Friday, March 21, 2014

Adam Smith's Men of Systems and the progressive medical elite

Adam smith spoke of the men of system- men with a dangerous mixture of hubris and naivete  who presumed to know what is best for every one  and how to plan to bring that optimal state into being.

The following commentary highlights the views of some physicians who might be considered the medical men of system.

The following quote from Drs Don Berwick and Troyen Brennan in their appropriately named book, "New Rules" captures the essence of the fundamental nature of how men of system would arrange medical care.
 
"Today, this isolated relationship[ he is speaking of the physician patient relationship] is no longer tenable or possible… Traditional medical ethics, based on the doctor-patient dyad must be reformulated to fit the new mold of the delivery of health care...Regulation must evolve. Regulating for improved medical care involves designing appropriate rules with authority...Health care is being rationalized through critical pathways and guidelines. The
primary function of regulation in health care, especially as it affects the quality of medical care, is to constrain decentralized individualized decision making

 

Dr. Robert Berenson strikes a  seemingly different but clearly related note in a commentary in the Annals of Internal Medicine , 1998,pg 395--402.  in which he promotes the health of the collective rather than the individual patient :

"We propose that devotion to the best interests of each individual be replaced with an ethic of devotion to the best interests of the group for which the physician is personally responsible."

Berenson recommends a replacement of the fiduciary duty of the physician to the patient with a duty to a group while Berwick and Brennan talk about dissolution of the physician patient relationship and moving the locus of medical decision making  away from the physician and his patient to a reliance of authoritarian rules.

More recently Berenson has this to say:

 "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"


A series of articles in JAMA in 1994 (Rationing Resources while improving Quality) by Dr. David Eddy also recommended a utilitarian type medical care structure in which funds would be  spent on medical tests and treatments that were most likely to benefit some majority subset so that in the aggregate there would be a greater good for the greatest number.

Dr. John Benson is the former CEO of ABIM and ABIMF and had this to say recently on the ABIMF's website:

"  ABIM could require candidates to achieve a perfect score on questions related to costs and redundant care as a requirement for admission to secure exams for initial certification or MOC."

So for candidates for certification or the Maintenance of Certification to even be allowed to take the test they would have to recite,perfectly, the catechism of the brainchild of ABIMF ,the Choosing Wisely guidelines.

This alone, in my opinion,should qualify Dr. Benson for membership,along with the aforementioned doctors,in the Medical Men of System hall of fame.  

The recommendations of Berwick,Brennan,Berenson and Eddy were met by some vocal resistance as least as documented by letters to the editors in JAMA and the Annal of Internal Medicine . These authors were advocating a paradigm shift ,arguing for a 180 degree reversal of traditional medical ethics for which , I believe, physicians at the time were not ready and I hope are not ready now but...

But there is another way to gather support for a sea change in medical ethics and practice behavior,one that will also bring about greater concern for the collective and aggregate outcomes and that will to a large and ever increasing degree move the locus of medical decision making from the individual dyads to a central decider .

This other way is to nudge physicians and later shove them a bit into the acceptance of the notion that physicians have a duty to work for social justice and to act as stewards of the nation"s finite medical resources.To strive for social justice is a political position, one that does not necessarily have any professional links. To declare, or assert gratuitously , as was done the in the  publication known as the Medical Charter that physicians have an obligation to strive for social justice represented a audacious move,one that I am afraid has been at least nominally successful.

To close with a quote from Adam Smith's "Theory of Moral Sentiments" :

"The man of system, on the contrary, is apt to be very wise in his own conceit; and is often so enamored with the supposed beauty of his own ideal plan of government, that he cannot suffer the smallest deviation from any part of it. He goes on to establish it completely and in all its parts, without any regard either to the great interests, or to the strong prejudices which may oppose it. He seems to imagine that he can arrange the different members of a great society with as much ease as the hand arranges the different pieces upon a chess-board. He does not consider that the pieces upon the chess-board have no other principle of motion besides that which the hand impresses upon them; but that, in the great chess-board of human society, every single piece has a principle of motion of its own,"





Thursday, March 06, 2014

Breaking news-OBM discovers economics prinicple of "incentives matter"

Several of my favorite economists have said that the real good stuff in economics is revealed in the econ 101 courses. One of the secrets revealed is that "incentives matter".

Milton Friedman said most of economics could be boiled down to two thoughts; 1) there is no free lunch 2)demand curves slope downwards which simply means people tend to buy more if something costs less and tend to buy less if something costs more.

Another principle is that generally supply curves slope upward which means that someone will tend to supply more of something if the price increases and tends to supply less if the price is lower.

The Chicago economist Casey Mulligan has been making that point for some time  in regard to certain aspects of Obamacare.Obamacare provides subsidies for folks when their income falls below a specified threshold.If they work more and earn more and exceed that threshold  they loose that subsidy.Hence the incentive to work less.In other words, less labor will be supplied if the effective pay is less which is what happens when someone works more and loose a subsidy so your net income falls. As Mulligan says you can decrease employment by changes in the supply side as well as by changes in the demand side.

The downward sloping demand curves notion enters into the Obamacare employment issue as well. If an employer has to provide health insurance or be fined if he employes more than 50 people the incentive is to keep his employee count under that number because the cost of hiring the 51th person is too high. He will tend to hire fewer employees when the cost of hiring increases.

See here for a WSJ article on Prof.Mulligan and his work and comments and how OMB finally caught on.

Wednesday, March 05, 2014

Are the Choosing Wisely leaders becoming impatient with the rank and file docs?

 At least one of them seems to be according to this commentary by the former CEO of ABIM and ABIMF., Dr. John Benson Jr. who is referred to by some as the "father of ABIM". With the respect that designation would imply I think it prudent to take what he has to say seriously.

Basically what he had to say was that the rank and file docs do not seem to be getting the message and more forceful "educational" methods need be employed.

Such as :
 "...hard choices and penalties must go beyond training the next generation"  and

" ABIM could require candidates to achieve a perfect score on questions related to costs and redundant care as a requirement for admission to secure exams for initial certification or MOC."

Yes, the former CEO of ABIM and ABIMF is really saying that candidates for  maintenance of certification (MOC )would have to take a pre-test of Choosing Wisely type material  (and not get any wrong answers) before they could even take the certification exam.

and

 " CMS, which has the ultimate negotiating position in the form of reimbursement for Medicare services, could only accept negotiated bundled charges. It could also refuse payment for non-compliance with the Choosing Wisely recommendations."

So if you do not comply with our "recommendations" CMS should not reimburse.

 Good grief, it sounds like Dr. Benson thinks the ABIMF Choosing Wisely wisdom should basically be determinative in regard to what sorts of health care we all should and should not have. The adjectives grandiose and hubristic seem to mild to characterize these proposals.I wonder what non-internists physicians think about a small group of internists who believe they should be in charge of so much,or for that matter internists actually in practice.

The Choosing Wisely campaign is spearheaded by the ABIMF which it seems to me to be basically the folks at ABIM. The two legal entities have the same CEO and President. See here for the IRS form 990 for 2011 for ABIMF The foundation at that time had net assets of $ 68,871,66.  Its stated goals are " to catalyze improvements in health care by advancing medical professionalism: In regard to professionalism  as elucidated in the Physician Charter  the foundation's website states the following: :

"The fundamental principles of the Physician Charter are the primacy of patient welfare, patient autonomy and social justice. The Charter also articulates professional commitments of physicians and health care professionals, including:
  • Improving access to high-quality health care,
  • Advocating for a just and cost-effective distribution of finite resources, and
  • Maintaining trust by managing conflicts of interest."
If you think Benson's recommendations are just talk, think again.The ABIM and ABIMF are well funded , have the support of at least one very rich foundation (RWJ) and have so far at least nominally brought about a sea change in medical ethics.I say nominally because I hope many docs have not received the memo.Once the majority of physicians believe their ethical duty is to be stewards of a collective medical resource,patient advocacy and duty to the individual patient will be down the memory hole and as far as physician behavior goes it will be how high to jump and when as the instructions come forth from the medical progressive elite.







Monday, March 03, 2014

Is this what ABIMF"s Choosing Wisely is really all about?

Dr. John Benson Jr, Emeritus President  of the American Board of Internal Medicine Foundation,makes it clear  what direction he wants the Choosing Wisely  (CW)  Campaign to go. See here for his comments.

 Dr. Benson begins his policy prescription with a gratuitous assertion which seem to be a favorite technique of the folks at ABIMF. (Their mother-of-all gratuitous assertions was that physicians were stewards of medical resources.)

 "The prospect of health care consuming 20% of the GDP by 2020 is unconscionable so corrective actions have enormous urgency."  

This recent commentary from The NEJM seems to share some of Dr. Benson's views which is basically "If you people do not do what we know is right someone needs to make you do it". He speaks of penalties.
He wants the CMS to enforce the  Choosing  Wisely 's wisdom.The NEJM article speaks of linking compliance with MOC ( Maintenance of Certification)as well as tying CW recommendation to CMS actions.

Quoting Dr. Benson:

"The time is well past exhortation. The issue has been recognized for decades. Hard choices and penalties must go beyond training the next generation. 2020 is closing in." ( He does not explain the ominous reference to the year 2020).

He continues

" CMS, which has the ultimate negotiating position in the form of reimbursement for Medicare services, could only accept negotiated bundled charges. It could also refuse payment for non-compliance with the Choosing Wisely recommendations."  (note the current President of ABIM and ABIMF is Dr. Richard Baron who left a post at CMS through the revolving door to assume his duties at ABIM and ABIMF)

and it gets worse

" ABIM could require candidates to achieve a perfect score on questions related to costs and redundant care as a requirement for admission to secure exams for initial certification or MOC."

So, a candidate for ABIM certification would have to properly quote the Choosing Wisely catechism before he even gets to take the certification of MOC examination.

Quoting the NEJM article by Dr N.E. Morden and her co-authors from Yale and Harvard:

"..physician-endorsed low-value labels will probably be leveraged to these purposes. [cost containment and quality measures]...We believe that if such efforts are designed and applied carefully they should be embraced as a promising method for reducing low-value services."

...linking the lists ( of tests and procedures not to do ) to specialty specific maintenance of certification act activities such as practice audits and improvement tasks could also advance their dissemination and uptake at very low cost."

"...Choosing Wisely items should also be incorporated into quality-measurement efforts such as Center for Medicare and Medicaid Services Physician Quality Reporting  ...linking low value service use to financial incentives ( translate penalties )  .. should accelerate ...into practice changes."


Remember the CW campaign,which was very low key in 2009. was just to get a dialogue going   so that  the physicians could explain to their patients how at least some of these tests and treatments really don't need to be done because they may be wasteful and sometimes harmful. In 2012 the program was ramped up as the ABIMF "invited various medical professional societies to take ownership of their role as "stewards of finite health resources". And now , in 2014 the movement to give the CW recommendations teeth is ramping up.


The coercive recommendations of Benson and the authors of the NEJM article are in the tradition of those who believe that medical care is too important ( and complex) to be left to the short sighted individual patient and her knowledge and the wisdom challenged physician health care provider.They seem to march to the drum beats orchestrated by  Dr. Don Berwick (the temporary head of CMS) and  Dr.Troyen Brennan (the current executive VP of CVS Caremark) who said in their book, New Rules:

"Today, this isolated relationship[ he is speaking of the physician patient relationship] is no longer tenable or possible… Traditional medical ethics, based on the doctor-patient dyad must be reformulated to fit the new mold of the delivery of health care...Regulation must evolve. Regulating for improved medical care involves designing appropriate rules with authority...Health care is being rationalized through critical pathways and guidelines...


 
Berwick and Brennan must be pleased as largely through the efforts of ABIMF and ACP much has been accomplished   in the reformulation of  traditional medical ethics. They have shaped the narrative to emphasize the bogus stewards-of- resources concept while letting the fiduciary role of the physician to the patient fall  quietly down the memory hole.Unfortunate  the leaders of other medical professional societies have swallowed the bait.

The progressive medical elite who hold positions variously at major medical societies and medical certification boards ,some of whom rotate through various government medical agencies and sometimes private third party payers, have not been shy about what they want to happen.For those of us who believe that the patient is best served by a physician acting as fiduciary to the patient and advocating for him have much to worry about.

 Addendum:Minor editorial changes to correct some grammar and spelling done on 6/8/2014 and again on 7/23/2014.