fiduciary role of the physician to the patient fall  quietly down the memory hole.Unfortunate  the leaders of other medical professional societies have swallowed the bait.

The progressive medical elite who hold positions variously at major medical societies and medical certification boards ,some of whom rotate through various government medical agencies and sometimes private third party payers, have not been shy about what they want to happen.For those of us who believe that the patient is best served by a physician acting as fiduciary to the patient and advocating for him have much to worry about.

Tuesday, February 25, 2014

Say it isn't so Joe, Medical "thought leaders" might have conflict of interests

 The issue of possible conflicts of interest (COI) has arisen in regard to both the National Quality Forum,  (NQF) and the popular UpToDate.

 This article in the Journal Of Medical ethics discusses that issue in regard to the popular UpToDate which on its web site describes its self as "premier evidence-based clinical decision support resource". The journal article has this to say regarding several sections of UpToDate comparing it to another rival medical resource:

"All articles from the UpToDate articles demonstrated a conflict of interest. At times, the editor and author would have a financial relationship with a company whose drug was mentioned within the article. This is in contrast with articles on the Dynamed website, in which no author or editor had a documented conflict. We offer recommendations regarding the role of conflict of interest disclosure in these point-of-care evidence-based medicine websites."  It should be noted that the journal authors did not review all of sections but selected ones that involved subjects for which treatment was controversial and/or involved recommendations for specific treatments that wee provided by a single supplier.

Much more has been written about possible COI regarding the NQF.

Details regarding Dr. Charles Denham can be found in this article in "Modern Health Care. Quoting that article:
"Dr. Charles Denham, co-chair of NQF's Safe Practices Committee in 2010, received $11.6 million from San Diego-based CareFusion to promote the company's ChloraPrep line of skin-preparation products. Denham's committee at the NQF also recommended surgeons use ChloraPrep products to prevent surgical infections, the NQF said."

Dr.Christine Cassel,currently CEO of NQF left little doubt about her assessment of Denham action saying simply "He lied" when he mislead the NQF regarding his possible COI and business interests. Dr. Cassel was not affiliated with NQF at the time of the allegedly kickback  related activities.

Ironically enough now Dr Casell has the spotlight on her in regard to possible COI  regarding her role at NQF.ProPublica takes up that issue here. I say ironically because one aspect of Dr.Cassel's academic reputation has been in the field of medical ethics.Dr. Cassel has written and lectured extensively on medical ethics, authored or co-authored several publications in the field including "Ethical Dimension in Health Professions" and completed a fellowship in bioethics.

 So what is it that Pro Publica finds of concern in regard to Dr. Cassel's role at NQF. It is in regard to other compensated positions that she holds.For example Dr. Cassel is a board member for Premier Inc with a reported compensation  of  $ 235,000 and stock.Does a board member of a corporation not have a fiduciary duty to the corporation.?

Since she has earned the title of expert in the field of medical ethics it seems astonishing to me that she apparently does not consider it an ethical breach to play a leadership role in the NQF and to  receive compensation  from two organizations that could profit ( or loose) based on some recommendations made by that organization. Two ethicist interviewed by Pro Publica seem to disagree and Dr Roy Poses ( see here) who is absolutely untiring in his efforts to point out issues of COI in health care has this to say regarding Dr. Cassel's dual roles:

"However, in my humble opinion, the issue here goes even beyond a blatant and undisclosed conflict of interest.  That a top steward of a big for-profit health care corporation could simultaneously be the top leader of an influential non-profit health care quality improvement organization suggests that increasingly US health care is run by an insular group of insiders whose influence gets ever larger because of their collective power, not necessarily because of their dedication or ability to improving health care.  As ProPublica put it,
Rosemary Gibson, an author and senior adviser to The Hastings Center, a research group dedicated to bioethics in the public interest, said she wasn’t surprised at Cassel’s outside compensation. So much money permeates decision-making in Washington, she said, that participants have become oblivious.'The insiders don’t see it,' Gibson said. 'It’s like a fish in water.'

Update: 2/27/2014 Dr Cassel has resigned from her posts at Premier and  Kaiser.