Tuesday, September 25, 2012

Quality adjusted life years (QALY)-More to life than counting the dead

Counting deaths is much easier than assessing quality of life.Drs Pamela Hartzband and Jerome Groopman discuss the vagaries and uncertainly of clinical decision analysis and in quantifying the impact of disease on a person's life in the September 13,2012 issue of NEJM in a perspective piece entitled There is More to Life than Death.

The authors point out in regard to the recent USPTF pronouncement regarding PSA testing that while the data are conflicting and the study (the PLCO trial) that largely controlled the panel's decision against PSA testing has serious defects the chairperson spoke as if the call was a slam dunk or in her words "a no brainer". The authors of the NEJM article were polite in their criticism. but I cannot talk about the panel's actions and comments without using the word hubris. Reasonable, well trained statisticians have differed in their analysis of the set of data on PSA testing. Actually hubris is not strong enough a descriptor.

The Harvard husband and wife team asks " Is it possible to put numbers on the "utility"or impact of these conditions on a man's life? Is the concept of aggregating utility valid? I have argued before that it is not. See here.

Hartzband and Groopman discuss methods to attempt to quantify utility. One such method is call the "time trade off". Here a person is simply asked how many years of life she would be willing to give up to reverse a medical condition and return to health. On the face of it this is a absurd counter factual. One is asked to imagine having for example a cancer and what number of years of life they would give up to not have the cancer? A similar absurdity is the "standard gamble" which asks which odds you would take to risk sudden death to reverse some condition.

H and G :

"People cannot anticipate the global impact of a specific future change in their lives".

Of course they cannot.The quality adjusted life years concept is built on a dual fallacy.The fallacy of determining of some one else"s quality of life-based on a hypothetical and the absurdity of adding those determinations to conjure up; some aggregate utility. Yet organizations such as ACP seems to proceed on making cost effectiveness "determinations" that likely will be used to limit a person's access to some element of medical care.Are they aware that the father of utilitarianism expressed the folly of adding up happiness (or the modern equivalent - utility)?

At least the authors of an Annals of Internal Medicine article hyping the cost effectiveness analysis did not claim their analysis were no brainers but rather assured the reader that those type decisions were complex and needed to be made by highly trained professionals.This meant training more advanced that the 7-10 years of post college education that a physician accumulates.The tone of the article made it clear than the Annals article authors were just the folks for that type of very difficult analysis.No hubris there.

Monday, September 24, 2012

The developing Vison of Primary Care in the Big Rock candy Mountain

Probably the primary care physicians in training who authored a recent commentary in the NEJM describing their view of what primary care should be may will have to google the candy mountain reference in the title or just look here.

KA Barnes,J. Kroening-Roche and BW Comfort wrote a perspective piece in the Sept 6 201212 issue of the NEJM.

In it they describe their vision of primary medical care in the U.S. I will not quote their description of what they hope primary care will be but I will quote a sentence that is the essence of what I believe to be a bogus concept.

"Primary care cannot be primary without the recognition that it is communities that experience health and sickness."

Their description of a typical day a primary care practice can be dismissed as idealistic and naive or wishful thinking as in lemon aid springs of the Big Rock Candy Mountain ( at least to an increasingly curmudgeonly old retired doc) but the quoted sentence expresses a conceptual error.

No, communities do not experience anything;nor do they choose anything nor do they suffer or rejoice. Only sentient beings can do any of those things and communities are an abstraction . Similar terms ( society,the country, etc) can be useful summary ways of thinking and talking- a useful short hand. To say that a community is ill or well is a figure of speech;to say that Mr. Brown is sick is an empirical fact. Mr.Brown can regret his earlier excessive use of alcohol, to say the community regrets anything is a category error.

This is not to deny that there are economic factors and social factors that might impact someone's health but to the degree that such things happen they impact the health of individual real life people not society and not a community.Government programs can improve the health of individuals, with such thins as immunization campaigns and providing health care to the indigent.But it is not the community whose health improves it is the individuals who can benefit.

Society or communities are not some super being or entity apart from the individuals who comprise it. To consider that they are or to reify this abstraction lays the foundation for consideration of weighing the value of the individual against this mythical creature and presto we have the new medical ethics.

Reification refers to the treating of an abstraction as if it were a concrete real thing or an actual physical entity.In short turning an idea into a thing and treating it as if the idea posses the attributes on an actual being.

It is the public health paradigm taking over clinical medicine. I hope that when I get older and ill that the physician I consult will realize that I am her patient and not the community in which I reside.

Thursday, September 20, 2012

Rule of law,property rights erode and USA economic freedom index drops to 18 th in world

Not too long ago the United States was one of the most economically free countries..Not so now, as measured by the Frazier Institute in Canada. See here for economist Lynn Kiesling's. comments on the latest ranking of the various countries on the economic freedom scale.

See here for the Executive Summary of the "Economic Freedom of the World.2012 Annual Report."

Forty-two variables are used  in this ranking exercise that cover five areas:

1.Size of government
2.Legal system and property rights
3.Sound money
4.Freedom to trade internationally

So why did the US drop further in the rankings?

"During the past decade, the U.S. rating fell nearly a full point on our 0-to-10 point scale, from 8.65 in 2000 to 7.70 in 2010. While it is difficult to pinpoint all the reasons for this decline, the increased use of eminent domain, the ramifications of the wars on terrorism and drugs, and the violation of the property rights of bondholders in the bailout of automobile companies have all clearly weakened private property and the rule of law tradition of the United States."

 It is getting worse.From 1980 to 2000 the US trails only Hong Kong and Singapore,by 2005 US fell to
 8th and now 18th.

Although I could find no analysis of the role of the Affordable Care Act in their publication, clearly the ACA did not enhance freedom economic or other wise. The regulations ( many of which are still being written) will limit the freedom of all elements of the health care system. The ACA which in this respect has been validated by the Supreme Count,forces individual to purchase a certain product ( health insurance). If  that is not the opposite of economic freedom, I don't know what is. If that were factored into the analysis (maybe it was),US would be even lower than 18th.

Tuesday, September 18, 2012

"Global" health care spending caps-the push ramps up

The clumsy, global health care spending caps enacted in Massachusetts is a harbinger of what the medical planning elites are pushing for the whole country. Global should be in scare quotes because it does not mean the entire world- just the US in regard to both pubic and private health care spending.

Let that sink in, the elite class wants to control how much everyone can spend on health care. This is central economic planning much more restrictive and coercive than what ACA has in store for roughly 1/6 of the US economy. I use the adjective clumsy because the Mass Plan does not have real teeth to enforce spending caps on the total amount spent on health care . A federal plan even it is nominally executed via numerous individual state plans will not make that mistake.

Dr Paul Hsieh talks about an article in the September 6,2012 issue of NEJM written by an all star team of proponents of central control. See here for his commentary. Here is one quote from the NEJM article :

"We recommend that an independent council composed
providers,payers,businesses,consumers and economists set and enforce the spending targets.

Folks associated with the Center for American Progress are well represented in the article's 23 authors (the Center sponsored the gathering of "health-policy experts) as are folks who have worked with the Obama and Clinton administrations. Peter Orszag,now with Citigroup, and Ezekiel Emanuel both played roles in the health planning of the Obama administration. The former president of the SEIU contributed as well as did Tom Daschle

Reinhardt was also a contributor and his affiliation on the print version of the article listed Princeton as an employer but his roles on the boards of Boston Scientific and Amerigroup Corp and as a trustee of Q Capital Management were not. However, those positions were designated on the ICMJE form which can be accessed via the online version of the article.There we learned that Dr. Reinhardt received stock and stock options from those organizations. I mention Reinhardt particularly because this is not the first time his paid associations with health care related companies does not appear on the print version of articles and commentaries to which he has contributed. Dr Roy Poses has been tireless in his efforts to point out various conflicts of interests in those who hold themselves out to be health care experts.See here for one of Poses's posting regarding COI s and Dr. Reinhardt.

Left unsaid was how the spending targets would be enforced.

Sunday, September 16, 2012

Government ignores Goodhart's law again

Goodhart's law expresses one of those insights to human behavior that we see play out again and again and increasing so in medical care as the farce of P4P expands in spite of all evidence indicating its negative effects. According to Charles Goodhart - When a measure become a target it looses its value as a measure.

History is replete with examples of Goodhart's law.The targets of various Soviet industrial centrally planned programs,the cash for clunkers program and high school teachers teaching to the test are just some of the many.The economist,David Henderson, wrote this excellent essay on Goodhart's law and the GDP .

See here for this Forbes article by Dr. Paul Hsieh for how we will see that story again with tragic results with the new Medicare rule about re-admission to hospital within 3o days for patients with certain medical conditions.The debacle of the four hour pneumonia rule seemingly taught the Medicare hierarchy absolutely nothing.See here. Similarly targeting wait times in British NHS hospital had deleterious results predictable from Goodhart' s law.See here for my earlier comments

So many factors outside of the hospital's control and the treating physician's control influence likelihood of a patient's condition exacerbating and necessitating readmission that considering readmission rate as a quality measure at all is absurd on its face.But whether the proposed measure is a valid measure or not does not matter, there will be unintended consequences.

People respond to incentives which can be positive or negative. If someone is penalized economically for not reaching a target or rewarded economically for reaching one, either way the person 'Teaches to the test".

Wednesday, September 12, 2012

R.I.P, Thomas Szasz -Define or be defined

Dr. Thomas Szasz died 9/08/2012 at age 92. I have read and admired his work for the past 30 years.A real champion of liberty is lost.

(Part of the following is from an earlier commentary with slight editorial tweaks and some additions.)

Thomas Szasz wrote brilliantly about the power of language.

"The struggle for definition is veritably the struggle for life itself. In the typical Western two men fight desperately for the possession of a gun that has been thrown to the ground: whoever reaches the weapon first shoots and lives; his adversary is shot and dies. In ordinary life, the struggle is not for guns but for words; whoever first defines the situation is the victor; his adversary, the victim. For example, in the family, husband and wife, mother and child do not get along; who defines whom as troublesome or mentally sick?...[the one] who first seizes the word imposes reality on the other; [the one] who defines thus dominates and lives; and [the one] who is defined is subjugated and may be killed."

In short, define or be defined. In the very recent past,within my medical professional life time , physicians in many ways defined their role.Their role was to act as a fiduciary to their patients,to do no harm and act in the interest of their patient.Now their role is being redefined as stewards of the collective medical resources.Yes, it has been members of the medical profession,largely a small group of internists, who have spear headed this effort to redefine medical ethics and have been able to implant those views in the medical schools and in post graduate curriculum and their new professionalism has at least been given lip service in over one hundred medical organizations.. While I would not impugn the motives and sincerity of those physicians who have promoted that view and value system,I cannot resist applying the often useful Mafia Rule. Follow the money.Who gains from transforming physicians into health care providers and resource stewards and tasking them with saving money for the health care collectives? Is it "society" or various medical collectives (HMOs,ACOs), who have hoodwinked us into accepting the colossal lie that their bottom line corresponds to some greater societal good.

Dr. Szasz : "In the animal kingdom, the rule is, eat or be eaten; in the human kingdom, define or be defined. "

In the last 25 years physicians have allowed themselves to be redefined in such a way that they have lost their independence, integrity and have sacrificed their prime directive of a fiduciary
duty to the patient to a nebulous,elastic vision of serving the community.

Monday, September 10, 2012

Maintenance of Licensure- another tool to ensure social justice?

Most physicians probably have never heard of the Federation of State Medical Boards (FSMB) though all are aware of their own state board and its requirements for licensure and the requirements for continuing medical education (CME).

In the June 26, 2012 issue of the Annals of Internal Medicine readers learn their latest plans. Let me focus on the third of three components of their current work in progress for their Maintenance of Licensure ( MOL) project. Writing about the third component which involves "How am I doing" the article says:

"...or over time submission of practice activities adhering to regional or national performance improvement benchmarks"

The authors continue to mention the adoption of electronic medical records would enable "easier volunteer sharing of practice performance records with state board "

"Volunteer sharing" indeed. More likely share and conform if you want your license renewed when the final plans are put into place.

A perfect storm is brewing for control of physicians' practices which is the holy grail of third party payers.

Let's see some of what is in place or in preparation.

1) changing medical ethics is well under way. The Physician Charter is now 10 years old (see here for comments regarding its anniversary) .This established social justice as one of the three ethical precepts of the practicing physician. Over a hundred medical professional organizations have signed on to this, the American College of Physicians have included social justice in its latest version of medical ethics and the catechism is being taught to medical students and house officers. When the Charter was first published some may have wondered just how practicing physicians were to bring about the "just distribution of finite resources"; many thought their days were adequately filled with trying to do what was right for individual patients. That problem has been solved. A just distribution will be achieved when physician comply with guidelines that are formulated by cost effectiveness methods. Doing what is good for the collective will be what is good for the patient even though,for example, the treatment he forgoes in the interest of collective good may have benefited him.

2)The Maintenance of Licensure activities of the FSMB will eventually include the mandatory reporting of the degree to which the physician complies with the social justice compatible, cost effective, parsimonious guidelines.

3) For those physicians who continue to treat Medicare and Medicaid patients their reimbursements will depend in part on reporting selected guideline compliance data.
(Do not rule out the possibility of one day there being a MOL requirement for physicians to see their fair share of the Medicaid patients).

4) ACGME has done its share in changing the mindset of physicians in training in part by disabusing them of the archaic notion that a physician should stay on duty in the hospital when her patient is in a critical, dynamic situation which requires a physician to be physically in attendance.Simply hand off those patients to the next "team". Now there are teams in charge not an individual physician in charge.

The title of this commentary could as easily be Maintenance of Certification-another tool to control medical costs .

Wednesday, September 05, 2012

Wise Massachusetts Solons realize value of central planning of health care

The Massachusetts legislature and governor realizing the incredible success of central economic planning from their study of the history of the 2oth century have acted decisively to control the amount of medical expenditures for the state and as a bonus to increase the quality of medicine.

See here for a news item on the new Mass. Plan to control all health care costs and here for my earlier comments.

The lessons of the Soviet collectivizing the farms and controlling the economy were not lost to the folks in Boston . The value of central planning could not have been more clear as they studied the success of the communist Chinese implementing collective farming . They could see from the iconic night time view of North and South Korea the success of a rationally controlled economy. The legislators were able to discern the real reason for the Berlin Wall was to exclude the west Germans from sharing in the economic miracle of East Germany.

They followed in the foot steps of fellow Massachusetts residents such as Paul Samuelson whose text book as late as the 1960s lauded the superiority of the soviet economic planning over the less efficient, plodding relatively free marker economy of the US and of John Kenneth Galbraith who advised a struggling Indian economy to adopt the successful five year type planning of USSR. Probably they had studied basic economics and learned that there was no way better than wage and price controls to abolish shortages and increase quality of goods and services.

As much praise as they they deserve for their historical and economic scholarship perhaps they should only receive a grade of B+ for they missed one important lesson that the Soviet leaders soon learned in their efforts to turn a sleepy backward agrarian nation into an industrial behemoth. That lesson put poetically is you have to crack eggs to make an omelet or more crudely you may have to starve a few million citizens to nudge them to get with the program.

The legislator failed to put any real teeth in the program.Without penalties for failure to meet the growth guidelines (ie not grow too much) the program mostly consisted of a suggestion to not spend too much on health care. Of course, that oversight can easily be corrected at the next session of the legislature should the citizens of the state fail to prudently act in the interest of the collective.

Satire and sarcasm aside, three hundred plus pages of dense,self referential prose do not get written solely on the basis of economic ignorance and historical illiteracy. ( OK sometimes they seem to) . Public policy theory suggests that things happen for a reason and that self interest of groups often initiate and devise legislation. Who profits from this bill? I don't know but the laudatory comments of the Massachusetts Hospital Association and Blue Cross regarding the legislation makes me think of a place to start in the inquiry.