Monday, January 26, 2015

Are patients pawns on the chess board of population medicine?

They would seem to at least so it appears to be in the presentation of the "population medicine approach" of by Dr. Harold Sox,former editor of the Annals of Internal Medicine, former president of the American College of Physicians (ACP) and former chair of the U.S. Preventive Services Task Force, offered in the November 13 ,2014 issue of  the Journal of the American Medical Association (JAMA).

Here is my thumbnail summary of what Dr. Sox wrote in describing how the population medicine approach would work.The major important diseases would be identified as would methods for their prevention. With that knowledge in hand , then funds could be transferred across patients and disease processes so that the maximal overall health benefit could be achieved.In this process it might well be that sometimes funds would be diverted away from the testing and treatment of some so that the preventive measures could be funded and then  " in a few generations" the benefit would be fully realized.He is explicit regarding the fact that in the short run some people would be harmed although he does not seem to explain why it would be only the short run as would not new preventative measures always be formulated and have funds diverted to their execution.The population medicine advocates claim the approaching of each patient strictly as a individual is "obsolete" and  are promoting a statistical medicine that claims to be capable of provided the greatest health benefit to the greatest number.Practicing physicians know how difficult it can be to recommend what might be best for the individual patient,the "populationists" glibly claim to know what is best for everyone.

In chess, pawns or for that matter any piece, might be sacrificed in executing a strategy of placing the opponent 's king in checkmate. Is it the case that individuals might be sacrificed in executing a strategy of maximizing the health of the specified population as measured by some metric such as quality adjusted life years  (QALY) per dollar spent ? After careful study and  multiple re-reads of Dr. Sox's article my answer to the question posed in this commentary's title is yes.The patients are the pawns on the chess board of population medicine.



Friday, January 23, 2015

Maybe the health care supply curve slopes upwards and more ACA bait and switch

See here for a review of a recent NEJM article that supplied data indicating that the temporary increase in Medicaid fees which was part of ACA  may have increased access to medical care.So as Medicaid professional fees increase more services are supplied.

From Nov 2012 to July 2014

" [t]he availability of primary care appointments in the Medicaid group increased by 7.7 percentage points, from 58.7% to 66.4%, between the two time periods. The states with the largest increases in availability tended to be those with the largest increases in reimbursements, with an estimated increase of 1.25 percentage points in availability per 10% increase in Medicaid reimbursements (P = 0.03). No such association was observed in the private-insurance group. During the same periods, waiting times to a scheduled new-patient appointment remained stable over time in the two study groups."

So now that the Medicaid fee increase has elapsed and fees will be cut should we not see a decrease in availability? The specter of more folks on Medicaid and fewer docs likely to see Medicaid patients is part of why this article talks about the great bait and switch of ACA.We see more of a distorted version of social justice emerging from Obamacare.

Thursday, January 15, 2015

Is Maintenance of Certification (MOC) part of ACA and who put it there?

The short answer is :

Yes, MOC  has been implanted into the legislative structure of ACA and for many (most?) practicing physicians this is really breaking news and for those of us who oppose the ABIM's MOC program, may mean  bad news.

 Dr. Wes explicates how the Maintenance of Certification has been made part of Obamacare in his recent blog entry in which he questions the viability of an alternative "Board" to challenge and hopefully replace the ABIM's widely criticized MOC program.Does the letter of the law with its establishment of MOC in some aspects of Medicare preclude the replacement of ABIM's MOC with some less onerous process by a rival organization?  


"The Affordable Care Act (ACA) modified Sections 1848(k) and 1848(m) of the Social Security Act which defines how CMS pays physicians for their services.  Section (k) is the section that defines how a "Quality Reporting System" is to be set up (with subsection (4) requiring the "Use of Registry-based Reporting") and Section (m) defining physician incentive payments physicians might receive if quality reporting occurs properly. (Sadly, those CMS incentive payments do not cover the cost of participating in MOC for most of us.)

Section (k) was modified by the ACA to include the ABMS MOC program as a "physician registry."  The registry was "defined" as requiring all four parts of the MOC program created by the ABMS, including the much-maligned "practice improvement modules" that have been described by the physician community as overly time-consuming, irrelevant ...."


After re-reading of the relevant sections, it is not clear to me exactly what penalty a physician would incur by forgoing MOC. I welcome any input regarding that.

ABMS's MOC program is part of the law and what ever alternative organization set up to do some version of less onerous MOC is not part of the law and IMO the political clout of the rank and file real physicians is likely not up to the task of changing the law.


Dr. Wes, see here, raises interesting questions about possible collusion between principals in certain organizations  and CMS, those certain organizations being some of the ones which would  benefit financially  from the statutory establishment of MOC in ACA.

 Medical certification boards would obviously profit from the MOC process being quasi mandatory  or tied in in real ways to a physician's compensation.  Dr. Wes focuses on two physicians with ties to ABIM and ABIMF and CMS and the National Quality Forum which incidentally receives significant funding from CMS.

[An interesting aside is that a member of NQF's Board is Liz Fowler, currently a VP at Johnson and Johnson and someone who  played a major role in the drafting of ACA. See my earlier commentary entitled  "Who Wrote Obamacare and where is she now?") Ms. Fowler has been described , accurately in my opinion, as the poster girl for the revolving door in regard to government and major health care players.It seems that some of the prominent medical elite know how to open the doors as well.}

Quoting Dr. Wes:

"Troubling concerns of collusion of ABIM board members with the Center for Medicare and Medicaid Services (CMS) and the National Quality Forum (which receives the bulk of its revenues from grants supplied by CMS) exist. Christine Cassel, MD, who is the current President and CEO of the National Quality Forum, was President and CEO of the ABIM from 2003 to 2013 and ultimately responsible for the $2.3 million dollar luxury condominium purchase by the ABIM Foundation in December, 2007....."

Dr. Wes then chronicles the job history of the current ABIM CEO, Dr. Richard Baron who was associated with ABIM and then left to be a full time employee of CMS from 2011 -2013 and came home to his current ABIM's six figure salary.

Again quoting Dr. Wes:

"Which leads to the question: how much influence did the ABIM leadership have in establishing a continuous money stream for itself and its Foundation during the writing and mark-up of the Affordable Care Act? (see pages 247 and 844-845 of this large pdf). Clearly, there should be public record available to this effect and physicians should inspect this record before creating an alternate MOC pathway"

The fact that the term "professionalism" is found in ACA may be significant.. ABIMF has been promoting their particular version of professionalism for several years such promotion being the major stated goal of that organization. Unlike traditional medical  ethics the ABIMF professionalism embeds the obligation of social justice and an obligation for physicians  to act not only for the individual patient but for some collective,which operationally could be a given ACO or HMO. Has or will ACA make the ABIMF's sea change professionalism "the law of the land"?

Statutory language does not appear by a random process.Public choice theory tells us to look at who might profit from a given law or regulation and often you will find who was responsible for it.  Cui bono.




Monday, December 22, 2014

If you wondered what the American Board of Internal Medicine Foundation was all about...

I have asked more than once on this blog why does the American Board of Internal Medicine (ABIM) have a foundation ( the ABIMF).Why did one non-profit set up another one?

 Dr. Westby Fisher, writing  on his blog "Dr. Wes"  provides an eye-opening and in my opinion, shocking narrative about what is happening at the ABIM and ABIMF.This detailed expose about the ABIM and the ABIMF should be required reading not just for internists but for all physicians .

This entire article should be read and shared with colleagues.Here are some highlights and excepts as well as some of my comments.

The ABIM established the ABIMF  and  is its major source of funds. (I am aware the the Robert Wood Johnson Foundation did give the ABIMF 5 million dollars for its Choosing Wisely campaign, but most comes from ABIM)

The ABIM's source of funds is mainly from testing internists for certification and more  recently for maintenance  of certification (MOC) testing. It seems that if you subtract their operating expenses from their money flow from testing and certifying and re-certifying internists there is a lot left over to give to the ABIMF.

The principle activities  of the ABIMF are promotion of the new medical professionalism and   the Choosing Wisely Campaign while the ABIM is pushing its maintenance of certification (MOC) program.. Choosing Wisely  began as an apparently reasonable, mom and apple pie  program but may well be morphing into more than that or at the least a number of policy wonks ( and the former CEO of ABIMF) want it to be more controlling than the simple "conversation" between  physician and patient that is was originally purported to be.See here for a commentary about remarks made by the former CEO of the ABIMF ( Dr. John Benson) on the ABIMF 'blog  and by Dr. N, Mortin writing in the NEJM. Both speak of enforcement of the ABIM's edicts recommendations.

So, internists take tests for the which the costs and requirements continue to increase and the "profits" (at least cash in minus expenses) or a significant percentage of it is funneled to the ABIMF where it is spent on   promotion  of the seemingly ever expanding Choosing Wisely campaign as well as the medical  ethics game changing new professionalism.

Quoting Dr. Wes:'s introduction:

"Is it "medically professional" for a non-profit organization to use physician testing fees to "choose wisely" a $2.3 million luxury condominium complete with a chauffeur-driven BMW 7-series town car? In my view, obviously not. To most people such an action would conjure up images of hypocrisy, waste, and corruption.
Yet, after a review of public and tax records, it appears to me this is exactly what has happened."

Hypocrisy,waste and corruption are strong words.Dr. John Mandrola, writing on his blog "Dr. John M:" uses the words, hubris,overreach and tone deafness. in regard to the ABIM's MOC efforts.

I think  Drs. Fisher and Mandrola are if anything too restrained in their characterizations of the activities of ABIM and ABIMF.

The greater uproar and push-back from practicing internists is , understandably, the egregious and over reaching MOC program but I am afraid that the promotion of the new professionalism and the  linked political agenda may be even more dangerous to the practice of  medicine all emanating from the ABIM-ABIMF conjoined twins.

Addendum: 1/26/15-Much deserved kudos to Dr. Wes ( AKA Dr.Wesby G Fisher,EP cardiologist) for pulling back the curtain revealing the back stage activities of the ABIM-ABIMF.


Friday, December 12, 2014

Fewer hospital readmissions,the seen and the unseen and Goodhart's Law

One of the multiple provisions of the Affordable Care Act (ACA) is something called the Medicare Hospital Readmission Program.This provision links provider payments to 30 day readmission rates for three conditions-heart attack,heart failure,and pneumonia.More medical conditions are scheduled to be added to the list including chronic obstructive lung disease (COPD).

Writing in the December 4,2014 issue of the  NEJM Dr. Christine Cassel claims success for this program quoting that national readmission rates decreased from 19% to 17.5%.

 The French economist,Frederic Bastiat writing in 1850 advised his readers that a good economists not only looks as the visible effect,the seen, but needs to consider the unseen or what comes next.

What is seen here is the results of the reporting, what is unseen is the reason(s) for the decrease.

Did more patients end up in nursing homes, did more patients die at home,were more patients treated in ERs and not readmitted,what restraints , if any, were placed on ER doctors to not readmit folks recently discharged,.If someone was admitted to a different hospital did that count in the statistics?.What actions did hospitals take in a effort to minimize the likelihood of patients being readmitted?

The patients who were not readmitted are not seen. What  happened to them? Does this reported decrease in readmission rate reflect better care or just less care in the hospitals? Did more people die at home?Were more patients prematurely placed in a hospice care setting?

Thomas Sowell tells his readers that in the real world of limited resources and virtually unlimited desires that  most of times we are involved in trade offs and not solutions.What are the trade offs in this reported decrease in admission?

Has the hospital readmission program managed to be an exception to  Goodhart's'aw?

Charles Goodhart,a professor at the London School of Economics,wrote in a 1975 paper that when a measure becomes a target it ceases to be a good measure.

Although not discussed explicitly  as a example of Goodhart's law, Dr. Cassel also reviewed the ill advised six hour rule for the administration of antibiotics in patients with community acquired pneumonia.It turned out that ER personnel were too profligate in the administration of antibiotics so as to not get cited for poor care. They were like school teachers who "teach to the test".

Dr. Cassel said that the data validated the readmission policy approach. Can you claim that without knowing the mechanism(s) for the fewer readmission? Do we know if the decrease helped or harmed patients? There was less expenditures from CMS in the hospitalization category but what costs were incurred and by whom?





Friday, December 05, 2014

Does a JAMA viewpoint essay by Dr. Harold Sox reveal what population health really means?

Dr. Harold C. Sox writing in the November 13,2013 issue of JAMA in an article entitled  "Resolving the tension between Population Health and individual health care" says:( my bolding ).

"Perhaps the de facto organizing principle for US health care,,approaching each patient strictly as an individual is obsolete.The population health approach is an alternative."

This sentence seems structured to allow for escape mechanisms. He hedges by beginning with "perhaps" and then says that" approaching each patient strictly as an individual " , so he could later claim that, of course ,treat the individual but you also have to consider the interests of society.

The money quote is :

 " Must the Population health approach compromise the needs of the individual to benefit the community?"

It will take several generations to realize the full benefit of investments in disease prevention . In the short run,the investments may draw resources away from tests and treatment for some sick people.In the long run, disease prevention and better low cost technology could reduce the outlay for treatment.In the interim, skillful clinical decision making can make the most of limited resources"

He is answering  his introductory question in the affirmative by giving an example of how an individual would suffer for the allegedly benefit of a group  and incredibly does not express any concern about sacrificing the individual to some hypothetical future benefit to the community or society.In fact and amazingly  the only benefit he actually mentions is "reduce the outlay for treatment".

 Sox continues:

 " Are the needs of the individual and the population reconcilable?
Using the same method of value and the same decision making principle for patients and for populations would be an important step toward a system that fairly allocated resources between the healthy many and the sick few"

The traditional role of the physician has been the care of "sick few".Are they now being asked to allocate some of the resources away from the sick to the "healthy many"?

But the principles involved in treating patient who requests help from a physician and  and proposing preventive measures for a population are not the same. The population has not requested help and may have not even authorized the "treatment"  A key principle in treating the individual is to respect his/her values. How can one determine the values of a population? Do all member of the population have to agree.? Is disease prevention is only principle to value, do liberty, and avoidance of coercion not matter? Who is to judge what is the fair allocation? Is disease prevention more important than treating the sick which historically is what physician basically did ?What about the possible harms of a preventive program?Should the population members have to agree to the preventive measures? Is informed consent not to be part of population medicine?




Thursday, December 04, 2014

The coruption of medical practice

Drs Hartzband and Groopman hit another major home run..See here .

This husband and wife physician team  from Harvard Medical School have published cogent thoughts before  regarding serious issues in  current day medical practice.See here for their critique of the concept of quality adjusted life year (QALY) and here .

They contend that  medical care is being corrupted by the actions of several groups-insurers,hospital networks and regulatory groups.I would add that philosophical (ethical ) cover is provided by health policy experts who are attempting to change medical ethics from one in which the  physician has a strong,primary fiduciary duty to her individual patient to one in which the physician is obligated to act in the alleged benefit of the group.This attempt is exemplified by the New Professionalism initiative which is spearheaded by the American College of Physicians (ACP) and the American Board of Internal Medicine (ABIM and its foundation (ABIMF) and the Robert Wood Johnson Foundation (RWJF). Additionally, the movement for a "Population Medicine " approach  depends heavily on this sea change in medical ethics.Simply put- the population medicine approach is dead in the water unless physicians reject their traditional fiduciary duty to their patient.

Quoting the authors from their NYT article:

" Insurers, hospital networks and regulatory groups have put in place both rewards and punishments that can powerfully influence your doctor’s decisions.Contracts for medical care that incorporate “pay for performance” direct physicians to meet strict metrics for testing and treatment. These metrics are population-based and generic, and do not take into account the individual characteristics and preferences of the patient or differing expert opinions on optimal practice."

and later


"When a patient asks “Is this treatment right for me?” the doctor faces a potential moral dilemma. How should he answer if the response is to his personal detriment? Some health policy experts suggest that there is no moral dilemma. They argue that it is obsolete for the doctor to approach each patient strictly as an individual; medical decisions should be made on the basis of what is best for the population as a whole.




addendum: 12/27/14.Minor spelling and punctuation corrections made.