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Tuesday, April 26, 2016

Former ACP presdient asks "must the population health approach compromise the needs of the individual"

Dr. Harold Sox in a JAMA viewpoint commentary ( see here for link) addresses  three questions regarding 'Population health approach" which he defines as  " a aim to improve and maintain health across a population"

1.Can the population health approach improve the outcome of US health care? 2.For this approach to succeed ,must it reconcile the need of the individual with the community  3.How might these needs be reconcilable?

"Must the Population Health Approach Compromise the Needs of the Individual to Benefit the Community?

  " It will take several generations to realize the full benefit of investments in disease prevention.In the short run,these investments may draw resources from tests and treatments for some sick  people. In the long run disease prevention and better low cost technology could reduce the outlay for treatment. In the interim, skillful clinical decision making can make the most of limited resources. "

 This IMO is an incredible paragraph on several grounds .First of all the author admits that some sick people may  be harmed as funds are diverted to prevention programs.So the answer to the question that introduces the paragraph is "yes" and is presented in a matter of fact manner. The distinction between short run and long run seems spurious. If limiting funds for  treatment for some sick people is used to for prevention, why would that be a one time occurrence. Would not funds continue  to be  used for prevention as the expense of some sick people if there is some purported advantage to that based on the currency of QALY? One can only guess what "skillful clinical decisions" might be that somehow mitigates the issue of denying treatment to some for some purported future aggregate benefit from a prevention program? Here putative preventive measures trump the need to treat a sick person which for centuries has been the essence of the physician's activity.Oh well to make a omelet..The omelet here would be improved health of the community as judged by some aggregate statistic and judged by some central entity.

Earlier in the article Sox speaks of making decisions regarding allocation of resources across patients and programs.The program that would be favored at  the expense of another would be based  on comparison of QALY ( quality adjusted life years). "One reasonable principle is to move resources from groups of patients less like to benefit to groups more  likely to benefit" The author does not specify who it is that will "move resources" and whose permission, if any, would be necessary for such rationing. or who will make that type decisions.This shift of resources might involve removing resources of value to some for putative somehow measured greater benefit to others.

 Individuals make trade-offs in many areas of their lives including health care. This utilitarian approach is based on a third party making trade-offs between lives. It treats people as means of reaching some social end, in this case "maximizing health" and in the process fails to respect the "discreteness of the individual"

Earlier in the commentary the author says :

"Planning to optimize population health will mean determining the frequency,causes and consequences of the common medical condition in a population and devising strategies for dealing with them over a life time" Wow, no hubris there.

Sox speaks of the health care system and the public health care system planning together, as if the health care system is a unitary entity capable of acts appropriate to a sentient being,such as planning and cooperation. and could  cooperate with another abstraction as if it were also a sentient  entity.He seemingly realizes something major will be required to force this cooperation and the answer is "global spending limits".This will "force the community  to cooperate in deciding how to maximize the health of the people?"

It is hard to make sense out of that last quote so riddled as it is with  reifications , regarding abstractions as concrete existential entities capable of  thought and action.Are you forcing the community which is the people to decide how  to maximize their own health? How will that decision making process be carried out? Voting,town hall meetings for every one in the country? What measure of health maximizing  would be used? Who would decide? Does this conflate community or society with  with government? The two are not the same.

A number of members of what I call the progressive medical  elite have apparently received the memo that says to push the concept of "global medical spending limits:. In the same issue of JAMA, Dr. Don Berwick and Dr. Zeke Emanuel  both recommend very specific limits. eg.for medical  spending to  increase no more than the increase in the GDP.

So are the needs of the individual and the population reconcilable? They are in the specific sense in which he uses the term, i e reconcilable in the sense of " using the same metric of value (QALY) and the same decision making principles.

But the answer to the question "Must the Population health approach compromise the needs of the individual to benefit the community?" is yes as demonstrated in the example he offered.

As if to camouflage the brutal reality of the "draw[ing] of resources" away from the sick, Dr Sox closes with the platitude that the basics of patient centered care have not changed. The hell they have not changed-they certainly have  in the population health world he envisions.

The progressives in general as well as subsets such as the medical progressive elite learned nothing from the history of the 20th century - nothing in terms of the outcome of central planning, nothing in terms of the slippery slope of sacrificing the individual to the collective.

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