Tuesday, April 29, 2014

Is the "social justice" of ABIMF and ACP what John Rawls had in mind?

The stated reason for the existence of the American Board of Internal Medicine Foundation (ABIMF) is to further medical professionalism.,the three principles of which are patient welfare,patient autonomy and social justice. By social justice they seem to mean the " just and cost effective distribution of finite [medical] resources ".

The Choosing Wisely campaign is promulgated by ABIMF and in its original version was an seemingly innocent and well intentioned suggestion that physicians and patients have a frank discussion about medical procedures and treatments to the end of trying to minimize those that might be wasteful and/or harmful. Of course,everyone want to do away with waste and harm.but it is morphing into something much more than that. Suggestions are being made and gaining momentum that lists should be made of those procedures and treatments that are "low value" which will be defined as falling below some threshold of quality adjusted life years (QALY) per amount of money. A figure  of  $150,000 per QALY is being proposed.Further, there are suggestions that CMS enforce the dictates of the Choosing Wisely campaign.

Note-if it is "determined" that something's value is  "low" i.e  if less than some dollar amount per QALY then physicians should not recommend that procedure and third party payers might just not cover it. So patients dependent on third party payers to obtain  that procedure would not receive it while more affluent folks who  are free to pay for their own treatments would be able to obtain this so called  low value procedures.

Social justice is a slippery term and its ambiguity may serve promotion of a given social movement  but it is generally recognized to be redistributive justice.Rawls said that redistribution would be acceptable only if the most disadvantaged members of society would benefit.

If the plan to suggest that "low value" treatment should not be done, then no one should receive it , at least in theory. But in practice it may well mean that those who cannot afford to pay for it on their own would not receive it, and such a group certainly would include the most disadvantaged members of society. Not a very Rawlian outcome.

Further, Rawls did not support decisions made on utilitarian grounds. The cost effectiveness analysis of the QALY calculus is clearly based on the dictum greatest good for the greatest number. Rawls believed that this approach did not support the autonomy,the individual rights and dignity of the individual.

Dr. Christine Cassel and Dr. Virginia Hood,both leaders of  the American College of Physicians spoke of "parsimonious care". Social justice a la Rawls would champion more care for the most disadvantaged .Parsimonious care is less care for everyone in theory but in practice the affluent may get it anyway. so who gains from that? Third party payers comes to mind.The ACP and ABIMF and others are going on a full court press to convince physicians that they are population doctors and to conserve resources they should follow guidelines. This will achieve the re-defined, non-Rawlian , social  justice imperative that they have said is required of physicians .Adherence to guidelines it is argued will improve the health of the collective though some individuals will suffer but the bottom line of the third party payers and ACOs will not suffer  and the medical elite mandarins will also do well.

Minor spelling,grammar and punctuation changes made on 7/11/14.

1 comment:

Walter Bond said...

It's even worse than you write with these cost analyses.

Prices communicate information about supply and demand.

Where do the "prices" for most U.S. medical services come from? From CMS, and they are arbitrary. There being no price mechanism for these services (including ancillary testing) there can be no real assessment of price cost/benefit.

So, the central planners can set the price high, and then not cover said procedure because (despite the benefit)...it's too expensive. Neat trick, that.