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Is the new professionalism and ACP's new ethics really just about following guidelines?

The Charter ( Medical Professionalism in the New Millennium.A Physician's Charter) did not deal with just the important relationship of ...

Friday, May 27, 2016

Medicine and the first rule of economics and the first rule of poltics

Thomas Sowell tells us that the first rule of economics is:

We live in a universe of scarcity and there will be trade-offs.

The first rule of politics is to ignore the first rule of economics.

In this column by Thomas Sowell we see examples of how the economic rule is ignored by offers of pie . I suggest there are offers of pie in the sky in regard to medical care and financing.

Can we have decreased medical cost and increased quality? No problem- all we need in a governmental single payer.(Interestingly the Medical Home advocates sometimes make that same promise although recent analysis from the Congressional Budget Office concludes they really can't tell if it will cost more or less.) Also more recently we are told if were pay for value not volume the same miracle will occur.

I first read about the notion of increasing quality while decreasing cost or at least containing cost in medical care in a series of article in JAMA by Dr. DM Eddy over ten years ago. The bait and switch trick here was for Eddy to redefine quality as the greatest good for the greatest number. Eddy's series of articles seemed mainly to deal with the topic of decision analysis, an area that Eddy had apparently specialized in after foregoing a surgical career but his major thesis was/is that the goal of a health care system should be to maximize the health of the group and individual physician's concern about individual patients is misplaced.Eddy seemed to claim there would be no trade off , we would have both higher quality and lower cost., by simply redefining quality.Of course he is suggesting a system with its own major dangerous  trade-off, namely the nebulous,loose and ambiguous good of the collective ( which will be in the eye of the elite in charge of the medical enterprise) over the much more easily discerned good of the individual.

Enter the decision analyst who can determine what is maximal health and how best to allocate or cost shift to achieve the maximal health of the group. He spoke of health care as a closed system and that it was a "zero-sum"game where for the good of the collective some patients may well be worse off, but although regrettable that is necessary for the greater good the details of which will be worked out by competent decision analysts.

This was an early proposal by the progressive medical elite  for a overt rationing of care that  self identified very smart people would be able to devise for the greater good of the herd. Eddy may well deserve a role in that group of smart people. The rationing that is part of the Independent Advisory Board ( IPAB) which was  part of PPAC but not yet activated  would be, I think, more of the covert rationing variety wherein there would be no explicit announcement of a utilitarian mandate but the board would rather simply say what was effective and ultimately what would be paid for by the third party- government and that would be leaped upon also by the third party private insurers. DrRich ( in a no longer active blog ) had a lot to say about that , see here.

Eddy's polemic is now more than  ten years old and rarely read but others have forged ahead in his footstep. Enter the folks and ABIM , ACP and ABIMF and their program to change medical ethics ,make physicians be considered stewards of a collectively owned medical resource base and  nudge and if necessary coerce physicians to dutifully follow guidelines that should boost the bottom line of the third party payers .

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