More and more to come on the concept of "value" in medical care

I have commented about this general topic before . See here.

The December 23, 2010 issue of NEJM has two articles on this topic. The first is from a member of the faculty of the Harvard Business School, M. E Porter and the second by T.H Lee. Dr. Lee is one of the NEJM editors and is also the network President for the Partners Health System.

Dr. Porter (Phd,Harvard,Business economics) is a widely published and widely quoted author.Concepts that he has popularized include: the Five Forces,the Value chain and the National Diamond model. In 2006 he co-authored a book with Elizabeth Teisberg entitled Redefining Health Care: Creating Value based Competition On Results.


Porter defines value as outcome achieved per dollar spent or value = outcome/cost. He has stated that health care should be restructured to consist of interdisciplinary teams to provide the outcome with the best value across "the full spectrum of health care". Having said that I am puzzled when he says that value is not an abstract ideal.To me that certainty sounds like an abstract idea because as pointed out in the second article in a understatement :

"No one should expect the value framework to be easy to implement.The measurement of outcomes and costs,the organization of clinicians into teams focused on improving care for patient populations,the evolution of a payments system that rewards providers who are more effective in improving the value of their care-they are all formidable tasks."

Formidable indeed. A reorganization of much or most of the medical system to one that conforms with Dr. Porter's conception of how it should be would be required.

I cannot help but be reminded of Will Roger's prescription for fixing the German U-boat problem -boil the oceans. Supposedly, when pressed for details he replied, in typical consultant fashion, he was an idea man and the engineers would have to work out the details. With the value framework model many details would have to worked out and then we could see how it would work and compare real world stuff with academic theorizing. We need to do it to see how it works.I've heard that somewhere before. Is there somewhere in the value framework some input from how much the patient values the service?

Waiting times in Canada for doctors-getting worse

During the last half of 2010 both my wife and I developed some ocular symptoms at different times. I developed more floaters and flashing lights and my wife developed some wavy lines in her visual fields. She called around 10Am to a local Eye group and was seen that day about 4PM by a retinal specialist-Diagnosis ocular migraine. When I called at 8am to the same group I was able to see a retinal specialist at 2PM-diagnosis posterior vitreous detachment with no signs of retinal detachment. Both were not actually emergencies but we were both glad we could be seen so soon and reassured.

Granted we live in a large metropolitan area with no shortage of medical specialists but even so the ease of seeing not just an eye doctor but retinal specialists was impressive.

It is an interesting contrast with recent data published by the Frazier Institute in Canada regarding wait times there to see medical specialists. See here.

Much data is presented and the entire report can be accessed. Here are some samples.
Wait time varies by specialist. For orthopedic procedures there was 35.6 week wait but happily "only" a 4.9 week wait before getting oncology treatment started. There was some good news the wait for psychiatry consultation nominally decreased from 16.8 weeks to a prompt 16 week wait.

h/t to the blog westandfirm

Does Obama care mean Medicaid type care for most-except the rich,

Tyler Cowen, economist from George Mason University,gives his views in this commentary which describes the effects of different payment schemes for medical services.


"Wealthy people will always be able to buy most of what they want. But for everyone else, if we stay on the current course, the lines are likely to get longer and longer.The underlying problem is that doctors are reimbursed at different rates, depending on whether they see a patient with private insurance, Medicare or Medicaid. As demand increases relative to supply, many doctors are likely to turn away patients whose coverage would pay the lower rates.

Since private insurance pays more per service than Medicare which pays more than Medicaid, physicians will increasingly attempt to structure their practices so that they can see more of the higher paying patients and less of the lower paying ones. This trend will increase with the pressures on demand for medical services brought about by ACA. Millions more patients will have insurance cards, more on Medicaid and more receiving cards from the insurance pools but there cannot be a corresponding increase in the number of physicians available to treat the new patients.

Simply put, more docs will restrict the number of Medicare patients they will treat. In fact, as the numbers of Medicare patients in a given internists practice increases the less viable is his practice from an economic viewpoint.I can illustrate that point with an anecdote from personal ( well second hand) experience.

My brother, also a retired doc, was recently told by his internist ( who also is approaching retirement ) that one of his partners "has to retire" because his Medicare patient load in his practice has reached the level at which he can no longer meet the income volume requirements of the practice. This, according to the back of the envelope calculations for that particular practice setting, is 42%.A recent survey by Merritt Hawkins quoted here, reports that 87% of physicians surveyed indicated that they will close or restrict the number of Medicare patients in their practice with a slightly higher number reported in regard to Medicaid patients.

Cowen continues saying:

Most people would end up with low, Medicaid-like reimbursement rates, and would endure long waits and low-quality service. But wealthier people could jump the line by paying more. Think of “Medicaid for everyone” but the rich.

Someone described Obama care as "robbing Peter to pay Paul" with Medicare patients playing Peter and Paul being the previously uninsured who gain insurance cards from the legislation. But with the effects of the looming shortage of primary care physicians it looks like both Peter and Paul can look forward to longer lines and poorer quality care. So while Peter gets robbed, Paul is paid little or nothing.

Price Controls in Medicine-Reality tends to support theory

What is the theory? Answer-price controls tend to 1)cause shortages,2) decrease the quality of the good or service controlled 3) increase demand and 4) encourage the development of black markets,bribes and other "work-arounds"

I am aware of all but number 4 happening in regard to Medicare in the U.S. Now we have apparent examples of black markets (or at least bribes) happening in the setting of the price control health care in Canada. See here for a discussion by Canada born economist, David R. Henderson writing at the blog Econolog.

The news story in the Montreal Gazette describes OB docs in Canada taking side money to guarantee that they will be available at the time of the delivery.

One commenter to the blog entry wondered if U.S. patients, after Obama Care really gets going,will be able to go to Canada to offer side payments to get their treatments there sooner than they could here due to the long lines that will develop when millions of more insurance card carrying patients compete for what will be a vastly too small supply of primary care docs. Actually the problem is already worse as seniors struggle in some areas to see physicians. See here for comments regarding that.

Dr. Don Berwick "answers questions" from senators

Due to Obama's interim appointment of Dr. Donald Berwick to lead CMS, before last week he did not have to appear before a Senate committee.Now he has. I had planned to pontificate about the encounter which seemed typically void of content but Dr. Doug Peredina at the Road to Hellth Blog has already offered an excellent commentary.See here. If you need a sleep aid and have no Ambien on hand you might go here and read and see the video of the prepared comments of the two lead Senators and Dr. Berwick.

What are the plans of Don Berwick's "leaders with plans"?

Dr. Don Berwick,head of the Center for Medicare/Medicaid Services (CMS),has made clear his views on how medical decisions should be made and on what kind of health care system the United states should have.This quote from a book he co-authored with Dr. Troyen Brennan,entitled New Rules leaves little room for ambiguity:

"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.
Berwick in a laudatory address to the British NHS said that we need "leaders with plans" to design and reform the U.S. health care system. He said that"excellent health care is by definition redistribution". See here for a portion of speech praising the British NHS for in which the "redistribution " quote appears.

A likely candidate for such a leader with plans is Dr. Robert A .Berenson.

I first became aware of Berenson's ideas in an important and to my mind- startling at the time- commentary in the Annals of Internal Medicine published in 1998. ( M Hall,and R. Berenson, Ethical Practice in Managed Care.A dose of Realism. Annals Internal Medicine 1998, 395-402.) Here is a quote from that article:

"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 and his law professor co-author were proposing a complete revision of the medical ethics that existed from hundreds of years.This fiduciary duty to the individual patient should be replaced by a nebulous co- duty to the collective to which the individual patient belonged. As outrageous as that appeared to someone trained in the traditional medical ethics, an obligation to serve the greater needs of society and to balance that against the individual patient's welfare has appeared to be widely accepted by various medical organizations. See here the New Professionalism as promulgated by the American College of Physicians.

Dr. Berenson's resume includes considerable work in the area of public policy regarding health care and he has served on a number of policy committees for the American College of Physicians. He served in one capacity or another in the Carter and Clinton administrations and was a member of the transition team for President Obama. He held a position with HCFA (April 1998 to October 2000) and according to his resume posted on the website for the ECRI Institute, see here , he was a vice president at the Lewin Group from 1997 -1998 before joining HCFA.

The Lewin group is part of Ingenix which is a subsidiary of United Health Group.That seems to place him at the Lewin Group in the general time frame of the Annals article publication referenced above. It is of interest that the authors' affiliations listed on the article included only a position at Wake Forest Medical School for both Hall and Berenson. ( I could not determine the exact timing of the article as relates to his time with Lewin so at the time of the publication he may well have not been affiliated with Lewin.)He was appointed as a commissioner for MedPac in July 2009 and in July 2010 became a vice-chairman of that organization. The role of MedPac after the-likely-to- be -very- powerful Independent Payment Advisory Board (IPAB), created by PPACA , becomes operational is unclear.

He is clearly a leader and certainly one with ideas and plans. A recent commentary published in the NEJM gives insight to some of his current ideas. In the Perspective section of the July 8,2010 issue of NEJM he submitted a piece entitled "Implementing Health Care Reform-Why Medicare Matters." ( NEJM,vol 363,no.2,p101-103).

While discussing the issue of medical costs and cost controls he talks about the "growing power of [medical service ] providers" (ask most physicians how much market power they have) and since Medicare price controls, already in place now for almost 20 years, won't control total medicare expenditures " 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".

The operative words there are "at least for now".

More on that appears in the next commentary in the same issue. ( "The Independent Payment Advisory Board : by Timothy S. Jost, J.D.) He says in part that as long as the gap in reimbursements between private insurers and CMS continues to grow physicians will increasing abandon Medicare. He closes with this:

"In the long run, Congress may not be able to cap Medicare expenditures without addressing private expenditures as well. If the IPAB opens the door to rate setting for all payers,it may well be the most revolutionary innovation of the ACA".

Price controls for private medical care would do what economics 101 says price controls do generally. There will be shortages, decreased quality and black markets and other methods to evade the restraints. We have seen the first two in the price controls for Medicare/Medicaid.

I wonder which is worse- a medical policy  leader recommending price controls out of ignorance of basic economics or being aware of the likely outcomes and make that recommendation anyway?

 addendum: Minor editorial change made 5/3/15

Could there really be a down side to the availability of inexpensive generic medications?

A recent commentary in the NEJM talks about unintended consequences of the 4 dollar generics that are becoming increasingly available. Go here for a news report about the concerns expressed by two researchers from Harvard and an audio interview with one of the authors.

Their concern is that with low cost medications often paid for in cash that the data bases used for various purposes will be even less reliable that they are currently . These data bases are used for such things as pay-for-performance and various programs which purport to be quality improvement efforts .Apparently with these cheap prescriptions many pharmacies do not file claims with the pharmacy management companies and insurance companies.

This might translate into less control by the pharmacy management companies and could possibly diminish the value of the services they sell to large insurance companies and the companies that self insure.

I find myself with little sympathy for what they claim is a dark lining in an otherwise silver cloud of cheaper medications and will have even less for the "solutions" that may fix the "problem". It seems to be a problem for the pharmacy management companies and not so much for the patients who spend less on their prescription medications.

At least some of the secrecy of the mysterious RUC is revealed

See here for an enlightening article from WSJ that goes -at least to some degree- behind the veil of the powerful AMA brain child, the RUC.Well, at least we are told who is the current chairman of the RUC and that she gave out baseball hats with "RUC" on the front and organized bowling for team building. This is encouraging to those who felt a major problem with the RUC was lack of baseball hats and bowling.

Once again kudos to the tireless Dr. Roy Poses for his continuing efforts to shine light on the AMA's RUC which plays a key role in dividing up the Medicare physician payment money which itself is limited by the price controls in place since 1991. Go here for his latest review of that situation and information about some recent efforts that have been somewhat successful in revealing what goes on behind the RUC veil.

We have had central planning in place for Medicare physician payments for almost a decade and we continue to see the consequences,both intended and unintended,not the least of which is a shortage of primary care physicians.

Pay for performance (P4P)-Goodhart's law aside is it unethcial?

This is a re-edited and lightly re-written version of a posting I made several years ago. Several years have passed and P4P has gone from a trial balloon to a more and more generally accepted fact of medical life, even though there continues to be cogent arguments in opposition to it and the broader bogus concept of "quality" measures.

Dr. Edmund Blum, an internist from Brooklyn makes the argument that pay for performance (P4P) involves a "irresolvable conflict " with the ethical standards of the medical profession.( American Medical News,Nov. 6,2006 issue in their "Professional Issue Section.) My bolding.


He says that P4P rests on 3 flawed premises or fallacies the most important of which is that P4P is consistent with medical ethics. He argues that it is not. (The other 2 fallacies are:P4P rests on a valid statistical foundation and P4P will improve the safety and quality of patient care). To those I would add a 4th namely that Goodhart's law would not be operable in the medical care setting.It has definitely been shown to operate there as well.

I quote:

"[medical] standards derive from a core of fiduciary responsibility, in which one person, the patient, depends on the superior knowledge and skills of another, the physician, and places complete confidence in that person in regard to a particular transaction-in this case, medical care."

"The fiduciary is held to a higher standard of legal and moral conduct and trust than a stranger or a business person...[This] obligates the physician to do his or her best for the patient regardless of reward.The duty goes beyond the 'due care' standard or tort law to a higher level of loyalty and commitment that is not contingent or rewards or penalties."

The idea of P4P involves an assumption that "the fiduciary relationship is insufficient motivation for the physicians to do their best."

To accept P4P is to accept the notion that physicians have not already been obligated to do their best for the patient and to place patient welfare above financial rewards and that they have to be giving a tip or a bribe to do their job. Dr. Faith Fitzgerald was on target when she said

" We must not servilely accept gratuities for doing our duty."

A few decades ago,I began the transformation from a lay person to a physician. Part of what was branded into my limbic cortex in that several year long process was the responsibility physicians have for their patients, a responsibility to do what is right for the patient,a responsibility to place their welfare above personal financial concerns. That responsibility cannot be canceled by a purported imperative to somehow also act as a steward of "society's resources" and work for social justice as the New Professionalism Charter implores.(See here for DrRich's comments on what that Charter has done to medical ethics).The prime directive was-and still should be- an individual physician's responsibility is to the individual patient .

The acceptance of P4P is so antithetical to the basic medical ethical tradition that I cannot believe professional organizations of physicians are supporting it, but they have -almost all of them have at least expressed written support. Tacit support of and advocacy for for P4P is equivalent to saying the ethics and culture of physicians are not adequate and to provide good clinical care it is necessary for third parties to proscribe behavior and reward and sanction accordingly. To sanction such thinking, in the words of Dr. Blum, is to "push us farther down the slippery slope to professionalization".

I am more pessimistic.We may already be at near the bottom of the slope and I see effort being made by relatively few physicians to try and climb back up.

Not what Dr. Berwick might want but more market based health care

More clinics are appearing in drug stores and groceries across the country providing quicker and cheaper health care with much shorter wait times for appointments. See here. ( h/t to economist Mark Perry's blog,Carpe Diem)
There are said to be about 8,700 of these urgent care clinics in the country.


These are not exactly the ACOs that are being heralded by some of the self appointed medical elite, the "leaders with ideas". The mini-clinics business models is somewhat simpler and more transparent than the Under Ware Gnome business plan of the ACOs.

ACO and HMO,A distinction with or with/out a difference -Are ACOs an example of Underware Gnome economics?

The current concept of an Accountable Care Organization (ACO) seems to have arisen at a 2006 meeting of MedPac and Dr. Elliot Fischer of the Dartmouth Atlas.See here for the 400 page transcript of the meeting.

A good place to begin an inquiry into HMOS v.ACOs is this entry by Jason Shafin,Phd Economics,on his blog Health-care Economics who discusses three difference between the two.

Dr. Robert Berenson,of the Urban Institute and of the Center for Studying Health System Change (HSC) and now a vice chair of the soon-to-be a very important player in health care ,namely the IPAB) co authored this article which is barely luke warm in its support of the ACOs and is even skeptical. See here for more on this center for HSC.

A later article he co-authored with two colleagues from the Center For Study of Health System Change went further and issued the warning that large vertically integrated organization such as ACOs can actually drive up health costs and offered the suggestion that price caps ( aka price controls) might be necessary.ACOs are, of course,said to be a means of increasing quality and decreasing costs at the same time.


A terse characterization of ACOs was offered by Dr. John Goodman in a comment to Dr. Shafin's above mentioned blog entry - " An HMO on steroids"

Two big issues with ACOs are market power and anti-trust concerns.So Far the FTC is still mulling over the rules of the game. See here.

I suggest a major difference between HMOS and ACOs is that the legal aspects of HMOs are well defined as are the regulatory rules while the rules for ACOS are yet to be written. There is so much uncertainty around almost every aspect of ACOs I am reminded of the South Park 's Underwear gnomes whose business plan is as follows:

Step 1.collect people's underwear
Step 2.???
Step 3.Make money

with ACO's business model being

Step 1.set up ACO
Step 2.???
Step 3.save money and increase quality of care

or perhaps

this version of the business plan of ACOs from WebMd is a more accurate description:

Step One: 'Provide connectivity and a full suite of services to the healthcare industry that improve administrative efficiencies and clinical effectiveness enabling high-quality patient care.'

Step Two:

Step Three: Profit.

Yes, step two is blank.

"The Secretary (HHA) shall determine"...can we all have a waiver?

According this editorial from Investors Business Daily, about one million workers have been spared a loss of their employer sponsored"minimedical" insurance, at least for the next year or so, until long after the November 2010 elections.

That is number whose insurance coverage has been "saved" by the waiver given by the Secretary of HHS.This includes 115,000 from McDonalds and 350,000 from the United Federation of Teachers Welfare Fund and according to IBD some 28 other companies or entities.

Quoting from IBD:

"How do you get a waiver from a law, anyway? This law was passed by elected representatives of Congress. How can unelected bureaucrats say some must obey this law but some don't have to?

Well, in lieu of specific guidelines in the law, it is riddled with the phrase "the Secretary shall determine." Which means we serve at the whim of the secretary of health and human services, currently Kathleen Sebelius."

Rule of law or rule of whim or of political expediency. This is likely just a sample sample of the many determinations that will be made by the HHS Secretary as ACA unfolds.

More welcome light shined on the problems with the"New Professionalism"

Kudos to Doug Peredina over at the blog roadtohellth with this commentary on medical nannies,the activities of CVS Caremark alone those lines and the broader topic of the problems with the new medical professionalism, also known as the "new ethics", a topic of considerable concern to me and one about which I have ranted repeatedly.See here and here.

Dr. Peredina discusses a lawsuit filed against CVS . Dr. Troyen Brennan is the CMO and executive vice-president of CVS Caremark. The following is a quote from the book "New Rules" which was written by Dr. Brennan and the current head of CMS Dr. Donald Berwick. They are discussing the physician patient relationship and say the following:

"Today, this isolated 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.”

In 2007,Dr. Brennan,then the executive vice president of Aetna cowrote an article in JAMA entitled "Managing Medical Resources. A return to the medical commons" which I blogged about ( see here) and I said in part:

"They speak of an abstract hypothetical " medical commons" and how the current emphasis by the physician on the welfare of the individual patient will spoil the commons much as the farmer who selfishly grazes his cattle on public land without regard for depleting the resource will destroy the resource.Physicians are implored to "reconstitute the medical commons" and think in terms of resource conservation and allocation so at the end the greatest medical good can be done for the greatest number of patients.They admit there is not currently such a commons. There never has been so I am unsure how a return is possible."

With this increasing constraint of decentralized individualized decision ( translation-individual docs advising individual patients about a course of action) someone else must make those decisions. Do you think the folks at insurance companies and pharmacy management companies might enjoy that role? Isn't it interesting that the head of CMS and the vice-president of a pharmacy management company share the same view of the "proper"role of the physician?

Also kudos to DrRich at his blog Covert Rationing Blog with this thoughtful and important criticism of the new medical ethics, in which the traditional physician patient relationship with its fiduciary duty of the physician is being replaced with a nebulous duty to society . Also DrRich-in his real life persona of Dr. Richard Fogoros- hosted a discussion on Sermo which from my vantage point was well received and he did an admirable job in fielding a variety of questions. It is instructive and worrisome that a number of the physicians writing in had not even heard about the New Professionalism. If you have not, go here to read about it in the original.

Also kudos to Dr. Beth Haynes at the blog Blackribbonproject for this entry concerning various aspects of the attack on the traditional physician-patient relationship.

This important topic deserves all the attention it can get.

Is government by whim the social justice that Obama advocates congratulate themselves about?

Obamacare mandated a percentage of premiums be used by health insurance company for patient care. Several large employers ( McDonalds and others) complained that would not allow them to continues to offer low premium health coverage to their lower paid employees.( It should be noted that there is some controversy if McDonald really complained or not, but that is not the major point).

The point is that the Secretary of HHS, Kathleen Sebelius waived the requirements for one year for certain employers and one large union welfare fund.

Ed Morrissey made this comment regarding this incident:

The Rule of Law depends on an environment with clear regulation and unbiased enforcement. From the start, ObamaCare lacked any clarity in regulation. Congress filled the bill with the phrase "The Secretary shall determine" in place of establishing rules and regulations for the massive regulatory regime Congress created. Now, the White House has added arbitrary enforcement to uncertain regulation and opaque processes. This is not the Rule of Law, but the Whim of Autocracy.

Obamacare contains hundreds of pages with anything but clear regulation and to expect unbiased enforcement is to believe in the power of fairy dust so much power being given by the four little words found throughout the bill "the secretary (of HHS) shall determine".

Both the AMA and ACP have congratulated themselves for their support of the bill because it served "social justice".

Are the actions of the HHS secretary an example of this social justice? Social justice by favoritism (catalyzed by the proximity of the upcoming election in this instance) is what they got.

What else they ( and all of us) may have gotten is more regime uncertainty. This is a term or concept developed and emphasized by the economist Robert Higgs. Higgs's thesis is that at least an important element in the prolongation of the great depression was the business uncertainty brought about by the actions of FDR. Simply put they were afraid to invest because they didn't know what the administration in Washington would do next. See here.

Higgs suggest a similar situation exist now. We have had some but not all major financial institutions bailed out with tax payers money,we have had some auto manufacturers bailed out and we now have some employers exempted for some provisions of a massive new law with powers so sweeping that one of its major effect is a deep and wide uncertainty.

Nancy Pelosi's comment that we have to pass the bill to find out what is in it was only partly true.When enforcement or administration of law is arbitrary we will be finding out piece by piece what it means with no way of predicting what will happen next.

Dr. Don Berwick addresses leaders of ACP, Tells them top-down government mandates won't work

Some would find that headline hard to believe. I do.While I believe the message I am surprised by the messenger.

It is hard to believe that the head of large government entity (CMS), which is noted for its top down mandates would express such a view. It is hard to believe that someone who heaped praise on the British National Health Service,also well known for its well known history of mandates, would hold such a view.

It is hard to believe that someone who has said that a health care system must,he emphasized the word "must", involve redistribution would say that. To achieve redistribution there must,now I emphasize the word "must", involve government mandates.


Berwick's address to the American College of Physicians Board of Governors was discussed in a blog entry by Bob Doherty,ACP's man in Washington, in his blog "The ACP Advocate Blog" See here for that entry.

There is much in Dr. Berwick's writings that strongly suggests his high regard for "rules with authority" and low opinion for the traditional doctor-patient relationship . The following is a quote from the book,"New Rules" which he co-authored with Dr. Troyen Brennan.

"Today, this isolated 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.”


He advocates regulation,rules with authority, constraint of individualized decision making and reformulating medical ethics. Clinical decisions, in this view, should not be in the hands of the patient and his physician. These views are clearly those of someone who believes in authoritative control over those clinical decisions, so if he believes that government top down rules won't work then he must envision some other,non-governmental system of controls.

Indeed, he has talked about vertically integrated medical systems which can seek out cost effective treatments and coordinate care referring to such things as accountable care organizations,and medical homes.So could he possibly think that they will be the source of the mandates rather than the federal government? The promotion of such organizations was a major theme of a recent article in the Annals of Internal Medicine by three member of the current White House staff which I blogged about here.

With the passage of the health care remake bill and the birth of scores of federal entities with the power to issue mandates and the unprecedented power given to the secretary of HHS to make mandates what else could possible happen but that medicine as it will be practiced will be medicine by federal mandate?

Mr. Doherty's interpretation of what Dr. Berwick has written is that Berwick believes that change must come from the bottom up. It is true that Dr. Berwick has earned an excellent reputation for working towards and catalyzing grass roots innovations to improve patient care and much of his rhetoric is consistent with that effort and promotion of that idea.

However, he is not leading a organization devoted to grass roots solutions but rather one whose history and thrust and machinery has and will continue to issue and enforce orders from the top.

Have we heard from Dr. Berwick any plans to dismantle the current CMS system of command and control?What will be the relationship of these vertical organizations to the central control systems of CMS and those created by the health care bill? Will they be the administrative arms of the central controllers?

Whatever vertically integrated entities emerge and regardless of the relationship of the accountable care-type organizations to the government particularly troubling to me is that the "bottom" of Berwick's bottom up solutions is not all the way down, namely to the level of the individual patient and the individual doctor as he has made it clear that the traditional doctor-patient relationship needs to be replaced."This relationship is no longer tenable or possible".

It is hard to say it better and simpler than the following questions posed by Dr. Edmund D. Pellegrino (JAMA,May 24/31/1995,Vol. 272,no 20)

" Is medical ethics a social, historical, or economic artifact? Or are there some universal , enduring principles?

Was the traditional physician-patient relationship with the strong and controlling fiduciary duty to the patient's welfare merely an artifact of an earlier economic time which was largely free of the third party payer hegemony? Fee-for-service and the traditional physician fiduciary duty are the two major enemies to centralized (private or public) control over medical care.

Avandia just barely hanging on and now Actos accused of increasing risk of bladder cancer

The TDZ's seem always to be in the news,the bad news. First, Rezulin was taken off the market because of liver toxicity.Next, the issue of Avandia increasing the risk of heart attack arose and arose and arose and seemingly the issue will never be settled. Now Actos is being accused of increasing the risk of bladder cancer.

Most recently the FDA has taken action to strictly limit its use and make it fairly difficult for a new patient to be prescribed that drug. In Europe, apparently it will be taken off the market and folks currently taking that medication will have to be switched to something else.

An interesting action taken by the FDA is to require GSK to commission an independent "re-adjudication" of the RECORD study. This was the clinical trial with 4447 patients in which rosiglitazone (Avandia) was compared with the combination of metformin and a sulfonylurea and concluded that results was inconclusive in regard to what everyone was interested, namely cardiovascular outcomes. Somehow the FDA expects more analysts looking at the data will turn the inconclusiveness into some conclusions. More likely it won't but then maybe everyone can move on and worry about some other adverse effect of something else.

FDA's reasoning seems to be that if these new adjudicators can get an answer then the TIDE trial ( still another trial that the optimists think will settle the issue) will not have to be taken off of hold. The FDA put TIDE on full clinical hold.

Several years ago when one attended the infomercials with food ( AKA drug company sponsored CME -dinners) several speakers could talk about little else but the PPAR receptors and after much time and money was aimed at doing something really good therapeutically with those receptors little was accomplished. See here for some comments by a research insider about the PPAR story.

Early on in the Avandia kerfuffle I went on and on about the issue of "small"increases in relative risk and how is relatively easy to tell a big thing from a little thing but how difficult it is for epidemiology to tell a little thing from nothing at all. The original Nissen and Wolski paper talks about a relative risk of 1.43. With risks of 3 and 4 there is typically little to argue about. With RRs less than 2 it seems we go round and round for a long time before the combatants run out of stream.

What is fate of physician-patient relationship in a Don Berwick designed health care system ?

The following quote from the book Dr. Berwick authored with Dr. Troyen A. Brennan,which is frighteningly entitled , "New Rules" answers the headline question. (see here for a review of that book published in the NEJM)

H/T to the blog " Black Ribbon Project"

“Today, this isolated 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.”

I have expressed my concern abut Dr. Berwick views before and one such commentary was re-e-published by Kevin,M.D. with my permission. One of the replies to that entry on his web site accused me of taking his remarks " out of context". While it is true that remarks and words and phrases can be cherry picked to give an impression contrary to the speaker's intentions I offer a friendly, rhetorical challenge to anyone who can propose a context in which Berwick's words could be said and not mean anything other than their obvious meaning. OK, I can think of one and it is trivial. The author precedes that paragraph with the words "I do not believe the following".

Berwick's and Brennan's views dovetail with the ground work constructed by the "New Professionalism" (see here for the details of that project ) which implores physicians to somehow balance their duty the patient with some nebulous responsibility of stewardship to take proper care of society's limited medical resources and strive for social justice. Dr. Troyen Brennan was the chair of the Professionalism project. In fact Dr. Brennan name crops up more than once in a narrative of the transformation of medicine in which medical care is taken from the hands of individual physician and into the control of various organizations.

In 2002, Dr. Brennan's new Professionalism was revealed to the world in the Annals of Internal Medicine ( see the above link). (OK, it wasn't just Brennan's,others played a role.)Physicians were admonished to work for the good of society and not just be concerned with the parochial concern for their own patients.

In 2006 Brennan and Berwick published the book, "New Rules". The operative word is "rules".

In an Article in 2007 (JAMA,Vol 208,#6,p 670) Drs J. Cohen, ,S. Cruess, and C. Davidson report their " discovery " that individual docs basically could not resolve the ethical dilemma posed by balancing their efforts for the patient's welfare with their duty to work for the good of the herd. ( see here for my comments on that article) What was needed was a "Medical Societal alliance" which could be made manifest through large vertically integrated organization such as something called an "Accountable care organization (ACO). Note, the old medical ethics had no major, crisis -level conflicts it was the New Ethics that posed the problem that the author purport to remedy with their nebulous alliance between collective abstractions.

Another article in JAMA in 2007 carried this theme further. The article was written by the then President of the American College of Physicians, Dr. Christine K. Cassel and the then executive vice-president of Aetna Insurance, Dr. Brennan. (JAMA ,June 13, 2007, Vol 297, no. 22, p. 2518, "Managing Medical resources.Return to the Commons")

They speak of an abstract hypothetical " medical commons" and how the current emphasis by the physician on the welfare of the individual patient will spoil the commons much as the farmer who selfishly grazes his cattle on public land without regard for depleting the resource will destroy the resource.Physicians are implored to "reconstitute the medical commons" and think in terms of resource conservation and allocation so at the end the greatest medical good can be done for the greatest number of patients.They admit there is not currently such a commons. There never has been so I am unsure how a return is possible.

The medical commons figure of speech seems bizarre and lame.While a grassy knoll for the villager's sheep can be defined by a specific surveyor description, the "medical commons" is a extremely large amorphous array,the elements of which defy enumeration, and is every changing, with some elements growing ,others contracting and innovations cropping up constantly. Various entities own various elements of this array-society owns none.The skills,and knowledge of thousands of physicians are aggregated and then allocated as if somehow society own them.There is no easily defined entity called "medical resources". Rather,it is an amorphous abstraction.Further, to speak of allocation means some one or some elite group will be the "allocator in chief ". Decisions will not be made by thousands of individual physician-patient pairs, since those individual physician-patient pairs plans to spend money are the worse nightmare an officer of a health care insurance company could have. Is anyone surprised that an officer on a large medical insurance company would propose a plan to eliminate the pesky problem of physician-patient "dyads" scheming to spend the insurance company's money simply because the two agreed such expenditure would be in the patient's interest?

The old follow-the-money strategy continues to have explanatory power. but why would the leadership of the ACP take part in that philosophical sham?

Is more primary care really not the answer to all that ails U.S. medicine after all?

A recent WSJ article reports a Dartmouth Atlas study (DA study) that seems to cast at least a little doubt on the thesis that the key to good health care is lots of primary care docs. See here. See here for a more detailed discussion from the blog ACP Internist about the findings of the DA article.

So ,why are the indicators of good care used by the Dartmouth folks not better in an area where more primary doctors are available? The authors make several suggestions? I offer another. Maybe use of aggregate data often makes things less rather than more clear. A similar argument has been raised by some economists in their criticism of the major role of aggregate demand in Keynesian economics namely that the aggregation obscures more than it clarifies.

OR maybe the indicators purported to be of quality care are little more than something chosen because it was easy to measure and the data were available.

I think the real bottom line in regard to this Dartmouth publication is found in the authors' hypothesis that perhaps primary care is really the answer to much of what ails medicine only if that primary care is integrated into a larger system of other health care providers. This is the it-takes-a-village-to- provide -health- care type thinking. Can you say Accountable Care Organization (ACO)?

For the centrally managed health care that Obamacare portends to succeed at least one obstacle has to be overcome. That obstacle is the thousands of individual primary care docs out there practicing outside of the control of an organization such as an HMO,giant clinic or ACO. The Dartmouth publication could be part of a emerging argument similar to that put forth in a recent article in the Annals of Internal Medicine written by members of the administration urging physicians to get on board with the [Obamacare] program. See Dr. Rich's recent commentary about that article and what the message of that was.

What follows is a quote from the White House authored Annals Internal Medicine Study followed by a quote from one of the authors of the DA study.

"These reforms will unleash forces that favor integration across the continuum of care. Some organizing function will need to be developed to track quality measures, account for and manage shared financial incentives, and oversee care coordination…"


"Our findings suggest that the nation's primary care deficit won't be solved by simply increasing access to primary care, either by boosting the number of primary care physicians in an area or by ensuring that most patients have better insurance coverage," said David C. Goodman, MD, MS, lead author and co-principal investigator for the Dartmouth Atlas Project. "Policy should also focus on improving the actual services primary care clinicians provide and making sure their efforts are coordinated with those of other providers, including specialists, nurses and hospitals."

So, an "organizing function" is needed and someone/ something needs to make sure efforts are coordinated.

The message is that medical care is too important,too complicated, too whatever to be left to the individual patient and his physician.

Here is an earlier quote from the DA folks from there website.

"The availability of excellent primary care is central to high performing health care and favorable patient outcomes. Unfortunately in many regions of the country, residents cannot find the care they want and need."

Attorneys like to find expert witnesses making apparent contradictory statements so they can ask the old classic: Were you wrong then or are you wrong now?

Annals Internal Medicine publishes Obamacare advocacy commentary -I am shocked,shocked

The Annals of Internal Medicine published an article ( see here for full text) authored by three current or former members of the Obama administration .It is difficult to consider it anything other than advocacy for the health care law ( The bill is now generally known as ACA or Affordable Care Act.) The article, first appearing on line, lead to a flurry of negative comments from readers See here.

The authors are: Dr.Ezekial Emanuel,brother of Rahm Emanuel who is President Obama's chief of staff,Nancy-Ann Deparle ,Counselor to the President, and Dr. Robert Kocher. Kocher who recently resigned from the President's Council of Economic Advisers to return to the McKenzie group, was the lead author.

The article begin with this incredible statement, " It guarantees access to health care to all Americans."

However, it is well recognized "all" will not be covered. There is a group of people too prosperous for Medicaid but who are not required to buy insurance because their income is too low to trigger the mandatory insurance purchase mandate.This has been well covered even in the mainstream press so it is difficult to imagine that Dr. Kocher and his co-authors were not aware of that fact.The Congressional Budget Office estimates 17 million Americans would remain uninsured.

Dr. Kocher joined (and is now departed from) the President's National Economic Council after having lead a team from the business consultant company, the Mckensey Group, to study health care systems in various countries.See here for the publication co- authored by Kocher.

The attribution section of the Annals article ( the part that explained which author did what in the preparation of the article) makes it clear that the principle author was Dr. Kocher., who since the Mckensey article, is considered an "expert" in health care cost and cost controls.

A recent town hall meeting between voters and Senator Max Baucus lead to an exchange in which the senator told the audience that he had not read the health care bill and that was left to the experts.

Said Baucus: "I don't think you want me to waste my time to read every page of the health care bill. You know why? It's statutory language. We hire experts."

From the glaring factual error in the Annals article it seems that at least one expert hasn't read the bill either.

The Little Book of Obamacare Horrors-a guide for the worried (most folks)

Go here to read a publication from the folks at the NCPA telling the readers much they need to know about PPACA.

It is a welcome counterpoint to the rosy and in parts misleading picture painted in this publication from CMS.

For example, CMS talks about the changes in Medicare Advantage in the following way in a section astoundingly labeled as "Improvement to Medicare Advantage". ..." The new law levels the playing field by gradually eliminating Medicare Overpayments to insurance companies." Contrast that characterization with the following from the NCPA booklet:

Loss of Medicare Advantage Coverage. About half of the enrollees in Medicare Advantage (MA) plans (7½ million people) are likely to lose their coverage and will be forced to return to conventional Medicare. If you are able to keep your MA plan, expect higher premiums and fewer benefits. ...Of the 15 million people expected to enroll in Medicare Advantage programs, 7½ million will lose their plans entirely, according to Medicare’s chief actuary, and the remainder will face higher premiums and lower benefits.

The playing field seems to be leveled by forcing several million elderly folks out the MA plans many of whom may have to sign up for a Medicare supplemental insurance which is conveniently offered by AARP who just happened to have championed the health deconstruction-reconstruction bill. The follow-the-money rule has such great explanatory power.The CMS publication's section on MA would be more appropriately titled
"Throwing Medicare Advantage patients under the bus".

The entire NCPA publication is important reading but here is one interesting aspect of the bill that I was not aware of:

The government will require you to give your employer your most recent income tax return. Both at work and in the newly created health insurance exchanges, out-of-pocket premiums will be limited to a percent of your income. In order to enforce that requirement, however, your employer or the operator of the exchange will have to know what your income is. Note: Under the new law, the income-based premium limits are not based on the wages your employer pays you. They are based on your family income — including nonwage income (dividends, interest, trust income, etc.), your spouse’s income (from all sources) and, if your children are dependents, their incomes as well.

Wow, what if you might not want your boss to know how much your spouse makes or how much you made on investments? Too bad. It all just gets better and better. (Well, I won't give Fred a raise, looks how much his wife makes.)

The NCPA booklet is great source for important details of the PPACA. For an insightful,succinct summary statement it is hard to beat this slightly paraphrased comment from the blog "Nostrums by Doc D".
The plan is to take 500 billion from Medicare, spend it on something else and then call it a savings and a quality improvement to Medicare. Compared to that game plan, the business model of the Underwear Gnomes appears brilliant.

Yet another valid criticism of pay-for-performance (P4P)

DB of "DB's Medical Rants" takes another opportunity to direct some of his typical well thought out criticism against the dangerous concept of pay for performance for physicians. See here.

The thoughts he expresses fall into the category of still-another-reason why P4P is a bad idea.

He refers to the concepts popularized by Daniel Pink in his book "Drive" which include intrinsic motivation and the notion that contingent rewards lead to a loss of autonomy and loss of motivation.As noted by a commentary to DB's entry, Pink seems to rely heavily on the work of Alfie Kohn which can be found in his book,"Punished by Rewards".

The basic idea as it applies to physicians is the following. To offer rewards to someone for tasks that they already find interesting and enjoyable and who are to a large degree driven by their intrinsic motivation to perform at a high level a job that they believe to be important will tend to destroy motivation and eats away at the autonomy which is a major element in that job satisfaction.

Fundamentally P4P ,while touted as a means of improving some nebulous "quality" is a method of control of physicians' activities and succeeds in that control if and only if physicians comply which because of the hegemony of third party payer has become, outside of retainer practices, a fait accompli.

The Initiative to Transform Medicine-The push for social justice goes on and on

Should medical student applicants be chosen less for their demonstrated ability to master large amounts of knowledge and solve problems and more for their social consciousness and desire to push forward with social justice?

That appears to be the suggestion of a panel of experts from the AMA in a project called the Initiative to Transform Medicine (ITM) who believe an altruism deficiency underlies the migration to certain more lucrative medical specializations at the expense of forsaking primary care causing a shortage of primary care doctors.See here for the AMA page regarding that initiative and from there a link to the recommendations of that panel.Yes, I realize this is not breaking news but I only now heard about it.

See here for a good summary and exposition of reasons more convincing than a sudden attack of selfishness, greed and hypertrophied self interest as to why fewer medical students choose primary care .Yes, it does depend to a significant degree on income, but there is more to it.

(h/t) to John Goodman's blog entry authored by Linda Goodman.

The suggestion made by the panel that social awareness or social consciousness should be weighed more heavily than ability to master a formidable load of knowledge and problem solving ability in selecting students for primary care residency training reflects a lack of awareness of what is required in primary care and a demeaning characterization of primary care medicine. Often more problem solving skill is demonstrated in sorting out a patients diagnoses from a myriad of often non-specific complaints that is evident in the specialists subsequent handling of the case which arrive in his office with the label already properly applied. Internists were once thought of as being at the top of the problem solving food chain but now those limit their practice to outpatients seem to be considered merely as members of the category of primary care provider.

I believe the shift of medical students from primary care to specialties is due less to some alleged "altruism gap" than to the combination of three other gaps; 1) an income differential gap, 2) a life style differential gap, and 3) a practice hassle gap.

The above referenced link contains a useful, succinct summary how the income gap came about. This is a story often told in the medical blogs of the Resource Based Relative Value Scale and the now infamous RUC and the role that once obscure group played in protecting the income of procedure oriented physicians versus those who do not do procedures.

In addition to the altruism deficiency the panel "determined" another weakness of physicians as they are trained today.

Physicians are generally not prepared to be advocates for patients on issues related to social justice (for example, elimination of health care disparities, access to care) and to be citizen leaders inside and outside of the medical profession. This also includes engaging in advocacy on public health issues.

Apparently in the view of this group of self designated experts, one of the many requirements of physician training is to prepare them to work for social justice, which must involve redistribution of wealth. Perhaps lessons in community organizing could be added to the curriculum. I suppose libertarians need not apply. Neither should anyone who thinks Thomas Jefferson had it right when he said;

"To take from one because it is thought that his own industry and that of his father's has acquired too much, in order to spare to others, who, or whose fathers have not exercised equal industry and skill, is to violate arbitrarily the first principle of association -- the guarantee to every one of a free exercise of his industry and the fruits acquired by it."

(h/t to Wealth is not the Problem blog)

The general philosophical basis of the ITM is the same as that underlying to the creation of The New Medical Professionalism,which seriously weakens the fiduciary duty of the physician and inserts a nebulous duty to society to the physician 's obligations .See here.

Will health care law make Medicare more fiscally viable by making care less available?

Two recently released projections of what Obama Care (PPACA aka ACA) will do paint different pictures.
The paper by the Medicare Trustees take the provisions as written,assume that the provisions will be met and conclude that Medicare will remain fiscally viable for a longer period time than would obtain that if the bill were not passed.

The Chief Medicare actuary, however,claims that it is highly improbable that the cuts to Medicare providers, that are necessary to make Medicare more solvent, will ever happen. Congress , so far, repeatedly postponed the looming SGR formula cut so that now to belatedly enact them would bring about a 30% cut in Medicare fees for physicians. This would cause an even greater exodus from Medicare on the part of physicians, particularly primary care docs-internists and family physicians, at a time when some 31 millions folks will have recently obtained health insurance and will be seeking primary care.At least some of these will have plans that will pay more than Medicare.Further with the cuts to Medicare Advantage more senior will be looking for primary care docs in the traditional Medicare program.

So, if Congress would re-grow a spine and invoke the cuts to Medicare it may well be the case that Medicare patients will struggle to find primary care and lines will form. If they don't, the allegedly effect of making Medicare more solvent will not occur.In any event lines will form. Shortages are one foreseeable consequence of price controls and University of Chicago Law School professor, Richard Epstein, has characterized the health care bill as a giant mishmash ( my paraphrasing ) of price controls.

If the cuts do occur it is projected (by the Medicare Trustees) that Medicare reimbursements will fall below those of Medicaid by 2019. How many internists will participate in Medicare with that level of reimbursement? How many internists accept Medicaid patients now? The leadership at AMA and ACP should have second thoughts for sponsoring a plan that would so seriously reduce access to care by the Medicare population.See here for John Goodman's comments about Medicare projections.

President Obama in a recent radio address and Paul Krugman in a recent column ( see here) and a spokesman for the American College of Physicians in a recent blog all heralded the projected increased soundness of Medicare.We were not told much if anything specifically about the report of the Medicare's chief actuary regarding the implausibility of the cuts to Medicare actually happening and thereby the savings evaporating.The wink-wink-nudge-nudge dance and the attempts try to find the right shade of pig lipstick continue.

Value,quality,rent seeking -Does value equal quality/cost

I suspect we will be hearing more and more about paying for "quality" since the recess appointment of Dr. Donald Berwick to be the head of CMS. His views on central planning of medical care are the subject of much discussion. The following is a lightly re-edited version of a commentary I wrote several years ago on "measuring" quality and value.

Dr. RobertWachter, Professor of Medicine at UCSF , tells us that "value=quality/cost" and we have a moral obligation to "solve" equations for various clinical services. I reference his comments in the ACP observer as he replies to a letter to the editor commenting on the interview he gave discussing the overseas out-sourcing of medical services.(ACP Observer,July/August/2006 pg4) Dr. Wachter says in part:

Health care will be judged by its value: i.e.quality/cost...It is immoral not to seek ways to provide high quality care at more affordable costs"

It seems to me that this "equation" presupposes an intrinsic theory of value in which value is considered to be something that can be objectively measured and is an intrinsic property of a good or service much like the specific gravity of a liquid or the density of a compound.

Since the Austrian School of economics popularized the subjective theory of value most mainstream economists reject the intrinsic value theory.

The same service may be more or less valued by a given person as her circumstances and desires change. No two individuals need value the same thing to the same degree though they may.Value to most economists is not an intrinsic measurable number but rather value is subjective and is in "the eye of the beholder". Thomas Sowell ( pg 51,Knowledge and Decisions,Basic Books, 1966) puts it this way:

"Value being ultimately subjective, it varies not only from person to person but from time to time with the same person, and varies according to how much of the given good he already has."

Advocates of the subjective value theory would argue that to define value with the above equation is to erroneously claim that value (or in this case "quality" which along with "cost" determines "value") is an objectively measured entity. Are the medical quality experts( as best I can tell this is a self proclaimed designation) who are able to or claim to be able devise means to measure quality merely substituting their preferences-dressed up as objective measurements-for the value judgments of others?

Wachter continues saying:

"Patients, payers and policy makers now expect us to tap into actual clinical data to assess a physician's quality of care.I suspect once we truly figure out how to do that..."

I take this to mean that exactly how to measure the quality of care has not yet been "figured out". Somehow, I think that compliance with guidelines and adherence to protocols will play a big role in this-it has so far- and I doubt if patients will be asked what it is they value. I agree that payers and policy makers want quality data to use as a cost containment tool, the gatekeeper concept now largely abandoned, but patients want a physician who will spend time with them,care about their problem and be more interested in doing what the doc and patients agree on as the right course for that person and not adherence to some guideline that the patient has probably never heard of and does not take the particulars of his situation into account.

I believe "quality" which is now the main rhetorical tool of the cost-containment movement has become a classic bait-and-switch term. Everyone, docs and patients alike,would naturally say we want to give/receive good care or "quality" care. But the quality guidelines so often turn out to be what some self-appointed quality guru, committee or task force says is an quality indicator and are often no more than simplistic, easy-to-count, check-off list items, some of which may have counterproductive or harmful effects.

I have no doubt there are many well-intentioned physicians working hard to improve medical care- if you will improve quality- but much of the quality movement and arguably its major motive force is to contain costs.


The movement to contain costs derives from so much of medical care being paid for with other people's money. We are not instructed about the moral imperative of providing high quality legal services, or haircuts or home repairs at more affordable costs because the people who use these services pay for them themselves.

Some may rejoice in the passage of Obama care as a golden opportunity to improve the quality of medical care while the more cynical think of the legislation with unparalleled power placed in the hands of various governmental agencies as the mother of all opportunities for what economists call rent seeking in which various interested parties ( now known a stake holders) seek special privilege.

Donald Berwick and Great Britain's Prime Minister talk about different NHS s

While Dr. Don Berwick, Obama's recess appointee to head CMS, speaks of Britain's NHS in glowing if not poetic and outlandishly laudatory terms,Britain's Prime Minister who has actually studied a report about NHS failings presents a different portrait . See here for the white paper on the NHS.

Here is one except from that report:

... the NHS has achieved relatively poor outcomes in some areas. For example, rates of mortality amenable to healthcare, rates of mortality from some respiratory diseases and some cancers, and some measures of stroke have been amongst the worst in the developed world.


"Worst in the developed world" Berwick began his remarks celebrating the 60th anniversary of the NHS with this:

"I am romantic about the NHS; I love it. All I need to do to rediscover the romance is to look at health care in my own country."

His expressed infatuation for the single payer,centrally planned health system of Great Britain is obvious.What is less obvious is how he (or anyone) could reconcile those views with his self admitted radical views of patients primacy.

Dr.RW takes on this daunting task in his recent blog posting (see here) and using in part material from a 2007 IHI publication (see here) he provides insight into Berwick's thinking about reconciling conflicting aims.

Everyone ,physicians,patients,anyone who might become a patient should read about the "goals" that Berwick's organization advocates for a health care system.Then consider on what planet or in what alternative reality those aims could be actually accomplished by governmental central planning.It makes Will Roger's quote " Boil the oceans" ( to get rid of German U-boats ) seem practical.

Dr RW says this about their formulation:

'Grandiose, nebulous and intrusive are adjectives that come to mind." I think he is too kind.

Wall Chart of PPACA is so complex that no one who supported the bill could have possibly known what they supported

Go here to see the labyrinth of provisions, regulations, deadlines,subsides and cross subsidies from the hundreds of thousands of words from PPACA that will transform American medicine. Read through it and try and see who gains and who loses. I suggest the countless details defy a comprehensive analysis. It will be years before the the unintended consequences can begin to be sorted out.Did the advocates for Obama care from AMA and ACP and other medical organizations who claim a victory for "social justice" have a clue about what the bill really contained? I suggest they understood even less that some of legislators who admitted they had not even read the bill.Further, many of the operational particulars have not yet been defined.That is a work in progress by the numerous governmental agencies who are now beset upon by the various lobbying interests(known euphemistically as stakeholders ).

Perusing the chart makes me wonder why there is so so much detail,why so many elements and provisions are there ,why laws are crafted to be so long and so opaque and why are so many agencies and governmental entities are necessary to carry out any stated goal.

Angelo Codevilla's essay on the ruling class provides one answer:

"[O]ur ruling class’s standard approach to any and all matters, its solution to any and all problems, is to increase the power of the government – meaning of those who run it, meaning themselves, to profit those who pay with political support for privileged jobs, contracts, etc."

Simply put, it has to be long and detailed and governmental agencies have to empowered to make many discriminatory decisions so that the folks in power can ensure who is that profits and who it is that picks up the tab. A statute's mind-boggling length and opacity serves to obscure what is happening.

Senator Baucus apparently really knew what the health care bill was all about even though he likely could not detail exactly what all the provisions were when he said in his exuberant candor after the bill was passed:

"Too often, much of late, the last couple three years, the mal-distribution of income in America is gone up way too much, the wealthy are getting way, way too wealthy and the middle income class is left behind," he said. "Wages have not kept up with increased income of the highest income in America. This legislation will have the effect of addressing that mal-distribution of income in America."

Right, it was all about redistribution of wealth which it just so happens is Dr. Don Berwick's desire as well as regards health care in America expressed in this quote from Berwick:

"...and that any health care funding plan that is just, equitable, civilized, and humane must – must – redistribute wealth from the richer among us to the poorer and less fortunate.


H/T to the Blog We Stand Firm

So did AMA and ACP have a seat at the medical legislative table or were they on the menu?

An essay that is receiving much attention as it should is available here .The author is Angelo M. Codevilla, a professor emeritus from Boston University. His characterizations of the" Ruling Class" and the "Country Class" is in the least thought provoking. I quote from the section labeled " Dependence Economics" with my bolding added:

"By taxing and parceling out more than a third of what Americans produce, through regulations that reach deep into American life, our ruling class is making itself the arbiter of wealth and poverty. While the economic value of anything depends on sellers and buyers agreeing on that value as civil equals in the absence of force, modern government is about nothing if not tampering with civil equality. By endowing some in society with power to force others to sell cheaper than they would, and forcing others yet to buy at higher prices -- even to buy in the first place -- modern government makes valuable some things that are not, and devalues others that are. Thus if you are not among the favored guests at the table where officials make detailed lists of who is to receive what at whose expense, you are on the menu.
Eventually, pretending forcibly that valueless things have value dilutes the currency's value for all. Laws and regulations nowadays are longer than ever because length is needed to specify how people will be treated unequally. For example, the health care bill of 2010 takes more than 2,700 pages to make sure not just that some states will be treated differently from others because their senators offered key political support, but more importantly to codify bargains between the government and various parts of the health care industry, state governments, and large employers about who would receive what benefits (e.g., public employee unions and auto workers) and who would pass what indirect taxes onto the general public."

Treating people differently seems to be the essence of "social justice" for which supporters of Obamacare claim a victory.

While the leaders of AMA and ACP ( and other medical organizations as well) announced proudly they had a seat at the adults' table with the Obama administration in planning health care reform , for most of the medical profession, I think the designation of "on the menu" is more appropriate as it is for many citizens who were "happy with their doctors and health care plans". Maybe sometimes folks just thought they had a seat at the table or , even worse, maybe they got what they wanted.

More medical blogs express concern about Donald Berwick's suitability for CMS head

For a while it seemed only a few medical blogs were expressing concern about Dr. Donald Berwick's suitability to be the head of CMS. See here for one of Dr. RW Donnell's posting on that topic and here for one by Dr. Doug Perednia of the new blog Road to Hellth. Now others are joining it.

The prolific and widely read Dr. David Gorski has submitted a detailed discussion about Dr. Berwick expressing in part concern about Berwick's apparent support for unscientific alternative medicine .See here for the commentary. Additionally, Gorski makes the case, based on quotes from Berwick, that in some regards his views appear to be naive and out of touch with real world physician-patient encounters and relationships. Quoting Gorski:

Berwick strikes me as a very well-meaning person with some good ideas about how to make our health care system less rigid and more responsive to patients’ needs, both medical and nonmedical. Unfortunately, he also appears to be naive to the point of my wondering whether he has any clue what it’s like to practice medicine in the real world or even in the idealized world of academics.

I agree.A number of Berwick's comments appear very naive,unrealistic, and something more expected from someone not actually caring for patients than a physician with any recent background in patient care.As best I can tell he had not been practices medicine for a while.

There is a major disconnect between Berwick's expressed adulation of the NHS and his statement that rationing must be done with his views of patient centerness which he self describes as radical.

Dr. Kimball Atwood,a tireless opponent of non-scientific alternative medicine expressed similar views to Gorski in his essay on the blog Health Care Renewal. See here. Quoting Atwood:

"In February of 2009, Dr. Berwick gave a 'keynote' address at the IOM and Bravewell Collaborative-sponsored Summit on Integrative Medicine and the Health of the Public. He shared the podium with Mehmet Oz, Dean Ornish, Senator Tom Harkin, and other advocates of pseudoscientific health claims. I wrote about the conference at the time, mainly to call attention to its misleading use of the term "integrative medicine": literature emanating from the Summit characterized it as "preventive" and "patient-centered," whereas the only characteristic that distinguishes it from modern medicine is an inclusion of various forms of pseudomedicine. I noticed that Dr. Berwick was on the speaker roster, which I found disappointing: I imagined that he had either gone over to the Dark Side or, perhaps, was sufficiently naive about the topic to have been duped; or, more likely, that he had cynically accepted the offer to further his ambitions."