Thursday, September 12, 2013

The new medical ethics and professionalism is good news for the viability of the ACOs

If most physicians believed and acted as if they were the fiduciary agent of their patient ( as was once their primary ethical imperative ) the new highly touted Accountable Care Organizations (ACOs) would be doomed to failure. They may fail anyway because the new ethics is not a sufficient condition for ACO and maybe not be necessary either but it sure won't hurt.

The new ethics has paved the ethical road for bigger medicine -in the form of ACOs and other vertically integrated health care entities..What was needed to be done was to change the role of the physician from steadfast advocate for the patient, which often put him in opposition to the insurance company,to a more compliant worker working with the suits to "conserve society's medical resources" and thereby enhance the bottom line of the organization.

   To accomplish that, long standing  medical ethical principles had to revised. These venerable precepts were welfare of the patient and preservation of patient autonomy. The new ethics architects did not launch a honest frontal attack on primacy of patient welfare but rather sneaked in a new element , namely social justice and added to the concern for the individual patient's welfare a co duty to preserve society's resources.

A facile veneer of ethical sounding verbiage serves to justify a localized, utilitarian statistical approach to clinical decision making in which the aggregate "good" or statistically defined utility-perhaps measured in quality adjusted life years- will trump the utility or good of any given individual patient.

This approach was raised to its most specious,arrogant level by a well known medical economist,Victor Fuchs writing in the New England Journal of Medicine. See here for my previous comment regarding Dr. Fuch's sophistry.

Fuchs tells his readers about a dilemma.

"How can a commitment to cost-effective care ( as physicians have been "committed" to that since the Physician charter and the New Professionalism) be reconciled with a fundamental principle of primacy of patient welfare"


He argues that  if all the physicians in a given health care collective(as in Accountable care Organizations) practice cost effective medicine, the resources saved can be used for the benefit of the defined population which includes the patients of the physician who seemingly may face a conflict. So, if all the physicians act in the same way all patients benefit.

 Here, Fuchs conflates the good of group as indicated by some aggregate number with the good of each individual in a particular situation in which a particular individual may not enjoy the benefit and may actually be harmed. In fact cost effectiveness analysis involves aggregate data. With any outcome in a group some may benefit and  some may be harmed.Years earlier, Dr David Eddy offered the same basic recipe for " increasing quality while decreasing costs" but, unlike Fuchs had the honesty to admit in such an arrangement there would be winners and losers. Fuchs maintains,apparently with a straight face,everyone wins.

The old medical ethics clashed with what is needed from physicians to make the collective a financial success. The medical progressive elite believe they have solved that problem by changing medical ethics .Many in the older generations of physicians do not buy in to the
stewards of society's resources concept but as waves of younger docs hear nothing else from the day they enter med school, the concept of fiduciary duty to the patient will be of fleeting historical interest.Certainly, that will be the case if the activities of the ABIM Foundation with its generous funding from the Robert Wood Johnson Foundation has its way.

If you wonder how big and bigger medicine will affect patient care see this excellent discussion by  Dr.Paul Hsieh.



1 comment:

Paul Hsieh said...

Thanks for the shout-out!