Friday, July 31, 2009

What might Hayek have said about Ezekiel Emanuel's "fair distribution of life years"

I do not claim to be an expert on the incredibly insightful writing of Friederick Hayek and certainly do not really know what he would said in regard to the system of allocation of health care that Dr. Emanuel and his co-authors at the NIH have proposed.(See here for their Jan 2009 Lancet article in which they describe and advocate for their "life years" system) but this quote from Hayek seems appropriate:

…the conception of a ‘value to society’ is sometimes carelessly used even by economists… there is strictly speaking no such thing and the expression implies [a] sort of anthropomorphism or personification of society…Services can have value only to particular people (or an organization), and any particular service will have very different values for different members of society. To regard them differently is to treat society not as a spontaneous order of free men but as an organization whose members are all made to serve a single hierarchy of ends (Law, Legislation and Liberty, vol. 2., p.75).









Wednesday, July 29, 2009

The "Complete Lives System"-why so little comment from the medical blogger world?

I missed this when it was published earlier this year in the Lancet and it was called to my attention in the blog "Junkfood Science". Here is the article in which Sandy Szwarc so correctly analyzes the Lancet in this entry of her blog which, by the way, seems to get better all the time.

The title of the Lancet article is Principles for allocation of scarce medical interventions.
I may have missed it but the medical ethics blogs that I regularly read seemed to have missed this or ignored it for some reason and the medical blogs generally have had little to say, with John Goodman (see here) and Sandy Szwarc being notable exceptions.

The basic premise seems to be that since someone or some entity must allocate scare medical resources there should be a "morally" acceptable method for such allocation. The authors, which include Dr. Ezekiel J Emanuel, brother of President Obama's Chief of Staff, and "Special Advisor for Health Policy" to the president presents a detailed proposal of how this allocation should be done. (Using the passive voice here serves the purpose or not having to say that the government will do the allocation.)

The authors begin with a critical review of the currently in existence allocation systems and finding flaws in each proceed to devise their own "hybrid" supposedly salvaging the good and casting out the less desirable elements of the various systems.

Expectedly, this "morally acceptable" allocation process would allocate less to the elderly and those with incurable illnesses. Perhaps unexpectedly, their process would place, for example, a fifteen year person allocation-wise above an infant because they say more social expenditures have been made on the adolescent and society need to get its money's worth.

The underlying theme is that individuals exist for the good of the collective ( state, society, pick one) and in health care decisions the greater good of society, now apparently denominated in "life years", trump the individual every time.

The authors describe their system:

This system
incorporates five principles ... youngest-first, prognosis, save the most lives, lottery, and instrumental value. As such, it prioritises younger people who have not yet lived a complete life and will be unlikely to do so without aid. Many thinkers have accepted complete lives as the appropriate focus of distributive justice: “individual human lives, rather than individual experiences, [are] the units over which any distributive principle should operate.”Although there are important differences between these thinkers, they share a core commitment to consider entire lives rather than events or episodes, which is also the defining feature of the complete lives system.

They explain further in regard to the old folks issue.

Unlike allocation by sex or race, allocation by age is not invidious discrimination; every person lives through different life stages rather than being a single age. Even if 25-year-olds receive priority over 65-year-olds, everyone who is 65 years now was previously 25 years. Treating 65-year olds differently because of stereotypes or falsehoods would be ageist; treating them differently because they have already had more life-years is not.

The blog Freerepublic.com summarizes the system in this way.

Infants get minimal treatment, because the State has not invested anything yet in their education. Old people get minimal treatment because their working lives are over.

So if you discriminate because someone is old that is ageism and invidious but if you treat differently because they have lived longer ( i.e. have had more life years) it is not. Talk about contrived nonsense.

Here is another quote that I find chilling.

the complete lives system assumes that, although life-years are equally valuable to all, justice requires the fair distribution of them.” (my bolding)

If you like social justice that sentence should really please you. Not only should most things be distributed fairly but now apparently how many "life-years" you get.

If you like distributive justice you will find a lot to like here. If you are old enough for Medicare or economically unfortunate enough to rely on Medicaid, you might be a little worried that the President's Advisor on health matters thinks this way.

It should be noted ,however, that Emanuel seems to believe that a two-tier system is ethically acceptable and he wrote the following about in 1996 :

... The fundamental challenge to theories of distributive justice for health care is to develop a principled mechanism for defining what fragment of the vast universe of technically available, effective medical care services is basic and will be guaranteed socially and what services are discretionary and will not be guaranteed socially. Such an approach accepts a two-tiered health system-some citizens will receive only basic services while others will receive both basic and some discretionary health services. Within the discretionary tier, some citizens will receive few discretionary services, other richer citizens will receive almost all of available services, creating a multiple-tiered system.

Link for the complete article for the above excerpt is here.

So, even though justice demands a fair distribution of life years, you can opt out of that distribution system by being rich enough.

After reading Dr. Emanuel's writings that seem to give his ethical blessing to a multiple-tiered system, my inner libertarian was somewhat relieved. Yet the chilling nature of the notion that life-years should be distributed fairly frightens the hell out of me.

Sunday, July 19, 2009

Should the symbol of Massachusetts Health Plan be the canary or the dead parrot?

An argument can be made for either candidate.

The canary,as in the canary in the coal mine, served as a early warning system for respirable hazards in the mines, and the experiment in Massachusetts in mandated health insurance can serve to demonstrate what might happen if the Mass. plan goes national as may occur with plans now being written in Congress. So far we have seen costs significantly higher than the plan's advocates claimed,significantly decreased access to care and most recently efforts underway to control costs cost by radically overhauling payment systems for medical care. The latest is a capitation plan which would turn the (at least) public portion of Mass-care into a big HMO with features that make regular managed care look like your overly generous uncle.

Economist Arnold Kling comments on the events in Massachusetts and the first comment in reply to his entry explains why capitation did not work when tried in the 1990s. Sandy Swarc at Junkfood Science has this detailed review of how badly capitation worked out and the implications and effects that a capitation system has on medical ethics.I have written before about the destructive effects of a HMO-capitation system on the physician-patient relationship and the attempts to redo medical ethical principles to be "better suited" for the statistical morality of group outcome data and payments directives based on them in which the physician is directed to care for the group's outcome and not be mired in the outdated belief in the primacy of the fiduciary duty to the individual patient.

The dead parrot also might be considered a mascot or symbol because of analogy to a classic Monty Python routine seen here. In this sketch the customer is complaining that the parrot he recently purchased is dead while the store clerk steadfastly maintains that the bird is sleeping or resting. The opponents of the Mass-care point to the rising costs and decreasing access to care as a failure while the advocates deny the bird is dead and scramble to devise more fixes to salvage a spiraling failure with more government controls and less patient choice and opportunity for physicians to use their judgment and care for their patients.

Friday, July 17, 2009

Can we really save the economy by spending more?

The Director of the CBO believes we can't at least not in the context of the spending involved in the health care bill. The administration's purposed health care re-do seems to go like this. Since the country will ultimately go broke if we continue top spend more and more on health care cost must be contained. This is expressed in the jaunty jargon of health care policy wonks as "bending the health care cost curve". To bend this curve the administration is recommending that we spend more on health care by making sure that all (well almost all) of everyone in the county have health care insurance. So how will this keep the country from going bankrupt?

Simple we will rely on the magic three: comparative effectiveness research (cer),prevention and use of electronic medical record (EMR) systems. Actually that appeard to be the gist of the original taking points points more recently there are varous tax increase proposals being formulated. Combining providing care for almost all with these three ( plus some as yet undecided upon package of increased taxes) will bring about a "budget neutral " economic miracle.Everyone (almost) will have health care and it won't cost anymore and the quality will be better and by not relentlessly increasing health care cost we will save the country from bankruptcy. QED.

Douglas Elmendorf, Director of the Congressional Budget Office testified before Congress and reminded everyone that the notion of there-is-no-such-thing-as-a free-lunch may still apply. He said in part:

".. bills crafted by House leaders and the Senate health committee do not propose "the sort of fundamental changes" necessary to rein in the skyrocketing cost of government health programs, particularly Medicare. On the contrary, Elmendorf said, the measures would pile on an expensive new program to cover the uninsured. (Quote is taken from this Washington Post article and the bolding is mine.)

Tuesday, July 07, 2009

New physician payment Rules for CMS,different slicing of a shrinking pie

New physician payment rules from CMS have been proposed, can be found here and will likely go into effect January 2010. The Obama administration has found money to increase the pay of primary care doctors a bit ( about 6-8%) by taking it away from other doctors. Radiologists and cardiologists will be paid less. DrRich comments on the understandable reaction of the cardiology leadership here. In the coming months we may get to see how effective the lobbying efforts of organized cardiology will be in their damage control.

Sandy Szwarz in this entry from her blog Junkfood Science sees more in this proposal that the simple pay-this-doctor-less-to-pay- this- doctor-more. She speaks of the vision of things to come. I quote from her posting:

The core of the new CMS proposals (described in section 1413-P33) was a new method for determining fees for services based on their costs (called “resource-based practice expenses”) and their relative value, as determined by a survey called the Physician Practice Information Survey (PPIS). This survey compiled the returned questionnaires from 3,656 physician and professional groups and had been conducted in 2007-8 by The Lewin Group, the contractor for the American Medical Association and the government.

It does not go unnoticed that the Lewin Group is part of Ingenix which is part of United Health Group.See here for some details of the flawed data used by Ingenix and some of the legal actions against them. It is not clear if the Lewin Group derived data used to determine the new pay scales are also flawed.

I recommend that everyone read the rest of her essay to get a flavor of the type of changes and emphasis we can expect in Medicare as the "reform" plays out.Look for emphasis on "lifestyle medicine"as a key element in the prevention part of purported ways to save money.

As suggested by Ms. Szwarz the plan is basically to cut funds to providers and hospitals and institute a covering of "quality" measures so the claim can be made-see we spent less and quality improved.Look, when we pay the bills , we get to say what quality is.

The change (aka "reform") of health care that is promoted by the administration promises to increase coverage and decrease costs while increasing quality by the magic of the triple whammy consisting of electronic medical records, comparative effectiveness research and prevention. It is instructive to look at what comparative effectiveness research has to say about the extensive efforts that have been made to prevent coronary artery disease by attacking multiple risk factors. This is what the Cochrane Group has to say about that.

In many countries, there is enthusiasm for "Healthy Heart Programmes" that use counseling and educational methods to encourage people to reduce their risks for developing heart disease. These risk factors include high cholesterol, excessive salt intake, high blood pressure, excess weight, a high-fat diet, smoking, diabetes, and a sedentary lifestyle. This updated review of all relevant studies found that the approach of trying to reduce more than one risk factor - multiple risk factor intervention - advocated by these Programmes do result in small reductions in blood pressure, cholesterol, salt intake, weight loss, etc. Contrary to expectations, these lifestyle changes had little or no impact on the risk of heart attack or death. Possible explanations for this are that the small risk factor changes are not maintained long-term or are not real but caused by some of the studies being poorly conducted. This review is based on the findings from 39 trials conducted in several countries over the course of three decades. Its authors discourage more research on the topic: "Our methods of attempting behaviour change in the general population are very limited. Different approaches to behaviour change are needed and should be tested empirically before being widely promoted. For example, the availability of foods and better access to recreational and sporting facilities may have a greater impact on dietary and exercise patterns respectively, than health professional advice."

As primary care physicians' practices have changed in large part due to the tightening of the reimbursement screws one of the effects has been the increased use of ER by the primary care doctors' patients ( in off hours and weekends) and/or those folks who cannot find a primary care doc to begin with. With this change one would think the increasing importance of the role of the ER docs should be evident to all including the policy wonks at CMS. Apparently they do not as their new pay schedule gives these figures for the ER physician and the chiropractor:EM docs are valued at $ 38.36 per hour versus chiropractors valued $65.33 a hour.