Monday, June 28, 2010

The best name yet for Obamacare-TNRKMA (turkey ma)

High fives to the endlessly insightful blog of John Goodman for what I believe is the best designation yet for PPACA which is also known as Obamacare.

I quote his introduction to the new name,TNRKMA.(The Thing that Nobody Really Knows Much About.)

'...what should we actually call this thing? That is, the Thing that Nobody Really Knows Much About (TNRKMA). At this blog, we have followed the convention of calling it “ObamaCare,” but that could be considered derisive. There is always “health reform,” but this bill will almost certainly be reformed many, many times, even before all of the original provisions are enacted.

On balance, I’m inclined to go with the acronym, TNRKMA — which is pronounced “Turkey Ma” (mother of all turkeys), with the N silent, or simply “Turkey,” for short.'

I tend to prefer the simpler designation, "turkey".Read his entire blog here.

Sunday, June 27, 2010

Business Roundtable suffers buyer's remorse with Obama care, will AMA, ACP, etc. be next ?

This article, from the WSJ, tells a precautionary tale that has been told many times in the past.It is a narrative with apparent deal-making,double cross ,doing what seemed expedient and the regrets of buying a pig in a poke.

The prominent business organization, the Business Roundtable, provided valuable support to the Obama administration in regard to the health care bill. Their support, according to this article, was based on the fear that the Obama administration would push forward with a tax on US corporations who have overseas operations. Now Mr. Orszag tells the group that the administration will go ahead with the tax anyway but by the way thanks for your help with the health care bill.

The folks at BR are now realizing what they "gained" from their earlier support .

"Roundtable President John Castellani, ... We stuck with that majority "through trying circumstances," even "alienating many of our traditional colleagues," and what did we get? They keep "vilifying" the private sector! And taxing it, and empowering unions, and ignoring trade. "The time has come for a new course," declared Mr. Castellani, a mere 18 months after Democrats announced plans to tax companies, empower unions and ignore trade."

Several professional medical organizations, including the AMA and the ACP, also supported the health care bill. Both have been rightly critical of the tardiness exhibited by Congress to fix the SGR but ,so far, I have heard no denunciation of the many provisions of Obama care that delegated unprecedented power to the HHS and other government entities and will exert increasing hegemony over the practice of medicine. Rather we have heard self congratulatory comments about furthering social justice which along with having a "seat at the table" may have been all organized medicine received for their support.

h/t to Wolf Files:12% Pure Hope for the link to the WSJ article.See here for his comments which close with this:

"It was the perfect execution of manipulative divide and conquer by a power-hungry government that sees the private sector as its adversary. And the proverbial man who sat idly by as the king ran over all others because it didn't affect him directly is now left without friends to defend him as the king comes knocking on his door."

Tuesday, June 08, 2010

Laymen find notion that more care and more expensive care can be worse as counter intuitive

A recent publication in the publication "Health Affairs" has evoked comments and some concern from advocates of comparative effectiveness research and admirers of the Dartmouth Atlas. See here for full text (pdf). A survey of "consumers" found a level of skepticism that is alarming to those folks who are in the business of claiming to know what aspects of medical care should be offered.

The idea that more care and more costly care gives inferior results to less care and less expensive care seem to be inconsistent with one's experience in a variety of areas. Many would relate to the experience of having a fly by night craftsman using cheaper materials doing a shoddy job at painting the house or doing household repairs. Few people believe that a cheaper car is better than an expensive luxury car. Think of a Mercedes versus those jokes made in Russia sold as cars. Most dental patients accept the notion that a root canal treatment followed by a crown is better than a dental extraction though the latter is much cheaper.

In the sixties what passed for treatment of acute myocardial infarction was cheaper than the much more effective and life saving treatment available now. In that instance more is better.

Until hip replacements became available patients with severe degenerative arthritis of the hip could look forward to years of limited mobility and pain. Now their lives are clearly improved but at a monetary cost considerably greater than the pain pills. In that instance more is better.

HIV-AIDS has been transformed from a rapidly debilitating and fatal illness to a chronic controlled illness with often very good quality of live.In that instance more is better.

I could easily generate a number of instances in which certain tests or procedures or medication use was/is not reasonably indicated and in the cases more is not better and I would agree that sometimes it is worse.

Surely, sometimes more is better and sometimes it is not. It is a more a matter of case law than the application of a universal general principle that cheaper is better. It is an empirical question regarding the particular intervention and the particular outcomes of interest. Sometime it may be but often the opposite seems to be the case. Many people seem to believe the lay adage that you get what you pay for even if that is not always right.

It is interesting that much of verbiage saying that more is not better comes from the progressive side of the spectrum of ideas and they will have their work cut out for them to disabuse the less informed of the naive notion that less is often not better.

An interesting parallel to this current day notion of there being too much spent on medical care ( not care for too many but too much care for some) is the economic nonsense that was spun out by the early Roosevelt administration. Their early theory as to why there was a recession/depression was that there was an overproduction of goods. Therefore,farmers had to cut back on production as did manufacturers. Interesting argument that the government tried to sell-people going hungry and the claim that farmers had to grow less.

Dr RW gives his take on this topic here and DB gives his here

I quote Dr.RW:

The Dartmouth Atlas was spun far beyond what the evidence supported, for political ends. That’s where the problem lies, not with the project itself. The data need to be viewed within the limitations of the methods. The findings are relevant. The sheer enormity of the variation in cost says deviation from best practice is widespread. Many questions remain unanswered. One is why? What external factors drive the variation? Another is in what direction? The popular assumption is that the error is in the direction of over utilization but it could just as easily be the other way around. After all, that’s what the best quality data we have and a sampling of public opinion say.

DB's headline got it right: "Sometimes money buy better care"

To avoid confusion let me say that I am not against comparative effectiveness research.There are many instances of it being done now and previously without a governmental agency being put in charge of it.I am quite concerned with the power that a governmental CER agency will have and afraid that the well known phenomenon of regulatory capture will happen there.On the basis of the article it looks like a number of "medical consumers" also have some concerns.

Sunday, June 06, 2010

Is refusal to accept government price controls "price fixing"

According to this article in the Christian Science Monitor, the Justice Department says it is -at least in regard to as physicians.

This governmental action seems to go past earlier efforts by the Federal Trade Commission who previously considered effort by groups of physicians to band together to try and increase their bargaining position with third parties as violating antitrust laws. See here for my 2007 commentary on one such case. Now physicians seem to have another governmental entity with even bigger teeth ( potential criminal penalties), the Justice Department, to content with as they deal with third party payers in and out of government.

Here is a quote from the CSM article describing the nature of the teeth"

"This is another reason why the DOJ’s presence in a physician case is more disturbing than the normal FTC case. The DOJ has a number of “tools” the FTC does not, including the self-granted power to award amnesties from criminal prosecutions to the first “conspirator” to step forward and provide evidence against one’s competitors.

A doctor that feared prosecution could seek amnesty — and provide the Justice Department a blank check to rummage through his files and private communications. And if that doesn’t work, the DOJ can always seek wiretaps of physicians’ phones and computers, a power awarded the DOJ during a 2006 renewal of the PATRIOT Act. The potential exposure of your physician’s confidential records — including your medical records — is limitless ."

As long as insurers set the prices for medical services and the FTC and now the Justice Department prohibits physician groups from fairly negotiating for fees, efforts by physicians to support and take part in P4P programs in the hope that the downward spiral of fees for primary care will be halted will be less effective than rearranging deck chairs on a sinking ship.More and more "going Gault" seems to be the way to go.My take on medical going Gault is to have a retainer practice and do not deal with insurers in and out of government.Unfortunately this seems feasible only for primary care docs.I don't see that arrangement viable for surgeons and procedurists.

H/T to Medical Pastiche.See here. See also here for a discussion of this recent development in limiting the ability of physicians to negotiate with third party payers from the blog " Road to Hellth"

Tuesday, June 01, 2010

Composite endpoints in clinical trials can be very misleading

The blog commentary by Dr. David Rind discusses the issue of composite end points in clinical trials and in particular the CREST trial which compared carotid endarterectomy with carotid stenting. See here.

The end points in Crest were periprocedural stroke,myocardial infarction,death or ipsilateral stroke occurring within four years after the procedure. Since both procedures are really done to decrease the risk of stroke in a patient with carotid stenosis, why not just compare the rate of stroke occurring in the two treatment groups over a several year period following the procedure? That would appear to be the key outcome of interest. Well, the more invasive endarterectomy procedure might be more likely to cause operative or post op problems than the catheter based treatment so some measure of that needs to be included in the accounting.

Basically end composite outcomes are done because the difference between two competing therapies is thought to be so small that a very large number of patients would be needed to provide a clinical trial that has sufficient ability or power to detect a difference between the two treatments. This has been particularly evident in regard to the treatment of acute myocardial infarction as treatments have continued to decrease the mortality of acute MI and incremental changes in benefit become smaller as therapies improve.

So what could be wrong with the composite approach?

CREST illustrates what could be wrong. Here the stinting group had fewer myocardial infarction with more strokes. So the trade offs appears to be more strokes with stints and more MIs with surgery. This could be interpreted to mean that the two techniques are quite equivalent but they differ in the adverse effects but are the two adverse effect equivalent? Most folks would say no since surviving a stroke can be much more devastating and life altering that a survived heart attack.

Rind put it this way:

Composites can quickly get you into trouble, though, if you combine events of very different importance to patients. Sometimes this appears to have been done with the intention of obscuring the real outcome of a trial or to make a therapy look far better than it really is

A recent commentary in JAMA also discussed the composite outcome issue and warned readers to beware of a" bait-and-switch" type phenomenon. See here. The following is the authors' final paragraph.

Readers of randomized trial reports must understand both the reasons for and pitfalls of choosing to combine clinical outcomes. Examination of the relative importance, frequency, and consistency of effect size across the components of a composite outcome are important steps in the interpretation of information derived from trials. But it is equally important to be aware of a potential bait and switch strategy. In some cases, readers and authors of reports of randomized trials may wish to weight each of the outcomes by an importance factor, similar to the way quality of life is measured.10 In other cases, they may wish to point out that even though a randomized trial was designed to detect a difference in the composite outcome (because the vast majority of the effect is on one component, typically the least severe), the trial has mainly showed the effect on surrogate outcomes and not definitive ones.