Friday, November 30, 2012

Will states opting out of insurance exchanges unravel Obamacare?

Michale Cannon of Cato seems to argue that.See here.

Michigan is the latest state to say no thanks to the insurance exchange deal.Cannon has argued that while the federal government can establish an exchange it cannot have the subsidies that were to be part of the state exchanges. The IRS has issued a ruling that claims the opposite. Cannon and his co authors argue that both the legislative history and the statutory  language make it clear that ACA did not authorize the subsidies to the federal run exchanges.

The key thing seems to be how the courts rule regarding  the federal established exchanges legal  authority to issue subsidies .Ultimately if the issue reaches SCOTUS , will Justice Roberts act in a way to redeem himself  in the eyes of his former conservative supporters or will he once again dazzle us with innovative legal reasoning? My pessimistic prediction is for more bedazzlement.

Even if the IRS ruling holds as Dr. Scott W. Atlas of Hoover Institute argues here ,Obamacare may prove to be unworkable as costs rise and access to health care actually decreases (insurance cards do not magically generate physician) and the public or interests groups and politicians clamor for a solution we may well face the single payer option. Some have argued that was the plan all along even though that assumes greater wisdom in those who planned ACA than I think they likely possess.


Thursday, November 29, 2012

More aspects of Obamacare being challenged in court

Some states are still refusing to set up the insurance exchanges contained in ACA.Subsidies are an important part of the exchanges.The IRS claims that when the federal government sets up an exchange when an individual state refuses to it can offer the same subsidies.However the claim underlying another challenge to ACA is that there is no statutory authority to do so.

See here for details.

Also the Liberty University litigation has been resurrected by the the Supreme Court. See here for details.The dogs keep barking but the pessimists believe the caravan has moved on and will not be recalled.

Monday, November 26, 2012

How Medicare CMS payment schemes push physicians to be employees

 The health care economist John Goodman explains  one more  incentive for the private practice doctor to become an employee of a hospital or some other vertically integrated health care corporation  and  for the vector that is pointing in the direction of increased health care costs.

 Differential price controls benefit some and harm others. See here for how much more CMS pays for the same procedure based on where it is provided.Wonder which group has the more effective rent seeking mechanisms-hospitals or private practice physicians.

In regard to the differential payments,Cui bono.Obviously the hospitals- but why would CMS adopt that tactic? I suggest it is in the interest of all third party payers not just CMS to eliminate the private practice of medicine by thousands of small, individual physician practices.If the goal is control of how physicians practice medicine, then to nudge them to become employees of a medical collective  would appear to be a good tactic.

More on the movement away from small medical practices to hospitals can be found here in the discussion on the effect of ACA (Bronco care) on that issue.

Wednesday, November 21, 2012

U.S. health care needs more regulation,bureaucratic oversight and expert panels

Fortunately, that is exactly what is on the way  thanks to ACA also known as Bronco care-formerly Obamacare. Efficiency and innovation will be forced from the top down with new regulations,more price controls sprinkled with the fairy dust of accountable care organizations,medical homes and high value care all of which will also preserve the medical commons.  Wise central planners will shape a system of rational health care thankfully cleansed of the short sighted, selfish collaboration of the archaic physician patient dyad which for so long impeded the effective,cost efficient, culturally competent health care for all which social justice demands.

We can see from scrutiny of the historical record  how those techniques were successful in generating cheaper,better quality goods and services and general public admiration in the following areas : Amtrak,the US post Office, public school education, airline regulation, DMVs, and the TSA- just to name a few of the more successful instances.

Again we are fortunate that the nameless planners,bureaucrats,politicians,lobbyists for the various rent seekers and the self-less, advice-giving intellectuals  wisely ignored the frivolous advice of FA Hayek . " It is the curious task of economics to demonstrate to men how little they really know about what they imagine they can design." Obstructionist pontification like that serves only to hamper progress.

With the "wise leaders with ideas" at the helm of health care one can be confident that we can rationalize health care while avoiding some of the inconvenient truths about the central planning of  Canadian health care as described here.

Further,we should be grateful that the archaic impediment to the new health care nirvana,namely the restrictive and shortsighted notion of there being a fiduciary duty of the physician to the individual patient,has been corrected by the new medical ethics and professionalism.





Monday, November 12, 2012

With the presidential election settled Obamacare is free to pour forth its bountiful social justice

Opponents of ACA had hoped that SCOTUS would find the act unconstitutional and failing that that the 2012 election would give republicans the legislative power and occupancy of the White House to find way to defang the statute. But no,Obamacare is now unfettered to benefit the citizens of the country with unbounded instances of  social justice. Here are just a few.

Health insurance premiums are set to rise probably everywhere but so far we have published evidence regarding the degree to which they will rise in one state,Ohio,see here for details

The social justice fairy will likely bring more part time jobs at the expense of full time jobs.See here.

 When HHS determined that various methods of birth control would be covered by insurance companies at no extra cost to anyone,not only was a bold step for justice taken but by outlawing the there is no free lunch dictum the gates opened for endless more justice- effortless accomplished by a stroke of the HHS secretary's pen.See here.

With Obamacare seemingly immune from repeal or significant alteration the particularly compassionate and just aspect of ACA ,the granting of waivers from certain aspects by the secretary of HHS can continue unabated. "The secretary shall determine".

Part of Obamacare is the Medical Device Tax.See here how some medical device companies are adjusting by eliminating some jobs.At least some of those employee may have well  "Liked their doctor" but they will not be able to keep them as promised prior to the passage of the statute.Strange sometimes how that justice thing works out.

In fairness it should be noted that the social justice will cost a little bit more than the slightly less than one trillion dollar number that was contrived to facilitate passage of the bill. See here.Nevertheless a bargain at nearly twice the projected cost.

Monday, November 05, 2012

Is the term "medical commons" a useful analogy to US health care or a lame figure of speech



  In the Animal kingdom,the rule is eat or be eaten;in the human kingdom,define or be defined. Thomas Szasz

A recurrent meme in the discourse of medical policy  is the notion of the "medical commons". This term can be traced back to the phrase " the tragedy of the commons" which was a term introduced in a 1968 article by Garrett Hardin.

Tragedy of the Commons refers to the situation in which a shared resource is depleted by individuals acting in their own short term interest to the detriment of the group.Typical stylized examples are herders overgrazing their sheep on a common field not allowing grass to regrow or fishermen overfishing an area of the ocean depleting the fish population thereby damaging all in the long run.A characteristic of these commons is that the property is unowned or is considered to be common property.In other words there is lack of strong property rights.

The earliest reference I could find for the notion of medical commons (MC) was in a 1975 NEJM special article entitled Protecting the Medical Commons:Who is responsible? by Dr. Howard H. Hiatt.(NEJM 1975;293:235-241,July 31,1975).

Dr. Hiatt made the following gratuitous assertion that medical resources in the country can be viewed as analogous to the grazing area problem.I say gratuitous because Hiatt does not elaborate of how the two phenomena are alike in significant ways.
"The total resources available for medical care can be viewed as analogous to the grazing areas on Hardin's common."
 An analogy is  a type of comparison in which one likens one thing to another in circumstances in which the two things have useful similarities such that knowledge of the one thing can aid in understanding the other.  For example one could consider the human heart to be analogous to a pump.From our understanding of a pump we gain some insight into the mechanics of the heart.

The problem I have with the medical commons analogy is that health care or health care resources share no essential features with the notion of a commons.

 For example, the common field or patch of ocean is owned by no one ( or every one,which in some regards is the same thing ) whereas medical resources are owned by numerous entities in particular. Hospital X is owned by someone or some real economic entity,a corporation  or perhaps a local government or the federal government. The MRI units and the physical therapy units and the commercial labs are all owned by someone or other. Ownership involves the right to use one's property,to dispose of one's property and to exclude others from the property. In the commons all can use the property but do not enjoy the other  elements of property ownership.

In the commons,all are allowed to bring in the sheep to feed but every patient cannot simply go to any of the numerous health care facilities and partake of their offering for free and ad lib.

The "tragedy" in the tragedy of the commons is that overuse leads to resource depletion but does overuse (how ever defined) of health care resources deplete those resource. I argue just the opposite .

 As the demand for health care resources increases often so does the supply. As demand for hip replacements goes up more facilities have become available for orthopedic surgery, the same for cardiac caths and for MRI etc etc.Increasing demand and use of medical resources does not deplete them but can lead to their increase.No one is using up the MRI exams.

 The issue is not the depletion of resources as one might think using the flawed medical commons analogy, rather it is the expenditure for using those resources about which alarms have been sounded. Even here though, money spend on a MRI or surgery or whatever is not money hurled down a black hold- it is simply redistributed . But could not that money have been better spent by for example preschool tutoring for under privileged inner city youth? Maybe, but there will always be some other use for money that is spent on any thing. So is the resource that is being "depleted" in the medical commons money or more accurately other people's money or the perception that it is other people's money.


If the medical common analogy is thought to be appropriate and valid why would not the following be equally so; the home construction commons,the  food supply commons, the hair care commons,the automobile manufacturing commons. Why do we not hear alarms being sounded about spoiling of the home construction industry by overbuilding or too many customers spoiling the food supply commons?After all money spent on burgers cannot be spent on housing for the poor. Hint: Much of medical care is paid for using someone else's money.


While a grassy field for the villager's sheep to graze 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 re arrangements cropping up constantly. Various entities own various elements of this array-society owns none even though various government entities own some but the government is not society.

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 ".

 If there is societal allocation decisions will not be made by thousands of individual physician-patient pairs.



Dr. Hiatt is a very accomplished medical scientist with a distinguished career .His article in my opinion was an attempt to call attention to what he believed was the need for "society to find ways to govern access and control of the use of the medical commons" and the role that physicians would have in those decisions. In that regard the use of the idea of medical commons was a rhetorical device  to imply that medical resources are in some meaningful sense owned collectively and that society should decide important allocation questions. Governing access and control are the operative words.

Once one accepts the notion that the medical resources are collectively owned then it is a short step to the idea that individual physicians and patients should not be selfishly decide how things are allocated, the allocation must be done for the collective good based on sound, cost effective, utilitarian considerations.Although the discussions speak of a medical commons implying everyone in the country, operationally what we would be dealing with are smaller commons such as that found in and HMO or the current HMO oid entity the ACO which is the panacea flavor of the month.


When someone speaks of society making a decision be wary because there is no one named society and society decides nothing.The medical commons concept is more than a very flawed analogy . It is a rhetorical  tool for the listener or reader to passively accept the notion that health care should be collectivized. Advocates of that may say society decides and society demands but basically some (most ?) of the advocates of that view believe that the medical intellectual elite with the power of the government should make those decisions . They believe that medical care is too complex,too complicated and costs too much to be left in the hands of the individual physician and patient.Drs. Donald Berwick and Troynen Brennan  clearly expressed  the view that the doctor patient decision making "dyad" in their book New Rules should be eliminated.

Here are two quotes expressing the desire to do away with the traditional physician patient relationship , the first from Berwick's New Rules, the second from a 1998 Annals of Internal Medicine article by Dr. Robert Berenson and Hall :

"Traditional medical ethics, based on the doctor-patient dyad must be reformulated to fit the new mold of the delivery of health care."

and

"we propose that the 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."

 Of course everyone using the medical commons figure of speech is not an advocate of the new medical ethics or of collectivization of medical care, but once a phrase is used  often enough  it becomes part of the common discourse sometimes (often?) without concern about what it might really mean to some.

If we want to make progress in solving or at least mitigating some of the problems with US health care I suggest referring to a meaningless analogy is not useful except to those whose agenda involves destruction of the old time medical ethics.You might remember the one that emphasized the primary fiduciary duty of the physician to the patient.

The medical commons meme is often invoked in polemics admonishing physician to not order unnecessary testing.Such comments as "spoiling the commons" appear. I suggest that advocates of prudent medical testing need not invoke collectivist views of medical resources or reference to non existent medical commons.

Physicians already have a firm ethical basis for not ordering unnecessary tests and procedures. Two well known,long standing, stalwart precepts cover that very well;beneficence and do no harm.

Ordering unnecessary tests and procedures bump up against both. The harm of doing a test that is not necessary should be evident to a physician before he finishes medical school let alone residency training. The patient is harmed by the cost of the test (even if she only pays a fraction of the cost),by the anxiety of a false positive result and the inevitable cascade of further testing and possible invasive procedures that commonly occur after a false positive result.

Simply put- a physician who orders tests that are not in the interest of the patient is harming his patient and not living up to his fiduciary duty.The problem is not harm to the medical commons,there is no such thing.

It is not an oversight that advocates of the new medical professionalism which posits a co-duty of the physician to the patient and to society conveniently leave the term fiduciary duty out of their discussions and admonitions regarding medical professionalism.The fiduciary duty of the physician to her patients has been nudged out of the definition of a ethical physician and quietly replaced by physician as steward of society's resources.






Friday, November 02, 2012

Naturalistic Decision Making,phronesis and the making of an expert

A recent blog posting by Dr Robert Centor, see here, introduced me to the term "naturalistic decision making" which seems to be one aspect of the broader area of the study of cognitive reasoning, or how we make decisions. In this regard one focus is on decisions in which there are high stakes, time pressure and complex situations as is common in emergent clinical situations.

Basically  faced with that type of situation,such as the challenging chest pain case  described in Dr. Centor's article, expert clinicians typically rapidly categorize the situation based on a pattern recognition ( as described by Kahneman as a System 1,fast and unconscious mental act) and then move on to use a deliberate,analytic System 2 approach involving,in part,  a search for missing data and for discrepancies and then a simulation of what might occur next if the first plan based on the first impression were carried out.

The Nobel prize winning work of Kahneman and others working to elucidate how people think in have apparently fleshed out possible mechanisms of  some of what Aristotle referred to as  Phronesis.

Aristotle spoke of the virtues of the  mind as including:

sophia (wisdom of first principles),
episteme (emperical knowledge,
techne (technical knowledge)
nous (intuition) and
phronesis (practical wisdom or prudence).

Evidence based medicine  with its emphatic focus on  techne and episteme may foster the illusion that good clinical practice can be encapsulated in guidelines and pathways and that quality lies in obedience to them but it is the blending of those elements of science and technique with practical wisdom that makes good practice. Treatment guidelines or algorithms come into play only after a diagnosis has been reached and in all but the most trivial cases a bit of phronesis might help.

 In Kathryn Montgomery's 2006 book, How Doctors Think, we find the following quote which sounds a lot like what we learn from the field of Naturalistic decision making:

"Clinical judgment done well is the intuitive and iterative negotiation of the patient's narrative of illness...This focus come with experience"

And for that I don't believe there is an algorithm.