Saturday, November 30, 2013

some of the week that was in the commentary regarding the magestic unfolding of Obabacare

1. Don Boudreaux , economist from George Mason University, blends the history of the Plymouth Colonies,Thanksgiving, the purported right to health care, ACA  and the incentive problem with his typical trenchant style , See here.

Referring to a recent article suggesting a significant increase in the numbers of Medicaid patients resulting from implementation of Obamacare would aggravate the already problematic doctor shortage , Professor Boudreaux said :

"This historical experience [ referring to the Plymouth colony's failed experiment in communal ownership] contains a lesson for health care.  The problems highlighted in your report – a surge in health-care consumption along with a shortage of health-care resources – is a predictable result of turning health care into a common-property resource.  Consumers have fewer incentives to consume it wisely while physicians and other health-care providers have fewer incentives to supply it in quantities sufficient to meet all of the demands for their services."

 The colonists in Massachusetts figured it out in the 1600s what  finally hit the leaders in the USSR when that  failed economic experiment imploded in the early 1990s.

Communal ownership of health care resources is a theme that the medical professional elite has put forth for some time, perhaps beginning with the lame analogy between health care resources and the so called  tragedy of the commons the coining of which is typically  attributed to  Garrett Hardin in a 1968 article.Later Dr Howard Hiatt wrote in the New England Journal of Medicine in 1975 : " the total resources available for medical care can be viewed as analogous to the grazing areas on Hardin's common."

 The absurdity of this analogy was dealt with in some detail here but the notion of medical care as a common property issue has flourished in the medical policy literature and gave birth to the meme
popular in progressive medical thought leader circles that physicians have an ethical duty to be stewards of the [mythical]  medical resources.To promote this stewardship theme and to to conserve these limited common resources  appears to be the reason for existence of the American Board of Internal Medicine Foundation  with its" choosing wisely" campaign which in turn is well funded from the Robert Wood Johnson Foundation.It should not go unnoticed that one of the authors of the New Medical Professionalism which promotes social justice as a ethical imperative  is current leader of the RWJF amd she was at the time of that pronouncement was sent forth.

2.The related topic of appropriateness guidelines is discussed by Dr. Westby Fisher in his blog "DrWes" . He traces the origin of that movement to the Rand Corporation in the broader theme of  the tension between the medicine of the individual and the medicine of the collective..See here.

quoting Dr.Fisher:

"Doctors are currently witnessing the profession of medicine moving from the ethic of the individual to the ethic of the collective. The passage of the Affordable Care Act has solidified this treatment ethic and, as a consequence, often creates conflicts between the treating physician and their individual patients.
Nowhere is this shift to the ethic of the collective clearer than our expanding attempt to determine treatment "appropriateness" using a look-up chart of euphemistically-scored clinical scenarios owned and trademarked as "Appropriateness Criteria®" or "AUC®" by our own medical professional organizations."

I did not realize that the organizations of cardiologists were as aggressive as the ACP and the ABIMF in their efforts to institutionalize guideline medicine  and  minimize the individual physician patient decision making process.

3.Dr. Robert Centor, one of my all time favorite medical bloggers, opened the can of worms of IPAB , a topic that had become somewhat dormant. He expressed support for IPAB and this was meet by several letter writers voicing the opposite view.See here. For those of us who believe that Public Choice theory is largely correct and worry about regulatory capture and cronyism  ,there is much to worry about with IPAB.

 4.More and more economists and others have been writing about what they believe to be the very  real possibly of the insurance exchanges,critical to the viability of Obamacare,entering into some type of Greek tragedy death spiral. Seth Chandler,a law professor who is a specialist in insurance law at the University of Houston Law school does a great job of very detailed and nuanced analyses of many of the incredibly complicated and complex details of that law and of the still emerging regulations that further define its operational meaning makes predictions iffy since may change tomorrow. See here for Prof.Chandler's blog.
Even NPR seemed to recognize that some called a death spiral could actually happen.

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