Thursday, February 21, 2013

The language of academic medicine has become the language of the collective

One of the many changes that have occurred in medicine over the last 40 years ( my professional lifetime)  has been the framing of certain aspects of  medical care into the language of the collective. I have written before abut the bogus nature of the concept of the "Medical commons" (see here for critique of the medical commons bogus analogy ) but that is only a small example of the dominant themes found in medical literature and not just just in the policy wonk journals and editorials such as those found in the NEJM but also in throw away comments found in the boiler plate like introductions to what otherwise are serious medical research papers. How many medical journal articles have you seen that begin with commenting that  disease x, y or z is an important pubic health problem? Defining everything as a public health problem cries out for public health solutions. Are there any health issues that are simply a matter between the patient and his physician?

The concept of social justice as an ethical imperative of physicians which has though the efforts of a small group of prolific academic writers,certain foundations with deep pockets  and medical insurance industry shills has  become the de facto default position of medical academia and the self proclaimed thought leadesr  and will become standard catechism for the present and future generations of medical students.Aspects of this con job (better word?) has aspects of the  features of the classic Baptist and Bootlegger phenomenon. As some  members of the medical academia promote this view and move out of and into the medical insurance upper level management and various government positions of power it become difficult to identify who are really the baptists and who is conning whom.  Yet,I continue to believe that many of those who advocate social justice and believe that physicians should be the stewards of society's medical resources do so with sincerity and in the belief that these are meaningful terms and worthy goals while at least a few of us believe that allegiance to bogus concepts usually does not work out very well.

 Ask not what you can do for your patient but what you can do for the greater good of the group,ACO or payment panel which you and your patients by random chance have become part of.After all if you do what is cost effective the group will benefit and through some type of metaphysical fairy dust so will your patient even if she or he is deprived on a beneficial test of procedure or medication because he/she is part of the group.Rather than comments like the preceding  being shouted down with a John McEnroe like " you've gotta be kidding" we see that that type  commentary in the NEJM offered by a well known medical economist.See here for the comments of Victor Fuchs and my criticism.

Since few would doubt that academia in general is populated by a preponderance of liberals, progressives and egalitarians ( See here for some survey data)  why be surprised that medical academia is no exception? The question is why is it that only fairly recently has the rhetoric of medical publications so strongly reflected that mind set appearing not just in editorials and commentaries and in health policy publications  but regularly in the boilerplate introductions to otherwise ordinary presentations of a medical studies.

Thursday, February 14, 2013

update on more Obamacare and central planning bad news

 There is an increasing stream of news almost hourly on the detrimental effects of Obamacare and to adequately review and highlight even the more flagrant examples would overwhelm my limited staff (me).
However from time to time I'll offer a few . Here are some for today.

1.The absurd nonsense of the Obama Administration health czars' (the designation czar is alarmingly correct) "compromise" on the contraceptive mandate.See here for  Cato's commentary on that in an article that explains Obamacare's shell game regarding the mandate.

A related story is that offered by David Catron at The American Spectator, see here. Catron tells a story about a lobbyist for  big Pharma who is now the appointee for a major position at HSS,the Barr Laboratories who make the morning after pill and pricing rules dictated by HHS.Crony Contraceptives is the appropriate title of the commentary.Is this another Cui Bono instance?

 2.The revelation of the egregious conditions at the Stafford Hospital in the UK ( see here for many details ) which can serve as a multiple poster child for the horrors of central planning gone bad,how really bad P4P can turn out and to illustrate once again the primacy of the economic principle that incentives matter. However,it may be that with the NHS 's program for reform,everything will work out especially since apparently Dr. Don Berwick may be chosen to lead the reformation of the system whose praises so loudly he sung some time ago.

3.This article from Cato by Michael Cannon explains that Obamacare from its beginning treated legal immigrants and citizens who were in a certain income bracket differently.The immigrants were granted a subsidy for health insurance under an insurance exchange while the citizen would get his health care from Medicaid.The health care obtained under Medicaid is widely regarded as inferior.How is that for social justice?

Monday, February 11, 2013

Social Justice quote for the day-by Thomas Sowell

Thomas Sowell makes the distinction between what he says is the traditional conception of justice and social justice.See here for the essay from which the following quote was taken.

   " Traditional concepts of justice or fairness, at least within the American tradition, boil down to applying the same rules and standards to everyone.  This is what is meant by a "level playing field"-- at least within that tradition, though the very same words mean something radically different within a framework that calls itself "social justice."  Words like "fairness," "advantage" and "disadvantage" likewise have radically different meanings within the very different frameworks of traditional justice and "social justice."
    John Rawls perhaps best summarized the differences when he distinguished "fair" equality of opportunity from merely "formal" equality of opportunity. Traditional justice, fairness, or equality of opportunity are merely formal in Professor Rawls' view and in the view of his many followers and comrades.  For those with this view, "genuine equality of opportunity" cannot be achieved by the application of the same rules and standards to all, but requires specific interventions to equalize either prospects or results.  As Rawls puts it, "undeserved inequalities call for redress." "

Libertarians and conservatives on one hand and egalitarians on the other all claim to be supporters of equal opportunity but they mean different things by the same words.The first group is talking about what Rawls calls formal opportunity and the second what he calls genuine opportunity.Egalitarians urge  corrective actions to transform a situation which has what  they consider ethically inadequate formal opportunity to their real deal of genuine opportunity.Libertarians not conversant with the egalitarian nomenclature consider the egalitarian's support of corrective actions to be a concern for and emphasis on outcomes while the egalitarians think of the outcome as an improved and the appropriate opportunity.Debates in which the two parties have different meanings for the same words usually do not get resolved.

The Charter (The Physician's Charter)( see here for article ) authored by a surprisingly small group (but apparently well funded, see here) internists in 2002 claims that to be  properly professional in the new millennium a physician must strive for social justice raising that goal to the same level as the  key traditional medical ethical precepts of patient autonomy and beneficence for the patient . This notion of justice is not the traditional concept of justice to which many in this country,including no doubt many physicians accept. Audacity is too weak a word to describe their assertions. Unbelievable is too weak a word to describe the apparent success their effort has had as least as judged by the nominal acceptance of that view by a large number of American medical professional organizations.

Who were the physicians  who lead the social justice movement in the medical profession? This is a topic for a later commentary.

Thursday, February 07, 2013

Foundation gave $ 2.5 million to ABIMF to promote Choosing Wisely

The Robert Wood Johnson Foundation in 2012 gave the American Board of Internal Medicine Foundation (ABIMF) $ 2.5 million to further the promotion of "professionalism" which as explicated in the  Physician 's Charter ( see here)  includes social justice and the wise stewardship of limited medical resources. In this instance the grant was to promote the stewardship theme.  RWJ's website announcement is found  here.

Specifically the grant was to promote ABIM's Choosing Wisely Campaign.In the words of the RWJ Foundation web site:

 "To (1) leverage and expand the reach of the 2012 Choosing Wisely campaign of the ABIM Foundation to raise awareness about avoiding unnecessary care; (2) spur physicians, patients and other health care stakeholders to think and talk about medical tests and procedures that may be unnecessary; and (3) prepare providers, patients and other stakeholders to decrease unnecessary health care utilization."

It is no surprise that RWJ Foundation would have warm feelings for the Charter as the link between the two foundations go back at least to 2002 which was the date of the Charter's publication '

One of the authors of the Physician's Charter was Dr. Risa Lavizza-Mourey who  since 2002 has been the President and CEO of  RWJ .  See here for a listing of the Charter's authors.

The apparent successful campaign to promote social justice and the stewardship notion has amazed me but it seems less amazing considering the value of  having friends with very  deep pockets. ( RWJ foundation has about 7.5 billion in assets). The person who invited Dr. Lavizza-Mourey to be a co-author in the Charter project (if that is what really happened,I have no insider information) really knows how to get things done. A  Google search was not successful when I attempted to learn how much money over the past 10 years RWJF has given to ABIMF to promote the Charter. If anyone can help with that, please let me know.

You have to wonder how that  $2.5 million  will be spent and if this ABIMF initiative will be as successful as the promotion of the Charter seems to have been. There are still many physicians who  believe that the promotion of social justice as an basic ethical imperative of physicians is harmful at best and destructive at worse to the physician patient relationship and usurps the fiduciary duty of the physician to the patient.
With the money behind the promotion of the  social justice-stewardship of society's resources program,we have to be a bit discouraged.

Avoiding unnecessary tests and treatments for patients does not necessitate  evoking concepts of social justice and  mythical caretakers of society's resources- the traditional medical ethical concepts of beneficence and non-malfeasance  take care of that. Of course,choose wisely in patient management advice but do so because it is right for the individual patient not on the basis of some fairy tale of collective resources being preserved.

addendum.2/11/2013.I apologize to the CEO of RWJ Foundation for misspelling her name on the initial publication of this post.It is now corrected.

Wednesday, February 06, 2013

Will Obamacare encourage more business to "go protean" ?

What does "go protean" mean? See here for this WSJ article on the phenomenon. Basically a business would outsource many of its functions to other corporate entities, not to individual contractors, which is often what out sourcing means.

Quoting WSJ:

 " Like a protozoan single-cell organism, the protean corporation has the ability to "shape shift," rapidly adapting to internal and external forces in the market and the company. At the heart of a true protean corporation is a tiny number of core employees surrounded by a large cloud of resources, generally contracted or outsourced talent that does most of the work."

To get under the fifty employee ACA head count threshold, a business might ofter that some of its employees form a corporation and then contract with that business to do whatever functions at that business. Now you have one corporation doing business with another and there is no longer the employer-employee relationship which is one that is controlled and regulated in many ways by local and federal governmental entities (e.g.OSHA,Fair Employment laws of various kinds,Etc)

H/T to Michael Cannon at Cato who closed his commentary on this issue with this:See here for his entire comments.

"Keeping the core company below 50 full-time employees will allow such companies to avoid the employer mandate. But it will also drive up Obamacare’s cost, because most of the workers in the new corporate entity will be eligible for government subsidies through the  health insurance “exchanges.” This will drive up the cost of Obamacare wherever those subsidies exist."

The list of unintended consequences of Obamacare continues to grow.The protean corporation scheme may or may not catch on,and the IRS or some other governmental entity may or may not have some regulatory counter move and since folks respond to incentives we can expect to see more ways for businesses to avoid or minimize the effects of Obamacare and counter moves by the government.The IRS has already issued proposed rules to restrict some of the self  protective actions of businesses in regard to how full time employees are counted and how to calculate full time equivalents.

Sunday, February 03, 2013

Social Justice quote for the day from Anthony De Jasay

The Hungarian economist Anthony De Jasay in his commentary posted in the Library of Economics and Liberty takes on the issue of social justice and wonders if the adjective really fits the noun and if what sense it is justice.See here for his entire comments.

"Justice is a property of acts. Just acts conform to certain rules, unjust ones violate them. A state of affairs is just if it is the outcome of just acts. If we want to claim that a state of affairs, say, a particular distribution of material advantages, is an injustice, it is incumbent upon us to show that it results from unjust acts. Otherwise, talk of injustice is just talk. This is where the problem of the identification of social justice as supposedly a branch of the general body of justice must be faced.
Stripped of rhetoric, an act of social justice (a) deliberately increases the relative share (though it may unwittingly decrease the absolute share) of the worse-off in total income, and (b) in achieving (a) it redresses part or all of an injustice. (Note that “income” is used in a broad sense to include stocks and flows of all material goods or claims on same that are transferable). This implies that some people being worse off than others is an injustice and that it must be redressed. However, redress can only be effected at the expense of the better- off; but it is not evident that they have committed the injustice in the first place. Consequently, nor is it clear why the better-off should be under an obligation to redress it, even though if they do not, no one else is left to do it."

So, if the better off did nothing wrong, where is the justice in forcing them to pay; would it not actually   be an injustice to force them to redress something for which they were not responsible? John Rawls's contractarian  theory seeks to support a negative answer to that question arguing that they, quoting Jasay," have agreed in a hypothetical but prima facie sane contract to bear the burden in their own interest". In this formulation redistribution would be the remedy for an unjust situation  and there need not have been any unjust acts committed. Comments regarding this hypothetical,fictitious social contract are deferred to a later posting.

Jasay's comments resonate with FA Hayek's characterization of the modifier "social" as a weasel word which like a weasel sucking a egg allegedly without collapsing it  can suck the meaning out of the word it modifies.   Question for the day: Has the Physician Charter (Medical Professionalism in the New Millenium) sold the medical profession a bill of goods for the next thousand years based on a weasel word?

Friday, February 01, 2013

Obama admistration defines "affordable" in a way denying subsidies to some lower income families

What does the affordable in the Affordable Care Act mean? It means exactly what the IRS says it means and now the IRS has had its say in that regard. See here for the NYT news report on this IRS ruling.

Quoting the NYT article:

"In deciding whether an employer’s health plan is affordable, the Internal Revenue Service said it would look at the cost of coverage only for an individual employee, not for a family. Family coverage might be prohibitively expensive, but federal subsidies would not be available to help buy insurance for children in the family."

Affordable means affordable coverage for the individual employee not for his or her family. If the employee share of the employer subsidized coverage exceeds 9.5% of the family's annual income then the family would be eligible for a federal subsidy.But,the percentage applies only to the cost of coverage for the employee and not for the entire family and the cost of family coverage is significantly higher than for single coverage. So if the company insurance does not include the family many employees will be faced with costly insurance with no government subsidy.

This interesting brand  of social justice administered by the IRS was countered by the Secretary of HHS exempting folks screwed over by this ruling from any penalty (or tax as Justice Roberts might say) resulting from this IRS ruling.

Many, if not most large, companies which already provide health insurance do so for the entire family not just the employee so no one has a good estimate regarding how many would be affected.The Times article claimed millions.

Speaking of affordable,the IRS has released educational material explaining how the penalty (they apparently have not read Justice Robert's decision that made the penalty a tax) for failure to buy health insurance.First, they say that in 2016 the cheapest insurance allowable (bronze plan)  will cost $ 20,000 for a family of five.See here for news article.

Next they reveal in typical IRS language how the "penalty will be computed.

 "(ii) For each month in 2016, under paragraphs (b)(2)(ii) and (b)(2)(iii) of this section, the applicable dollar amount is $2,780 (($695 x 3 adults) + (($695/2) x 2 children)). Under paragraph (b)(2)(i) of this section, the flat dollar amount is $2,085 (the lesser of $2,780 and $2,085 ($695 x 3)). Under paragraph (b)(3) of this section, the excess income amount is $2,400 (($120,000 - $24,000) x 0.025). Therefore, under paragraph (b)(1) of this section, the monthly penalty amount is $200 (the greater of $173.75 ($2,085/12) or $200 ($2,400/12))."

If you had wondered about the role of the IRS in health insurance ,that quote should give a flavor.What did you expect?