retired doc's thoughts

More of the weird social justice that Obamacare has given us

2012-01-24T05:00:00.000-08:00

See this article from Cato. By reclassifying the status of one hospital in Massachusetts, a number of hospitals in that state by some bizarre bureaucratic mechanism receive more Medicare payment from the Federal Government while that amount is made up for by cuts to the rest of hospitals in the country.This is a big blob of social justice right in your face.

Redistribution of funds based on arbitrary government bureaucratic decisions seems to be a recurrent feature of Obamacare,one poster child for which was the early on exceptions of certain companies from some of the provisions of the law. "The secretary shall determine" theme plays over and over.

The core of laws such a Obama care is that the devilish details are placed in the hands of executive branch entities who can then dish out favors as they see fit and the factions (Madison's quaint term for special interest groups) that can gain or loose from those decisions busy themselves with efforts to bring about some decree of regulatory capture or just simple payoffs.

The crap of "crony capitalism" get wrongfully blamed on capitalism while in reality the rent seeking ( the quaint term economists use for privilege seeking ) is a phenomenon that has become gargantuan because of the progressive mindset's endless quest to give more and more power to the government and to focus that power and control into ever increasing aspects of people's lives. No, I have not forgotten big government conservative's hypocritical initiatives to do about the same,albeit with a different rhetorical cover. More power to the government and thereby more efforts to harness that power for one's focused individual interest paid for by everyone else. But isn't Obamacare furthering social justice?

CBO give results (largely negative) on several buzz word medicare demonstration projects

2012-01-22T05:10:00.000-08:00

Buzz words abound in the wonky sector of health care, a domain in which many commentators comment more than they actually do health care.

Here is a CMO report on 10 demonstrations projects which sought to test the operational results
of several buzz word projects.

Dr. Robert Centor gives a brief summary of some of the finding on his blog.See here.

In the Disease Management programs,the costs seemed to exceed the benefits.In three out of four "Value based payment" program there was little or no savings.This is similar to comments I made almost 5 years ago regarding a radomized trial that show no value for a particular disease management program.

Dr Centor said:

Boys and girls, this stuff is much more complex than these demonstration projects can address. Physicians really do their best out there.

You bet it is more complex.

"The curious task of economics is to demonstrate to men how little they really know about what they imagine they can design." FA Hayek.The Fatal Conceit.

Russ Roberts writing in his blog, Cafe Hayek said in regard to some or other government program

"So many things the government does are attempts to circumvent the bad things caused by something else they already do."

It seems to be there are a lot of buzz word filled initiatives that are, at least in part, efforts to try and undo the mess made by CMS price controls on physicians fees and the primary care destroying RBRVS .

Is the American College of Physician's new Ethical Manual an ethical game changer

2012-01-17T05:13:00.000-08:00

Dr. Michael Kirsch, author of the blog, MD Whistleblower, thinks so; see here for his view.

Here is a money quote from his commentary: He begins with a quotation from the ACP Ethics Manual;

Physicians have a responsibility to practice effective and efficient health care and to use health care resources responsibly.

This is an ethical game changer. According to the updated ethics manual, physicians should consider preserving health care resources for the population at large, which may conflict with our patient’s interest. Now, we are told that we are ethically obligated not only to advocate for our own patient, but also for hundreds of millions of other patients. If this becomes standard operating procedure, how will it impact the doctor-patient relationship? Will patients, who are increasingly skeptical of the medical profession, trust us? Will they suspect that we are restraining their care to serve the greater good?

The camel's nose (along with other anatomical parts) that sneaked under the medical ethical framework tent was the publication of a physician's" Charter" (aka New Professionalism) which in a gigantic non sequitur gratuitously asserted that social justice was now a major element in what they said what was medical professionalism, stopping just short of explicitly saying it was part of ethics.However, it was not clear what the separation between professionalism and ethics really was. Now the ACP makes that final move equating social justice with preserving health care resources for everyone and somehow balancing that against the individual patient's interest as an ethical responsibility. Has the concept of fiduciary duty to the patient really been shoved down the memory hole?

This is an ethical game changer but sometimes the ACP spokespeople seem to write and speak about both the charter and the ethics manual as if nothing has really changed. For example, I offer the following quote from recent comments from the president of the ACP, Dr. Virginia L. Hood in her message printed in the ACP Internist of January 2012.

She refers to the 2002 publication of a "physician charter to confront the health care challenges of a new millennium ". She continues " As well as restating (my bolding) the principles of 'primacy of patient welfare,patient autonomy, and social justice' ,it outlined a set of professional responsibilities..."

The charter did not restate social justice;it gratuitously inserted it and certainly never explained how striving for social justice enabled physicians to confront the new challenges. Now Dr. Hood writes about it as if social justice had always been a key element of medical ethics. It may be a useful rhetorical tool to just assume away a controversial issue but it should be clear that social justice based on a utilitarian calculus to allocate health care " resources" was when the charter was published and continues to be a source of considerable controversy in the medical community.

In a 1988 Annals of Internal Medicine Article,Hall and Berenson made- what appeared to many of us who were raised medically with the "old" medical professionalism of fiduciary duty to the patients- a startling proposal:

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

Dr. Edmund Pelligrino writing in 1995 asked in the ethics of a profession could be changed at will.

Judging on the basis of the New Professionalism and the statements in the recent ACP Ethics Manual, it seems like it has.

DrRich of the blog "The Covert Rationing blog also believes it is a game changer.Further he offers his view as to what the real import of the new ethics is in this passage:

And here is the real import of the updated Ethics Manual. It aims to assuage the guilty conscience of physicians who follow handed-down guidelines to the letter, even against their better medical judgment, instead of tailoring the application of those guidelines to the benefit of their individual patients'

Exactly. It is an 180 degree switch from the antiquated ,fuddy duddy "fiduciary duty" silliness of a by gone era.

The ethical physician of today (again quoting DrRich) is "to follow the best evidence , in particular the best evidence on cost-effectiveness" and

" it is now the ethical obligation for doctors to follow expert produced guidelines" ( see here for DrRich's full commentary).

It is of some interest (or irony) that the introductory section of the 6th edition of the American College of Physicians Ethics Manual was written by an attorney, Lois Synder and there was no mention of a physician's fiduciary duty to his patient .

I do have trouble reconciling the words of the manual-particularly those quoted above-with these comments regarding the new manual from Dr. Hood as quoted in the 1/11/2012 Modern Medicine, on line:

“We have to consider cost as one of the factors when we make medical decisions, because that’s in the best interest of our patients,” Virginia Hood, MBBS, MPH, FACP, an internist and nephrologist and president of the ACP, tells eConsult. “It shouldn’t ever be an overriding part of a decision, but physicians need to take it into consideration.”

She continues:We have been advocating for efficient care since 1984, but it’s been given a slightly greater emphasis because the costs of care are so much higher,”,

So what is it- a slightly greater emphasis on cost or a real ethical game changer in which the fiduciary duty of the physician to the patient is not mentioned. Dr Hood's words quoted above seem reassuring but the black letter words as written in the ethics manual seem to pit the needs of the individual against the nebulous and ambiguously defined common good. In "box no.4 which addresses "Patients First and stewardship of resources" it says in part there is a responsibility to provide "parsimonious care that utilizes the most efficient means" [for diagnosis and treatment] . That sounds to me to be more than a slightly greater emphasis.

Also seemingly contrary to the representation that the new ethics manual really does not represent a major shift are several comments found in the editorial by Dr. Ezekiel Emanuel.(3 January 2012,Annals Internal Medicine,volume 156.number 1.pg 56)

Emanuel says :"Here is a professional society unafraid of advocating the principle of cost-effectiveness." Here aren't we talking about stuff like amount of dollars per life year saved?

He continues :These positions on efficiency, parsimony and cost effectiveness constitute an important shift,if not in ethics , then in emphasis." and

"It goes well beyond the usual banalities to take brave stand on current issues".

Price controls have worked so well in medical care, let's do some more

2012-01-16T04:13:00.000-08:00

Doing some more is exactly what the Administration is doing here with its case by case decision regarding how medical insurers do their business. Of course, this level of central plannng on a mico level is part of the disaster unfolding as we see Obamacare play out. See here for the newspaper account of the Secretary of HHS ordering an insurance company to rescind its rate increase.

Arnold Kling,a MIT trained economist,is fond of saying that economists do not hold back the good stuff when they teach economics. Rather they reveal the important stuff in econ 101. In econ 101 the effects of price controls are clearly spelled out.Price controls in the form of price ceiling create several things:
1.Shortages
2.reduction in quality of goods or services provided
3.Search costs including wasteful lines
4.loss gains from trade
5.allocations of economic resources.

Here is what George Mason University economist, Don Boudreaux, has to say about the HHS actions in his typical trenchant style.

As millions of more people will have insurance cards,and think they now have access to medical care, consider how much worse the shortage of primary care ( think Medicare price controls) will be and how much longer and more wasteful and frustrating the lines in emergency rooms will be.

Addendum: See here for the blog entry by John Goodman entitled "How Doctors are Trapped" for a detailed discussion of some of the particular ways that the CMS physician fee price controls are destructive and demoralizing to physicians and patients .

Fans of crony capitalism should love Obamacare

2012-01-13T04:33:00.000-08:00

Writing in Forbes, Warren Meyers offered this eye catching title, " Crony Capitalism?Blame the Progressives."

Here is how it works as explained by Meyers in his posting in Forbes. See here for article.

Capitalism is simply the free exchange of individuals based on their self interest. There is no room for government subsides,bailouts or any of the other myriad forms of government interventions into the economy that favors one entity or groups over others. Whenever government has the power to dole out favors folks will seek those favors. They will seek out those privileges. The bigger the goverment, the more power to dole out favors, the more favor seeking and the more the targeted few benefit at the expense of the rest.

This privilege seeking activity in the jargon of the economist is called "rent seeking". Progressives as a group favor more goverment power to do all those things that they think wise leaders and technocrats can do much better than the people could do for themselves.Of course, Progressives share the blame with other big government politicians whether they be called big government conservatives or moderates or whatever.

Enter Obamacare as the poster child for what George Will has called the tendency of congress to pass intentions rather than statutes. What we get is legislation that outline an aspiration or a dream or a nice thought and then hands over the details which actually define the actions to various governmental appointees and agencies,who then become the target for possible regulatory capture or at the least effective lobbying efforts the results of which can be described as crony capitalism.

Here is an excellent essay on the nature of crony capitalism versus "Market capitalism" and how Obamacare is a poster child for the former.How does the furtherance of crony capitalism mesh with the alleged social justice that Obamacare was said to represent?

American Psychiatric Association "Slapps" down web site critical of DSM5

2012-01-12T06:39:00.000-08:00

Dr. Bernard Carroll,former head of psychiatry at Duke,writing on the blog Health Care Renewal ,writes about an interesting conflict between the APA and a former editor of DSM. See here.

Dr. Allen Francis who edited DSM4 has been highly critical of the DSM process and particularly of the yet to be released DSM5.He expresses concern that psychiatry is being practiced less by psychiatrists and more by primary care physicians, who are busy and often s not very well trained in managing psychiatric problem and at times strongly influenced by marketing .

His criticism includes the charge that with the publication of DSM5, not yet released, there will be more patients diagnosed with DMS defined mental conditions as new diagnoses are being added and the criteria for others have been broadened. His comments regarding his view of the problems with DSM were appearing on at least one web site.

Now the APA,who owns DSM and profits from its publication and use, has sent out a cease and desist threat to the website previously known as "dsm5watch" Their argument was that the website to which he contributed a contained the letters DSM and that was a copyright infringement. The new name for the website is "dxrevisionwatch.wordpress.com"

The explanation for the strange spelling of "slap" in this post's headline is that the APA actions might be described by some as a "Strategic Lawsuit Against Public Participation". In this case only a threat.

See here for more comments by Dr. Francis and here for a reply by the APA to some of the criticism it has received lately.

More on the New Professionalism (medical) and what it is really about

2012-01-06T05:51:00.000-08:00

The New Medical Professionalism has been a topic of concern to me for some time and I have tried to express my objections to what it represents on more than one occasion. See here.

But what I believe to be the definitive critique and explanation of what that document is all about has been published on the blog The Covert Rationing Blog by DrRich. See here.

Everyone should read it and share it with a colleague .Here is one quote:

To summarize, by the turn of the millennium doctors were being coerced to withhold healthcare from their patients at the bedside, and thus to violate their time-honored primary professional directive. The intent of the 2002 Charter on medical professionalism was to repair the problem (i.e., to cure the “frustration”), not by confronting the forces of evil doing the coercion, but rather, by simply changing medical ethics to make bedside rationing OK. And that’s just what the document did, though only after careful re-editing to make this radical change to medical ethics sound as benign as possible.

By explicitly endorsing the 2002 Charter on medical professionalism, the Sixth Edition of the ACP Ethics Manual thereby endorses healthcare rationing at the bedside – but it does so quietly, at arm’s length, so as not to stir up unwanted passions.

DrRich's topic for this essay is actually the New Ethics Manuel authored by the ACP and comments on the New Professionalism are offered in that context. Read his blog to learn about what Dr. Ezekiel Emanuel found particularly praise worthy regarding the new ethics.

Bryan Caplan tears apart Jonathan Gruber's graphic novel on health care reform

2012-01-05T05:59:00.000-08:00

Jonathan Gruber is a major player in the health care wonk games and has recently written a graphic novel ( aka comic book) on health care" reform", an area in which he has written and worked extensively. See here for GMU economist Bryan Caplan's detailed shredding of that work.

I have blogged before on the paper by a MIT economist see here which "startled" the health care wonk world with the data driven observation that when folks have access to a government financed health care programs ( ie. Medicare) the demand for health care services increases about that which occurred when folks paid for those services with their own money.

On that issue Caplan says the following:

Gruber explains the basic facts about health care costs: they're rising, and government picks up much of the tab. But he almost totally neglects the connection between the two. Medicare and Medicaid vastly increase demand for health care. There's no denying it. Imagine how much more affordable health care would be if these programs had never been adopted - or if they were abolished.

Let's see if I get it.People tend to spend other people's money with less prudence that when spending their own. I think Milton Freeman might have made that point.

In the Accountable Care Organizations (ACOs) to whom is the physician accountable?

2012-01-03T04:52:00.000-08:00

Hint: It is not the patient, at least not in the structure or intent of the ACOs. See here for Paul Hsieh 's discussion of this issue.

Dr.Hsieh succinctly nails it here:

... under ObamaCare, your doctor will be increasingly pressured into sacrificing your individual medical interests for a nebulous “social justice.”

Exactly

He references some key quotes from physicians and physician organizations who favor and have been lobbying for the substitution of the pursuit of an elastic and nebulous collective good for the long standing fiduciary duty of the physician to the patients.

A now-famous article in the 1998 Annals of Internal Medicine recommended that “devotion to the best medical interests of each individual patient be replaced with an ethic of devotion to the best medical interests of the group...” The American College of Physicians ethics charter now states that physicians should balance traditional principles of patient welfare and patient autonomy with “social justice” to achieve “a just distribution of finite resources.” A 2011 New England Journal of Medicine article urged abandoning “the primacy of patient welfare” in favor of “collectively caring for a defined population within a fixed annual budget.”

Read the entire piece. It is excellent. Dr.Hsieh has been working tirelessly to support the concept of freedom and individual rights particularly in regard to the individual rights of doctors and the practice of medicine. Read more from him here.

In health care we don't need no stinking rule of law

2011-12-12T05:37:00.000-08:00

The concept of rule of law at a minimal means clarity of laws and regulations and uniform enforcement.

Consider the recent action of the Centers for Medicare and Medicaid (CMS) in regard to the imposition of pre-payment audits of certain procedures ( cardiac,joint replacements,spinal fusions)but only in certain states. See here.

This means that for these procedures hospitals will not be paid until government auditors review patient records and confirm that the procedure was "appropriate". How will that determination be made? What criteria will be applied to conclude that something was appropriate. Why does this only apply to NY,Texas,Florida,Michigan ,Ohio,North Carolina,Missouri and Pennsylvania? Uniform enforcement ? Clear Rules? According to CMS, some of the states have a high number of error or fraud cases while others just have a high volume of the procedures.

Rule of law fans have had little to cheer about since Obamacare was passed. The Secretary of HHS has issued exceptions to certain provisions of the law only to certain firms.See here for more on the waivers.

Dr.Wes has commented on the CMS plan suggesting that CMS may not actually have the expertise and organizational skills to render decisions in anything approaching a timely manner or to employ a rational evidence based decision making process. See here.

The blog "Secondhand Smoke" offered a commentary on Obamacare and its assault on the rule of law.

Richard Epstein has commented on Obamacare and Rule of Law. See Here.

Ambiguity in laws and regulations coupled with discretionary implementation are the friends of politicians and bureaucrats and the enemies of the rest of us.

Hayek's decades old comments as applied to Obamacare

2011-12-05T04:05:00.000-08:00

See here for a posting on John Goodman's blog which features comments by Ed Feulner on how appropriate are FA Hayek's comments from Road to Serfdom are to how Obamacare is working.

Read the entire commentary but here is a flavor:

Hayek :"the legislative body will be reduced to choosing the persons who are to have practically absolute power."

Feulner :"Sound a bit like the Independent Payment Advisory Board (IPAB) of 15 unelected bureaucrats who will arbitrarily determine Medicare payment rates?"

Remember IPAB? See here to refresh memory of the power that this board of presidential appointees will have.

What could possibly go wrong with the IPAB? For those who seem to believe that government officials typically act in some nebulous "public interest"- nothing. For those who cynically think that people tend to respond to incentives and act in their own interests and believe that "regulatory capture" is real-a lot.

Obamacare is the prototypical progressive legislation.The progressive mindset is what Hayek talked about with his notion of the "fatal conceit".This is the belief that goverment will and should make the world better by social and economic planning and not by letting people free to coordinate their private plans.

Physicians have group data but treat individual patient-

2011-11-12T04:12:00.000-08:00

Physicians are informed by studies which examine group data but deal with individual patients. How to apply the group data in clinical setting is not as easy as it might appear at first glance.
I blogged about this general topic several years ago.See here.

The term "Heterogeneity of treatment effects" (HET) is the translation into the jargon of the statistician of the basic fact that everyone does not respond the same to a particular treatment. Can the patient in the doctor's office be assumed to have the average response to a given treatment reported in a medical journal article? In a given group treated with a certain medication some subjects will fare better than average along some parameter of interest while others respond not at all and some in either group may have adverse effects,some serious some minor.You cannot expect every patient receiving a given treatment to do well let alone better than average which only occurs in the statistically impossible world of the children highlighted by Garrison Keillor.

RL Kravitz,N Duran and J Braslow authored the classic article on the issue of HET. See here for full text of the article which should be part of every medical student's education.

Dr. Michel Accad in his Blog Alert and Oriented discusses a recent paper that offers suggestions for ways to tame the problem of HET. The suggestions are aimed as those who carry out the clinical trials . See here for Accad's discussion entitled "Dealing with variable risk" and see here for a link to the full text of the article by Kent et al that he references.

Is retainer medicine unethical?

2011-11-04T04:23:00.000-07:00

Drs Thomas S. Huddle and Robert M. Centor answer that question with a well reasoned and emphatic "no". Surprising to me was that their commentary appeared in a prominent medical journal,Annals of Internal Medicine, that generally has been the site of a number of commentaries and articles promoting the notion of social justice and inserting into the basket of medical ethical principles the obligation of the physician to promote social justice. The "New Medical Professionalism " was introduced to U.S. medical audiences in the Annals.See here for abstract of the Huddle-Centor article.

A dual premise criticism of the retainer practice model is that is damages the furtherence of social justice as it applies to health care and that physicians have a ethical obligation to act to further social justice. Social justice is a usefully elastic concept and reasonable people may differ as to what it means in a given situation . It is also a key arrow in the quiver of those who favor a progressive and re-distributional agenda. It was inserted into the area of medical ethics by the New Professionalism by a small group of energetic and prolific medical "thought leaders" whose views may or may not be representative of the group whose thoughts they were leading.Nevertheless , many professional organizations accepted the package deal giving at least lip service to the notion and in my opinion without fulling vetted the concept or thinking through the consequences.To convince many medical professional organizations that to be "professional" a physician had to work for social justice was a very significant propaganda accomplishment.

Huddle and Centor cut to the chase with this:

..we should not assume that the pursuit of social justice is an integral aspect of physician identity,despite numerous assertions to that effect.We contend that social justice is a civic virtue that makes its claims upon physician as citizens.If we are obligated to further health care access for every member of society,we have that obligation as members of society,not as physicians.Promoting nonprofessional virtues or ethical imperatives is not the province of professional ethics.

Yes and amen. The authors of the New Professionalism did simplify assert that medical professionalism should include the obligation of the physician to strive for social justice.

Three years ago I wrote about the issue of social justice and retainer practice and framing the debate.See here. Once the nose of social justice was in the ethics tent we could expect that it would be used to rhetorically justify a given agenda or criticize opposition to it.It seems that some critics of retainer medicine are proposing banning the practice as they allege it decreases access to health care and is socially unjust. Well, a little coercion and restriction of individual freedom in name of social justice is occasionally necessary.

Previously I have suggested that the new professionalism project was a way,and increasingly it seems a successful way to high jack medical ethics for a social agenda.See here.

The new PSA screening recommendation is not just a recommendation

2011-10-24T14:09:00.000-07:00

What has mostly been neglected by the press in reporting the latest pronouncement of the USPSTF is that their conclusion that PSA measurements should not be done to screen men for prostate cancer is much more than a recommendation. Before the passage of ACA it was merely a recommendation but now the rules of the game have changed.

Dr. Rich at The Covert Rationing Blog gives us his excellent analysis of the the panel's recommendations and the data they emphasized as well as the data they underplayed.Here is a quote from that commentary that explains why what the panel at the Task Force says really matters.

Obamacare, which is now the law of the land, makes the USPSTF the final arbiter of which preventive services are to be covered by private insurers (Section 2713), by Medicare (Section 4105), and by Medicaid (Section 4106). Only those that have achieved a grade of A or B by the USPSTF will be covered. And if you believe you will be able to purchase for yourself PSA screening (or any other medical service which Obamacare has decided not to cover) you have not been paying attention. Perhaps you can do so today (if you’re not on Medicare or Medicaid), but probably not for long.

So CMS (Medicare and Medicaid ) will not pay for the tests.How long will it take private insurers to follow suit?The question remains can you pay for the test yourself.It is not clear that you cannot but I share Dr.Rick's concern that prohibiting private choices paid for with private money for health care issue may become illegal.

Cato has recently published their report on economic freedom. Freedom fans will not be pleased with the falling economic freedom indicators in the U.S. noted in their report. Health care freedom is incompatible with the vision that medical progressives have for the U.S.,namely that medical care is too important to be left in the control of individual physicians and individual patients. From the perspective of the progressives, Obamacare is a great step forward and has been heralded by certain medical organizations as promoting social justice while loss of individual freedom to make one's health care choices seems to be part of the price of that "justice".

Two great blog commentaries on "Diagnostic skepticism" and why we are seeing less of that?

2011-10-21T14:18:00.000-07:00

Dr. RW Donnell in this blog commentary outlines some of the factors that are impeding the diagnostic skepticism that traditionally internists had drummed into their heads during their training period. Dr. Donnell carried forward and expanded comments made by Dr. Robert Centor in his recent blog offering.

Guidelines,the worse aspects of EMRs,time pressures and the metrics by which hospitalists are too often graded are some of the factors that make it more difficult than it used to be to ask "what else could the diagnosis be".

Have we seen the last of the CLASS act fraud?

2011-10-18T07:19:00.000-07:00

The CLASS Act was a long term care plan appended to Obamacare to give the impression that the total cost would be less than one trillion dollars,which was a slight psychological barrier to its passage.It was a spending program that magically would reduce the defect.It was purported to contribute some 80 billion to the projected health care savings that the Obama health care plan would bring about.

See here for the economist Alex Tabarrok's commentary on this fraud that contributed to the passage of Obamacare. Now, the Secretary of HHS has admitted the plan can't work and will be dropped,but even later breaking news is that the White House hints maybe not yet.

Thomas Szasz's "define or be defined" and Physicians morphed in to health care providers

2011-10-14T04:39:00.001-07:00

The husband and wife physician writing team of J. Groopman and P. Harztband make strong points in their commentary found in the Perspective section of the October 13,2011 issue of the NEJM. The title is The New Language of Medicine.

They relate certain changes in language related to health care to the movement to industrialize and standardize health care. These changes include the word "consumer" or "customer" for "patient" and lumping doctors,nurses,PAs,and NPs together under the designation of "health care provider".

The relationship and interaction between physician and patient fades out and is minimized by referring to the generic "health care", as if is in the words of the authors " fundamentally a prepacked commodity on a shelf that is "provided" to the "consumer".

What happens to considerations about the physician-patient relationship when you speak about providers and consumers.

Thomas Szasz wrote brilliantly about the power of language.

"The struggle for definition is veritably the struggle for life itself. In the typical Western two men fight desperately for the possession of a gun that has been thrown to the ground: whoever reaches the weapon first shoots and lives; his adversary is shot and dies. In ordinary life, the struggle is not for guns but for words; whoever first defines the situation is the victor; his adversary, the victim. For example, in the family, husband and wife, mother and child do not get along; who defines whom as troublesome or mentally sick?...[the one] who first seizes the word imposes reality on the other; [the one] who defines thus dominates and lives; and [the one] who is defined is subjugated and may be killed."

In short, define or be defined. There was a time not long ago when physicians in many ways defined their role.Their role was to act as a fiduciary to their patients,to do no harm and act in the interest of their patient.Now their role is being redefined as in part acting as stewards of resources.Yes, it has been members of the medical profession,largely a small group of internists, who have helped considerably in this effort to redefined medical ethics and have been able to implant those views in the medical school and post graduate curriculum. While I would not impugn the motives and sincerity of those physicians who have promoted that view and value system,I cannot resist applying the venerable Mafia Rule. Follow the money.Who gains from transforming physicians into health care providers and tasking them with saving money for the health care collective?

Their commentary closes with:

"We believe doctors and nurses,and others engaged in care should eschew the use of such terms (consumer,health care provider)that demean patients and professional alike and dangerous neglect the essence of medicine."

Amen.

Obamacare-A great opportunity for Medical Hubris

2011-10-10T04:16:00.000-07:00

In 2005, I outlined a few thoughts about what I would include in a lecture to medical students about hubris and the practice of medicine. See here. At the time, I had no idea about the surge of exuberant hubris that the next few years would bring although I should have because of the strikingly hubristic five part series in JAMA which was a plea for utilitarian planning for allocation of health care resources.

Hubris is defined as excessive pride or self confidence.From Wikipedia we read that the word implies an overestimation of one's own competence and capabilities particularly as exhibited by someone in a position of power. In Greek tragedy it leads to nemesis, or the end result of harm or ruin. However,in the context of public health expert advice and edicts, it seems to be the beneficiaries of the edits that run into harm's way and not the expert.

Several thinkers have issued warnings to those who would take portions of the scientific wisdom of the day and go forward with hypertrophied self confidence and idealistic certitude to make the world (or their little sector of interest) better.

Boris Pasternak said; " What is laid down, ordered, factual is never enough to embrace the whole truth.Life always spills over the rip of every cup." The medical elite in the public health sector who would tell everyone how to eat, or treat all folks with a given medical condition think "Well, not my cup" and charge ahead as if the concept of unintended consequences had never been formulated and that individual variation , personal circumstances and values would not have to be contended with and progress in medical knowledge would be frozen in time so as to not make necessary changes with their determinations.

Morton Hadler ( J.O.M.,Vol 31, pg 823,1989) spoke of various categories of truth including the distinction between scientific truth and clinical truth,the latter informed in part by the former and is determined by the joint efforts of the physician and the patient.

Karl Popper said "We know a great deal but our ignorance is sobering and boundless.All things are insecure and in a state of flux."

Ian Stewart and Jack Cohen in their book "Figments of Reality" spoke of "what science offers is not facts but understanding, not answers but contingency plans"

Those type comments could be considered life advice to the newly minted practitioners of various discipline, and in particular , in this commentary to medical doctors.

The type of hubris often seem in novices is typically what I am calling the more benign form and is often cured by experience and seeing highly regarding paradigms and treatment plans replaced by others often 180 degrees from the discarded notion.This is what I call Type 1 hubris. It is an unwarranted and persistent belief in the correctness and permanence of contemporary consensus views.It is a failure to realize they are working with concepts that are often more contingency plans than permanent solutions.This type of hubris often dissipates as the practitioner gains more experience and sees the various ways disease patterns play out and how patient's disease scripts differ from the text book. Aristotle spoke of phronesis or practical wisdom which is the result of combining the lessons of experience with empirical knowledge (episteme) and technical knowledge (teche).

However, there is a second type of hubris, a more dangerous form, logically named Type 2. Type 2 includes the over blown pride and hypertrophied confidence in one's beliefs and idealistic certitude as is found Type 1 but in addition includes the internalized imperative to to bring about widespread practice (s) consistent with their version of current medical wisdom or truth. Starkly put" I'm know what should be done,everyone should do it and when someone with Type 2 is in a position of power,let's make them do it.

The five part series of articles published in JAMA in 1994 by David Eddy is , in my opinion,a candidate for the most hubristic series ever published in a major medical journal.Reference is "Rationing Resources while Improving Quality", Eddy, DM, JAMA,1994:272,817-824)

Eddy's answer to the problem of how to save resources while improving quality was to employ the utilitarian maxim/imperative strategy to do the greatest good for the greatest number or make the herd healthier along some metric even though some cows might be worse off.The herd here was a medical collective such as a HMO.This also applies to the ACOs put into play by Obamacare to the extent those entities based as they are on an Underware Gnome type plan will survive .

Dr. Don Berwick speaks of the need for "leaders with ideas" and the need to replace the physician-patient "dyad" with a group outcome oriented decision process authored by the wise leaders with ideas. ( You have to worry when someone talks about "dyads"). Those views conform with the Progressive Medical Axiom of " medicine is too complex and too important to be be left in the hands of the individual physicians and patients."

For most physicians, the Type 1 hubris wears off or withers away after the realities of a few years of clinical experience bump up against the overly simplistic concepts of the novice. Type 2 is what we need to worry about and to fear those leaders in positions of authority (or advisers to those in power) who never caught on to the Hayekian notion of "how little men know about what they imagine they can design..." But no matter, being a public health expert or a medical planner means you have never say you are sorry.

With Obamacare and IPAB's unprecedented powers as well as CMS's control over Medicare,there are great opportunities for leaders with ideas and the requisite amount of hubris to do unprecedented damage to the practice of medicine.

More worrisome news about hazards of long term marathoning

2011-09-30T04:48:00.000-07:00

I have written before about the troubling reports of certain test results following endurance events.

There is evidence that in the early hours after a marathon or an Ironman type triathlon there sometimes are elevations of troponin in the range seen in myocardial infarctions.There are also reports of echocardiographic changes that could be described as cardiac "fatigue". The changes are those of altered relaxation characteristics and a decreased contractility all of which, along with the elevated troponins returned to normal in 48 hours.There is the hope that all of this is just analogous to the sore leg muscles and raised total CK values that remit in a few days and is of as little consequence but there may be more to it that that.There is at least one report of some of the more subtle echo changes persist at least for one month after a race.

One post marathon study suggested that the above mentioned abnormalities were less marked in the better conditioned runners and another paper found the alterations more likely in first time runners versus more seasoned veteran marathoners. See here for my earlier blog entry discussing some of the issues involved in assessing the harm or absence thereof in marathoners.It should be noted that not all runners show the echo changes and there is a suggestion that the type of ACE gene pattern may play a role in that.

Well,all of the above really address the issue of over use damage that certainly is at least acute and some worry may lead to long lasting permanent cardiac damage, i.e. myocardial fibrosis or an endurance exercise induced cardiomyopathy.

Now for something completely different. There is a report suggesting that many years of marathon running may increase (not a typo) the risk of coronary artery disease at least as possibly indicated by increased coronary artery calcification.This seems counter intuitive as conventional wisdom tells us that exercise may decrease the risk of coronary diseas but could this be an instance of " too much of a good thing".See here for that study.

Drs Robert and Jonathan Schwartz reported on a CTA (Coronary Computed Angiogram) study that involved 25 runners who had been running in the 26.2 mile races for 25 years or more and had completed 25 or more marathons.They found a statistically significant increase in calcified coronary plaques and an increase in non-calcified plaques that did not reach the level of statistical significance as compared with 25 controls.

If Health care planning is like green energy planning, hold on to your seats

2011-09-22T02:12:00.000-07:00

In this article in Investor Business Daily we see how well government planning is working out in the Green area.

Here is in in a nutshell. The government gives a 527 million dollar loan guarantee to a solar panel manufacturing company whose business plan worked out badly and the company went broke.Now the employees have applied for a government funded jobs retraining program to cost another 14 million dollars.

On the one hand we have the government tossing away half a billion dollars on a company who was not viable in the market and on the other we have the government raiding and closing down ( hopefully only temporarily) a company on the basis on vague foreign laws.See here for DrRick's take on the Gibson Guitar Company raid by the Fish and Wildlife police and how that exemplifies the principle of Regulatory Speed Trap.

And speaking of regulations,it makes one feel warm and fuzzy and very secure to know that hundreds ( thousands ?) of government technocrats are working on the details that will give ambiguous and flexible operational meaning to the hundreds of pages of Obamacare. Yes, the very same government that gave us Solargate and raids a viable US company for using the wrong kind of wood is busy at work finishing the details that will shape health care for the country.What could go wrong with that??

Medical decision making moves to Washington

2011-09-19T02:53:00.000-07:00

Every time I re-read a section of Thomas Sowell's Knowledge and Decisions I am more impressed with how brilliant it is,how filled with insights and how well written .

A central theme of the second half of the book is described by Sowell in this way: (my bolding)

Even within democratic nations,the locus of decision making has drifted way from the individual,the family and voluntary associations of various thoughts and toward government.And within government, it has moved away from elected officials subject to voter feedback,and toward more insulated governmental institutions, such as bureaucracies and the appointed judiciary.

The ACA (Obamacare) represents a major shift in the locus of decision making regarding medical care. One could consider Obamacare the poster child for that concept. Of course, the locus has already been shifted to a major decree away from the the individual physician and individual patient ( the "dyad" in Don Berwick's quirky terminology ) by the hegemony of third party payers and the virtual single-payer status of government finance health care administered through CMS (Medicare and Medicaid).

A major theme of the first half of his book is the following. One should analyze the decision making processes of institutions in terms of the incentives faced,the constraints in place and the likely outcomes and if the decision makers are immune from feedback mechanisms .Do not look at the "hoped for results" or the mission statements but rather at the mechanics of the decision making process.

Consider those mechanics in the context of ACA and how the myriad details which will make the lofty goals operational will be determined. Various governmental agencies and panels will deliberate and churn out the pages of rules and regulations that physicians and patients will have to live with. For the most part these rules makers will be immune from meaningful feedback but they will will not be immune to lobbying efforts by various special interest groups during the rule making p;process.

Consider the mechanics of the Independent Payment Advisory Board ( IPAB) and how decisions will be made by its fifteen member presidential appointed panel and how lobbyists for various special interests will target this group and likely their efforts will be proportional to the power that IPAB has been given.

Victor Fuchs solves the "doctor's dilemma"-appropriate care is cost effective and ethical too

2011-08-18T07:06:00.000-07:00

Victor R. Fuchs,Economics Professor Emeritus at Stanford, wrote a Perspective commentary in the August 18,2011 Issue of the New England Journal of Medicine entitled: The Doctor's Dilemma-What is "Appropriate" Care ?

The dilemma he describes is the following;

"How can a commitment to cost-effective care ( as physicians have been "committed" to that since the Physician charter and the New Professionalism) be reconciled with a fundamental principle of primacy of patient welfare"

Fuchs tell the readers if all the physicians in a given health care collective practice (as in HMOs and now Accountable care Organizations) cost effective medicine the resources saved can be used for the benefit of the defined population which includes the patients of the physician who seemingly may face a conflict. So, if all the physicians act in the same way all patients benefit.

I believe Fuchs conflates the good of group as indicated by some aggregate number with the good of each individual in a particular situation in which a particular individual may not enjoy the benefit and may actually be harmed. In fact cost effectiveness analysis involves aggregate data. With any outcome in a group some may benefit some may be harmed.

In his closing paragraph, Fuchs tells us that when a physician works in a health care collective in which there is a fixed annual budget the physician resolves the dilemma by favoring the cost effective option. This according to Fuchs become "appropriate". ( Why does Fuchs use quotes marks?) So,the cost effective choice is the appropriate choice and also the ethical one. It is ethical in the moral calculus of Kant "because if all physicians act the same way,all patients benefit" .

The basis of Kant's ethical precepts was the categorical imperative which is:

"Act only according to that maxim whereby you can,at the same time, will that it should become a universal law."

In other words, a person acts morally when he acts as if that conduct were establishing a universal law governing others in a similar situation.

I find it interesting and puzzling that Fuchs uses a Kantian based ethical argument to support cost effectiveness based decisions in health care as cost effectiveness analysis is typically justified using a consequentialist type argument. Philosophical support for the notion of resource allocation based on the best bang for the buck is supplied by this outcome based school of ethics.

Kantian ethics, on the other hand, is duty or rule based ,an approach called deontological in the literature of ethics.Kant believed that the individual should be considered an end in himself not as a means to an end. In the medical collective the individual's interests are subjugated to the aggregated good of the group;the individual functioning as a means to achieve the greater good of the collective whether or not a particular member of the collective enjoys the benefit.

In the moral conflict between the physician's fiduciary duty to do what is right for the individual patient and the imperative to serve the best interests ( by what ever aggregate parameter that is being used) of the group as a whole, would not Kantian rule-duty based ethics support the rule of do what is best for your patient and patient is a singular noun. If Fuchs is suggesting that cost effectiveness analysis should be determinative in medical decisions and that it is justified by Kantian ethics, I suppose the "rule" would be always do what is cost effective.Never mind that pesky notion of a person being considered an end in himself and not as a means.

Once again price control in medicine results in shortages,this time cancer drugs

2011-08-08T02:08:00.000-07:00

There has been and continues to be shortages in some of the older well proven cancer drugs. See here for an explanation of what is happening there.

Dr. Ezekiel J. Emanuel blames much of the problem of the 2001 Medicare Prescription Improvement and Modernization Act.

Here is a quote from Emanuel's opinion piece in the August 6,2011 NYT Sunday Review:

The act had an unintended consequence. In the first two or three years after a cancer drug goes generic, its price can drop by as much as 90 percent as manufacturers compete for market share. But if a shortage develops, the drug’s price should be able to increase again to attract more manufacturers. Because the 2003 act effectively limits drug price increases, it prevents this from happening. The low profit margins mean that manufacturers face a hard choice: lose money producing a lifesaving drug or switch limited production capacity to a more lucrative drug.

The economist Arnold Kling is fond of saying that they teach all the important stuff in Econ 101 not saving any big secrets for more advance study.I'm fairly sure Econ 101 explains the effects of wage and price controls and that incentives matter.

Aggregate Healthiness, Gross Body Health,Keynesian Medicine

2011-08-07T04:05:00.000-07:00

I have ranted and sometime more reflectively argued quietly against the morality of the aggregate as it applies to medical practice. Rules,pay for performance (now re branded as value based purchasing) rely on the statistical aggregates and often overly simplified guidelines. I know, aggregates can be useful in a number of contexts but the individual patient ( what other kind of patient is there?) may have her interest devoured by obsession with rules based on the statistical abstractions.

Here, George Mason Economist,Don Boudreaux, tells a satirical tale about a medical analogue to Keynesian aggregate demand.

No, the fictional gross body health is not exactly what I argue about with the guideline-P4P thrust in clinical medicine but Boudreaux's commentary is worth reading.

MIT Prof discovers people like to spend other people's money

2011-08-01T03:59:00.000-07:00

Amy Finkelstein,a PhD economist from MIT,has "discovered" that people when given a card that lets them buy something cheaper than they could otherwise buy more stuff. Thanks to David Accad at the blog, Alert and Oriented,for calling this discovery to my attention.

This link from a news story on the discovery briefly discusses her findings and the mind boggling claim that this finding will change thinking about health care spending. Yeah, it is that old
"demand curves slope downward" thing again. Note: this is not breaking news her reports and news items on it date back to 2007 but I have fallen way behind on my health wonk literature reading.

Here is a quote from the news report:
Already, Finkelstein's analysis is shaking up views across the political spectrum. "This is pathbreaking work," says Joseph R. Antos, a health economist at the conservative American Enterprise Institute. Adds the more liberal MIT economist Jonathan Gruber: "This really changes the whole landscape in the way we think about health economics."

Wow, pathbreaking work.Apparently no one heard or remembered what Milton Friedman had said about the ways people can spend.See here for that concept in Dr.Friedman's own words.The key point here is that when you spend someone else's money on yourself , you are not very careful about how much you spend.

Dr. Finkelstein work supports the notion that health care costs have increased in no small measure because millions of older American have Medicare insurance and they realize that they can get medical services much cheaper than otherwise when they show their card to various health care providers. The fact that some health care wonks thought her findings will change the way people will think about health care policy seems to mean that until now some health care experts believed that demand curves slope upward. Some admirers of Milton Friedman are celebrating the 99th anniversary of his birth. See here. Maybe health care economists might browse through some of his work.Perhaps an econometric demonstration of the absence of a free lunch might be forthcoming.

Health Care and Education-the new "commanding heights -"Kling and Schult

2011-07-28T11:36:00.000-07:00

An interesting and insightful commentary by Arnold Kling and Mick Schult is found in the Summer issue of "National Affairs" and is entitled "The New Commanding Heights".The title is a play on the title of the book by Daniel Yergin and Joseph Stanislaw "entitled "The Commanding Heights:The battle for the world economy". See here for the Kling essay.

The term Commanding Heights was used by Lenin in a 1922 speech in which he refers to the dominate industries in Russia at the time indicating that they would be target of the central control of the communists. He gave up trying to control everything so he decided to control the key industries.These included heavy manufacturing,mining,electric generation and transportation.

Kling and Schult contend that those industries are now largely not controlled by the state in the United States and in western countries generally and while these sectors are important they present data showing they are no longer the major growth sectors in our economy.They argue convincingly that education and health care are the growth sectors in the United States.

History has made it clear that markets work. Market economies lead to prosperity,economic growth and innovation while central planning results in dismal and often tragic failures. Lenin promised to do what capitalism did plus eliminating waste, recessions, and inequality:what was produced was mass starvation and mass murder.

However, the authors warn markets advocates against premature celebration. Their thesis is that in the U.S., both in education and medical care, the new commanding heights, governmental controls are prevalent and growing and if the U.S. is to continues to grow and prosper, we need innovation in these areas? How much innovation occurs in government controlled economic sector?

Many (most?) discussions of the medical economy emphasize the overall
cost" of medical care and its growth ( it is a growth sector) and that it is a bad thing. Two comments are appropriate: 1) often overall costs are conflated with government costs ( i.e. Medicare and Medicaid) with overall costs 2) Costs are only one side of the accounting, one person's costs are another's income stream.

Controlling the amount of money that the government spends on health care or farm subsidies or foreign wars is one thing and is well within legitimate government activity, attempting to limit private spending on healthcare or cosmetics or anything other legal activity is quite something else.So with GDP not snapping back to previous more healthy levels do we really want to decrease activity in one of the two major economic growth centers?

Surprise-economic principles apply to old folks and Medicare costs

2011-07-20T04:26:00.000-07:00

See here for a report on some data gathering that should be filed under the heading of "very bloody obvious". The link is to the 7/16/2011 blog entry from Dr. Mark J.Perry which tells us 1)Medicare utilization is about 50% higher than private health insurance utilization and 2) why Medicare patients see their doctor so (too?) much. Hint:it has something to do with spending someone's else money and the law of demand.

Economists are fond of saying "demand curves slope downward" which is their jargony way of saying that people buy more when the prices is lower and less when it is higher. Milton Friedman has been quoted as saying that economics is simple- just remember there is no free lunch and demand curves slope downward.

Economists ,for some obscure reason possibly found deep in the history of their discipline, place the dependent variables on the X-axis and the independent variable on the Y-axis. This is just the reverse of the practice of physicists and engineers and most other people who like to draw graphs. So they place price on the Y axis and quantity demanded on the X axis and thus the demand curves slope downward because folks buy more when the price is cheaper.

Medicare patients "buy" more health care because of the way Medicare works they get a really good deal on the price that CMS allows to be charged. It gets better, Medicare generally pay 80% of a significantly lower "allowed price" and many seniors have supplemental insurance which further amplifies the illusion of a free lunch.So,of course,Medicare users utilize more services and the reason is not that fee-for-service doesn't work. Blaming fee-for-service is the current battle cry on many in Congress and many of the organizations who allegedly represent the practicing physicians.

Some would conflate fee-for-service with free markets in medicine but there has been no free market in medical care for many years now (except for a few markets such as lasik surgery and some plastic surgery and much of alternative medicine) and the Medicare system is characterized by price controls and the demand side characterized by folks buying services with someone else's money,both of which are the products of central planning. What could possibly go wrong with that circumstance?

The list of problems in medical practice are not due to fee-for-service but rather what happens in a nominal fee-for-service setting when there are price controls namely shortages,long waiting lines,poor quality and various other forms of rationing by other than prices.As is often the case, the results of central planning are blamed on that heartless,run-away greed all the way down, free market.And as is also often the case the solution is more central planning,which is what Obama care is all about.

More on IPAB and the risk of regulatory capture

2011-07-14T08:58:00.001-07:00

See here for a recent report on views of the IPAB.

Particularly interesting were comments of someone who has been there and done things in the setting of a very important and powerful governmental appointed post.

Bruce Vladecks, the former head of CMS under Bill Clinton, had this to say :

"In the short term, it might theoretically work," he said. But the history with other independent regulatory agencies, like the Interstate Commerce Commission and the Civil Aeronautics Board is that over time "the regulated industries tend to capture them; and they tend to do more to protect the regulated industries than they do to protect consumers."

Considering the legislative hurdles that Obamacare put in place for Congress to over ride the edicts of IPAB, capturing IPAB would be prize well worth capturing.

What is the moral case for Obamacare?

2011-07-11T04:03:00.000-07:00

Is there one at all?This commentary by the economist John Goodman argues there is none. After Dr.Goodman made his case he invited readers to offer such a moral justification.I could find none in the forty reply to his article.

Several commentators ( including spokesmen for the ACP and the AMA ) claimed that Obamacare furthered social justice. So could that be the moral justification for Obamcare?

In regard to social justice Thomas Sowell said the following:

Their passionate arguments for particular results tend to obscure or distract attention from the question of the social processes by which these hoped-for results are to be pursued.

Goodman,in this most recent cited commentary, and in numerous others posting on his blog gives great detail of the various social process set in motion by Obamacare and the numerous apparently unintended consequences

In short, the various elements of this outlandish long bill do just about anything other than the putative hoped-for results which is "affordable , accessible health care for all" and instead offer a mind boggling array of counterproductive results and bizarre inequities and the frightening promise that many more such dystopian outcomes will arise from the hundreds ( more likely thousands) of pages yet to be written by agencies created by Obamacare and the incredible discretionary powers given to the Secretary of HHS.

Perhaps,spokesmen for the medical organizations who champion (yes, they still support it in spite of the increasing evidence that the bill is a very bad idea) can offer a moral justification .

Meta-analyses-money well spent?

2011-07-10T04:26:00.000-07:00

I have blogged more than once ( see here and here )about meta-analyses (MA) and quoted Steve Goodman MD PhD more than once when he said that MAs are just observational studies in which the observed elements are studies. I would add and we just don't know what went on behind the curtain.

They are not super randomized trials as the prefix "meta" might imply but should rightly reside significantly under RCTs in the hierarchy of clinical research methods.

Since the views expressed conform nicely with my biases I was drawn to this commentary by Dr Wes.

"Wise Legislators " pass ACA with IPAB,their "good deed"

2011-07-08T05:15:00.000-07:00

Henry J.Aaron,of the Brookings Institute, has written three commentaries in the Perspective section of the NEJM in the last year. He seems to be their go-to guy for IPAB issues.Here is a link to his latest.

He praises Congress for their willingness to "abstain from meddling in matters they are poorly equipped to handle." He seems to be aware of Public Choice theory (he has a PhD in Economics from Harvard) when he talks about the temptation of Congress to spend money for political ends but seems to have missed the point when he apparently assumes that the IPAB panelists would be immune to lobbying efforts.Clearly, he believes it is a good and desirable thing for Congress to delegate its powers to agencies and other bodies- a view somewhat in opposition to how James Madison thought things would work out.

This is in stark contrast with the friend of the court brief that the Pacific Legal Foundation has filed to challenge the constitutionality of the creation of IPAB. See here for their comments on IPAB and a reference link to their brief challenging IPAB.

Aarons likens the creation of IPAB to the creation of the Federal Reserve which was to be an entity not subject to congressional control.

This may not be the best analogy with the increasing efforts of Congress (and not just Ron Paul ) to at least exert some surveillance of what the Fed does.

July 4th, all about the right to vote or much more than that?

2011-07-04T04:34:00.001-07:00

This commentary from the Coyote Blog is good fourth of July reading.

Warren Meyer,a libertarian entrepreneur and prolific writer, who writes the blog as well as being a contributor to Forbes list three principles more important than the right to vote. Here is the first one he discusses:

"The Rule of Law. For about 99% of human history, political power has been exercised at the unchecked capricious whim of a few individuals. The great innovation of western countries like the US, and before it England and the Netherlands, has been to subjugate the power of government officials to the rule of law. Criminal justice, adjudication of disputes, contracts, etc. all operate based on a set of laws known to all in advance and applying equally to all."

Meyer then points out the obvious contempt for the rule of law with the exemptions to certain provisions of the health care law .

More of the "social justice" fallout from ACA

2011-07-03T04:22:00.000-07:00

As more and more inequities and unintended consequences of Obamacare are revealed as we learn more and more about the bill,we can see that the social justice Obamacare advocates (you know who you are )boasted about following its passage is a very strange type of justice.

See here for one of the latest revelations about how basically unfair various aspects of the bill turn out to to be. As the AP article explains two families with same income would pay significantly different health insurance premiums to the exchange based on what type of income they receive.This problem seems to be tied to the definition of income used in the statute.

But it gets even worse, more folks become eligible for Medicaid based on the law's wording.

Medicare's top number-cruncher is warning that up to 3 million middle-class people in households that get at least part of their income from Social Security could suddenly become eligible for nearly free coverage through Medicaid, the federal-state safety net program for the poor. Chief Actuary Richard Fosters says that situation "just doesn't make sense."

The progressive mind set worries about inequality just about everywhere

2011-07-03T02:21:00.000-07:00

See here for David Henderson's remarks about a commentary from former white house adviser and Director of OMB and now VP of global banking at Goldman Sachs.Peter Orszag.

Here,Orszag worries that high tech advances will worsen the gap between the rich and poor in longevity. The various (endless?) parameters that can be used to illustrate the fact that the rich and the poor are different is many ways provide much source of professed worry and endless calls to action from the progressives.

His move to Goldman Sacs should do much to insure that he will be at the top of that gap so that any "solution" to this problem must involve raising up the poor and not lowering the rich although his commentary seemed to offer no practical solution to this worrisome gap .

We will never run out of gaps.Market economics is the engine of prosperity and also the engine of inequality according to Milton Friedman.

There is a body of literature and discourse which emphasizes the notion that inequality is a major problem in the western world, as least in the U.S., and the inequality per se is bad and harmful and therefore there should be continuing policy efforts to shrink the gaps. Here is a well reasoned counterargument to that notion.

Platonic Medicine and the ACA with its IPAB

2011-06-22T02:12:00.000-07:00

I had been sketching out some comments about what I was going to call "Platonic Medicine" referring to the "leaders with ideas" who will lead the way to transform medicine based on the underlying premise that "medicine is too complex and important to be left to the individual physician and the individual patient" and therefore it should be controlled and directed by the wise medical elite who will determine the collective utility of a given approach and its value.I have commented before about Don Berwick's advocacy of that view.

However, someone had written something in that regard better than I could.See here.

Hat tip to the Pacific Legal Foundation who filed a friend-of-the-court brief to challenge the constitutionality of IPAB on the grounds of violation of the non-delegation doctrine and for the above mentioned link which alerted to Jost's comments.

It turns out that an outspoken advocate and supporter of Obamacare,law professor, Timothy Jost has already praised that legislative act in part because of what the IPAB will provide. He said:

A board of “Platonic Guardians” to govern the health care system or some aspects of it. The cost of health care is spinning dangerously out of control…. [O]ur traditional political institutions—Congress and the executive administrative agencies—are too driven by special interest politics and too limited in their expertise and vision to control costs. Enter the Platonic guardians…an impartial, independent board of experts who could make evidence-based policy determinations based purely on the basis of effectiveness and perhaps efficiency.

Incredibly Jost is asserting that this board will be immune to the influence of special interests and will make decisions rationally and in a proper evidence based manner.From what planet will these board member be chosen? Philosopher kings in charge,what could go wrong with that?

The PLF commentary pointed out that a Platonic government was definitely not what the founding fathers had in mind and Jefferson and associates were not big fans of Plato.

In the commentary that I was considering I thought perhaps calling the panel members Platonic Guardians would earn me the accusation of being overly dramatic and hyperbolic, but now we see an IPAB advocate using the same characterization and believing that to be a very good thing.

Dictating the coverage to control the cost for Medicare and Medicaid may not be enough for the medical Platonic elite as is illustrated by this quote from Dr. Robert Berenson:

"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".

I wonder who the "we" is that Berenson references.

Finally, another chilling quote from Mr. Jost:

"In the long run, Congress may not be able to cap Medicare expenditures without addressing private expenditures as well. If the IPAB opens the door to rate setting for all payers,it may well be the most revolutionary innovation of the ACA".

Yeah, it just might be.

Why is there a shortage of certain drugs?

2011-06-21T04:30:00.000-07:00

When faced with a shortage in some good or services a good first guess as to what might be going on is to see if there are price controls at work?

Go here to read a detailed analysis by John Goodman of what factors are at work in the ongoing shortage of over 200 hundred medications. It turns out that at least a contributing factor to the shortage is price controls which are part of a 1992 Federal 340B drug rebate program to certain medical facilities.

Another, perhaps more important governmental factor is at work in the form of the the output controls put in place by the FDA which limits the production of product by drug companies and diminishes their ability to quickly react to market conditions with increased production.

No, price controls are not the entire explanation but government price controls and other regulatory actions impeding market process are playing a role. The situation is more complicated that the two factors mentioned above and some of the other contributing factors are discussed here. But,as the various shortages play out, I'll be it won't be long until we hear that the free market has failed again and more governmental controls are necessary to protect the public.

Peripheral arterial disease (PAD) and smoking, now there is a real relative risk

2011-06-17T04:42:00.000-07:00

While I thought there was little doubt remaining about the relationship between cigarette smoking and PAD, a recent study published in the Annals of Internal Medicine (see here for abstract) provided more convincing data, this time in women. Yes, cigarettes are bad for women's peripheral arteries as well.

This study from the Women's Health Study generated some robust, relative risk numbers.I am not talking about the puny 1.2-1.4 relative risks (RRs) we often see in the typical data dredging articles and certainty not the ridiculous RR of 1.01 (not a typo) that was the alleged increased risk of death from vitamin E use.See here for that silliness.

Here are the age adjusted incidence numbers for symptomatic PAD

0.12 never smoked
0.34 former smoker
0.45 smoked less than 15 cigarettes per day
1.63 smoked greater than 15 cigarettes per day

1.63/0.12 =13.6

You are not likely to see RRs greater 10 from the typical data dredge and the WHS data also demonstrated a dose-response effect.

So, how large should a RR be before one worries about it or seriously believes we may have a causal relationship?

Sackett ,of McMaster EBM fame, asked one of the giants of epidemiology that question. Sir Richard Doll said that if the RR were 20 or greater that would be almost sufficient to indicate causality.Sackett was not quite that cautious and indicated that a RR of greater than 3 was "convincing".

Some courts use a RR greater than 2 to reach the threshold of "more likely than not".This is the current level of proof in most tort cases.

Michale Thun, who at the time was vice-president of epidemiology and Surveillance at the American Cancer Society, said:

With epidemiology you can tell a little thing from a big thing.What's very hard to do it to tell a little thing from nothing at all.

With cigarettes and PAD, we have big thing and we will not likely see battling statisticians debating the data. However, we did see that when Nissen's NEJM article claimed a RR of 1.43 for of Avandia and heart disease and we will likely get to see another again with the current breaking news of a RR around 1.4 with Actos and bladder cancer.

Independent Payment Advisory Board (IPAB)-what could go wrong with that?

2011-06-14T05:03:00.000-07:00

The IPAB which was inserted into Obamacare at the last minute without anything approaching proper legislative review and contemplation establishes a 15 member panel appointed by the President which will beginning in 2014 have unprecedented power to control medical spending in the country with almost no significant or likely effective congressional oversight.

Now what could possibly be wrong with that?

James Madison had some thoughts about that.He was concerned about what he referred to as "factions' which today would be thought of as special interest groups.Special interest groups have developed a potent skill set to influence government bodies to focus benefits on themselves while the cost are diffused.

In general, the founding fathers of the country has some thoughts about what could be wrong with that sort of entity.They tried to design a government not so that wise leaders could do great good but rather one that would limit the damage done by fools,thugs and would be despots who might(most assuredly would) find their way to influential posts in government.

Their wisdom seemed brushed aside as the view of a benevolent and wise government assumed the default position as it was persistently promoted by a cadre of progressive minded academia intellectuals and high school civics texts which visualized a government that would wisely recognize problems,devise safe and effective solutions and then without special favors execute remedial plans marvelously bereft of significant unintended consequences.

Fortunately, James Buchanan and Gordon Tullock resurrected Madisonian wisdom, enlarged upon it and explicated the theory of public choice which basically asserts that government officials and bureaucrats display the same characteristics as other humans, namely a proclivity to look after their own self interest. They definitely has some thoughts about what could possibly go wrong with something like the IPAB.

The economist, George Stigler,who did much to develop the concept of regulatory capture might have some to say about what could go wrong with the IPAB.Governmental agencies and organizations can be subject to the influence of the very groups that they are created to regulate and control to regulate and control.

Mafia dons and wise guys alike know the explanatory value of the "follow the money" and could explain simply what could go wrong with the IPAB.

Big Pharma had supported the passage of ACA but it is hard to believe that their support would have been forthcoming had they realized what IPAB would be.They certainty recognize the danger now.

The American College of Physicians (ACP) also supported Obamacare but now express opposition to the IPAB section "as written".Although (unfortunately in my view) they do not recommend repeal of IPAB but instead want certain changes that would make the entity acceptable.See here for ACP's position which objects to the exemption of hospitals and hospices from IPAB's edicts until 2019,the absence of primary care physicians on the panel,the lack of a mechanisms for significant congressional oversight and for preserving quality while decreasing costs.

So, much can go very,very wrong with IPAB but it gets even worse. Go here to read a recent commentary by George Will which discusses the chilling thought that the IPAB may not be stoppable. It may well be " entrenched".

Entrenchment refers to one legislative body passing a law that contains provisions that prohibit later legislature from repeal the law.

Can a legislative body really pass a law that contains a wording to prohibit further changes in that law?Is the IMAB really an immutable entity?

Eric Posner discusses it here and, as best I can translate it from the legal dialect academic lawyers speak into everyday English is that the Supreme Court has decided that they cannot allow that but as with anything that might be litigated there are at least as many sides to the issue as there are interests who can loose or gain from a decision.

It is hard to find a better summation that the one penned by Mr. Will in his above cited recent column:

"The essence of progressivism, and of the administrative state that is progressivism’s project, is this doctrine: Modern society is too complex for popular sovereignty, so government of, by and for supposedly disinterested experts must not perish from the earth. "

And the corollary for progressive medicine is that "medical care is too important and complex to be left to the individual physician and the individual patient."

Harvard economist expresses concern over plans for IPAB

2011-06-12T04:02:00.000-07:00

When a main-stream, Harvard economist expresses concern about a entity created by the enormous health care bill (ACA,Obamacare) known as the IPAB, it should evoke more wide spread concern about the wide reaching aspects of the legislation.

Professor Greg Mankiw has written with alarm about what a progressive think tank has proposed regarding the IPAB. See here for his commentary but I believe there is more to worry about than a proposal in regard to the IPAB. Mankiw references a proposal by the Liberal Center for American Progress to allow the IPAB to control the expenditures of private health insurance plans not just those expenditures regarding Medicare and Medicaid.

From what I understand the IPAB already has been given that power by Obamacare.

Dr.Richard Fogoros writing in his blog The Covert Rationing Blog explains how the IPAB was created and what it is authorized to do beginning in 2014. His reading of the statute indicates that this presidential appointed panel already has the legislative authority to limit expenditures by private health insurance companies. His analysis also describes how difficult it will be for Congress to over ride the panel's edicts. See here for his comments.

Remember the notion that "more [medical care] is less " and harmful as well -Guess what

2011-06-02T11:25:00.000-07:00

Dr. Buz Cooper sticks a dagger in the heart of the non-sense that claims more medical care is harmful and less care is better. See here for his take on the latest study from the Dartmouth group which seems to contradict the mantra they have been selling to the gullible and to the progressive planners for years.

Dr. Cooper sums it up this way:

"Medicare beneficiaries who received more medical care had better outcomes, even when they are sicker. MORE was MORE."

Isn't this what common sense would suggest?

Being a (public health) expert means never having to say you are sorry

2011-05-31T05:03:00.000-07:00

One of the continuing pleasures of following and sometimes participating in the world of medical blogging is the enjoyment of watching some bloggers who regularly hit things out of the park. I am thinking particularly about DrRich (aka Dr Richard Fogoros of the blog " the covert rationing blog") and his recent commentary about public health efforts that go wrong,sometimes badly so,and how the experts cram their previous advice down the memory hole and go on with their latest recommendations . See here for his latest and then here for an earlier spot-on critique of our public health brothers and their follies .

Public health experts enjoy a decision making advantage over the medical doctor who has to often take aggregate data-such as randomized clinical trials but often less reliable data) and then attempt to apply that to the individual patients sitting in his office.All the public health expert has to do is to look at the aggregate data and base recommendations on that while the practicing physician realizes that lying under the summary statistics are individual patients some of whom may will benefit from the proposed treatment while others are unaffected and still others are harmed. Life in the dealing with real patient trenches is more complicated ,nuanced and reality based than in the offices of the academic public health experts who can base their conclusions and recommendation on the utilitarian imperative .

DrRich talks about public health experts " displaying every ounce of the overblown self-confidence traditionally enjoyed by the expert class operating within our Progressive
institutions "

The public health experts share the following view with " leaders with ideas " who vie for the position of architect in the redoing of American health care :

The basic tenet of what I call the medical progressive is that:

health care is too important (and too complicated) to be left to the individual physician and her patient.

"..to demonstrate to men how little they really know about what they imagine they can design.

This F.A.Hayek's quote was directed to the central planners who believed they could control an economy from a governmental perch and did not need the knowledge derived from competition of a price driven market.The problem of knowing what and how much everyone should and should not eat is of a different sort but Hayek's words can function as a much needed counterpoint to their hubris .

Is WHO's "World Health report 2000" the worst study ever?

2011-05-25T06:29:00.000-07:00

After reading the commentary (see here )by Dr. Scott W. Atlas I would give that publication my vote as the worst or darn close to it. Dr. Atlas is a Senior Fellow at the Hoover Institution and is chief of neuroradiology at the Stanford University Medical Center and has a long list of scientific publications to his credit.

It is amazing how often sound bites from that study are quoted not only by the main stream media but also recited as gospel by medical researchers often in the boiler plate introductions to what otherwise would legitimately pass for a scientific publication.

How many times have we been told that something must be done about the U.S. health care system because although the U.S. spends 16 % of its GDP on health care it ranks 37th (out 191 countries) in something the WHO staffers called "overall performance".

Dr. Atlas said the the WHO publication " ranked countries according to their alignment with a specific political and economic ideal-socialized medicine-and then claimed it was an objective measure of "quality" ".

Quality,which is always a usefully ambiguous concept, was in the view of the report's authors the degree to which a country had distributed wealth and centralized administration of health care.

Atlas explains that 62.5 % of the overall performance index created by the report to rank countries was an assessment of one particular concept of equality and not about health care outcomes at all.

Quoting Dr. Atlas :

In fact, World Health Report 2000 was an intellectual fraud of historic consequence—a profoundly deceptive document that is only marginally a measure of health-care performance at all.

Read Dr. Atlas's commentary for more details of the methods used by the WHO staffers to achieve this propaganda masterpiece. I expect politicians and policy wonks with a particular agenda to quote the WHO's factoids but it is embarrassing to see medical researchers use the bogus material from the report as fillers and appropriately politically correct genuflexions to the notion of social justice in their publications.

Can this really happen in the U.S.?

2011-05-22T04:18:00.000-07:00

This commentary is fairly far afield from the areas of my usual writing but the facts are so egregious and frightening that I had to say something. The topic is civil forfeiture. I defer to the excellent commentary on this subject by one of my favorite writers,Dr. Donald Boudreaux who is trained in economics and the law having a PhD in the former and is teaching at George Mason University.See here.

The case he discusses and the subsequent decision of the Supreme Court can fairly be described as mind-boggling , the dictionary definition of which is "intellectually or emotionally overwhelming".

In regard to the case,Bennis versus Michigan,Boudreaux and his co-author, A.C. Pritchard, said in part the following:

[the Supreme Court's decision] allows government to impose huge costs on people never charged with criminal wrongdoing"

Those of us who,probably against all reason,still think that the Supreme Court will overturn Obamacare find little hope that the supremes will do the right thing after one reads their decision in this case.

A slightly positive note is this was a five to four decision by the court and one of the dissents was penned by Justice Kennedy who is generally thought to be the possible swing vote when the health care bill gets to the court. Maybe he will do the right thing again.

Will the over crowded ERs generated by Obama care reflect social justice

2011-05-16T05:25:00.000-07:00

As the facts continue to flow out of various analyses of Obamacare and we learn that it will not keep the nation from "going bankrupt"and (shockingly) it will actually cost money and that various elements of it have to be postponed or exemptions for certain provisions have to manufactured to avoid voter push back in 20122, advocates are running out of justifications and may have to fall back on their claim of furtherance of social justice.

Some Democratic Senators and several spokesmen for medical organizations risked shoulder injury so exuberant were their efforts at self congratulation when the bill was signed into law.To be able to discern what the results would be in a bill so long, dense and ambiguous regarding details would require analytic ability not yet achieved by any creature who evolved on this earth.In fact, the details of the bill had not yet been written as the particulars were in numerous instances delegated to government entities for rule making some of which were yet to be formed.

Down the road there will be a situation in which this justice will be quite visible.That will play out in the emergency rooms across the country. The rich and the poor alike, those with insurance cards and those without will wait together as increasingly overworked and overstressed ER docs ( and their physician extenders) try and cope with the infusion of 30 plus million more insurance card holders into the health care system. Everyone waiting together to be screened by the NP or PA or as things evoke a NP assistant will give a lovely portrait of the wisdom of the central plan for [almost] everyone having nominal access to medical care but operationally finding little of it.

Social justice typically means redistribution and accordingly to CMS czar Dr. Donald Berwick good medicine must mean redistribution . Easier access to health care will be redistributed and diluted so that everyone gets to wait and wait and everyone's quality of care goes south.

For those of us who hope that having a retainer doc will help, and I think it will, here is a sobering thought and something else to worry about. With more vertical integration of medical care and the latest acclaimed saviors of medicine (the ACOs) becoming prevalent and perhaps dominant, will independent retainer docs even be allowed to admit and treat patients in a hospital or will her patients also end up in the increasingly long lines in the ERAs and the retainer physician unable do anything about it.Is there really anyway to escape from the clutches of Obamacare? Will it all be up to Justice Kennedy? Will it even be possible (i.e. legal) for someone to purchase health care outside of the centrally planned system? If you have not worried about that issue before I suggest you visit this and other commentaries by DrRich.

Here is a commentary from NPR on what ER docs think will happen when millions ( about 34 million) of new folks get an insurance card to show the clerk in the ER. Let us see-increased demand and no significant increase in supply combined with the already in place price controls in Medicare just might mean shortages , long lines, and decreased quality of care.You think.

The semi-secret RUC is getting less and less secret

2011-04-28T07:40:00.000-07:00

The RUC (more formerly known as the AMA/Specialty Relative Value Update Committee) up until recently has been an obscure creature of the AMA about which little was known and even less was written about. Thanks to a number of physicians,including Dr. Roy Poses, more and more information of the composition of that group is being revealed. See here for Dr. Poses's latest revelations about the current members of the RUC and and some of their relationships which might represent conflicts of interest.

Not only are we treated to looking behind the curtains but there is an organized effort to opt out of the RUC influence. See here for information about the "Replace the RUC" effort.

Dr Poses raises several of the unanswered questions regarding the RUC. The one that interested me for some time is this. Why was there and is there so little outcry about the central governmental management of physician's fees, i.e. price controls.? (If there is anything Keynesians and non-Keynesians agree on it is that price controls lead to shortages and decreased quality) Could part of it be that the AMA whose brainchild we are talking about kept the whole process obscure and largely behind the scenes?

How bad is the Supreme's denial for expedited review of Obamacare?

2011-04-26T09:00:00.000-07:00

According to David Catron the news is really bad for those of us who still hold out some hope that Obbamacare will be stopped by the Supreme Court. Here is his commentary in the American Spectator. While the issue(s) crawl though the courts, the "leaders with ideas" are cranking out rules and regulations for the statute's implementation.

Meta-analysis fails to show all-cause mortality benefits to statins in primary prevention

2011-04-22T04:26:00.000-07:00

A 2010 meta-analysis by Dr. KK Ray et al ( see here for full text) in the Archives of Internal Medicine stirred a bit of interest and commentary as it failed to show an all-cause mortality benefit from statin use in the setting of primary prevention in patients with elevated risk factors for coronary artery disease.

A few context setting comments are in order. First, it is well established that statins are clearly beneficial in secondary prevention of coronary disease. In patients with proven coronary artery disease few would disagree with statin use.Its efficacy and safety have been demonstrated in several of the well known so-called landmark statin trials.

Second, the argument is strong for the conclusion that statin use in primary prevention results in a decrease in cardiovascular (CV) deaths. The authors of the Archives article make their position clear in that regard when they say in their comments sections "the benefits of statins in CV deaths are unequivocal based on primary prevention data from the CTT meta-analysis." The Cholesterol Treatment Trialist Collaboration or CTT was published in Lancet in 2005 ( see here ) .

So, the issue that Ray and his fellow authors addressed was not do statins reduce CV mortality in primary prevention but do statins reduce all cause mortality and their data analysis lead to the conclusion it does not.

Ray analyzed data from 11 randomized clinical trials of patients with what they considered to be high risk for coronary artery disease ( 244,000 patient years). Big numbers for patient years tends to give credence to findings but the key thing here is that in these trials the follow-up period was only 4-5 years as is typical of clinical trials. In patients with increased CV risk -as opposed to patients with proven CAD-the ratio of CV deaths to total deaths is relatively low particularly in a 4-5 year time frame. So that it is not surprising that all cause mortality may not be decreased, which is what Ray demonstrated.

Both the editorialist in the Archives and a subsequent commentator in a Update section in the April 5, 2011
Annals of Internal Medicine seem to conflate failure to show decrease in all cause mortality in a short observation period with overall lack of benefit. Ray and co-authors do not deny benefits in terms of decrease in C-V mortality.
.

Major cuts in Medicare Advantage postponed until after election

2011-04-21T03:41:00.000-07:00

Remember how we were told that if ACA ( Obamacare) were not passed the country would "go broke". Obamacare would reduce the deficit. One of the cost saving mechanisms contained in the bill was a major reduction in Medicare costs including significant reductions in Medicare Advantage (MA).This was supposed to bolster the long term solvency of the entire Medicare program. Now the Obama administration has decided to postpone saving the country from going broke until after the election and actually spend a little more money of the MA program.Why? To avoid a voter push back from looming cuts in Medicare Advantage seems the obvious answer . AARP can't be happy with that. See here for more on AARP.

See more about the Medicare Advantage ploy from Black Ribbon Project blog here. Also I commented on this egregious political play before.

Another alleged cost saving proposal included in Obamacare was the Community Living Assistance and Support Act (CLASS).

Early on, opponents of the health care bill insisted that its provisions were not fiscally sound and were placed in the bill to give the illusion that Obamacare would cost less than the magic one trillion dollar price tag. The plan was to front load the plan with premiums without any benefit payments for a number of years. It was advertised as a mechanism to decrease the federal deficit by 86 billion over a ten year period. Now even with the deck as rigged as it was it will not work . The Secretary of HHS has admitted that.

More and more elements of the Obamacare monster bill seem to be either unraveling completely or postponed until after the 2012 election.

Still more data on adverse and beneficial effects of statins

2011-04-18T02:28:00.000-07:00

Here is a recent article in the BMJ detailing the absence of numerous adverse effects of the statin class of drugs and the occurrence on a few beneficial effects. The article mentions cataract as a complication of statin therpay , an adverse effect that was of concern in very early animal work by Merck but about which I had stopped worrying until the BMJ article. In fact, there was this study from 2010 which claimed the opposite, i.e . a decrease in the risk of cataracts from statin use and this 2003 fairly large case-control article that found no effect in regard to cataract.

For a while those who read or skimmed medical literature were treated to an array of articles that claimed numerous effects of the statins that were not just further evidence of the pleotrophic effects of statins but were really just short of miraculous. I wrote about some of those claims here. Most of those claims did not pan out. Another claim,that of the statins causing an epidemic of heart failure made by Dr. Peter Langsjoen ( see here),does not appear verified by the BMJ article.

Federal Judge" Entitlements" are mandatory-people are trapped [in Medicare]

2011-04-05T09:51:00.000-07:00

Regulations put into place during the administration of Bill Clinton prohibited folks from opting out of Medicare part A unless they agreed to forgo their social security payments ( and pay back whatever SS funds they had received).

It seemed to take a long time for someone to challenge this rule but someone finally did and the federal judge presiding over the case has now rejected the case with an appeal pending. Here is a link to the decision by the US District Court Judge Rosemary M. Collyer.

Her convoluted and self-contradictory reasoning (see here) concluded that this entitlement ( to Part A) is mandatory .To some the notion of a "mandatory entitlement" may seem Orwellian but at least the judge did offer some interesting comments in her written opinion that suggests lawyers even when they become judges might retain a sense of irony.

For example Judge Collyer said in her conclusion:

Plaintiffs are trapped in a government program intended for their benefit. They disagree and wish to escape. The Court can find no loophole...

In her introduction she stated:

Medicare costs are skyrocketing and may bankrupt us all; nonetheless, participation in Medicare Part A (for hospital insurance) is statutorily mandated for retirees who are 65 years old or older and are receiving Social Security Retirement (so-called ‘old age’) benefits. Whether Congress intended this result in 1965 or whether it is good fiscal and public policy in 2011 cannot gainsay the language of the statute and the regulations

It seems to me she might have well said, the program is ridiculous but that is the law -get over it.

DrRich takes up this case (see here) in his blog and considers this case in the broader context of his lingering (or growing) concern about the possibility that down the road seniors and others may face a health care system which prohibits the patient from purchasing any health care not approved by the central authorities. See here for his earlier commentaries on the efforts to limit individual prerogatives in obtaining medical care. I share his concern.

Follow the money rule suggests reason for AARP support of Obmacare

2011-04-01T06:03:00.000-07:00

The venerable follow the money rule continues to have explanatory power. This time, apply it to AARP's support for the health care overhaul-reconfiguration bill and presto we have a plausible explanation for AARP support for the bill . Simply put, AARP makes a hefty brokerage fee for selling Medicare supplemental policies and Obamacare dealt a blow to the Medicare Advantage programs so that it is likely many senors will migrate from MA plans to traditional Medicare and will likely purchase a supplemental policy the sale of which is a major income stream for AARP.

See here for details about how much money AARP might make as a result of changes brought about by the health care bill that they vigorously supported.

Meanwhile surveys suggest that most seniors believe Obamacare will diminish access to care for them (that they are the Peters robbed to pay Paul) and more entities are receiving waivers from some of the provisions of Obamacare. Things just get better and better.

Earth Day again-time to look at the satellite view of Korea

2011-03-24T07:31:00.000-07:00

Rather than encouraging school kids to guilt their parents into turning off the lights for a while to "celebrate" earth day ,my suggestion is for school teachers to assign an essay to their charges. The topic-why is North Korea dark and South Korea lighted as illustrated in this iconic image.

An alternative topic might be what would our lives be without electricity.

Here is an earlier earth day commentary offered as a counterpoint to the usual sanctimonious
earth day platitudes and indoctrination of youth with the secular religion of naive environmentalism with its rituals of turning off lights and mindless recycling.

Finally, here is an essay from the economist Steven E. Landsburg from his book "The Armchair Economist" in which he makes the distinction between the religion of environmentalism and the science of ecology and makes clear my choice of "mindless" to modify "recycling", putting forward the notion that recycling per se is not a moral issue and therefore always right (or wrong) but each case is an empirical one.

Still another argument against P4P

2011-03-23T07:33:00.000-07:00

I have based my opposition to P4P in medicine on several lines of argument. These included :

1) It is unethical (see here for the comments of Drs. Edmund Blum and Faith Fitzgerald)

2 ) it often is a disingenuous method to control costs with feigning a desire to improve care

3)Goodhart's Law (see here).

Now the prolific Dr. Doug Perednia offers another reason to oppose P4P. Read about it here ( this is part 2, read Part 1 also). He offers a brief and very instructive introduction to a field of study known as Self-determination Theory (SDT) and relates that to the P4P issue.

SDT is based upon the idea that there are many things that people do not for the promise of external reward, but because of some sort of intrinsic, human desire for autonomy, competence and relatedness.

Including in that category of things people do not necessarily because of carrots and sticks is the practice of medicine.

The theoretical and empirical case against P4P has grown so strong that the only reason physicians and their organizations put up with it must be they just want to go along to get along.

HHS gets more efficient , now giving an entire state an exemption from Obamacare

2011-03-10T10:25:00.000-08:00

The task of giving exemptions to aspects of Obamacare company by company might have proved to be to time consuming for the Department of Health and Human services so they are issuing state by state. See here.

The state of Maine was given a waiver,good for three years,exempting health care insurers from the requirement that they spend at least 80% of premium fees on actual patient care. In Maine, at least for a while, 65% will suffice.

Earlier Maine's secretary of insurance has expressed concern that one company,Healthmarkets,Inc, would drop coverage for policyholders and leave the state.See here for some background on that company .

Class Act a fraud? Secretary HHS claims she will "reform" it

2011-03-04T03:24:00.000-08:00

Financially unsound is the most generous way one can describe the part of Obamacare known as the CLASS Act ( The Community Living Assistance and Supports Act). see here.

Even the secretary of HHS admits to problems with this section of ACA but her answer is that she will use her discretionary powers to " reform it". What ever happened to the rule of law? A law is passed and if there are problems with it and an administrative arm of the executive branch will alter the law to fix it.It will be fixed by a politically appointed administrator who serves at the pleasure of the president.

Secretary Sebelius,at a congressional hearing, said that those provisions were "totally unsustainable" meaning it would not pay for itself and would require taxpayer money to make it fiscally viable.

Early on, opponents of ACA insisted that the provisions were not fiscally sound and were placed in the bill to give the illusion that Obamacare would cost less than the magic one trillion dollar price tag. The plan was to front load the plan with premiums without any benefit payments for a number of years. It was advertised as a mechanism to decrease the federal deficit by 86 billion over a ten year period. Now even the administration admits it will do no such thing.

Either the authors of the CLASS Act were aware of the lack of sustainability but proceeded on in a wink-wink-nod-nod manner or they did not know what they were doing. Ms. Sebelius testified that they (the folks at HHS) realized right way that was the case. Did the folks at HHS have no input to the crafting of the legislation?

One of the ways Obamacare was to "save money" was to cut Medicare Advantage but now..

2011-03-01T03:44:00.000-08:00

But now HHS announces that , at least for the short term- that is until the 2012 elections, payments will increase for Medicare Advantage Programs. See here.

It was a decrease in the Medicare Advantage Payments ,along with cuts to hospitals and other providers, that was to provide about half of the funding for the expanded insurance coverage to low income folks. It was projected that some 137 billion would be saved from cuts to Medicare Advantage programs. The alleged savings was touted to also extend the solvency of the Medicare Part A Trust fund.

The actions of HHS in this regard is typical of what George Will references as the "administrative state" which the United States have (has?) morphed into. In the "administrative state", Congress passes "sentiments" not laws, and delegates to the administrative tentacles of the Executive Branch the authorship and administration of the various rules that make the Congressional sentiments operational.See here for Will's comments.

Woodrow Wilson envisioned a government that would be run by experts who would be unencumbered by the messy give and take of politicians who would stray from what was right and good for the people by the actions of various interest groups and their own selfish urges. Somehow the only PhD to occupy the White House did not realize that the experts of the various agencies might themselves posses human characteristics that steer them to act for political reasons. It is hard to consider the recent actions of HHS other than being politically motivated.

So how did that P4P thing work out in Great Britain?

2011-02-22T04:03:00.000-08:00

If you want to know the answer to that headline question, go here to Dr. Doug Perednia masterful analysis of a large study of how P4p worked out in Britain's NHS. The bottom line was that P4P had no useful effect at all.None.

If the so-called thought leaders and powers that be in such organizations as AMA and ACP and others supported ( continue to support?) P4P because of a belief that patient care would improve they should now take a strong stand against such programs. P4P does not work.

Implicit in P4P program is the concept of target goals. Goodhart's Law stands the test of time and logic. When a measure ( as in a purported measure of "quality") becomes a target it looses its value as a measure.

Is lying for the greater good part of the New Medical Ethics

2011-02-21T11:55:00.000-08:00

Dr. Paul Hsieh discusses the antics of alleged physicians in the current Wisconsin kerfuffle writing notes falsifying an illness to excuse absence from work while the recipients attended the rally.See here.

He suggests that this dishonest behavior ties in nicely with the New Medical Ethics as promulgated by the American college of Physicians in which the notion of Social Justice is elevated to a prominent position.

Well, one way or another someone is lying. If those claiming to be physicians are really not, they are obviously lying and if they are physicians they are lying about the purported sick time.

Dr. Scott Silverstein, writing on the blog "Health Care Renewal" discusses the sick-note incident in terms of the slippery-slope situation that arises when there is "physician dishonesty-on-an-agenda " which he describes as the face of postmodern medicine.

Overhauling America's Health Care - a must read book

2011-02-16T14:08:00.000-08:00

Go here to read a lucid review of an excellent book by Dr. Douglas Perednia.Then go to Amazon to buy the book.It is entitled "Overhauling America's Healthcare Machine."

Dr. Perednia provides a brilliant and detailed description of what is wrong with the current system/non system and then offers his proposal to remedy the mess, a proposal very similar to that offered by Dr. Richard Fogoros in his book, "Fixing American Healthcare".

Wait- why read about plans to overhaul American healthcare, don't we already have a solution in the form of ACA? If you want to read a brief explanation of why ACA is not the answer, go and read Dr. John Goodman's latest comments on the incredible absurdity that Congress put together.

AND congratulation to DrRich At Covert Rationing Blog for his Weblog award for the category of Health Policy and Ethics.

Limited "coarse grain" data suggest following certain pneumonia guidelines can be bad for survival

2011-02-11T03:58:00.000-08:00

While that headline sounds like a typo that is what a recent article in Lancet seemed to show.Further we are not talking about all pneumonia guidelines,as , for example the guidelines for the treatment of community acquired pneumonia (CAP) actually work out rather well. The focus in the above headlined article was on the ATS and IDSA guidelines for the treatment of hospital acquired pneumonia (HAP).

When I read about that finding my first thought was to look more closely at the guidelines and importantly what was the evidence underlying the recommendation. As has happened more than once, Dr.RW saved me the trouble. See here.

Dr RW's analysis suggests that the evidentiary basis of the recommendation of the IDSA and does not belong on the top of the classical,mythical evidence based medicine (EBM) evidence hierarchy in which randomized clinical trials and meta-analyses perch at the top.

My take on this article is that we might be cautious in accepting the findings on face value. After all this was a retrospective observational study replete with all the potential biases this type study might possess. This is what I call coarse grain data without the fine grain detail that might be provided by detailed patient level analysis. For example, the authors speculated that perhaps the side effect of the double gram negative antibiotic combination may have contributed to the increased mortality in the group treated in accord with the guidelines. Maybe so, but more detailed analysis might provide support or refute that speculation.

Runner has seizure at near the end of Houston Marathon

2011-02-09T02:21:00.000-08:00

On an unusually warm and humid day in Houston ( Jan. 30,2010) the Houston marathon was held.According to this local TV report,a female runner had an apparent seizure near the finish line.She was treated on the scene , experienced two cardiac arrests and was successfully resuscitated,intubated and transported to a hospital.Further details are not available.

One of the first things that comes to mind is exercised associated hyponatremia (EAH).

EAH has attracted much attention in recent years. Dr. Tim Noakes,from Cape Town ,South Africa, attributes the apparent increase incidence of the condition to overemphasis of encouraging runners to drink liquids past the point of reasonable and safe short term replacement needs. Subsequently more physiologically reasonable recommendations regarding drinking during longer races have been issued. The New York Marathon's fluid replacement advice was 8 ounces every 20 minutes. The International Marathon Medical Directors Association (IMMA) recommended 400-800 ml per hour. Too often in the past the advice seemed to be drink as much as possible.This advice seemingly lead to some slower runners ingesting so much liquid that they actually gained weight during the event.

Acute EAH has been associated with cerebral edema and non-cardiac pulmonary edema. With acute lowering of the serum sodium and less than instant re-equilibration of cerebral intracellular solutes, water moves into brain cells. If untreated in severe forms, cerebral herniation can occur with brainstem compression. Judicious amounts of three percent saline I.V. has become the consensus treatment.

Here is an earlier blog entry on putative mechanisms in EAH.

An elite runner collapsed and died early on in the marathon trials in New York and at least early reports indicated no specific cause was determined. Exercise associated hyponatremia was not a likely cause in this case.See here for comments regarding causes of sudden death in athletes.

Marathons in hot weather can be a disaster ( the Houston weather was merely warm and humid) which is how some reporters described the ill fated 2007 Chicago Marathon. See here.

New Guidelines for treatment of carotid artery stenosis

2011-02-08T04:06:00.000-08:00

The full text of the new guidelines for treatment of vertebral and carotid stenosis can be found here.

The guidelines apparently were a joint effort of the cardiologists and practically everybody else who had interest in the diagnosis,medical or surgical or catheter treatment of vascular construction to the brain.

The paper is gives a wealth of information and references and could easily take up many hours of study. Here is one snippet-

It is reasonable to prefer endarterectomy (CEA) over stenting in asymptomatic patients with greater than 70% stenosis.The panel had grade A evidence for that recommendation.

Although they do not recommend screening for carotid obstruction in asymptomatic patients, many folks will be getting ultrasound exams of their necks,abdomens and doppler exams for vascular disease of the lower extremities as roaming, proprietary groups are frequenting churches and other sites.So when your patient for whom you did not recommended screening shows up with a report suggesting significant blockage you have a good resource to consult.

"High-value"health care achieves buzz word status-An ACP Committee defines "rationing"

2011-02-03T04:51:00.000-08:00

In the 1 Feb 2011 issue of the Annals of Internal Medicine in the Clinical Guideline section, ACP's Clinical Guideline Committee authored an article entitled :

High-Value, Cost Conscious Health Care: Concepts for Clinicians to Evaluate the Benefits,Harms,, and Costs of Medical Intervention". see here for full text.

Dr. Douglass K. Owens, author of numerous cost effectiveness studies, was the lead author.

The article begins with expression of the customary alarm about increasing health care costs and the need for cost control, an effort the authors believe should focus on the value of the health care interventions.

Their operational definition of value is " an assessment of the benefit of an intervention relative to expenditures".Value is determined by balancing benefit and costs.

This is consistent with Harvard Business School professor, M.E. Porter's definition which is:

Value =outcome/cost.

Simple enough we just figure out the benefits and the cost and ...but the devil is in the details as always.

The Annals authors then make what they believe to be critical distinction -the distinction between cost and value. A high cost item may or may not provide high value and low cost may have little benefit , therefore that intervention is of low value. So what we want is high-value health care.

(As best I can tell,the busswordification of" high-value health care" can be attributed at least in part to the efforts of Porter and Dr. Elizabeth Teisberg, although I don't wish to slight Dr. Don Berwick and physicians at the ACP.Whatever it origins and vectors of spread, medical authors and policy wonks talk about it now as if everyone knows what it is.)

The authors then redefine rationing (or in the authors words " more appropriately" define) to mean "restricting the use of effective, high-value care". So that if an intervention that is "determined" to be low value is restricted that would not be by the new definition considered rationing. This should provide comfort to those who worry about the rationing of health care. eliminating an intervention that is determined (By whom?) to be of low value is not rationing at all. One can see what power this puts in the hands of those determining what is high and low value.

The authors then discuss the importance of considering the downstream costs and benefits of an intervention.For example, one has to factor in the cost of maintaining a ICD not just the initial cost of assessment and placement of the device.

If a treatment is both better and cheaper than an alternative there is no problem in deciding between the two. More complexity emerges when an alternative provides more benefits but also costs more.

In this situation we are told we need comparative effectiveness analysis which is basically cost benefit analysis (CAB) that compares the various alternative interventions. Conceding this point, at least for the sake of argument, one now asks who will make that analysis

Owens et al provide the answer:

...we recommend assessing their value [competing interventions] to patients and society by using cost effectiveness analysis. Such analysis require specialized expertise and training,are often expensive, and thus are typically performed by investigators.

Note this type of assessment cannot be done by just anybody, only those with specialized expertise and note what they claim to provide-assessment of value not only to patients but to society.

Realizing that some may find that level of hubris unsettling, the real money quote of the article is :

"The choice of a cost effectiveness threshold is itself a value judgment and depends on several factors, including who the decision maker is.

That is the heart of the matter, after all of the gathering of various costs and developing estimates of the quality adjusted life years (QALY) and the aggregation of costs and aggregation of estimated benefits and using various analytic tools ( e.g. cost-effectiveness ratios), someone or some committee has to make a value judgment. Is the benefit worth the cost or not? At the end, it is a human value judgment- not the solving of some equation. Then the question is who will decide.

In the same issue of the Annals of Internal Medicine there is an Editorial by Michael Gusmano and Daniel Callahan of the Hasting Center offering cautionary counterpoints.

They emphasize Owen and co-authors' admission that effectiveness evidence is lacking and our ability to assess quality of life is inadequate. If the evidence is lacking and our ability to assess quality of life is inadequate even investigators with expertise and special training might be challenged. Gusmano and Callahan continue:

Perhaps the biggest problem with cost-utility analysis in that the expenditures on health care cannot be compared with other societal needs..the failure to consider opportunity costs may eliminate existing,but un-assessed health care technologies and services that are a better value than the "cost effective" technology included in these assessments.

My take is that the Owens article is old wine in bottles with little if any design changes. In his 1992 JAMA series Dr. David Eddy suggested that the quality of health care could be increased while decreasing costs if we only applied cost effectiveness techniques and that would lead to the greatest good for the greatest number . This seems little different from eliminating only low value care the determination of which can only be made by experts with extra training. I commented on those series of JAMA article here.

More on the concept expressed by Goodhart's law

2011-02-02T03:16:00.000-08:00

Calling it "teaching to the test" or ...

John Goodman asks the question "Does measuring quality actually decrease quality?". See here for his recent blog entry.

Charles Goodhart, a British economist put it this way in 1975:

Any observed statistical regularity will tend to collapse once pressure is placed upon it for control purposes

In other words, a measurement when used as a target looses its value as a measure.

This basic notion was expressed about the same time by a sociologist, Donald Campbell, who said :

"The more any quantitative social indicator is used for social decision-making, the more subject it will be to corruption pressures and the more apt it will be to distort and corrupt the social processes it is intended to monitor."

A poster child for this phenomenon in the context of quality measures in medicine is the absurd 4-hour pneumonia rule.I have blogged about that before.

When the incentive for ED staff was to get the antibiotics to pneumonia patients within 4 hours, because that was established as a quality measure, distortion and corruption emerged in the form of giving less prompt attention to non-pneumonia suspects and treating folks who really didn't have pneumonia with antibiotics.

From Goodman's post:

Quality measures also degrade quality by distorting behavior.

Dr. Douglas Perednia had a great discussion of this topic here.

(some)Hospital emergency departments re-discover concept of opportunity cost

2011-01-31T12:33:00.000-08:00

Back in the day,physicians would often see patients in their office and then dictate the clinical notes and have them transcribed and placed in the clinical record often in a matter of a few hours. Then came computers and later electronic medical records (EMR) and as stupid as it was, the physicians were called upon to key in their notes themselves. At least that was the case for those physicians who worked for large organizations.Private practice docs in 1-5 person practices were not forced into that.But wait-now the big federal push for EMR for all and we will see more physician-typists slogging away often to the chagrin of the patient who would like the doc to look at him.

David Henderson, writing in the Concise Encyclopedia of Economics,says this about the economic concept of opportunity cost. "Its [the term] value is to remind us that the cost of using a resource arises from the value of what it could be used for instead." In this case what could the physician's time be used for instead. If she spend less time keying stuff into the clinical record, she could be seeing and evaluating more patients in a given time period and in the language of the administrators- generating more income.

Investipedia put it this way : Opportunity cost is the cost of an action that must be forgone to pursue a certain action. The physician is forgoing caring for patients in the time she takes to enter in the data, even if she is can enter data at a world class speed, it does not make economic sense for the doc to spend time typing. Economists love to say things like "economics is just about incentives"

I still get updates from placement agencies regarding locum tenems. A recent one described a position at a VA hospital. One of the job requirements was the ability to key in information .In this setting the above economic incentives may not apply.The doctors gets a set salary and he will not generate more income for the VA (they don't generate income at all) by seeing more patients so why not have the doc spend his time typing.

Some emergency departments (EDs) apparently caught on and not just recently. See here for an article on that topic as early as 2009. The EDs are hiring scribes to sit in on the physician-patient encounter and key in the relevant details freeing the doc to do all those doctor things and not appear distracted with his computer while he talks to the patient. Of course this would also work in other practice situations.

Many physicians who may have never hear the term opportunity cost when introduced to the notion that they would key in clinical encounters said in effect " why should I waste my time doing that" operationally knew all about that concept.However, some of the suits in HMOs and large clinics "run like businesses" who hired self appointed experts in IT must have slept through the economics course they must have taken to get the MBA.

First it was interventional cardiologists vrs chest surgeons,now the pulmonologists?

2011-01-31T06:27:00.000-08:00

See here for details regarding the headline. Back in the day, it was the pulmonary folks who helped diagnose and stage the lung cancers and the surgeons took over if the cancer was thought to be resectable. But now things are changing.

From the article linked above which quoted comments made at a recent meeting of the Society of Thoracic Surgery

.. minimally-invasive strategies, such as ablation, to treat small lung tumors without radical resection or even lobectomy are under development [ ed ; and threaten the chest surgeons]

Maybe 'under development" but don't we have a long way to go to treat (remove?) lung cancer through the bronchoscope? But I think one of the participants in the conference linked in the first paragraph above was saying why can't chest surgeons do those things with the bronchoscope if and when those developments get ready for prime time.

The Prospect Study give some more insight into mechanisms for ACS recurrence after PCI

2011-01-31T03:12:00.000-08:00

See here for the Prospect study published in the NEJM.

This multi-institutional study involved a follow up of 697 patients who presented with an acute coronary syndrome (ACS) treated with an invasive catheter procedure ( percutaneous coronary intervention or PCI). The patients underwent coronary angiography and coronary artery intravascular ultrasound imaging.

Over a three year period 20.4 % had another adverse coronary event . The authors analysis indicated that about half of these events were due to obstruction at the location of the culprit lesions ( i.e the obstructive lesion that was treated by PCI) and half were due to non-culprit lesions. Most of the non-culprit lesions were considered angiographically mild (typically with an obstruction less than 70%) and were described as "thin-walled fibroatheromas" with a large amount of plaque . I suppose if those lesions were not thought to be mild by the cardiologist that they would have been "fixed".

According to the authors, a lesion with a thin wall, a lumen area of less than 4 mm,and a plague burden of 70% has a three year risk of causing a coronary event of 17%.

Potentially useful information not provided in the article would include to what extent patient with these non-obstruction lesions were treated with medications thought capable of stabilizing plaques, e.g. clopidogrel, aspirin, and statins. You have to believe (hope?) that the percentage would have been higher if patients had not been treated with drugs that "pacify the platelets" and decrease inflammation.

The authors emphasize that the intravascular imaging techniques used in this study are not ready for prime time, everyday clinical use because the specificity of lesions with the most predictive risk characteristics is low and there were serious side effects (including rupture of a cornoary artery) .Further, data was only obtainable on the proximal portion of the major epicardial coronary arteries ( about 6-7 cm) so what was going on more distally is unknown.

Everybody knows that thiazides are clearly the best anti-hypertensive. On the other hand..

2011-01-27T02:57:00.000-08:00

All seven versions of the recommendations of the Joint National Committee for the Prevention, Detection,Evaluation and Treatment of High Blood Pressure (JNC 1 through 7) made it quite clear that thiazides were the drugs of choice for the treatment of hypertension. See here for JNC 7 which says, in part:

"Thiazide-type diuretics should be used for most patients with uncomplicated hypertension either alone or in combination with other drugs."

The ALLHAT trial has been used in support of that recommendation although that trial has generated hundreds if not thousands of pages of rebuttal and re-rebuttal. See here for an ALLHAT summary.We reassured later that the diabetes that sometimes might be precipitated by thiazides is a different and really benign type of diabetes, so not to worry about that.

The European approach is arguably less dogmatic that JNC's emphasis on diuretics.Here is the ESH/ESC 2007 update on hypertension treatment.

Now we have this meta-analysis ( yes, I am very skeptical of MAs in general but when they suit my biases, I shamelessly quote them).See here.

The authors included 14 studies that used 24-hour blood pressure monitoring and concluded"

Conclusions: The antihypertensive efficacy of HCTZ in its daily dose of 12.5to 25 mg as measured in head-to-head studies by ambulatory BPmeasurement is consistently inferior to that of all other drugclasses. Because outcome data at this dose are lacking, HCTZis an inappropriate first-line drug for the treatment of hypertension.

Their last sentence could not be more in opposition to JNC. Let the games begin again.

Dr.Buz Cooper's continuing battle with the Dartmouth Atlas dogma

2011-01-26T06:13:00.000-08:00

I have written about Dr. Buz Cooper before ( see here).Very well worth reading is his latest salvo that further strengthens his position that the reason for geographical variation in health care cost is poverty.Here he reviews the latest MEDPAC data.

I think he is saying in part that the "problem" isn't some mysterious regional variation in how doctor practice medicine ( i.e greed seems to distributed geographically by some as yet undiscovered mechanism); the problem is it costs more to care for poor sick patients. Changing doctor's practice patterns won't fix poverty. Somehow, I think electronic medical records (EMRs) won't either.

Here is his nutshell paragraph:

"MedPAC, the IOM and countless other organizations are on a quest to explain geographic variation in health care. Yet the puzzle has been solved, and it is solved again here. Geographic variation in health care is a manifestation of geographic variation in poverty. The logic is obvious to all of us in our every day experiences. Poverty is associated with more disease, and poor people cope with disease more poorly. And poverty is geographic. So it should not be surprising that health care utilization and spending are geographic."

More pile on the band wagon of demonizing the obese

2011-01-25T13:20:00.000-08:00

DrRich has written this essay on the topic of demonizing the obese. Now the legendary and feared (feared at least by employees whose boss hires them to "help cut costs") McKensey group has joined the chorus singing the horrors of the obesity epidemic.They have determined the real cost of obesity which is supposed to be in the U.S.450 billion per year which is three times the direct medical costs.So what are the other costs?

They include in the overall cost of obesity the increased cost of food and of purchasing extra sized clothing. somehow they consider purchases of food and clothing to be some mythical "cost to society". I wonder if someone at McKensey actually sat in on economics 101 and learned that one person's cost is another's stream of income. Buying food, regardless of one's BMI, is not a cost to society but just a market transaction just as it is when the thin person buys a car. However, economics can be such a subtle and counter intuitive discipline.Apparently giving folks money to buy new cars was thought to stimulate the economy (remember cash for clunkers) but some "incremental" money spent by the obese on extra food and big shirts is a cost to society.

McKensey speaks obesity as a pandemic, the whole world is getting more obese and they contend that the problem is so vast and important than "governments must lead the fight against obesity" Well at least they didn't call it a war.

The McKensey group has been knee deep in health care policy matters for some time. Dr. Robert Kocher has been in and out of the group serving in between with President Obama's Council of Economic Advisers. He was a co-author of this fluff piece promoting Obamacare that appeared in the Annals of Internal Medicine and will be long remembered for this incredible quote; "It (Obama care) guarantees access to health care to all Americans."

While it has become dogma that the obese increase health care costs because of their increased incidence of such things as heart disease and arthritis and that by mitigating obesity there will be cost savings ,one should be aware of a attractive counterargument .Simply put that argument is that the obese will die at a younger age and therefore it is at least logically possible that they will consume less health care service overall. This is exactly what this article from Dutch authors concluded based on a series of simulation mathematical model scenarios. Here is a quote:

As with all mathematical models such as this, the accuracy of these findings depend on how well the model reflects real life and the data fed into it. In this case, the model does not take into account varying degrees of obesity, which are likely to affect lifetime health-care costs, nor indirect costs of obesity such as reduced productivity. Nevertheless, these findings suggest that although effective obesity prevention reduces the costs of obesity-related diseases, this reduction is offset by the increased costs of diseases unrelated to obesity that occur during the extra years of life gained by slimming down.

Over ten years ago I did some consulting to a large intentional petrochemical company. One day a group came by hawking their employee wellness packet .After their presentation, a Human Resources manager asked will not their pension expenses go up if we keep future retirees healthy longer. A refreshingly honest presenter said yes- that was probably so and added that the best thing for a pension plan would be for employees to be healthy productive workers, then retire and die the next day without a prolonged expensive illness .Of course we would never want to do that.

So if cost to "society" is behind the movement to fix the obesity problem maybe we should at least keep the topic on the drawing board even if anti-obesity advocates aren't ready to consider going back to the drawing board.

A public health initiative that improves people's health is a goal many would support but the claim that prevention necessarily saves money is one that is based more on faith than sound empirical evidence.

Can psychiatry differentiate disease from everyday suffering?

2011-01-25T03:12:00.000-08:00

That question seems to be asked by not just one but two former chairman of the committees who authored editions of the fabled DSM. Dr. Allen J. Francis has been very critical of the currently being written DSM 5 ( Yes, they changed from Roman to Arabic numbers). An interesting family feud is depicted in this article from Wired on line.

The first time I came across this general thought was when I was discussing a case with a psychiatrist to whom I had referred a patient I thought might be chronically depressed.He said she was not depressed but in his view she was just a very unhappy person. I can't recall if he then proposed to treat her with the antidepressant flavor of the day or just talk her out of being unhappy or what.

While non psychiatry medicine which I will refer to as "real medicine" (somewhat tongue in cheek) sometimes uses a symptom counting method of diagnosis ( e.g use of a number of symptoms in the a major or minor category to reach a diagnosis) it has the cognitive luxury of being able to rely on physical findings, imaging techniques, sometimes fairly definitive blood tests and often definitive biopsy results.

However, our psychiatry brethren- as best I can tell as an outsider- depends on a symptom counting based diagnostic paradigm outlined in excruciating- to- read- details in the powerful DSM. For example,if a patient has five out of the nine official symptoms of depression over a two week period then they are diagnosed with major depression.Apparently for a while there was a "bereavement exclusion" for depression diagnosis but with the newest classification that has been removed, exemplifying how fluid the definition of a given disease can be.This descriptive diagnosis system was heralded as a marked improvement over the situation in the old days in which psychiatrists of different psychoanalytic schools would differ as to the diagnosis of a given patient.

Symptom listing,counting and matching was considered more scientific and importantly became available to non-psychiatrist physicians ( or any clinical health care provider). With a check list type diagnostic paradigm generally available and multiple psychiatric drugs being promoted by big pharma, primary care docs might conclude that "this psychiatry stuff is easier than I thought" and I suspect many did.Numerous dinner CMEoid sessions with primary care docs featured as the "thought leader"showing their fellow PCPs ( and NP and PAs) that psychiatric diagnoses were not something to be afraid of probably paid off for the sponsoring drug companies.

More "Social Justice" surprises for the middle class-more taxes

2011-01-21T11:21:00.000-08:00

This article from Investor's Business Daily explains one of the counter-intuitive quirks of the tax increases which are part of PPACA.

New taxes kick in in 2013 for households with incomes over 250K ( 200 for a single filer); a 0.9% wage and salary tax and a 3.5% tax on some investment income.The article's authors walk the reader through what happens to families in three income ranges and oddly enough those in the middle of the three ranges are taxed more than the higher range group for an increase in their income, as might occur if one of the two spouses receives a job promotion or work extra. Nothing like a good partially regressive tax to sock folks in the face with some some hard hitting anti-productive social justice.Readers might recall that after PPACA was signed, we were told by Senators and some medical organizations ( you know who you are) that social justice was served.

A broader analysis of taxes and PPACA is offered by the Harvard economist,Greg Mankiw. His plan to decrease the deficit is for the government to give him one billion dollars and increase taxes by three billions.This reduces the deficit by 2 billion. He then relates this scheme to the arguments made about PPACA.

"Healthcare reform, its advocates tell us, is fiscal reform. The healthcare reform bill passed last year increased government spending to cover the uninsured, but it also reduced the budget deficit by increasing various taxes as well. Because of this bill, the advocates say, the federal government is on a sounder fiscal footing. Repealing it, they say, would make the budget deficit worse."

Professor Mankiw, in a more serious moment, refers readers to this article that explains how repeal of PPACA will not increase the deficit.That a repeal will increase the deficit is the latest argument from some of those who continue to support PPACA, the social justice argument getting a bit stale,now that the bill is passed and we are finding out what is in it.

It seems hard to believe that Internists are asking what is an internist?

2011-01-20T05:33:00.000-08:00

Two of my favorite bloggers have recently taken up the questions " what is an internist?". Both Dr. RW (see here) and Dr. DB (see here) have written about this. My speculation is that orthopedists and neurosurgeons are experiencing less of an identity crisis.

My hunch is that both would have much less trouble with that question when they were in their Internal Medicine training programs. ( in fact Dr. RW made that point in his commentary ).

I know I had little doubt about what an internist was and what an internist did when I was a resident in IM. An internist was someone who was respected and called upon to deal with the diagnosis and management of complex medical problems and of critically ill patients. That was what a general internist did.General practitioners would consult with an internist for difficult cases and their expertise and knowledge was respected by both the GPs and surgeons.

Major changes in medical practice has brought about the current ambiguous nature of the internist's identity.

The general internist's role has been bifurcated into an office doctor and a hospitalist, with a rapidly decreasing number of internists playing both roles. While the hospitalist role more closely resembles the internist of 30-40 years ago the office internist is becoming harder and harder to be distinguished from the family practice physician.They both spend a significant part of their day doing preventive medicine,an activity particularity suited to guidelines and flowsheets and readily adaptable to delegation to nurse practitioners and physician assistants and likely ultimately to NP assistants or PA assistants.

The family practice physicians has evolved from the GP s of years ago and while the GPs were a source of referrals to the internist the Family Practice docs are more often than not competitors in the fairly recently defined world of what has become to be known as "primary care practice" . Both FP and IM docs will face more competition from NP and PAs if and when Obamacare plays out as demand from the number of insurance card carrying patients increasingly outpaces the supply of FPs and general IM docs and likely NPs as well.

The earlier version of the internist practiced in a very different world. He took call at night and would go to the hospital to see his patients in the ED and if they had problems in the hospital and some went to nursing homes.

The modern version so often now signs out at five o'clock with a telephone answering device informing the caller to call back during regular hours or if "an emergency" go to the Emergency Department.

I found the following paragraph from Dr RW's commentary as on target as it is depressing to someone who spend many years training to be an internist and more years practicing internal medicine as it used to be and now watching it change almost to the point of being unrecognizable.

The American College of Physicians slogan “Doctors for Adults” is unfortunate because it defines Internal Medicine as Family Practice without Pediatrics. This view has led to a proposal, published in the Journal Academic Medicine, that IM and FP be merged. It would mean the dissolution of general IM as a specialty. It's little wonder so few trainees want to go into general IM anymore. Who in their right mind would sign up for a specialty that's slated for dissolution in the next decade.

I know I would not.

More on how Electronic Medical Records will fix mostly everything

2011-01-19T10:53:00.000-08:00

If you read this entry from Health Care Renewal you will realize how stupid and counterproductive electronic health care records can be.I say "can be" and sometimes are , not they have to be.

AND this entry from the same blog gives some very revealing insights as to who can get what from electronic medical records.Hint- it won't always be the patient or the physician. Dr. Scot Silverstein deserves much credit for his seemingly untiring efforts to educate us all about some of the really harmful ( and hypocritical) things going on in the EMR business.

Obamacare poster child for "growing autonomy of the regulatory state"

2011-01-17T07:33:00.000-08:00

George Will, in his recent Jan. 16,2011 essay, " A Congress that reasserts its power", comments on the eclipse of Congress by the executive branch and the various federal agencies .
See here for the entire column.

Will says in part:

"The eclipse of Congress by the executive branch and other agencies is Congress' fault. It is the result of lazy legislating and lax oversight. Too many 'laws"actually are little more than pious sentiments endorsing social goals-environmental,educational,etc.-the meaning of which are later defined by executive-branch-rule-making."

The "etc." could well include the recently passed health care bill. The phrase "the Secretary (of HHS) shall determine" occurs repeatedly in the bill.If ever the phrase " the devil is in the details" applies it is in Obamacare.

Federal bureaucrats will write the rules that will be the very essence of the program. Congress endorsed a social goal ( health insurance for all-well, all but some 14-23 million, depending on whose estimate you believe) and abrogated the defining details to various federal agencies .

Will points out that the Federal register is a more important guide to governance than is the Congressional record.

To describe the belief that health care in this country will be improved by thousands of federal regulations patched together by scores of agencies, each subject to lobbying pressures and the risk of regulatory capture, requires a modifier stronger than the word "panglossian".

The antibiotic pendulum for treatment of Acute Otitis Media swings back

2011-01-16T04:10:00.000-08:00

In the antibiotic era, the complications of acute bacterial otitis media (AOM) largely disappeared. One of the complications,mastoiditis, became a rare entity.Antibiotic treatment for AOM was standard treatment but in recent years the practice became challenged.

Several clinical research papers concluded that a number of children recovered from AOM without antibiotic treatment and seemingly without sequelae. Those findings were amplified by a couple of meta-analyses which derived the number needed to treat with antibiotic (NNT) and claimed that at least 7 children need to be treated (NNT) to shorten the illness of one child.

Perhaps encouraged by policies regarding antibiotic treatment in Europe and the growing concern about bacterial resistance caused by widespread and at times imprudent antibiotic use, several medical professional bodies issued guidelines that said antibiotics need not always be given to a child with AOM.

Now, two articles in the January 13, 2011 issue of NEJM present evidence from which one may reasonably conclude that antibiotic treatment is a good thing after all.An accompanying editorial supports a pull back from the current guidelines. The editorialist and authors of at least one of the two NEJM articles point out serious flaws in the clinical trials which lead to the current guidelines including ; imprecise criteria for the diagnosis of AOM,inclusion of children with minimal disease,ambiguous endpoints,small sample size and improper choice and dosing of the antibiotics used.

If the trials were as poorly done as implied about you have to wonder how repacking them in the fancy wrapping of meta-analyses strengthened the argument that lead several medical organizations to recommend a watchful waiting approach to AOM.A meta-analysis is only as good as the underlying studies that are included in the data set. I have repeatedly argued that meta-analysis should not rest at or near the top of the hierarchical structure of doctrinaire Evidence Based Medicine.

The specter of antibiotic resistance or rather the concern over the resistance may have played a role there. It is interesting that in regard to the treatment of AOM, it seems that resistance has not actually become a major factor.Apparently there has been a unexplained shift in the bacteria that cause AOM.Previously beta-hemolytic streptococcus was the major player and now the less invasive Hemophilus influenza ( H.Flu) and Moraxella catarrhalis are more common.

Although dissenting views were offered in 2003 by Dr. E.R. Wald ( one of the authors of one of the two NEJM articles) from the pediatrics department at the University of Pittsburgh in 2003, both the AAP and the AAFP issued guidelines in 2004 recommending initial observation in some cases ( described as nonsevere) rather than immediate treatment with antibiotics.Other groups joined the parade as well.

It will be interesting to see if these two publications lead to changes in recommendations and if so how much of a lag time there will be.

Does endurance exercise damage the heart?

2011-01-10T05:24:00.000-08:00

Elevated heart muscle damage biomarkers have been reported in runners after completion of a marathon. Treponin has become the major biomarker used in the clinical assessment of a patient with acute chest pain and elevated levels have been reported in subjects immediately after completing a 26.2 mile marathon and other endurance athletic events.

Does the increase represent myocardial cell necrosis or could the increase be due to "leaky muscle membranes" also known as "cytosolic release". The authors of this recent article suggest the second mechanism may be responsible. I hope they are right as I have not given up running marathons just yet. See here for an abstract of that research.

A 2009 paper by Knebel et al investigated biomarkers and echocardiographic changes in 28 older marathon runners ( aged 60-72) and found no changes suggestive of systolic dysfunction but confirmed the finding previously reported of transient right ventricular diastolic dysfunction.These changes were no different from a group of younger marathoners. See here for abstract. So at least here the older runners were no worse off.

A 2002 paper by Shave,RE et al reported left ventricular systolic and diastolic dysfunction in 11 bikers after a 2 day mountain bike marathon.See here for abstract.

Twenty-seven athletes were studied with echocardiography after what was described as a ultra-endurance triathlon. In all, right ventricular dysfunction was demonstrated and while LV ejection fraction was normal and unchanged in most . However,in the 7 who demonstrated post exercise LV wall motion abnormalities there was a decrease in average LVEF from 57.8% to 45.9%. The authors described also that the "integrated systolic strain decreased from 16.9 to 15.1." I have no idea of the significance of that index nor if that degree of decrease mean anything.See here for abstract.

More elaborate cardiac echo testing was carried out on twenty 2003 Boston marathon finishers pre and post race and one month later. They used regular TTE (trans thoracic echo) but in addition used a technique called "spectal and tissue doppler (TD"). While systolic ejection fractions were unchanged, TD derived indices of LV and RV systolic function were said to be abnormal with at least some of the diastolic dysfunction indicators remaining abnormal one month later.See here for abstract.

Neilan and co workers published detailed results from extensive echo and biomarker studies on 60 finishers of the 2004 and 2005 Boston marathon. See here for full text. They reported elevations in cTnT and NT-ProBNP and similar echo findings to those reported in the previous article from the 2003 Boston marathoners.They noted more marked changes in biomarkers and echo changes in the group who trained less ( less than 35 miles per week in preparation for the race .) So maybe the better trained runners were less susceptible to whatever it is that long events bring about with heart function which is also suggested by the following reference.

A slightly optimistic note is sounded in this paper which describes echo findings of dysynchrony only in first time participants in a long distance event and not in more experienced distance runners and that a predictor of the echo changes was the type of ACE gene polymorphism.

More recently, a review also expressed an optimistic,reassuring note while a rebuttal letter to the editor offered the opposite view proposing the term " exercise induced right ventricular dysplasia" suggesting that the elevation in troponin post endurance events actually reflects tissue death and not just leakage. Both views lack the support on longitudinal follow up data. See here for the two letters.If troponin elevation does signal cell death would we see some type of clinically apparent cardiomyopathy in older endurance event participants after years of beating up their hearts or perhaps myocardial fibrosis noted on autopsy. I wonder if anyone has investigated cardiac function or reported autopsy data on the prolific running Tarahumara Indians.

At least so far there do not seem to be cases of what might represent endurance exercise induced cardiomyopathy.

Three commnentaries and a synthesis on central planning of health care

2011-01-06T05:22:00.000-08:00

I strongly recommend this entry on the blog roadtohellthcare by Dr. Douglas Perednia .

He discusses three commentaries on the same broad subject, two by physician bloggers and one by a health care insurance industry executive. The physicians are Dr. Richard Fogoros, aka DrRich of Covert Rationing Blog and Dr. Scot Silverstein of the blog Health Care Renewal and of another blog devoted to issues involving medical information systems.see here.

The important message ( there are other messages as well and all three blog entries are well worth reading) from these blogs is best summarized by a concluding paragraph from Dr. Perednia;

Together these articles cover an enormous amount of ground, but the central message is that we’re making a big mistake if we think that coercing our doctors into using expensive and complex information technology and following the edicts of centralized “panels of experts” is going to get us where we want to go as patients. These are the obsessions and grand managerial plans of people who really don’t know much about doctors, patients and the real-world of delivering and receiving healthcare services. People in government bureaucracies, insurance companies, think tanks and academic medical centers, whose livelihoods depend upon claiming to be smarter, better informed and more creative than clinicians who actually deliver the care. These regulators and technocrats have now been in charge and working their will on healthcare for over 20 years.

More Social InJustice revealed as we find out what is in store with Obamacare

2011-01-01T02:03:00.000-08:00

More than one observer commented after the passage of PPACA (Obamacare) that social justice has been served. This included at least one U.S. Senator and spokesmen for both the AMA and ACP. As more and more of the thousands of pages are deciphered and given operational meaning and are jiggered with by Congress we find at least some aspects speak more of injustice than justice.

One case in point was elucidated in this commentary by Reason Foundation Senior Policy analyst,Shika Dalmia. She tells the reader about something called the "exchange recapture subsidy".

Under this provision, the government will go after low-wage families to return any excess subsidies they get under the Patient Protection and Affordable Care Act...

When the government hands out subsidies, it will use a household’s income in the previous year as the basis for guessing what the household is qualified to get in the current year. But if the household’s income grows midyear, the subsidy recapture provision will require it to repay anywhere from $600 to $3,500, compared to the $450 that the law originally called for.

So, if a poor working family manages to somehow increase its income higher than the number which the government guessed to be their income for the purpose of handing out a subsidy they are hit with higher taxes with the result being that the marginal tax rate on their incremental gain in income is insanely high. If much or most all or economics is about incentives, what will that do to efforts to move up to the next level of income.

In the interest of fairness, it has been pointed out (see here) that this recapture mess was apparently added on to the last minute doctor-fix in an effort to scrounge up money to help pay for the subsidies and was part of an amendment authored by Republicans. So, maybe Obamacare set up the subsidies and Republicans tried to help pay for it and that was enacted by a legislature nominally controlled by Democrats and made it even worse. In any event, it is a bad deal thanks to those darn unintended consequences. Central planning might not be as easy as its advocates claim.

2010-12-31T07:02:00.001-08:00

More and more to come on the concept of "value" in medical care

2010-12-29T05:34:00.000-08:00

I have commented about this general topic before . See here.

The December 23, 2010 issue of NEJM has two articles on this topic. The first is from a member of the faculty of the Harvard Business School, M. E Porter and the second by T.H Lee. Dr. Lee is one of the NEJM editors and is also the network President for the Partners Health System.

Dr. Porter (Phd,Harvard,Business economics) is a widely published and widely quoted author.Concepts that he has popularized include: the Five Forces,the Value chain and the National Diamond model. In 2006 he co-authored a book with Elizabeth Teisberg entitled Redefining Health Care: Creating Value based Competition On Results.

Porter defines value as outcome achieved per dollar spent or value = outcome/cost. He has stated that health care should be restructured to consist of interdisciplinary teams to provide the outcome with the best value across "the full spectrum of health care". Having said that I am puzzled when he says that value is not an abstract ideal.To me that certainty sounds like an abstract idea because as pointed out in the second article in a understatement :

"No one should expect the value framework to be easy to implement.The measurement of outcomes and costs,the organization of clinicians into teams focused on improving care for patient populations,the evolution of a payments system that rewards providers who are more effective in improving the value of their care-they are all formidable tasks."

Formidable indeed. A reorganization of much or most of the medical system to one that conforms with Dr. Porter's conception of how it should be would be required.

I cannot help but be reminded of Will Roger's prescription for fixing the German U-boat problem -boil the oceans. Supposedly, when pressed for details he replied, in typical consultant fashion, he was an idea man and the engineers would have to work out the details. With the value framework model many details would have to worked out and then we could see how it would work and compare real world stuff with academic theorizing. We need to do it to see how it works.I've heard that somewhere before. Is there somewhere in the value framework some input from how much the patient values the service?

Waiting times in Canada for doctors-getting worse

2010-12-23T11:54:00.000-08:00

During the last half of 2010 both my wife and I developed some ocular symptoms at different times. I developed more floaters and flashing lights and my wife developed some wavy lines in her visual fields. She called around 10Am to a local Eye group and was seen that day about 4PM by a retinal specialist-Diagnosis ocular migraine. When I called at 8am to the same group I was able to see a retinal specialist at 2PM-diagnosis posterior vitreous detachment with no signs of retinal detachment. Both were not actually emergencies but we were both glad we could be seen so soon and reassured.

Granted we live in a large metropolitan area with no shortage of medical specialists but even so the ease of seeing not just an eye doctor but retinal specialists was impressive.

It is an interesting contrast with recent data published by the Frazier Institute in Canada regarding wait times there to see medical specialists. See here.

Much data is presented and the entire report can be accessed. Here are some samples.
Wait time varies by specialist. For orthopedic procedures there was 35.6 week wait but happily "only" a 4.9 week wait before getting oncology treatment started. There was some good news the wait for psychiatry consultation nominally decreased from 16.8 weeks to a prompt 16 week wait.

h/t to the blog westandfirm

Does Obama care mean Medicaid type care for most-except the rich,

2010-12-13T04:30:00.000-08:00

Tyler Cowen, economist from George Mason University,gives his views in this commentary which describes the effects of different payment schemes for medical services.

"Wealthy people will always be able to buy most of what they want. But for everyone else, if we stay on the current course, the lines are likely to get longer and longer.The underlying problem is that doctors are reimbursed at different rates, depending on whether they see a patient with private insurance, Medicare or Medicaid. As demand increases relative to supply, many doctors are likely to turn away patients whose coverage would pay the lower rates.

Since private insurance pays more per service than Medicare which pays more than Medicaid, physicians will increasingly attempt to structure their practices so that they can see more of the higher paying patients and less of the lower paying ones. This trend will increase with the pressures on demand for medical services brought about by ACA. Millions more patients will have insurance cards, more on Medicaid and more receiving cards from the insurance pools but there cannot be a corresponding increase in the number of physicians available to treat the new patients.

Simply put, more docs will restrict the number of Medicare patients they will treat. In fact, as the numbers of Medicare patients in a given internists practice increases the less viable is his practice from an economic viewpoint.I can illustrate that point with an anecdote from personal ( well second hand) experience.

My brother, also a retired doc, was recently told by his internist ( who also is approaching retirement ) that one of his partners "has to retire" because his Medicare patient load in his practice has reached the level at which he can no longer meet the income volume requirements of the practice. This, according to the back of the envelope calculations for that particular practice setting, is 42%.A recent survey by Merritt Hawkins quoted here, reports that 87% of physicians surveyed indicated that they will close or restrict the number of Medicare patients in their practice with a slightly higher number reported in regard to Medicaid patients.

Cowen continues saying:

Most people would end up with low, Medicaid-like reimbursement rates, and would endure long waits and low-quality service. But wealthier people could jump the line by paying more. Think of “Medicaid for everyone” but the rich.

Someone described Obama care as "robbing Peter to pay Paul" with Medicare patients playing Peter and Paul being the previously uninsured who gain insurance cards from the legislation. But with the effects of the looming shortage of primary care physicians it looks like both Peter and Paul can look forward to longer lines and poorer quality care. So while Peter gets robbed, Paul is paid little or nothing.

Price Controls in Medicine-Reality tends to support theory

2010-12-01T04:55:00.000-08:00

What is the theory? Answer-price controls tend to 1)cause shortages,2) decrease the quality of the good or service controlled 3) increase demand and 4) encourage the development of black markets,bribes and other "work-arounds"

I am aware of all but number 4 happening in regard to Medicare in the U.S. Now we have apparent examples of black markets (or at least bribes) happening in the setting of the price control health care in Canada. See here for a discussion by Canada born economist, David R. Henderson writing at the blog Econolog.

The news story in the Montreal Gazette describes OB docs in Canada taking side money to guarantee that they will be available at the time of the delivery.

One commenter to the blog entry wondered if U.S. patients, after Obama Care really gets going,will be able to go to Canada to offer side payments to get their treatments there sooner than they could here due to the long lines that will develop when millions of more insurance card carrying patients compete for what will be a vastly too small supply of primary care docs. Actually the problem is already worse as seniors struggle in some areas to see physicians. See here for comments regarding that.

Dr. Don Berwick "answers questions" from senators

2010-11-21T04:25:00.000-08:00

Due to Obama's interim appointment of Dr. Donald Berwick to lead CMS, before last week he did not have to appear before a Senate committee.Now he has. I had planned to pontificate about the encounter which seemed typically void of content but Dr. Doug Peredina at the Road to Hellth Blog has already offered an excellent commentary.See here. If you need a sleep aid and have no Ambien on hand you might go here and read and see the video of the prepared comments of the two lead Senators and Dr. Berwick.

What are the plans of Don Berwick's "leaders with plans"?

2010-11-14T05:19:00.000-08:00

Dr. Don Berwick,head of the Center for Medicare/Medicaid Services (CMS),has made clear his views on how medical decisions should be made and on what kind of health care system the United states should have.This quote from a book he co-authored with Dr. Troyen Brennan,entitled New Rules leaves little room for ambiguity:

"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.

Berwick in a laudatory address to the British NHS said that we need "leaders with plans" to design and reform the U.S. health care system. He said that"excellent health care is by definition redistribution". See here for a portion of speech praising the British NHS for in which the "redistribution " quote appears.

A likely candidate for such a leader with plans is Dr. Robert A .Berenson.

I first became aware of Berenson's ideas in an important and to my mind- startling at the time- commentary in the Annals of Internal Medicine published in 1998. ( M Hall,and R. Berenson, Ethical Practice in Managed Care.A dose of Realism. Annals Internal Medicine 1998, 395-402.) Here is a quote from that article:

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 and his law professor co-author were proposing a complete revision of the medical ethics that existed from hundreds of years.This fiduciary duty to the individual patient should be replaced by a nebulous co- duty to the collective to which the individual patient belonged. As outrageous as that appeared to someone trained in the traditional medical ethics, an obligation to serve the greater needs of society and to balance that against the individual patient's welfare has appeared to be widely accepted by various medical organizations. See here the New Professionalism as promulgated by the American College of Physicians.

Dr. Berenson's resume includes considerable work in the area of public policy regarding health care and he has served on a number of policy committees for the American College of Physicians. He served in one capacity or another in the Carter and Clinton administrations and was a member of the transition team for President Obama. He held a position with HCFA (April 1998 to October 2000) and according to his resume posted on the website for the ECRI Institute, see here , he was a vice president at the Lewin Group from 1997 -1998 before joining HCFA.

The Lewin group is part of Ingenix which is a subsidiary of United Health Group.That seems to place him at the Lewin Group in the general time frame of the Annals article publication referenced above. It is of interest that the authors' affiliations listed on the article included only a position at Wake Forest Medical School for both Hall and Berenson. ( I could not determine the exact timing of the article as relates to his time with Lewin so at the time of the publication he may well have not been affiliated with Lewin.)He was appointed as a commissioner for MedPac in July 2009 and in July 2010 became a vice-chairman of that organization. The role of MedPac after the-likely-to- be -very- powerful Independent Payment Advisory Board (IPAB), created by PPACA , becomes operational is unclear.

He is clearly a leader and certainly one with ideas and plans. A recent commentary published in the NEJM gives insight to some of his current ideas. In the Perspective section of the July 8,2010 issue of NEJM he submitted a piece entitled "Implementing Health Care Reform-Why Medicare Matters." ( NEJM,vol 363,no.2,p101-103).

While discussing the issue of medical costs and cost controls he talks about the "growing power of [medical service ] providers" (ask most physicians how much market power they have) and since Medicare price controls, already in place now for almost 20 years, won't control total medicare expenditures " 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".

The operative words there are "at least for now".

More on that appears in the next commentary in the same issue. ( "The Independent Payment Advisory Board : by Timothy S. Jost, J.D.) He says in part that as long as the gap in reimbursements between private insurers and CMS continues to grow physicians will increasing abandon Medicare. He closes with this:

"In the long run, Congress may not be able to cap Medicare expenditures without addressing private expenditures as well. If the IPAB opens the door to rate setting for all payers,it may well be the most revolutionary innovation of the ACA".

Price controls for private medical care would do what economics 101 says price controls do generally. There will be shortages, decreased quality and black markets and other methods to evade the restraints. We have seen the first two in the price controls for Medicare/Medicaid.

I wonder which is worse- a medical leader recommending price controls out of ignorance of basic economics or being aware of the likely outcomes and make that recommendation anyway?

Could there really be a down side to the availability of inexpensive generic medications?

2010-11-11T03:57:00.000-08:00

A recent commentary in the NEJM talks about unintended consequences of the 4 dollar generics that are becoming increasingly available. Go here for a news report about the concerns expressed by two researchers from Harvard and an audio interview with one of the authors.

Their concern is that with low cost medications often paid for in cash that the data bases used for various purposes will be even less reliable that they are currently . These data bases are used for such things as pay-for-performance and various programs which purport to be quality improvement efforts .Apparently with these cheap prescriptions many pharmacies do not file claims with the pharmacy management companies and insurance companies.

This might translate into less control by the pharmacy management companies and could possibly diminish the value of the services they sell to large insurance companies and the companies that self insure.

I find myself with little sympathy for what they claim is a dark lining in an otherwise silver cloud of cheaper medications and will have even less for the "solutions" that may fix the "problem". It seems to be a problem for the pharmacy management companies and not so much for the patients who spend less on their prescription medications.

At least some of the secrecy of the mysterious RUC is revealed

2010-10-29T05:09:00.000-07:00

See here for an enlightening article from WSJ that goes -at least to some degree- behind the veil of the powerful AMA brain child, the RUC.Well, at least we are told who is the current chairman of the RUC and that she gave out baseball hats with "RUC" on the front and organized bowling for team building. This is encouraging to those who felt a major problem with the RUC was lack of baseball hats and bowling.

Once again kudos to the tireless Dr. Roy Poses for his continuing efforts to shine light on the AMA's RUC which plays a key role in dividing up the Medicare physician payment money which itself is limited by the price controls in place since 1991. Go here for his latest review of that situation and information about some recent efforts that have been somewhat successful in revealing what goes on behind the RUC veil.

We have had central planning in place for Medicare physician payments for almost a decade and we continue to see the consequences,both intended and unintended,not the least of which is a shortage of primary care physicians.

Pay for performance (P4P)-Goodhart's law aside is it unethcial?

2010-10-24T04:28:00.000-07:00

This is a re-edited and lightly re-written version of a posting I made several years ago. Several years have passed and P4P has gone from a trial balloon to a more and more generally accepted fact of medical life, even though there continues to be cogent arguments in opposition to it and the broader bogus concept of "quality" measures.

Dr. Edmund Blum, an internist from Brooklyn makes the argument that pay for performance (P4P) involves a "irresolvable conflict " with the ethical standards of the medical profession.( American Medical News,Nov. 6,2006 issue in their "Professional Issue Section.) My bolding.

He says that P4P rests on 3 flawed premises or fallacies the most important of which is that P4P is consistent with medical ethics. He argues that it is not. (The other 2 fallacies are:P4P rests on a valid statistical foundation and P4P will improve the safety and quality of patient care). To those I would add a 4th namely that Goodhart's law would not be operable in the medical care setting.It has definitely been shown to operate there as well.

I quote:

"[medical] standards derive from a core of fiduciary responsibility, in which one person, the patient, depends on the superior knowledge and skills of another, the physician, and places complete confidence in that person in regard to a particular transaction-in this case, medical care."

"The fiduciary is held to a higher standard of legal and moral conduct and trust than a stranger or a business person...[This] obligates the physician to do his or her best for the patient regardless of reward.The duty goes beyond the 'due care' standard or tort law to a higher level of loyalty and commitment that is not contingent or rewards or penalties."

The idea of P4P involves an assumption that "the fiduciary relationship is insufficient motivation for the physicians to do their best."

To accept P4P is to accept the notion that physicians have not already been obligated to do their best for the patient and to place patient welfare above financial rewards and that they have to be giving a tip or a bribe to do their job. Dr. Faith Fitzgerald was on target when she said

" We must not servilely accept gratuities for doing our duty."

A few decades ago,I began the transformation from a lay person to a physician. Part of what was branded into my limbic cortex in that several year long process was the responsibility physicians have for their patients, a responsibility to do what is right for the patient,a responsibility to place their welfare above personal financial concerns. That responsibility cannot be canceled by a purported imperative to somehow also act as a steward of "society's resources" and work for social justice as the New Professionalism Charter implores.(See here for DrRich's comments on what that Charter has done to medical ethics).The prime directive was-and still should be- an individual physician's responsibility is to the individual patient .

The acceptance of P4P is so antithetical to the basic medical ethical tradition that I cannot believe professional organizations of physicians are supporting it, but they have -almost all of them have at least expressed written support. Tacit support of and advocacy for for P4P is equivalent to saying the ethics and culture of physicians are not adequate and to provide good clinical care it is necessary for third parties to proscribe behavior and reward and sanction accordingly. To sanction such thinking, in the words of Dr. Blum, is to "push us farther down the slippery slope to professionalization".

I am more pessimistic.We may already be at near the bottom of the slope and I see effort being made by relatively few physicians to try and climb back up.

Not what Dr. Berwick might want but more market based health care

2010-10-20T03:41:00.000-07:00

More clinics are appearing in drug stores and groceries across the country providing quicker and cheaper health care with much shorter wait times for appointments. See here. ( h/t to economist Mark Perry's blog,Carpe Diem)
There are said to be about 8,700 of these urgent care clinics in the country.

These are not exactly the ACOs that are being heralded by some of the self appointed medical elite, the "leaders with ideas". The mini-clinics business models is somewhat simpler and more transparent than the Under Ware Gnome business plan of the ACOs.

ACO and HMO,A distinction with or with/out a difference -Are ACOs an example of Underware Gnome economics?

2010-10-17T04:55:00.001-07:00

The current concept of an Accountable Care Organization (ACO) seems to have arisen at a 2006 meeting of MedPac and Dr. Elliot Fischer of the Dartmouth Atlas.See here for the 400 page transcript of the meeting.

A good place to begin an inquiry into HMOS v.ACOs is this entry by Jason Shafin,Phd Economics,on his blog Health-care Economics who discusses three difference between the two.

Dr. Robert Berenson,of the Urban Institute and of the Center for Studying Health System Change (HSC) and now a vice chair of the soon-to-be a very important player in health care ,namely the IPAB) co authored this article which is barely luke warm in its support of the ACOs and is even skeptical. See here for more on this center for HSC.

A later article he co-authored with two colleagues from the Center For Study of Health System Change went further and issued the warning that large vertically integrated organization such as ACOs can actually drive up health costs and offered the suggestion that price caps ( aka price controls) might be necessary.ACOs are, of course,said to be a means of increasing quality and decreasing costs at the same time.

A terse characterization of ACOs was offered by Dr. John Goodman in a comment to Dr. Shafin's above mentioned blog entry - " An HMO on steroids"

Two big issues with ACOs are market power and anti-trust concerns.So Far the FTC is still mulling over the rules of the game. See here.

I suggest a major difference between HMOS and ACOs is that the legal aspects of HMOs are well defined as are the regulatory rules while the rules for ACOS are yet to be written. There is so much uncertainty around almost every aspect of ACOs I am reminded of the South Park 's Underwear gnomes whose business plan is as follows:

Step 1.collect people's underwear
Step 2.???
Step 3.Make money

with ACO's business model being

Step 1.set up ACO
Step 2.???
Step 3.save money and increase quality of care

or perhaps

this version of the business plan of ACOs from WebMd is a more accurate description:

Step One: 'Provide connectivity and a full suite of services to the healthcare industry that improve administrative efficiencies and clinical effectiveness enabling high-quality patient care.'

Step Two:

Step Three: Profit.

Yes, step two is blank.

"The Secretary (HHA) shall determine"...can we all have a waiver?

2010-10-15T08:04:00.000-07:00

According this editorial from Investors Business Daily, about one million workers have been spared a loss of their employer sponsored"minimedical" insurance, at least for the next year or so, until long after the November 2010 elections.

That is number whose insurance coverage has been "saved" by the waiver given by the Secretary of HHS.This includes 115,000 from McDonalds and 350,000 from the United Federation of Teachers Welfare Fund and according to IBD some 28 other companies or entities.

Quoting from IBD:

"How do you get a waiver from a law, anyway? This law was passed by elected representatives of Congress. How can unelected bureaucrats say some must obey this law but some don't have to?

Well, in lieu of specific guidelines in the law, it is riddled with the phrase "the Secretary shall determine." Which means we serve at the whim of the secretary of health and human services, currently Kathleen Sebelius."

Rule of law or rule of whim or of political expediency. This is likely just a sample sample of the many determinations that will be made by the HHS Secretary as ACA unfolds.

Is government by whim the social justice that Obama advocates congratulate themselves about?

2010-10-10T04:45:00.000-07:00

Obamacare mandated a percentage of premiums be used by health insurance company for patient care. Several large employers ( McDonalds and others) complained that would not allow them to continues to offer low premium health coverage to their lower paid employees.( It should be noted that there is some controversy if McDonald really complained or not, but that is not the major point).

The point is that the Secretary of HHS, Kathleen Sebelius waived the requirements for one year for certain employers and one large union welfare fund.

Ed Morrissey made this comment regarding this incident:

The Rule of Law depends on an environment with clear regulation and unbiased enforcement. From the start, ObamaCare lacked any clarity in regulation. Congress filled the bill with the phrase "The Secretary shall determine" in place of establishing rules and regulations for the massive regulatory regime Congress created. Now, the White House has added arbitrary enforcement to uncertain regulation and opaque processes. This is not the Rule of Law, but the Whim of Autocracy.

Obamacare contains hundreds of pages with anything but clear regulation and to expect unbiased enforcement is to believe in the power of fairy dust so much power being given by the four little words found throughout the bill "the secretary (of HHS) shall determine".

Both the AMA and ACP have congratulated themselves for their support of the bill because it served "social justice".

Are the actions of the HHS secretary an example of this social justice? Social justice by favoritism (catalyzed by the proximity of the upcoming election in this instance) is what they got.

What else they ( and all of us) may have gotten is more regime uncertainty. This is a term or concept developed and emphasized by the economist Robert Higgs. Higgs's thesis is that at least an important element in the prolongation of the great depression was the business uncertainty brought about by the actions of FDR. Simply put they were afraid to invest because they didn't know what the administration in Washington would do next. See here.

Higgs suggest a similar situation exist now. We have had some but not all major financial institutions bailed out with tax payers money,we have had some auto manufacturers bailed out and we now have some employers exempted for some provisions of a massive new law with powers so sweeping that one of its major effect is a deep and wide uncertainty.

Nancy Pelosi's comment that we have to pass the bill to find out what is in it was only partly true.When enforcement or administration of law is arbitrary we will be finding out piece by piece what it means with no way of predicting what will happen next.

Dr. Don Berwick addresses leaders of ACP, Tells them top-down government mandates won't work

2010-09-30T06:27:00.000-07:00

Some would find that headline hard to believe. I do.While I believe the message I am surprised by the messenger.

It is hard to believe that the head of large government entity (CMS), which is noted for its top down mandates would express such a view. It is hard to believe that someone who heaped praise on the British National Health Service,also well known for its well known history of mandates, would hold such a view.

It is hard to believe that someone who has said that a health care system must,he emphasized the word "must", involve redistribution would say that. To achieve redistribution there must,now I emphasize the word "must", involve government mandates.

Berwick's address to the American College of Physicians Board of Governors was discussed in a blog entry by Bob Doherty,ACP's man in Washington, in his blog "The ACP Advocate Blog" See here for that entry.

There is much in Dr. Berwick's writings that strongly suggests his high regard for "rules with authority" and low opinion for the traditional doctor-patient relationship . The following is a quote from the book,"New Rules" which he co-authored with Dr. Troyen Brennan.

"Today, this isolated 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.”

He advocates regulation,rules with authority, constraint of individualized decision making and reformulating medical ethics. Clinical decisions, in this view, should not be in the hands of the patient and his physician. These views are clearly those of someone who believes in authoritative control over those clinical decisions, so if he believes that government top down rules won't work then he must envision some other,non-governmental system of controls.

Indeed, he has talked about vertically integrated medical systems which can seek out cost effective treatments and coordinate care referring to such things as accountable care organizations,and medical homes.So could he possibly think that they will be the source of the mandates rather than the federal government? The promotion of such organizations was a major theme of a recent article in the Annals of Internal Medicine by three member of the current White House staff which I blogged about here.

With the passage of the health care remake bill and the birth of scores of federal entities with the power to issue mandates and the unprecedented power given to the secretary of HHS to make mandates what else could possible happen but that medicine as it will be practiced will be medicine by federal mandate?

Mr. Doherty's interpretation of what Dr. Berwick has written is that Berwick believes that change must come from the bottom up. It is true that Dr. Berwick has earned an excellent reputation for working towards and catalyzing grass roots innovations to improve patient care and much of his rhetoric is consistent with that effort and promotion of that idea.

However, he is not leading a organization devoted to grass roots solutions but rather one whose history and thrust and machinery has and will continue to issue and enforce orders from the top.

Have we heard from Dr. Berwick any plans to dismantle the current CMS system of command and control?What will be the relationship of these vertical organizations to the central control systems of CMS and those created by the health care bill? Will they be the administrative arms of the central controllers?

Whatever vertically integrated entities emerge and regardless of the relationship of the accountable care-type organizations to the government particularly troubling to me is that the "bottom" of Berwick's bottom up solutions is not all the way down, namely to the level of the individual patient and the individual doctor as he has made it clear that the traditional doctor-patient relationship needs to be replaced."This relationship is no longer tenable or possible".

It is hard to say it better and simpler than the following questions posed by Dr. Edmund D. Pellegrino (JAMA,May 24/31/1995,Vol. 272,no 20)

" Is medical ethics a social, historical, or economic artifact? Or are there some universal , enduring principles?

Was the traditional physician-patient relationship with the strong and controlling fiduciary duty to the patient's welfare merely an artifact of an earlier economic time which was largely free of the third party payer hegemony? Fee-for-service and the traditional physician fiduciary duty are the two major enemies to centralized (private or public) control over medical care.

Avandia just barely hanging on and now Actos accused of increasing risk of bladder cancer

2010-09-27T02:53:00.000-07:00

The TDZ's seem always to be in the news,the bad news. First, Rezulin was taken off the market because of liver toxicity.Next, the issue of Avandia increasing the risk of heart attack arose and arose and arose and seemingly the issue will never be settled. Now Actos is being accused of increasing the risk of bladder cancer.

Most recently the FDA has taken action to strictly limit its use and make it fairly difficult for a new patient to be prescribed that drug. In Europe, apparently it will be taken off the market and folks currently taking that medication will have to be switched to something else.

An interesting action taken by the FDA is to require GSK to commission an independent "re-adjudication" of the RECORD study. This was the clinical trial with 4447 patients in which rosiglitazone (Avandia) was compared with the combination of metformin and a sulfonylurea and concluded that results was inconclusive in regard to what everyone was interested, namely cardiovascular outcomes. Somehow the FDA expects more analysts looking at the data will turn the inconclusiveness into some conclusions. More likely it won't but then maybe everyone can move on and worry about some other adverse effect of something else.

FDA's reasoning seems to be that if these new adjudicators can get an answer then the TIDE trial ( still another trial that the optimists think will settle the issue) will not have to be taken off of hold. The FDA put TIDE on full clinical hold.

Several years ago when one attended the infomercials with food ( AKA drug company sponsored CME -dinners) several speakers could talk about little else but the PPAR receptors and after much time and money was aimed at doing something really good therapeutically with those receptors little was accomplished. See here for some comments by a research insider about the PPAR story.

Early on in the Avandia kerfuffle I went on and on about the issue of "small"increases in relative risk and how is relatively easy to tell a big thing from a little thing but how difficult it is for epidemiology to tell a little thing from nothing at all. The original Nissen and Wolski paper talks about a relative risk of 1.43. With risks of 3 and 4 there is typically little to argue about. With RRs less than 2 it seems we go round and round for a long time before the combatants run out of stream.

What is fate of physician-patient relationship in a Don Berwick designed health care system ?

2010-09-23T07:02:00.000-07:00

The following quote from the book Dr. Berwick authored with Dr. Troyen A. Brennan,which is frighteningly entitled , "New Rules" answers the headline question. (see here for a review of that book published in the NEJM)

H/T to the blog " Black Ribbon Project"

“Today, this isolated 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.”

I have expressed my concern abut Dr. Berwick views before and one such commentary was re-e-published by Kevin,M.D. with my permission. One of the replies to that entry on his web site accused me of taking his remarks " out of context". While it is true that remarks and words and phrases can be cherry picked to give an impression contrary to the speaker's intentions I offer a friendly, rhetorical challenge to anyone who can propose a context in which Berwick's words could be said and not mean anything other than their obvious meaning. OK, I can think of one and it is trivial. The author precedes that paragraph with the words "I do not believe the following".

Berwick's and Brennan's views dovetail with the ground work constructed by the "New Professionalism" (see here for the details of that project ) which implores physicians to somehow balance their duty the patient with some nebulous responsibility of stewardship to take proper care of society's limited medical resources and strive for social justice. Dr. Troyen Brennan was the chair of the Professionalism project. In fact Dr. Brennan name crops up more than once in a narrative of the transformation of medicine in which medical care is taken from the hands of individual physician and into the control of various organizations.

In 2002, Dr. Brennan's new Professionalism was revealed to the world in the Annals of Internal Medicine ( see the above link). (OK, it wasn't just Brennan's,others played a role.)Physicians were admonished to work for the good of society and not just be concerned with the parochial concern for their own patients.

In 2006 Brennan and Berwick published the book, "New Rules". The operative word is "rules".

In an Article in 2007 (JAMA,Vol 208,#6,p 670) Drs J. Cohen, ,S. Cruess, and C. Davidson report their " discovery " that individual docs basically could not resolve the ethical dilemma posed by balancing their efforts for the patient's welfare with their duty to work for the good of the herd. ( see here for my comments on that article) What was needed was a "Medical Societal alliance" which could be made manifest through large vertically integrated organization such as something called an "Accountable care organization (ACO). Note, the old medical ethics had no major, crisis -level conflicts it was the New Ethics that posed the problem that the author purport to remedy with their nebulous alliance between collective abstractions.

Another article in JAMA in 2007 carried this theme further. The article was written by the then President of the American College of Physicians, Dr. Christine K. Cassel and the then executive vice-president of Aetna Insurance, Dr. Brennan. (JAMA ,June 13, 2007, Vol 297, no. 22, p. 2518, "Managing Medical resources.Return to the Commons")

They speak of an abstract hypothetical " medical commons" and how the current emphasis by the physician on the welfare of the individual patient will spoil the commons much as the farmer who selfishly grazes his cattle on public land without regard for depleting the resource will destroy the resource.Physicians are implored to "reconstitute the medical commons" and think in terms of resource conservation and allocation so at the end the greatest medical good can be done for the greatest number of patients.They admit there is not currently such a commons. There never has been so I am unsure how a return is possible.

The medical commons figure of speech seems bizarre and lame.While a grassy knoll for the villager's sheep can be defined by a specific surveyor description, the "medical commons" is a extremely large amorphous array,the elements of which defy enumeration, and is every changing, with some elements growing ,others contracting and innovations cropping up constantly. Various entities own various elements of this array-society owns none.The skills,and knowledge of thousands of physicians are aggregated and then allocated as if somehow society own them.There is no easily defined entity called "medical resources". Rather,it is an amorphous abstraction.Further, to speak of allocation means some one or some elite group will be the "allocator in chief ". Decisions will not be made by thousands of individual physician-patient pairs, since those individual physician-patient pairs plans to spend money are the worse nightmare an officer of a health care insurance company could have. Is anyone surprised that an officer on a large medical insurance company would propose a plan to eliminate the pesky problem of physician-patient "dyads" scheming to spend the insurance company's money simply because the two agreed such expenditure would be in the patient's interest?

The old follow-the-money strategy continues to have explanatory power. but why would the leadership of the ACP take part in that philosophical sham?

Is more primary care really not the answer to all that ails U.S. medicine after all?

2010-09-10T09:57:00.000-07:00

A recent WSJ article reports a Dartmouth Atlas study (DA study) that seems to cast at least a little doubt on the thesis that the key to good health care is lots of primary care docs. See here. See here for a more detailed discussion from the blog ACP Internist about the findings of the DA article.

So ,why are the indicators of good care used by the Dartmouth folks not better in an area where more primary doctors are available? The authors make several suggestions? I offer another. Maybe use of aggregate data often makes things less rather than more clear. A similar argument has been raised by some economists in their criticism of the major role of aggregate demand in Keynesian economics namely that the aggregation obscures more than it clarifies.

OR maybe the indicators purported to be of quality care are little more than something chosen because it was easy to measure and the data were available.

I think the real bottom line in regard to this Dartmouth publication is found in the authors' hypothesis that perhaps primary care is really the answer to much of what ails medicine only if that primary care is integrated into a larger system of other health care providers. This is the it-takes-a-village-to- provide -health- care type thinking. Can you say Accountable Care Organization (ACO)?

For the centrally managed health care that Obamacare portends to succeed at least one obstacle has to be overcome. That obstacle is the thousands of individual primary care docs out there practicing outside of the control of an organization such as an HMO,giant clinic or ACO. The Dartmouth publication could be part of a emerging argument similar to that put forth in a recent article in the Annals of Internal Medicine written by members of the administration urging physicians to get on board with the [Obamacare] program. See Dr. Rich's recent commentary about that article and what the message of that was.

What follows is a quote from the White House authored Annals Internal Medicine Study followed by a quote from one of the authors of the DA study.

"These reforms will unleash forces that favor integration across the continuum of care. Some organizing function will need to be developed to track quality measures, account for and manage shared financial incentives, and oversee care coordination…"

"Our findings suggest that the nation's primary care deficit won't be solved by simply increasing access to primary care, either by boosting the number of primary care physicians in an area or by ensuring that most patients have better insurance coverage," said David C. Goodman, MD, MS, lead author and co-principal investigator for the Dartmouth Atlas Project. "Policy should also focus on improving the actual services primary care clinicians provide and making sure their efforts are coordinated with those of other providers, including specialists, nurses and hospitals."

So, an "organizing function" is needed and someone/ something needs to make sure efforts are coordinated.

The message is that medical care is too important,too complicated, too whatever to be left to the individual patient and his physician.

Here is an earlier quote from the DA folks from there website.

"The availability of excellent primary care is central to high performing health care and favorable patient outcomes. Unfortunately in many regions of the country, residents cannot find the care they want and need."

Attorneys like to find expert witnesses making apparent contradictory statements so they can ask the old classic: Were you wrong then or are you wrong now?

Annals Internal Medicine publishes Obamacare advocacy commentary -I am shocked,shocked

2010-09-08T02:13:00.000-07:00

The Annals of Internal Medicine published an article ( see here for full text) authored by three current or former members of the Obama administration .It is difficult to consider it anything other than advocacy for the health care law ( The bill is now generally known as ACA or Affordable Care Act.) The article, first appearing on line, lead to a flurry of negative comments from readers See here.

The authors are: Dr.Ezekial Emanuel,brother of Rahm Emanuel who is President Obama's chief of staff,Nancy-Ann Deparle ,Counselor to the President, and Dr. Robert Kocher. Kocher who recently resigned from the President's Council of Economic Advisers to return to the McKenzie group, was the lead author.

The article begin with this incredible statement, " It guarantees access to health care to all Americans."

However, it is well recognized "all" will not be covered. There is a group of people too prosperous for Medicaid but who are not required to buy insurance because their income is too low to trigger the mandatory insurance purchase mandate.This has been well covered even in the mainstream press so it is difficult to imagine that Dr. Kocher and his co-authors were not aware of that fact.The Congressional Budget Office estimates 17 million Americans would remain uninsured.

Dr. Kocher joined (and is now departed from) the President's National Economic Council after having lead a team from the business consultant company, the Mckensey Group, to study health care systems in various countries.See here for the publication co- authored by Kocher.

The attribution section of the Annals article ( the part that explained which author did what in the preparation of the article) makes it clear that the principle author was Dr. Kocher., who since the Mckensey article, is considered an "expert" in health care cost and cost controls.

A recent town hall meeting between voters and Senator Max Baucus lead to an exchange in which the senator told the audience that he had not read the health care bill and that was left to the experts.

Said Baucus: "I don't think you want me to waste my time to read every page of the health care bill. You know why? It's statutory language. We hire experts."

From the glaring factual error in the Annals article it seems that at least one expert hasn't read the bill either.

The Little Book of Obamacare Horrors-a guide for the worried (most folks)

2010-08-27T03:36:00.000-07:00

Go here to read a publication from the folks at the NCPA telling the readers much they need to know about PPACA.

It is a welcome counterpoint to the rosy and in parts misleading picture painted in this publication from CMS.

For example, CMS talks about the changes in Medicare Advantage in the following way in a section astoundingly labeled as "Improvement to Medicare Advantage". ..." The new law levels the playing field by gradually eliminating Medicare Overpayments to insurance companies." Contrast that characterization with the following from the NCPA booklet:

Loss of Medicare Advantage Coverage. About half of the enrollees in Medicare Advantage (MA) plans (7½ million people) are likely to lose their coverage and will be forced to return to conventional Medicare. If you are able to keep your MA plan, expect higher premiums and fewer benefits. ...Of the 15 million people expected to enroll in Medicare Advantage programs, 7½ million will lose their plans entirely, according to Medicare’s chief actuary, and the remainder will face higher premiums and lower benefits.

The playing field seems to be leveled by forcing several million elderly folks out the MA plans many of whom may have to sign up for a Medicare supplemental insurance which is conveniently offered by AARP who just happened to have championed the health deconstruction-reconstruction bill. The follow-the-money rule has such great explanatory power.The CMS publication's section on MA would be more appropriately titled
"Throwing Medicare Advantage patients under the bus".

The entire NCPA publication is important reading but here is one interesting aspect of the bill that I was not aware of:

The government will require you to give your employer your most recent income tax return. Both at work and in the newly created health insurance exchanges, out-of-pocket premiums will be limited to a percent of your income. In order to enforce that requirement, however, your employer or the operator of the exchange will have to know what your income is. Note: Under the new law, the income-based premium limits are not based on the wages your employer pays you. They are based on your family income — including nonwage income (dividends, interest, trust income, etc.), your spouse’s income (from all sources) and, if your children are dependents, their incomes as well.

Wow, what if you might not want your boss to know how much your spouse makes or how much you made on investments? Too bad. It all just gets better and better. (Well, I won't give Fred a raise, looks how much his wife makes.)

The NCPA booklet is great source for important details of the PPACA. For an insightful,succinct summary statement it is hard to beat this slightly paraphrased comment from the blog "Nostrums by Doc D".
The plan is to take 500 billion from Medicare, spend it on something else and then call it a savings and a quality improvement to Medicare. Compared to that game plan, the business model of the Underwear Gnomes appears brilliant.