Tuesday, January 26, 2010

Enactment of Comparative Effectiveness Research -Libertarian Parternalism or Orszag type coercion

An excellent commentary by Dr. Jerome Groopman can be found here . It which offers a very thoughtful analysis of a number of issues related to comparative effectiveness research (CER) and what comes next.

He tells a narrative of two highly placed Obama administration players who views are seemingly widely divergent in regard to how to implement findings from clinical research; Cass Sunstein and Peter Orszag.

Sustein would "nudge" us along to do what is best for us while Orszag would implement, for example, the findings of comparative effectiveness research (CER) with " aggressive promulgation of standards and changes in financial and other incentives", the later approach finding a statutory home in the Senate health care bill but not the House bill.

Sustein and his collaborator Richard Thaler have brought to the current trendy universe of discourse and commentary the notion of "libertarian paternalism" (LP) replete with the concept of "Choice architect" and "nudging folks" to make the right decision in areas wherein their ignorance, cognitive limitations and lack of will power cloud their minds so that they do not do what in the view of the architects is the action which really is in their best interests. Basically the LP camp seems to say we ( the experts ) know what is best for you and we will in various not- really- coercive ways gently push you in the right direction. The more traditional progressive view, as exemplified by Orszag, is we know what is right and we,if necessary, will summon the force of law to make you do it.

Groopman favors the LP view and adduces persuasive evidence to the argument that a number of the so-called best practices and quality measures have been simply very bad ideas with bad consequences and I would add monuments to the hypertrophied hubris of those architects.These fiascos include the now notorious 4 hour rule for pneumonia,fountain of youth estrogen movement,very tight blood sugar control for critically ill patients, and relatively tight glucose control for ambulatory patients,statins for dialysis patients and I would add:beta blockers for almost everyone pre op.Other quality measures have been shown to have no effect one way or the other.

Goopman, in a David Hume-like argument, turns the notion of the cognitive biases that limit the non-expert humans back on the experts pointing out the obvious that they too may fall victim to the same biases, such as overconfidence, the focusing illusion and confirmation bias and that they tend to " overestimate [their] ability to analyze information, make accurate estimates and project outcomes". He even admits that he was subject to some of those foibles in what turned out to be an over-zealous push for Erythropoiesis-stimulating agents, in cancer patients.

Dr. Goopman then offers what I believe is a profound insight in regard to expert panel's "best practices".They may often fail to recognize and distinguish between those practices that can be standardized and not significantly altered by the particulars of the individual patient and those that those practices that must be altered to the individual patient. A check list to prevent infection when an IV catheter is inserted exemplifies the former and issuing a dictum that all ambulatory patients with diabetes should be treated to a given Hb AIc is an example of the latter.What blood sugar target level is optimal may vary not only between individual patients but also may vary often time with the same patient and the one size for everyone is a recipe for trouble.

To the extent they actually believe their own rhetoric both Obama and Orszag demonstrate a naive view of science and medical research. They speak of simply "finding out what works and what doesn't" seemingly ignorant of the fact that so often what we "determine" today from clinical research is contradicted tomorrow and how very difficult it can be to find out what is best or even define "best"Science offers provisional conclusions subject to refutation.

Dr. Groopman hopes that the Sunstein approach will be used- preferring nudging to coercion. Given a binary choice I would opt for nudging as well However, some have suggested that notion of libertarian paternalism is an oxymoron and some have raised a slippery slope concern see here for one discussion of those issues.Nudging might gradually morph into regular traditional coercive paternalism. I am reminded of the "third party experts" who profess to know what is best for you better than you do and Thomas Sowell's comments in that regard.See here to see and hear Sowell on that issue.

Interesting new term-"Insurance free medicine" That may be what we need.

Go here to read a very interesting and thoughtful commentary by an academic internist whose thoughts I have quoted before.Dr Matthew Mintz suggests a new term, "Insurance free medicine" which I agree is a useful way to encompass several other terms and to reference modes of medical practice that have evolved to escape the increasingly intolerable world of primary care dominated by insurance companies and CMS. Here I refer to both family practice and internal medicine. do not have enough information about current day pediatric practice to comment meaningfully in regard to the current status of that aspect of primary care.))

Insurance free medicine would cover practice arrangements that are now called the following:
concierge medicine,retainer medicine,cash only medicine and boutique medicine.

I would sign up today if I could find an internist in my area offering insurance only medicine.

Monday, January 18, 2010

Toronto ACP meeting to offer mini-courses in minor surgery-what is that about?

I recently received a copy of the advance program for the April 2010 scientific meeting of the American College of Physicians (ACP). On page 38 we find a list of mini-courses in "Clinical Skills in Procedures". These include: skin biopsy and cryosurgery,suturing skills, and my favorite,"toenail removal" about which they state :

"Learn the indications for toenail removal. Using a realistic model and actual surgical instruments ( I guess as opposed to fake instruments),practice a digital block,wedge resection and removal of an ingrown toenail and wound care."

I am puzzled as to the intent of the ACP planners in offering this course. Do they intend that an internist whose post medical school training to my knowledge does not involve the development of surgical skills offer this procedure in his office with only several hours of instruction/practice as his qualifications? Do they believe that one serves his patient well by having an under trained physician perform a surgical procedure?

Should the planners of this course develop a painful ingrown toenail who would seek out for treatment: a general surgeon, an orthopedic foot surgeon, a podiatrist or an internist who took a course at the ACP meeting? I am reminded of this Monty Python skit of a job counseling interview in which the applicant's sole quality for lion taming was a hat that said 'Lion Tamer".

I have written before as has Dr RW (see here and here for his comments and here for mine) on what seems to me to be an identity crisis in internal medicine evidence for which is found in the more recent editions of MKSAP as well as the annual scientific meeting wherein the planners seem to be trying hard to make internists more like family practice physicians. The general internal medicine section of MKSAP had many sections removed from typical or traditional internist's training and areas of expertise such as diagnosis and treatment of corneal abrasions and detailed evaluations of uterine bleeding to name just two. A suturing skills mini-course practicing on pig's feet is part of the "why can't internists be more like family practitioners ?" movement, one that I believe does not enhance internist's patients' care nor the public or self image of internists.

Thursday, January 07, 2010

If Mayo Clinic loses money on Medicare , what will the "average" internist do?

While the AMA and the ACP seemingly see better things ahead ( I assume they do because of their support for a bill whose particulars still remain a secret) after passage of the final health insurance deconstruction-reconstruction bill, the prestigious Mayo Clinic has seen fit to restrict Medicare patients because they loose money on their care.

Mayo's primary care physicians will only see Medicare patients at its Arizona facility if they agree to pay a $ 1500 annual fee. The Rochester mother ship facility has announced it will see Medicaid patients only from certain states.

Dr. Toni Brayer, author of the blog Everythinghealth, in her Jan 6,2010 on line issue of the ACP Internist tells her readers she has the same problem.Because of other sources of income she plans to continues to care for her Medicare patients but how many other internists will continue to choose to eat that economic loss. How many can afford to?

According to Dr. Brayer, Mayo clinic looses $ 840 million on Medicare patients' care and that about 70% of hospitals loose money on Medicare patients.

The issue is much bigger than Mayo's decision. Many physicians are not accepting new Medicare patients. The Texas Medical Association has reported that their survey of primary care physician indicates only 38% of Texas primary care docs are accepting new Medicare patients.

The incredibly arrogant purposeful secrecy and what has been described as "cash for caucus" of what the legislative process has descended to, makes it impossible to know what is planned to alleviate the problem of primary care docs not being financially able to treat Medicare patients. I share Dr. Wes's indignation at the failure of the leadership of major medical organizations when he states:

We see this as our professional membership leaders failed to ask about the details of the health bills ( my bolding) before them nor inquired about the potential flaws inherent to comparative effectiveness research promulgated on large, unfiltered populations. Rather, our representatives capitulated and mollified themselves with platitudes.

Here is what a recent commentary in the Boston Globe said in regard to the growing disconnect between primary care physician and Medicare-Medicaid patients and the Senate health bill;

The Centers for Medicare and Medicaid Services, a branch of the US Department of Health and Human Services, estimated last month that the Senate bill would squeeze $493 billion out of Medicare over the next 10 years. As a result, it cautioned, “providers for whom Medicare constitutes a substantive portion of their business could find it difficult to remain profitable and . . . might end their participation in the program (possibly jeopardizing access to care for beneficiaries).’’ In short, the Democratic understanding of health care reform - more government power to set prices, combined with reduced freedom for individuals - will make medical care harder to come by: an Economics 101 lesson in the pitfalls of price controls.

With many millions ( no, Virginia there will not be "universal coverage, still about 23 million will not be insured) more added to the medically insured population, with no meaningful relief in the wage-price controls on physician's fees from CMS and numerous hints in the bills of a heavier and more obtuse administration thumb on medical care details it seems inevitable that more and more physicians, unlike Dr. Brayer, will just shrug.

Tuesday, January 05, 2010

Why does the AMA support senate and House health insurance bills?

Several blogs have taken up the issue of the AMA 's support of the health insurance bills currently sliding behind the scenes through Congress. Here is a newspaper article that makes the case for a theme that is found in a number of blogs.

Essentially the charge is that the AMA supports the bill because of the fees it receives for what is described as a monopoly of the insurance billing codes (the CPT codes ). Linda Gorman explains it here.

Apparently HCFA and the AMA reached an agreement with the AMA to use AMA's copyrighted CPT Codes (Current Procedural Terminology codes) for Medicare billing purposes. AMA does not report income from their CPT business separately but estimates suggest something in the range of $ 70 million per year,not a large number by today's standards but significantly more than AMA receives from dues. (Only about 15% of physicians now belong to AMA)

The 1983 HCFA-AMA pact originally precluded the use of other codes for purposes of physician outpatient fees for Medicare and Medicaid.A 1997 Ninth Circuit finding that the AMA was misusing a copyright lliminated the exclusivity but by that time the CPT was the industry standard.

Dr. J.J. Rohack had this to say in reply to Gorman's commentary :

This democratic forum of grassroots physicians and medical students directed the AMA in 1983 to have Reagan Administration recognize CPT as the standard for physician coding. At the time, physicians struggled to cope with the multiple code sets used by third party payers, including the government. AMA brought calm to this chaos by securing a physician-driven standard used to describe medical services.


SERMO, the online physician social network, has become very critical of AMA's role in CPT and in fact has severed an earlier working agreement with AMA. See here for comments from SERMO's founder, Dr. Daniel Palestrant.

The AMA has received CPT fees for a number of years, why now have they reversed earlier opposition to universal health care plans? What exactly is the alleged link between the two? I do not claim the two are not related but I am having trouble seeing exactly how that works. I ask my handful of readers for their input.