George H. Smith in his book "The System of Liberty" in the chapter entitled "Liberalism,Old and New" discusses how the concept of liberalism and its advocates were victims of a linguistic coup in the latter part of the nineteenth century.
The classic liberals thought of freedom as the absence of coercion.They championed the notion of a limited government whose function was to secure the rights of individuals.Enter a group of thinkers who proposed a " new liberalism" , one that would,in their view, correct this inadequate,limited definition of freedom.To the newcomers liberty without equality was freedom in name only and true freedom involved equal opportunity and power to enjoy one's life. They wanted to replace the idea of "negative freedom" of the classical liberals with what would become the focus of the welfare state.True freedom in their view was more than mere removal of compulsion or coercion. The new liberals were paternalistic and believed the state should do much more than secure the people from internal and external predators but rather protect them from the effects of their own uncoerced actions.The classic liberals defended their position in part by asserting that the new liberalism was old wine in new bottles, with the wine being advocacy for a paternalistic government.The new liberals continued to dispense rhetoric that supported liberty but they had redefined the word liberty.
The new liberals won the day and the old or classic liberals lost much influence but re-appeared in the 20th century with a new label, libertarian. The new liberals were simply known as liberals and later referred to by some as progressives.
I argue analogously that the traditional ,classical medical ethics and its advocates ( physicians themselves) were victims of a similar linguistic coup. Throughout most of the 20th century and earlier the core of medical ethics was primacy of patient welfare and respect of the autonomy of the patient,the later gradually replacing an older paternalism of medicine.Physicians were considered to have a fiduciary duty to the patient.
At the end of the 20th century and the early years of the 21th century a new medical ethics emerged,one in which -while its proponents claimed nothing had really changed-there was a radical sea-change in regard to the duties of the physician.This was accomplished by nothing more rhetorically solid based or intellectually justified than a simple gratuitous assertion.The notion of social justice was simply declared to be part of medical professionalism and medical ethics.The degree to which this bogus concept has been accepted and endlessly repeated in medical publication is a tragic shame.The victims of this linguistic coup are the physicians themselves but to a greater degree the patients are the real losers as they have lost their advocates at a time when they may need them the most.
Tuesday, December 31, 2013
Friday, December 27, 2013
Obamacare's noble lie meets the iatrogenics of the statute's reality
Matt Welch, writing in Reason.com ( see here) offers the following concise summary of what is fundamental to making ACA work.
"The estimated scores of millions of eventual health plan cancellations that Americans will soon face are not some weird unintended consequence of Obamacare. They are fundamental to making the law work as written. The Affordable Care Act relies on previously uninsured young people to overpay for coverage they don’t need, and for previously insured adults to pay for health contingencies they will never face, be it childbirth for men or pediatric dental care for grandparents. That is what is supposed to allow more people to be covered and to keep overall rates in check. Since making people’s health insurance more expensive is not particularly popular, Obama lied about it, and not only when he claimed you could keep your plan and your doctor."
It is making some people pay for other people's stuff or in other words social justice. The possibly fatal flaw in Obamacare is that the payer class is literally getting the bill for this redistribution and they know the bill is being sent to them. This violates the principle rule of redistributional politics which is to focus the benefits and diffuse the cost and don't let those who are paying the cost realize what is happening. Now with Obamacare lots of folks are realizing that are paying for it and they don't like it.
The noble lie,sometimes referred to as Plato's noble lie refers to the situation in which the elite knowingly expresses an untruth in order to advance an agenda.
The "ball don't lie" expression is a basketball phrase referring to the situation in which a foul is called in error and the player awarded the free throws misses. The injustice of the foul is negated by the missing of the free throws.
Jordan Bruneau writing in the blog "Mises Daily" comments on the iatrogenics of Obamacare. The term iatrogenics enlarges the concept of medically induced harm to the more general meaning of unintended negative consequences which harms the very people the act was intended to help. For example, by the end of 2013 there may well be more people losing their health insurance than the previously uninsured who gained a insurance card.Obamacare is the latest poster child of iatrogenics.Rent control,various anti poverty programs and the war on drugs are among some of the numerous government programs that illustrate this principle of negative unintended consequences.
Obamacare was devised with major crony, special interest influences in mind but poorly crafted,sold to the public by markedly minimizing the projected costs and misleading the public about its negative consequences,rolled out with numerous politically expedient exemptions to friends of the administration and then a monumental website failure, and was soon recognized by millions of people that the law resulted in their loss of insurance and/or significantly more expensive health insurance costs in spite of several ad hoc ,possibly illegal,likely ineffective and possible counterproductive fixes by an increasingly panicking administration .
The ineptitude of the entire project in its public relations fiasco,its ignoring of the fundamental rule of distributional politics, its ignoring of the rule of law as it executes the law by political expediency and its world class disjointed complexity resulting in quotidian unintended consequences brings to mind the following Hayek quote:
“The curious task of economics is to demonstrate to men how little they really know about what they imagine they can design.”
Thursday, December 26, 2013
What happens when health care is based on spending other people's money?
Dr. Paul Hsieh answers the question posed in the title in his recent commentary in Forbes. See here.
He outlines four important ominous consequences of basing health care on spending other people's money.
Everyone should read this excellent article in its entirety but let me briefly highlight and comment on the first in the list.
"Doctors will be increasingly expected to save money' for the system ' ."
This is already happening.Various medical professional organizations are re-writing traditional medical ethics, pushing the fiduciary duty of the physician to the patients in the memory hole and substituting the bogus concept of the physician as a steward of society's medical resources. I have ranted about this before but the caravan rolls on and increasingly the rhetoric in various medical forums emphasizes saving money for the system. The medicine of the collective is replacing the medicine of the individual. This is being promoted in part by what I have called the progressive medical elite who, to a frightening degree, seem to occupy the leadership position in many influential medical organization . Their unspoken mantra is that medical care is too complex and too important to be left to the individual patient and his physician. Wise leaders with ideas need to be in charge. Of course, it is promoted by the third party payers, private and public who may well consider the medical professional elite in this ethical paradigm shift as useful idiots.
The notion of "the system" [in regard to medical care] while a rhetorically useful notion for a certain agenda, is basically fallacious aggregating elements that do not belong together. In short, there is no system for health care just as there is no car delivery system or a home building system. It makes no sense to speak of the situation in which someone buys a new car as a cost to the car supply system or a person buying a home as a cost to the home supply system.All of these are transactions in which there are buyers and sellers and exchanges take place.Mr Jones gets a CT of the abdomen.. This is not a cost to any system. It is a cost to Jones and/or his insurance company while to the providers of care it is a payment.. One person's cost is another person's income.To call this a cost to a system is nonsense.Unless all the health care is provided, operated and owned by a single entity, usually the government., then the services provided could be considered a cost to the system.
Who gains from acceptance of this bogus notion of physicians as stewards of some mythical collectively owned medical resources? The third party payers and the medical elite progressives who stand to gain from their position of prestige as experts and rule makers gain and the rest of us lose.
He outlines four important ominous consequences of basing health care on spending other people's money.
Everyone should read this excellent article in its entirety but let me briefly highlight and comment on the first in the list.
"Doctors will be increasingly expected to save money' for the system ' ."
This is already happening.Various medical professional organizations are re-writing traditional medical ethics, pushing the fiduciary duty of the physician to the patients in the memory hole and substituting the bogus concept of the physician as a steward of society's medical resources. I have ranted about this before but the caravan rolls on and increasingly the rhetoric in various medical forums emphasizes saving money for the system. The medicine of the collective is replacing the medicine of the individual. This is being promoted in part by what I have called the progressive medical elite who, to a frightening degree, seem to occupy the leadership position in many influential medical organization . Their unspoken mantra is that medical care is too complex and too important to be left to the individual patient and his physician. Wise leaders with ideas need to be in charge. Of course, it is promoted by the third party payers, private and public who may well consider the medical professional elite in this ethical paradigm shift as useful idiots.
The notion of "the system" [in regard to medical care] while a rhetorically useful notion for a certain agenda, is basically fallacious aggregating elements that do not belong together. In short, there is no system for health care just as there is no car delivery system or a home building system. It makes no sense to speak of the situation in which someone buys a new car as a cost to the car supply system or a person buying a home as a cost to the home supply system.All of these are transactions in which there are buyers and sellers and exchanges take place.Mr Jones gets a CT of the abdomen.. This is not a cost to any system. It is a cost to Jones and/or his insurance company while to the providers of care it is a payment.. One person's cost is another person's income.To call this a cost to a system is nonsense.Unless all the health care is provided, operated and owned by a single entity, usually the government., then the services provided could be considered a cost to the system.
Who gains from acceptance of this bogus notion of physicians as stewards of some mythical collectively owned medical resources? The third party payers and the medical elite progressives who stand to gain from their position of prestige as experts and rule makers gain and the rest of us lose.
Thursday, December 19, 2013
so why don't we really know about breast cancer screening? Is it really turtles all the way down?
The more I read and the more I think about what I read and the more things seem to change but really stay the same I develop a renewed sense of just how damn hard is it to figure out what to do or what advice to give in regard to cancer screening as well as other so called preventive measures.
The verbal scuffles following the USPSTF recommendations on mammograms settled little. The best commentary I have read on this matter is from the amazingly prolific Dr. Roy Poses and is found in this paragraph from his recent blog posting:
One would think that a big point of discussion about breast cancer screening would be why after eight trials enrolling a total of about 350,000 patients reported over 20 years we still cannot answer the big clinical questions. A related point for discussion in the US is why only one, and the earliest trial was conducted here. If we here in the US think breast cancer screening is such a major concern (and we should think so), why have we been unable to mount a single important trial of it since the HIP trial conducted more than 30 years ago?
The big clinical questions of which he spoke were:
does screening mammography improve survival
does it improve quality of life
do the benefits outweigh the risk and harms
Yeah, so how come we don't know after all those studies and trials and analysis and meta-analysis.
Part of the evidence that the USPSTF panel used in formulating its recommendations came from a recent meta-analysis. I always cringe a bit when a meta-analysis seems to play an important role in a decision. I am reminded of an commentary by Dr. Steve Goodman regarding what seemed to be dueling meta-analysis regarding the very topic of breast cancer screening.
This is what I said about that before with slight editorial reconfiguration:
[An] important Annals of Internal Medicine Articles and related editorial by Dr. Steve Goodman of Johns Hopkins made it clear to me that meta-analyses (MAs) were basically themselves observational studies in which the studies themselves were subjects. He discussed two major MAs on the value of mammograms, one which concluded they were effective and valuable and the other concluded the opposite.The major difference between the studies was their choice of studies to include and to exclude. Both sets of authors maintained their criteria for exclusion were valid and yet they were quite different and resulted in opposite conclusions. Quoting Goodman:
... this controversy shows that the justification for why studies are included or excluded from the evidence base can rest on competing claims of methodological authority that look little different from the traditional claims of medical authority that proponents of evidence-based medicine have criticized.
I have no doubt that the panelists did their work according to generally accepted evidence based medicine "rules of the game". But along the way both within and apart from the meta-analyses used in their calculus there are many gaps in which subjectivity and yes even personal bias come upon the scene. When human beings approach problems , gather evidence and analyze it is not evidence turtles all the way down, judgment turtles crawl in.I quote Goodman again:
"Controversies like this one about mammography are
likely to appear more frequently as we move toward reassessing
the evidence base after each new study appears
(15). Such reassessments will guarantee that we are often in
a gray zone between moderate and strong evidence, where
scientific judgment can make a critical difference. We must
learn to navigate within this gray zone better. Judgment
determines what evidence is admissible and how strongly
to weigh different forms of admissible evidence. When
there is consensus on these judgments and the data are
strong, an illusion is created that the evidence is speaking for itself and that the methods are objective. But this episode
should raise awareness that judgment cannot be excised
from the process of evidence synthesis and that the
variation of this judgment among experts generates uncertainty
just as real as the probabilistic uncertainty of statistical
calculations."
I am even more cynical-there may not be any way to navigate this grey zone better. There are many more trade offs than there are solutions.
The verbal scuffles following the USPSTF recommendations on mammograms settled little. The best commentary I have read on this matter is from the amazingly prolific Dr. Roy Poses and is found in this paragraph from his recent blog posting:
One would think that a big point of discussion about breast cancer screening would be why after eight trials enrolling a total of about 350,000 patients reported over 20 years we still cannot answer the big clinical questions. A related point for discussion in the US is why only one, and the earliest trial was conducted here. If we here in the US think breast cancer screening is such a major concern (and we should think so), why have we been unable to mount a single important trial of it since the HIP trial conducted more than 30 years ago?
The big clinical questions of which he spoke were:
does screening mammography improve survival
does it improve quality of life
do the benefits outweigh the risk and harms
Yeah, so how come we don't know after all those studies and trials and analysis and meta-analysis.
Part of the evidence that the USPSTF panel used in formulating its recommendations came from a recent meta-analysis. I always cringe a bit when a meta-analysis seems to play an important role in a decision. I am reminded of an commentary by Dr. Steve Goodman regarding what seemed to be dueling meta-analysis regarding the very topic of breast cancer screening.
This is what I said about that before with slight editorial reconfiguration:
[An] important Annals of Internal Medicine Articles and related editorial by Dr. Steve Goodman of Johns Hopkins made it clear to me that meta-analyses (MAs) were basically themselves observational studies in which the studies themselves were subjects. He discussed two major MAs on the value of mammograms, one which concluded they were effective and valuable and the other concluded the opposite.The major difference between the studies was their choice of studies to include and to exclude. Both sets of authors maintained their criteria for exclusion were valid and yet they were quite different and resulted in opposite conclusions. Quoting Goodman:
... this controversy shows that the justification for why studies are included or excluded from the evidence base can rest on competing claims of methodological authority that look little different from the traditional claims of medical authority that proponents of evidence-based medicine have criticized.
I have no doubt that the panelists did their work according to generally accepted evidence based medicine "rules of the game". But along the way both within and apart from the meta-analyses used in their calculus there are many gaps in which subjectivity and yes even personal bias come upon the scene. When human beings approach problems , gather evidence and analyze it is not evidence turtles all the way down, judgment turtles crawl in.I quote Goodman again:
"Controversies like this one about mammography are
likely to appear more frequently as we move toward reassessing
the evidence base after each new study appears
(15). Such reassessments will guarantee that we are often in
a gray zone between moderate and strong evidence, where
scientific judgment can make a critical difference. We must
learn to navigate within this gray zone better. Judgment
determines what evidence is admissible and how strongly
to weigh different forms of admissible evidence. When
there is consensus on these judgments and the data are
strong, an illusion is created that the evidence is speaking for itself and that the methods are objective. But this episode
should raise awareness that judgment cannot be excised
from the process of evidence synthesis and that the
variation of this judgment among experts generates uncertainty
just as real as the probabilistic uncertainty of statistical
calculations."
I am even more cynical-there may not be any way to navigate this grey zone better. There are many more trade offs than there are solutions.
Tuesday, December 17, 2013
ACA and " improvisational government"
Daily, both in the main stream press and in the blogger world, more and more ACA bad news is reported and dissected. But the cancelled policies and the sticker shock, and the shrinking of provider networks and insurance policy formularies may not be the most frightening aspect of the Affordable Care Act.
"... the most harrowing aspect of Obamacare is that it vests political executives and government administrators with sweeping discretionary power, free of conventional checks and balances. It gives federal officials the authority to set insurance prices without any of the economic and legal standards that govern regulation of public utilities...
Collaterally, Obamacare is introducing a new form of government—improvisational government, characterized by continuous ad hoc revisions of statutory law by executive decree. This is a reversion to a primitive form that long antedates our Constitution and rule-of-law traditions. Transported to the modern world, it leaves the private sector in a state of constant uncertainty and subjection."
The above quote is from Chris Demuth writing in the Weekly Standard.. See here for the entire article. Forget Rule of Law, Obamacare is being administered by the rule of men often with the driving motivation being political, minimizing or delaying the bill's harmful effects until after the 2014 election. H/T to the economist John H. Cochrane,aka the Grumpy Economist. See here.
ACA could be described as the "improv health care bill".If provision X of ACA stipulates that this or that be enacted as of a date certain, no problem provision X can be postponed ( until after the next election) . If folks are having their insurance policies cancelled, no problem just postpone those cancellations or more recently pressure the insurers to provide free care. for awhile at least.See here for the latest edict from HHS.If the letter of the law of ACA provides subsidies only under the exchanges that states establish, no problem, just provide subsidies for the federally established exchanges as well regardless of what the plain language of section 1311 might say. See here for a recent update on the legal aspects of that issue.
Section 3, clause 5 of the US Constitution ( [the President shall] " take care that the laws be faithfully executed" might as well never be written.
The talking point of the administration has changed from " if you like your insurance,you can keep it" to" if you are unhappy with some aspect of ACA we'll change it".
The increasingly strident defenses raised by die hard ACA advocates ring less and less credible as they continue to claim that ACA provides affordable health care to almost everyone. More and more folks being stung with higher payments and fewer benefits makes the "affordable" claim much weaker and does "almost all " now mean everyone but maybe 31 millions.( For the CBO estimate for those not insured under ACA,see here.). With July 4,2012 census estimate of the US population being about 313.93 million, just under 10% of the population would not be covered, not to mention an unknown number of the young and healthy who choose to pay the
".. constant uncertainty and subjection" was not was Madison had in mind but that seems to be the promise of Obamacare.
Monday, December 16, 2013
Individual risk assessment- Is that a concept that resists meaning?
Following the Annals of Internal Medicine's publication of the latest recommendations of the USPTSP regarding breast cancer screening, was an editorial by Dr. Karla Kerlikowske discussing the need for "individual risk assessment" of breast cancer.See here for excerpt, subscription required for full text
Previously it was a commentary in the same journal regarding breast cancer and the need for "better" (more accurate?) risk assessment in the context of whether women in the 40-49 age group should be advised to get a mammogram. I wrote this entry making the claim that at the core it is debatable if the concept of individual risk risk makes any sense at all as opposed to speaking of the risk of an event in a group of people.
Dr. Kerlikowske begin her final paragraph with this sentence:
We can improve primary and secondary breast cancer prevention effectiveness by implementing risk assessment in primary care and mammography facilities and providing tailored recommendations for prevention based on individual risk.
So what is this thing called individual risk and how do we determine it?
What follows is a re-write of my 2007 blog entry on this issue with the addition of skeptical comments by my brother, Jarrad ,who is a radiologist considering retirement.
Risk assessment for various medical conditions has become an everyday part of the activities of primary care physicians. Risk assessment involves the identification of something called risk factors, personal characteristics or test findings that are associated with increased incidence of a given disease. This term was coined by the researchers in the Framingham study when they spoke of factors that were associated with an increased risk of coronary artery disease. As the "practice model" of internist practices changes from hospital based consultation type to office outpatient, more attention is given to preventive medicine which is a world of risk factor identification and risk assessment exercises as well as recitation of various guidelines and targets or as Jarrad says treating folks who have no demonstrable diseases.
Here is an example of risk assessment using the equation from the National Cholesterol Panel's (NCEP) web site.A 67 year old non-smoking man, Mr. Jones,with a history of hypertension under control and systolic blood pressure of 120, with a total cholesterol of 170 and an HDL cholesterol of 75 would have a risk estimate of 9 % according to their risk equation.
This means that if we consider the 10 year health outcomes of 100 men from the Framingham data base with this particular set of characteristics, 9 would have a coronary event. (A so-called hard end point of either a myocardial infarction or coronary death.) Of course, we do not know who the 9 will be until the event occurs and we cannot tell Mr. Jones if he will be one of the nine or not raising the question of in what sense is this number "his" individual risk.
What does this" risk "of 9% for Mr Jones mean? Maybe the following mind experiment will shed some light on that. Let's pretend we can clone Mr. Jones and we do so 100 times and consider the question of what will be the outcomes of these 100 Joneses. Will 9% have a coronary artery event or will it be the case that either all will be fine or all will have a coronary event. (My gratitude again to Dr. Goodman and his memorable article in the Annals of Internal Medicine for this line of though that I blogged about here.)
If we believe in medical determinism- that clinical outcomes are determined by a causal chain of events-we believe that either all will be fine or all will have a heart attack. They will all be fine if they and the original Mr. Jones do not posses the factor(s) that sum up or interact to bring on an event or all will have an event if Mr. Jones had-as will all his clones have-whatever factor(s) known and unknown which determine a coronary artery event. If we believe in a cosmic dice roll then some 9% will have an event and medical science will never know ahead of the event who will because it is simply random.
Another consideration is that while we have placed Mr. Jones in this set of men with these particular features , we could have -if we had the data available-place him into a different set or as a member of as many sets as the imagination allows. We might consider him as a member of a set defined by his age, his c-reactive protein value, his performance on a stress test, his calcium score on a heart CT scan and his triglyceride level and if we consider the event rate in a group of men with these features we may well arrive a different value which could be 22%. So what is his risk- 9% or 22% or any of the multitude of other numbers that we could construct in a similar manner and are any of these numbers his individual risk? With the publication of the 2013 Guidelines from AHA and ACC we have a new prediction tool.Is the new tool better than Framigham and how do we make that determination? What if the expert panel who uses their new rule give recommendations and risk level cut points that differ from what the old expert panel with their predictions and rules? Doctor,were you wrong then or are you wrong now?
That type of consideration led the imminent German statistical theorist, Richard Von Mises to say in his book " Probability,Statistics and Truth" that it is only possible to speak of probability in terms of a collective (or in more modern terms -a set or a group) and that to say, for example, that a given person has the probability 0.10 of dying in the next year is nonsense. Yet, isn't this is exactly what we do when we we punch in a person's numbers into the Framingham equation and announce to the patient that his risk of a cardiac event in the next 10 years is 9%. ?
Jarrad,offers this: "But wait,if you believe that "determination" of individual risk is nonsense why is it that seemingly there are a number of very useful prediction models used by physicians for such things as risk or likelihood of pulmonary embolus given several clinical variables?In what way does the use of those prediction model equation differ from telling Mr. Jones that he has a risk of 9 % of a heart attack in the next ten years?"
Well, I'm not sure but one thing is usually those prediction models classify patients into low, moderate and high risk of the disease at issue and based on that certain further testing is or is not done and those strategies seemed to have been shown to work out reasonably well in clinical trials.Further the determination of risk in general terms ( low, medium, high) has at times been proven to be of clinical value in diagnosing pulmonary embolism or whatever, but telling someone their risk is 9% of a future disease is not per se an actionable item.We can link the numbers to some recommendations for statins or whatever but.... I am not sure there is any practical or useful outcome from that. Trying to figure out the best way to clinically manage someone with a given clinical picture is one thing, advising someone to take or not take statins or bisphophonates based on some "determination" of her risk based on some expert panel's judgment is another matter entirely.Although I spent a number of years doing just that sort thing for many hours per week,now I am much less certain about the validity of the entire enterprise and whether I was doing my patients good or harm.
Previously it was a commentary in the same journal regarding breast cancer and the need for "better" (more accurate?) risk assessment in the context of whether women in the 40-49 age group should be advised to get a mammogram. I wrote this entry making the claim that at the core it is debatable if the concept of individual risk risk makes any sense at all as opposed to speaking of the risk of an event in a group of people.
Dr. Kerlikowske begin her final paragraph with this sentence:
We can improve primary and secondary breast cancer prevention effectiveness by implementing risk assessment in primary care and mammography facilities and providing tailored recommendations for prevention based on individual risk.
So what is this thing called individual risk and how do we determine it?
What follows is a re-write of my 2007 blog entry on this issue with the addition of skeptical comments by my brother, Jarrad ,who is a radiologist considering retirement.
Risk assessment for various medical conditions has become an everyday part of the activities of primary care physicians. Risk assessment involves the identification of something called risk factors, personal characteristics or test findings that are associated with increased incidence of a given disease. This term was coined by the researchers in the Framingham study when they spoke of factors that were associated with an increased risk of coronary artery disease. As the "practice model" of internist practices changes from hospital based consultation type to office outpatient, more attention is given to preventive medicine which is a world of risk factor identification and risk assessment exercises as well as recitation of various guidelines and targets or as Jarrad says treating folks who have no demonstrable diseases.
Here is an example of risk assessment using the equation from the National Cholesterol Panel's (NCEP) web site.A 67 year old non-smoking man, Mr. Jones,with a history of hypertension under control and systolic blood pressure of 120, with a total cholesterol of 170 and an HDL cholesterol of 75 would have a risk estimate of 9 % according to their risk equation.
This means that if we consider the 10 year health outcomes of 100 men from the Framingham data base with this particular set of characteristics, 9 would have a coronary event. (A so-called hard end point of either a myocardial infarction or coronary death.) Of course, we do not know who the 9 will be until the event occurs and we cannot tell Mr. Jones if he will be one of the nine or not raising the question of in what sense is this number "his" individual risk.
What does this" risk "of 9% for Mr Jones mean? Maybe the following mind experiment will shed some light on that. Let's pretend we can clone Mr. Jones and we do so 100 times and consider the question of what will be the outcomes of these 100 Joneses. Will 9% have a coronary artery event or will it be the case that either all will be fine or all will have a coronary event. (My gratitude again to Dr. Goodman and his memorable article in the Annals of Internal Medicine for this line of though that I blogged about here.)
If we believe in medical determinism- that clinical outcomes are determined by a causal chain of events-we believe that either all will be fine or all will have a heart attack. They will all be fine if they and the original Mr. Jones do not posses the factor(s) that sum up or interact to bring on an event or all will have an event if Mr. Jones had-as will all his clones have-whatever factor(s) known and unknown which determine a coronary artery event. If we believe in a cosmic dice roll then some 9% will have an event and medical science will never know ahead of the event who will because it is simply random.
Another consideration is that while we have placed Mr. Jones in this set of men with these particular features , we could have -if we had the data available-place him into a different set or as a member of as many sets as the imagination allows. We might consider him as a member of a set defined by his age, his c-reactive protein value, his performance on a stress test, his calcium score on a heart CT scan and his triglyceride level and if we consider the event rate in a group of men with these features we may well arrive a different value which could be 22%. So what is his risk- 9% or 22% or any of the multitude of other numbers that we could construct in a similar manner and are any of these numbers his individual risk? With the publication of the 2013 Guidelines from AHA and ACC we have a new prediction tool.Is the new tool better than Framigham and how do we make that determination? What if the expert panel who uses their new rule give recommendations and risk level cut points that differ from what the old expert panel with their predictions and rules? Doctor,were you wrong then or are you wrong now?
That type of consideration led the imminent German statistical theorist, Richard Von Mises to say in his book " Probability,Statistics and Truth" that it is only possible to speak of probability in terms of a collective (or in more modern terms -a set or a group) and that to say, for example, that a given person has the probability 0.10 of dying in the next year is nonsense. Yet, isn't this is exactly what we do when we we punch in a person's numbers into the Framingham equation and announce to the patient that his risk of a cardiac event in the next 10 years is 9%. ?
Jarrad,offers this: "But wait,if you believe that "determination" of individual risk is nonsense why is it that seemingly there are a number of very useful prediction models used by physicians for such things as risk or likelihood of pulmonary embolus given several clinical variables?In what way does the use of those prediction model equation differ from telling Mr. Jones that he has a risk of 9 % of a heart attack in the next ten years?"
Well, I'm not sure but one thing is usually those prediction models classify patients into low, moderate and high risk of the disease at issue and based on that certain further testing is or is not done and those strategies seemed to have been shown to work out reasonably well in clinical trials.Further the determination of risk in general terms ( low, medium, high) has at times been proven to be of clinical value in diagnosing pulmonary embolism or whatever, but telling someone their risk is 9% of a future disease is not per se an actionable item.We can link the numbers to some recommendations for statins or whatever but.... I am not sure there is any practical or useful outcome from that. Trying to figure out the best way to clinically manage someone with a given clinical picture is one thing, advising someone to take or not take statins or bisphophonates based on some "determination" of her risk based on some expert panel's judgment is another matter entirely.Although I spent a number of years doing just that sort thing for many hours per week,now I am much less certain about the validity of the entire enterprise and whether I was doing my patients good or harm.
Friday, December 06, 2013
Obamacare's chief economist does not raise the important "and then what" question.
In a recent interview Dr. Jonathan Gruber,a MIT economist whose name is closely linked to ACA gave a broad outline of who gains and who looses as the legislation becomes operational. See here for details of the interview in the New Yorker article.
Here is the brief overview.
80% of folks are basically "left alone", as they will keep their employer sponsored medical insurance.
3% loose as they will no longer have their individual policies.
14% are winners as they will now be able to obtain medical insurance.
Since there seem to be many more winners than loosers, from a utilitarian perspective, the greatest good for the greatest number has been achieved and ACA must be considered a success .After all, you know to make an omelet..
So, he seems to say " not much here to see, move one"
However, there is much more to it than recitation of the alleged head counts of the various Gruber categories.
Economists such as Walter Williams and Thomas Sowell in talking about the economic way of thinking emphasize the importance of asking "and then what ". For example, if some one praises rent controls as providing affordable housing for the disadvantaged, the then-what question might lead to a discussion of how such measures typically result in a shortage of available housing , lower quality of the housing and possible black market behaviors and non-price based rationing.
Had Gruber asked the and-then what question in regard to ACA he might have begun a discussion about how much policies would cost in each subset-would the 80% be paying more or less and would the coverage be better or worse or unchanged. Or even as some reports indicate (even one by the CBO) that significant numbers of the " left alone" 80% might loose their employer provided health care insurance although not necessarily for reasons directly related to ACA..See here.
The and then-what question could lead to consideration of the issue: will there be enough physicians to care for the significantly increased numbers of folks who have an insurance card. Will insurance companies be reimbursing health care providers at their current rate? Will insurance plans offer significantly less choice as to providers? Further, rules issued from HHS have put providers on the hook for service charges not paid by insurance after a policy holder defaults on their monthly premiums.See here. How far will the rule makers at HHS go as they are continually modifying the law go to minimize any lose insurance companies might incur in the exchanges? See here for a detailed analysis of some of the efforts from HHS to minimize those potential loses.Basically HHS rules changed the 90 grace period to a 30 day period during which insurance companies were at risk for reimbursement of of services rendered .
This day to day, or week to week, ad hoc, de facto central planning which "readjusting" of the provisions of Obamacare as they were written continues in the rule making offices of HHS regularly shredding what is left of the rule of law. The lobbying and crony capitalism continues long after the president signs the law. The article 11 , section 3 part of the Constitution ( " he shall take care that the laws be faithfully executed" ) might just as well never have been written.
How will the $ 700 billion cut in Medicaid funding which in part pays for Obamacare impact the care Medicare recipients receive? How will the $170 Billion cut in Medicare Advantage impact the quality of care of care of folks on those plans?
Gruber's discussion ignores the secondary effects and only looks at the head counts of those who keep insurance,those who loose it and those who gain it ignoring the cost and quality of coverage and access to care issues that are the unintended consequences.
You can easily see why the " and then what" question is something ACA apologists would rather not dealt with.
Here is the brief overview.
80% of folks are basically "left alone", as they will keep their employer sponsored medical insurance.
3% loose as they will no longer have their individual policies.
14% are winners as they will now be able to obtain medical insurance.
Since there seem to be many more winners than loosers, from a utilitarian perspective, the greatest good for the greatest number has been achieved and ACA must be considered a success .After all, you know to make an omelet..
So, he seems to say " not much here to see, move one"
However, there is much more to it than recitation of the alleged head counts of the various Gruber categories.
Economists such as Walter Williams and Thomas Sowell in talking about the economic way of thinking emphasize the importance of asking "and then what ". For example, if some one praises rent controls as providing affordable housing for the disadvantaged, the then-what question might lead to a discussion of how such measures typically result in a shortage of available housing , lower quality of the housing and possible black market behaviors and non-price based rationing.
Had Gruber asked the and-then what question in regard to ACA he might have begun a discussion about how much policies would cost in each subset-would the 80% be paying more or less and would the coverage be better or worse or unchanged. Or even as some reports indicate (even one by the CBO) that significant numbers of the " left alone" 80% might loose their employer provided health care insurance although not necessarily for reasons directly related to ACA..See here.
The and then-what question could lead to consideration of the issue: will there be enough physicians to care for the significantly increased numbers of folks who have an insurance card. Will insurance companies be reimbursing health care providers at their current rate? Will insurance plans offer significantly less choice as to providers? Further, rules issued from HHS have put providers on the hook for service charges not paid by insurance after a policy holder defaults on their monthly premiums.See here. How far will the rule makers at HHS go as they are continually modifying the law go to minimize any lose insurance companies might incur in the exchanges? See here for a detailed analysis of some of the efforts from HHS to minimize those potential loses.Basically HHS rules changed the 90 grace period to a 30 day period during which insurance companies were at risk for reimbursement of of services rendered .
This day to day, or week to week, ad hoc, de facto central planning which "readjusting" of the provisions of Obamacare as they were written continues in the rule making offices of HHS regularly shredding what is left of the rule of law. The lobbying and crony capitalism continues long after the president signs the law. The article 11 , section 3 part of the Constitution ( " he shall take care that the laws be faithfully executed" ) might just as well never have been written.
How will the $ 700 billion cut in Medicaid funding which in part pays for Obamacare impact the care Medicare recipients receive? How will the $170 Billion cut in Medicare Advantage impact the quality of care of care of folks on those plans?
Gruber's discussion ignores the secondary effects and only looks at the head counts of those who keep insurance,those who loose it and those who gain it ignoring the cost and quality of coverage and access to care issues that are the unintended consequences.
You can easily see why the " and then what" question is something ACA apologists would rather not dealt with.
Thursday, December 05, 2013
The dangerous shift from the medical ethics of the individual to the ethics of the collective
The long running,thoughtful blog "DrWes" discusses an important issue .See here.
The author is Dr.Westby G. Fisher,a cardiac electrophysiologist from Illinois.
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."
A important-perhaps critical-step in this shift was the effort to change medical ethics. At least nominally this has occurred. I believe this conceptual sea change was largely brought about -at least in the United States- about by a relatively small number of physicians who I describe as the progressive medical elite. Influential folks in the American College of Physicians and the American Board of Internal Medicine and its foundation , the ABIM Foundation, are among those who have lead the charge.I have written about this development more than once. See here details on this sea change in ethics.
These new ethics and a movement labelled medical professionalism push the fiduciary duty of the physician to the patient past the back burner and attempts to shove that notion into the memory hole. This duty has ( had?) been the fundamental core of the physician patient relationship. Try and find the word "fiduciary" in the most recent rendition of medical ethics from ACP or in the white paper on Medical Professionalism.
The first encounter I had with this notion of treat the collective not the patient was in a series of articles in JAMA in 1995 written by Dr. David Eddy in which he promised to show the medical world how to increase quality while conserving costs. The answer was simply to allocate resources in a medical collective ( such as an HMO) using some version of cost benefit analysis so as there would be achieved the greatest benefit to the greatest number, i.e. utilitarianism.Letters to the editor raised the issue of the upending of traditional medical ethics, the tort system which did not and does not recognize a utilitarian defense of harming the individual patient to benefit some statistical aggregate and the basic human tendency to act in one own perceived best interest and those of their family and not that of some possibly hypothetical collective.The dogs barked and the caravan moved on and currently we see that this duty to the collective notion has hijacked traditional medical ethics and I fear is doing the same to medical education.
The author is Dr.Westby G. Fisher,a cardiac electrophysiologist from Illinois.
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."
A important-perhaps critical-step in this shift was the effort to change medical ethics. At least nominally this has occurred. I believe this conceptual sea change was largely brought about -at least in the United States- about by a relatively small number of physicians who I describe as the progressive medical elite. Influential folks in the American College of Physicians and the American Board of Internal Medicine and its foundation , the ABIM Foundation, are among those who have lead the charge.I have written about this development more than once. See here details on this sea change in ethics.
These new ethics and a movement labelled medical professionalism push the fiduciary duty of the physician to the patient past the back burner and attempts to shove that notion into the memory hole. This duty has ( had?) been the fundamental core of the physician patient relationship. Try and find the word "fiduciary" in the most recent rendition of medical ethics from ACP or in the white paper on Medical Professionalism.
The first encounter I had with this notion of treat the collective not the patient was in a series of articles in JAMA in 1995 written by Dr. David Eddy in which he promised to show the medical world how to increase quality while conserving costs. The answer was simply to allocate resources in a medical collective ( such as an HMO) using some version of cost benefit analysis so as there would be achieved the greatest benefit to the greatest number, i.e. utilitarianism.Letters to the editor raised the issue of the upending of traditional medical ethics, the tort system which did not and does not recognize a utilitarian defense of harming the individual patient to benefit some statistical aggregate and the basic human tendency to act in one own perceived best interest and those of their family and not that of some possibly hypothetical collective.The dogs barked and the caravan moved on and currently we see that this duty to the collective notion has hijacked traditional medical ethics and I fear is doing the same to medical education.
Monday, December 02, 2013
ACA's IPAB and Platonic Medicine led by Platonic guardians
A recent commentary by one of favorite bloggers,Dr. Robert Centor,
spoke favorably about IPAB, one of many,many provisions of ACA.See here.I
made a brief reply to his entry. I recalled my earlier blog entry and
if Dr.Centror's comments stir up much furor I want to add this earlier
blog post to the kerfuffle.Originally published 6/22/11 and now submitted with little editing:
----
I had been sketching out some comments about what I was going to call "Platonic Medicine" referring to the "leaders with ideas" who will lead the way to transform medicine based on the underlying premise that "medicine is too complex and important to be left to the individual physician and the individual patient" and therefore it should be controlled and directed by the wise medical elite who will determine the collective utility of a given approach and its value.I have commented before about Don Berwick's advocacy of that view.
However, someone had written something in that regard better than I could.See here.
Hat tip to the Pacific Legal Foundation who filed a friend-of-the-court brief to challenge the constitutionality of IPAB on the grounds of violation of the non-delegation doctrine and for the above mentioned link which alerted me to Jost's frightening comments.
It turns out that an outspoken advocate and supporter of Obamacare,law professor, Timothy Jost has already praised that legislative act in part because of what the IPAB will provide. He said:
A board of “Platonic Guardians” to govern the health care system or some aspects of it. The cost of health care is spinning dangerously out of control…. [O]ur traditional political institutions—Congress and the executive administrative agencies—are too driven by special interest politics and too limited in their expertise and vision to control costs. Enter the Platonic guardians…an impartial, independent board of experts who could make evidence-based policy determinations based purely on the basis of effectiveness and perhaps efficiency.
Incredibly Jost is asserting that this board will be immune to the influence of special interests and will make decisions rationally and in a proper evidence based manner.From what planet will these board member be chosen? Philosopher kings in charge,what could go wrong with that?
Consider the following: The federal government establishes a body, which is politically appointed and whose decisions will direct impact hundreds of millions of dollars of health care expenditure.Will it be likely or unlikely that interested parties,the usual suspects in the health care "system",will do everything they can to influence the composition and decision of that board.
The PLF commentary pointed out that a Platonic government was definitely not what the founding fathers had in mind and Jefferson and associates were not big fans of Plato.
In the commentary that I was considering I thought perhaps calling the panel members Platonic Guardians would earn me the accusation of being overly dramatic and hyperbolic, but now we see an IPAB advocate using the same characterization and believing that to be a very good thing.
Dictating the coverage to control the cost for Medicare and Medicaid may not be enough for the medical Platonic elite as is illustrated by this quote from Dr. Robert Berenson:
"we ought to consider setting all payer-rates for providers." He continues "but the country's antigovernment mood renders such a discussion unlikely,at least for now".
I wonder who the "we" is that Berenson references.
Finally, another chilling quote from Mr. Jost:
"In the long run, Congress may not be able to cap Medicare expenditures without addressing private expenditures as well. If the IPAB opens the door to rate setting for all payers,it may well be the most revolutionary innovation of the ACA".
Yeah, it just might be.
----
I had been sketching out some comments about what I was going to call "Platonic Medicine" referring to the "leaders with ideas" who will lead the way to transform medicine based on the underlying premise that "medicine is too complex and important to be left to the individual physician and the individual patient" and therefore it should be controlled and directed by the wise medical elite who will determine the collective utility of a given approach and its value.I have commented before about Don Berwick's advocacy of that view.
However, someone had written something in that regard better than I could.See here.
Hat tip to the Pacific Legal Foundation who filed a friend-of-the-court brief to challenge the constitutionality of IPAB on the grounds of violation of the non-delegation doctrine and for the above mentioned link which alerted me to Jost's frightening comments.
It turns out that an outspoken advocate and supporter of Obamacare,law professor, Timothy Jost has already praised that legislative act in part because of what the IPAB will provide. He said:
A board of “Platonic Guardians” to govern the health care system or some aspects of it. The cost of health care is spinning dangerously out of control…. [O]ur traditional political institutions—Congress and the executive administrative agencies—are too driven by special interest politics and too limited in their expertise and vision to control costs. Enter the Platonic guardians…an impartial, independent board of experts who could make evidence-based policy determinations based purely on the basis of effectiveness and perhaps efficiency.
Incredibly Jost is asserting that this board will be immune to the influence of special interests and will make decisions rationally and in a proper evidence based manner.From what planet will these board member be chosen? Philosopher kings in charge,what could go wrong with that?
Consider the following: The federal government establishes a body, which is politically appointed and whose decisions will direct impact hundreds of millions of dollars of health care expenditure.Will it be likely or unlikely that interested parties,the usual suspects in the health care "system",will do everything they can to influence the composition and decision of that board.
The PLF commentary pointed out that a Platonic government was definitely not what the founding fathers had in mind and Jefferson and associates were not big fans of Plato.
In the commentary that I was considering I thought perhaps calling the panel members Platonic Guardians would earn me the accusation of being overly dramatic and hyperbolic, but now we see an IPAB advocate using the same characterization and believing that to be a very good thing.
Dictating the coverage to control the cost for Medicare and Medicaid may not be enough for the medical Platonic elite as is illustrated by this quote from Dr. Robert Berenson:
"we ought to consider setting all payer-rates for providers." He continues "but the country's antigovernment mood renders such a discussion unlikely,at least for now".
I wonder who the "we" is that Berenson references.
Finally, another chilling quote from Mr. Jost:
"In the long run, Congress may not be able to cap Medicare expenditures without addressing private expenditures as well. If the IPAB opens the door to rate setting for all payers,it may well be the most revolutionary innovation of the ACA".
Yeah, it just might be.
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