The other side of the health Care "debate"

As for as the main stream medical journals (JAMA, NEJM, Annals Internal Medicine) the health care issue is largely already decided with certain conclusions reached and as such now exist beyond debate or refutation. The conclusions are :U.S. health care costs too much, many folks are "denied" access to care and the care is of inferior quality to that received in the other developed countries.

There are cogent arguments to the contrary and those can be found here.

The authors include John Goodman , a Phd in Economics and a prolific author on the subject of health care economics but unlike Uwe Reinhardt is rarely quoted in the big three journals mentioned above. (It seems to help to be on the board of a managed care company to get quoted in JAMA).

Another author is Dr. Robert M Sade. I first heard of Dr. Sade when he published a NEJM article in support of the proposition that health care is not a right. The type of fire storm that his article elicited was not unexpected and included a blistering admonition from the editor of the journal. Dr. Sade, a trained heart surgeon, later left practice and has devoted some of his energies to biomedical ethics and health policy and organ transplantation issues.

Dr. Wes gives his views on the "broken health care system" here.

The new HFA inhalers may or may not help the environment and drug companies but are the users the forgotten men?

Here is on article discussing the possible cons of the introduction of the HFA inhalers and the outlawing of the older CFC type (except for Maxair).

Some patients complain they do not work as well and more complain about the increased costs and more than a few physicians have spent time educating patients regarding their use and offering reassurance.

If you wonder, as I do, about how much effect the CFC pulmonary inhalers have on ozone depletion and how much good this prohibition will generate, this reference might offer some information and opinion in that regard.

When I wrote about this before I said:

.. I think this is the first time that the FDA [has banned] a medication or group of medications not because they are thought or proven to be harmful to those who use them but because they are thought to possibly harm folks who do not use it. (OK, the purported skin carcinogenic effect of increased sun rays from the purported decrease in ozone layer thickness would affect everyone- even asthmatics.) Since the task of determining harm to medication users has proven much harder that the FDA or anyone ever thought, it is admirable that the FDA will take on an even more difficult task.

I don't have a tracking on the course this regulation took through the regulatory mechanisms and who supported it, but I cannot help but wonder if we are dealing with still another instance of the "Baptists and the Bootleggers". Since there are no generic versions of the HFA inhalers, guess who the bootleggers would be and would the Baptist role be played be the more radical environmentalists?

Wait-Maybe electronic medical records might not save money.

We have been told by President Obama that we cannot fix the economic mess without fixing health care (and education and the environment, for that matter). OK, some of us think that may rank as the non sequitur of the year (decade?) but let us look deeper. Electronic medical records (EMR) has been heralded as one of the ways we can simultaneously improve quality,provide medical care for all and save money. One prominent medical blogger and a fairly well known medical author both suggest that might not be true at least in regard to money part.

KevinMD, see here, offers a interesting take. Hospitals may get more proficient at maximizing coding techniques with computers and therefore increase their share of the medicare and insurance pots and thereby increase costs.With the stimulus plan the government will give money to the hospitals to get the computer systems to code better and get more payments.

Dr. Jerome Groopman whose writings on medical cognitive tricks and traps has now taken on the topic of putative savings from EMR and challenges the often quoted Rand study that claims EMR would save huge amounts of money.See here.The study needs to be analyzed on its own merits as Dr. G. apparently has done but it did not go unnoticed that the study was founded by HP and Xerox, who could be described as interested parties. We all know how the money behind drug studies always raises a red flag and a reflex skepticism of the results but here only now ( at least I can't find other references) does someone make that point with the Rand study.

What does universal health care have to do with the economic mess?

Tell me again why we cannot get out of this economic mess without fixing health care? I have read over twenty putative explanations for why and how we got where we are in one scary recession and so far none of the financial pundits nor card carrying economists have suggested that lack of medical coverage and too high health care costs caused the problem or was even a major contributing cause.

I have read that we had first a housing boom and then a bubble and then a crash whose effects were hyper-amplified beyond most analysts' wildest fears by a situation in which: entities that made loans sold them to others who packaged them in ways few understood, many of the loans were made to people who could not afford them,mortgage based securities (MBS) based in part on bad loan were markedly overvalued by rating companies,financial entities who bought and sold MBSs were dangerously over leveraged and according to one school of economic thought (the Austrian School) a major driving force was the artificially low interest rate driven down by the Federal Reserve system in this country and by other central banks around the world.

If one plows through a lucid and laboriously documented academic discussion by Marcus Brunnermeier from Princeton's economic department you will be treated to a discussion of how he suggests the housing bubble was made possible by cheap credit supplied both by a surplus of foreign ( mainly Asian) money looking for a good return on investment and an expansionary Federal Reserve Policy,of lowered lending standards ,of major changes in the banking system (i.e. going from loan and keep , to loan and sell off the loans), of various actions by banks to establish a "shadow banking"system involving off balance sheet investment vehicles exposing them to liquidity risk, of investments entities relying more and more on a borrow short and loan long arrangement . In short he describes elements of the events that took place as a mortgage crisis was amplified into a severe finanacial crisis.

If medical costs and folks without medical insurance played a role in any of this he and every other economists and financial analysts and pundits who has written about it really missed the boat.

Yet, we told by the new administration that we cannot get out of this financial mess without fixing the health care system. We are told that for recovery we will have to simultaneously cut medical care costs and ensure that everyone has medical care and improve quality of care. Of course, there are good arguments to the point that we do spend a lot of medical care and thoughtful people have a legitimate concern that some folks do not have health insurance and that there is a great deal that needs fixing but what do those concerns have to do with a housing bubble,burst, and mortgage crisis amplified into a financial crisis and why is a health care fix a necessary part of recovery?

Dr. Krauthammer hammered away at what he describes as Obama's glaring non-sequiturs in his Washington Post commentary dated 3/6/2009 entitle "The great Non-sequitur"

President Obama has asserted that the mess we are in relates to the country failing to obtain universal health care, green energy and better education. Dr. Krauthammer gives us this quote from the President's speech in which we are seemingly finally told why the real reasons of why we are where we are now:

"Our economy did not fall into decline overnight," he averred. Indeed, it all began before the housing crisis. What did we do wrong? We are paying for past sins in three principal areas: energy, health care and education -- importing too much oil and not finding new sources of energy (as in the Arctic National Wildlife Refuge and the Outer Continental Shelf?), not reforming health care, and tolerating too many bad schools.
Krauthammer says in reply:
.. the list of causes of the collapse of the financial system does not include the absence of universal health care, let alone of computerized medical records. Nor the absence of an industry-killing cap-and-trade carbon levy. Nor the lack of college graduates. Indeed, one could perversely make the case that, if anything, the proliferation of overeducated, Gucci-wearing, smart-ass MBAs inventing ever more sophisticated and opaque mathematical models and debt instruments helped get us into this credit catastrophe. .......
Clever politics, but intellectually dishonest to the core. Health, education and energy -- worthy and weighty as they may be -- are not the cause of our financial collapse. And they are not the cure. The fraudulent claim that they are both cause and cure is the rhetorical device by which an ambitious president intends to enact the most radical agenda of social transformation seen in our lifetime.

Whether on not you agree with Dr.K's characterization of what Mr. Obama's agenda really is, it is very hard to accept the claim that fixing his big three initiative is necessary for the economic repair.To be fair I have to recuse myself regarding expressing an opinion on the carbon cap and trade issue,I have not researched that enough to justify comment but if the lack of a universal health care plan in this country is a cause of the economic downturn, it must be the best keep secret on the century. Should not Great Britain have been spared the economic turmoil since they have had a universal health coverage system in place for years?

Two (three) must read articles on clinical guidelines

Clinical guidelines,virtually non-existent a few decades ago now have reached hyper-epidemic proportions. Two of the best medical bloggers have recently penned commentaries that are must reading. DM,know in the real world as Dr.Robert Centor published a great editorial in JAMA

DrRich, known in real life as Dr. Fogoros wrote the blog postings linked below and as usual gives a take on the guidelines issue that should make physicians and other interested readers sit up and notice and one that I'll bet you won't see elsewhere. Dr. Fogoros is a card-carrying cardiologist (well maybe, he does not carry his card any longer and after they read his Part 2, they may try to take the card away) and with the credibility that should go with that dives into the subject of cardiology guidelines.Part 1 is good but Part 2 should knock your socks off and offers a great insight into what we might expect from comparative effectiveness research even if the government sponsors it as long as they use humans to do the work.

Still More on comparative clinical effectiveness and the role of government

A number of medical bloggers have offered their opinions regarding the inclusion of "stimulus money" for a federal CER (comparative effectiveness research) unit . A particularly well balanced view is presented here by Dr. Val who has obviously spend some time and effort in trying to understand exactly what has passed and offers some thoughts about what it all might mean.

It seems like a major influence in this undertaking will be forthcoming from our colleagues at the Institute of Medicine (IOM) whose reports ring like pronouncements floating above the level of criticism and discussion that ordinarily pertains to comments by most other folks. They apparently will be given one million dollars to prepare a report indicating on what areas the early efforts at CER should focus. This will give some people at the IOM considerable clout since there are endless issues that could be addressed but for the limits of time, money and manpower so what gets studied is what it is all about. So the locus of lobbying and influence may shift for a while to this non-governmental organization.

DrRich offers his view on CER here. Among other insightful comments he tears into comments from the ACP that they will not countenance rationing,which some fear may result from the decisions issued by the federal CER group:

"The ACP seems to be delusional. Despite the ACP’s new protestation that they will not countenance healthcare rationing, this organization is one of the chief signatories of the recently updated version of medical ethics, updated to honor the “new realities” of the 21st century, which explicitly recognizes physicians’ inability to fully advocate for their individual patients in today’s healthcare system, and which therefore gives them permission to ration healthcare at the bedside in order to meet the demands of our larger society. (As DrRich has argued, this new version of medical ethics fundamentally wrecks medicine as a true profession.) So for the ACP to come out at this time foresquare against rationing seems somewhat hollow."

Also ringing hollow to me are comments that the results of the CER studies will not be used to limit care. Although verbiage from government sources denies that will occur regarding government funded programs(and if we can't trust the government who can we trust) as Dr. Val points out isn't it likely that private insurers will pounce on results that can be used to save them money.

Dr.RW expresses his view on CER here and in this typically strong and well researched posting Dr. RW shows us why the premise that we don't already have have CER is just plain incorrect as he lists case after case of useful CER that was done without the federal goverment's largess.

Dr. Robert Centor,whose views are always worth considering seriously,offers a more optimistic take here. I hope he is right and the new federal agency can do better than the ad for chiropractors that NCCAM published and that I commented on here. KevinMD also expresses a positive view of the fed funded CER effort seemingly surprising himself that he agrees with Paul Krugman in that regard.

NIH publication looks like ad for chiropractors

This month I received in the mail a copy of NIH Medline Plus and was attracted to the article on CAM. The publication is also available online. Go here for what looks to me a lot like an advertisement for chiropractors rather than the unbiased scientific assessment which we should expect from the NIH and our taxes and what some medical bloggers expect will come forth from the federal CER group who is recently the recipient of part of the stimulus package.

The article does reference a clinical trial which apparently showed some benefit for folks with low back pain from what I consider to be basically physical therapy done by a chiropractor but the glossy page seems to imply more than that.We are told that "even super fit athletes, like marathoner Scimonelli (his picture is above the text) can benefit from CAM treatment for conditions such as low back pain."Note it says "conditions such as.." implying there are other conditions that can benefit from CAM.

This message is set out from NCCAM (National Center for Complementary and Alternative Medicine) who proudly announces it is now ten years old. There is a timeline heralded as a decade of progress. Go here to see what the tax payers received for that ten years of government spending. Tell me again why we expect great things from the government in regard to comparative effectiveness research.

A positive article in WSJ about concierge docs

The Wall Street Journal published a positive article on concierge medicine.See here. I do not yet have a concierge type physician only because I have not yet found one in my area.

We can only hope that the powers that be and the forces that influence the powers that be will not manage to pass legislation to outlaw the practice or influence insurance regulators to assume jurisdiction over their practices. See here for details on the efforts of the Maryland Insurance Commission to do just that.

"Health care associated pneumonia" looks like a concept here to stay

The article from the Jan. 6,2009 issue of the Annals of Internal Medicine provides outcome data from 55 hospitals in Italy that offers more validation to the concept of Health care associated pneumonia (HCA pneumonia) as a "distinct subset" of pneumonia, which had been proposed in 2005 by the American Thoracic Society.

HCA pneumonia is pneumonia occurring in patients who have had association with the health care system as in residence in a nursing home care or treatment at a dialysis clinics or hospitalizations in the recent past.Basically,these are patients who present more acutely ill with the lung infection often superimposed on various chronic illnesses and who have a higher incidence of certain microbes, namely staph aureus and various gram negative bacteria.Compared with community acquired pneumonia there are longer hospital stays and a higher mortality which is really what is expected when chronically ill patients develop pneumonia.

The American Thoracic Society's guidelines for HCA can be found here.

Advocates of "Medical Homes" find little cheer in coordinated care study

A recently published study of 15 coordinated care programs found little evidence of benefit,no cost saving and no change in various "adherence" measures. A detailed discussion of the JAMA article can be found here at Junkfood Science.The JAMA article can be found here.

The notion that if we could educate patients better and interact with them more closely to encourage adherence to recommended care then costs would fall and quality of care would increase has been advocated by several professional organizations and policy wonks and disease management companies. The Balanced Budget Act of 1997 mandated that the Secretary of HHS study coordination of care programs in the Medicare setting. The JAMA article is the result of one such large study. Coordination of care is a major element in the Medical Home concept.Basically these coordinated care programs consisted mainly of educational activities by nurses and monitoring (usually by telephone calls) of patient adherence to medical care recommendations.

The negative results here remind me of a earlier publication investigating the similar results of a disease management program that I discussed several years ago.

Government funded comparative effectiveness project-mechanism for rationing or,boon to special interests or neither

To some,the allocation of 1 billion dollars to a government project to evaluate comparative effectiveness represents a danger, the specter of a mechanism to ration care and cut costs, and cast a big brother eye of physicians' practices glossed over with the veneer of scientific research. Others fear the capture of the government mechanism to further the special interests of various interested parties, such as drug and medical equipment companies. and to provide third party payers a rationale to limit payments.Others see the potential for unbiased, transparent research that could lead to better information for practicing physicians and a resultant improvement in medical care.

Dr. Roy Poses offers a thoughtful discussion of these issues here.

George Will talks about the Council of comparative effectiveness research (CER) here.

It is hard to ignore the possibility that at least one of the reasons for the existence of the council of CER might be to save money and limit Medicare expenditure-even if indirectly- as illustrated in this quote from Will's commentary.

The stimulus legislation would create a council for Comparative Effectiveness Research. This is about medicine but not about healing the economy. The CER would identify (this is language from the draft report on the legislation) medical "items, procedures, and interventions" that it deems insufficiently effective or excessively expensive. They "will no longer be prescribed" by federal health programs. The next secretary of health and human services, Tom Daschle, ( Written before Daschle declined the nomination) has advocated a "Federal Health Board" similar to the CER, whose recommendations "would have teeth Congress could restrict the tax exclusion for health insurance to "insurance that complies with the Board's recommendation." The CER, which would dramatically advance government control -- and rationing -- of health care, should be thoroughly debated, not stealthily created in the name of "stimulus."

Bob Doherty, The American College of Physicians' man in Washington, expresses the opinion that rationing is not the reason behind the bill and that it is really about "giving physicians and patients transparent and evidence based information to make their decisions."

That conclusion seems inconsistent with Will's quoting from the language of the bill ,although there is some doubt about exactly what the actual wording is, see below . Doherty argues further that the assertion that the council's decisions will lead to micromanagement of medical care as stated in a Wall Street Journal commentary found here cannot be true because the ACP favors the project. (There must be more to his argument that it seems-is he not simply saying it will not lead to micromanagement because the ACP says it won't).

In a second related posting, Doherty charges that the bill is mis-characterized in the widely read and quoted Bloomberg article by Betsy McCaughsey.He asserts that the bill does not create or empower the agency to make decisions to limit care,will not monitor physician's care nor mandate appropriate therapy. I wonder if CMS might find the CER's findings useful in their activities to control costs.

Another aspect of the CER matter is the issue of regulatory capture which I talked about here.

To muddy the waters even more, see this notice by Media Matters that asserts that the language of the bill does not in fact actually say federal health program will not pay for certain programs based on the CER analysis. We will have to wait a bit to clarify exactly what the bill says.

To the extent that the bill reflects the views expressed in Daschle's book on health care, cost containment will be on the table.See here for some comments about what his views are on that subject. Yes, I know Daschle won't be the health czar but will the views of the health wonks that wrote (or at least helped write) his book prevail.

Will A national coordinator of health information technology jump start the economy?

The first I read about the post of National Coordinator of Health Information technology (NCHIT) as being part of the stimulus package was in this commentary by Betsy McCaughey.

Reference to the relevant sections of the bill can be found in McCaughey's article in Bloomberg. including a description of the duties and powers of this office as outlined in one version of the House stimulus bill. Actually, this office already exists as shown here ,it is the expansion of a program headed by this office that is contained in the House Bill and so far seems to escaped much scrutiny.

The provisions as described by Ms.McCaughey,if accurately depicted, should be of concern to anyone old enough to be a member of AARP as it looks like the old folks will get screwed first. My attempts to verify Ms. McCaughey's comments by referring to the bill's language itself have not been successful. There are hundreds of pages of the type dense statutory prose that send the reader back and forth to various internal references.I will repeat some of her comments regarding the bill with the caveat that they are her comments and I have not been able to confirm their accuracy.

One new bureaucracy, the National Coordinator of Health Information Technology, will monitor treatments to make sure your doctor is doing what the federal government deems appropriate and cost effective. The goal is to reduce costs and “guide” your doctor’s decisions (442, 446). These provisions in the stimulus bill are virtually identical to what Daschle prescribed in his 2008 book, “Critical: What We Can Do About the Health-Care Crisis.” According to Daschle, doctors have to give up autonomy and “learn to operate less like solo practitioners.” .......

Hospitals and doctors that are not “meaningful users” of the new system will face penalties. “Meaningful user” isn’t defined in the bill. That will be left to the HHS secretary, who will be empowered to impose “more stringent measures of meaningful use over time” (511, 518, 540-541)

What penalties will deter your doctor from going beyond the electronically delivered protocols when your condition is atypical or you need an experimental treatment? The vagueness is intentional. In his book, Daschle proposed an appointed body with vast powers to make the “tough” decisions elected politicians won’t make.

It looks like Mr. Daschle,though no longer to be the czar of health care reform, will leave his imprint in the language of the bill which according to the Bloomberg article resonates with the ideas and plans outlined in the former senator's book.

MedInformaticsMD writing on the blog HealthCare Renewal also quotes the Bloomberg article but expresses in convincing detail another issue with the plan. That issue , simply put is that when governments have attempted to pull off an IT system of that complexity is that they will very likely screw it really badly and may never finish and he gives examples.

Whether it be considered as a Trojan horse to sneak in socialized medicine,a gigantic boondoggle that will have never ending cost overruns and myriad unintended consequences,or an important circuit in the electrified apparatus to jump start the economy, many would feel better about it if it could approached in the open with public comment and committee hearings rather than being rushed past Congress with warnings of the dire consequences of delay.

Lobbyists, including health care representatives,flood Washington on a pork hunt

Those who believed the claims that pork barrel legislation and special interest pleading would become things of the past will be disappointed in the events playing out as the current stimulus bill percolates through the Washington sausage factory.

The thousands of lobbyists (registered and unregistered influence peddlers) are pushing each other out of the way as this hurriedly prepared gigantic spending bill is being assembled. This bill is considered to be a great opportunity to insert provisions that groups may have had on their wish lists for some time. The concrete lobbyists are battling with the asphalt lobbyists over whether money should go mainly to repair work or new construction projects while the solar energy folks compete with the geo-thermal business interests for government favors,just to mention two contests of the many that are underway.

A Forbes article had this to say:

...Lobbyists for virtually every conceivable interest have tried shaping the measure, lured by its enormous size and scope, its must-pass status and a sense that budget pressures will make federal dollars scarcer in legislation later this year.

"This is a bill that's got just about as much room as you need," said Steve Verdier, top lobbyist for the Independent Community Bankers of America, which successfully supported expanded tax credits for home buyers and other provisions it said would help create jobs. "So if you've got some ideas you've been trying to push for a number of years, this is certainly the vehicle you want to use."

Various health care interests are well represented and in the game . Here is one news story of the lobby efforts for the Hospice business. The Biotech sector is asking for money for research claiming that with the credit crunch investment firms are no longer supplying some of the funds they typically rely upon for certain research projects.See here for a detailed discussion of what tactics the CAM (complementary integrative medicine) forces are using to get their feet into the doors of the health care reform funding,a key element of which appears to be coopting the preventive medicine angle.

This item suggest that there is money to made in the medical technology and computerized medical records provision of the stimulus bill and big players are interested.

This article outlines some of the conflicts involved in the electronic medical records issues and some of the players concerned with protection of patient data privacy and says in part:

Lobbyists for insurers, drug benefit managers and others in the health industry are mobilizing a campaign to persuade Congress that overly stringent privacy protections would frustrate the potential benefits of digital records.

The 20 billion dollar "jump start" of the health IT is a large enough slice for a number of interests to send their lobbyists to secure what they can get. I wonder though if the really big prize in will be the opportunity to data mine. Think of it, everyone's medical records on line somewhere, medications, procures, history,insurance data.Clearly the privacy issue mentioned above is critical and an issue of that important should not be part of legislation that is hurried through congress on the winds of rhetoric claims that delay will turn "crisis into catastrophe".Shoot, ready, aim is not the way to go.The British experience with their NHS IT adventure should give us some pause.

If you feel some reassurance that HIPAA will be protective, it is instructive to look into the lobbying origins of what the law was all about in the beginning. In spite of its veneer of privacy protection it was not about protecting patient privacy and facilitating medical insurance portability. A strong case can be made that it was driven by the health insurance lobby to obtain a federal law to give broad access to patient records and to facilitate insurance claims processing. That was achieved and the rest can be considered either collateral damage or incidental benefit. I am afraid of the collateral damage,unintended consequences and intended benefit to special interests that are all likely to occur as the health care IT bill is hastily put together under the watchful and helpful eyes of the relevant interested "stake holders".

Normal Weight Obesity joins normal blood pressure hypertension and others

It has been well recognized for a while that an elevated body mass index (BMI) does not necessary mean that a person has too much fat. Men and women with well developed muscles may have an elevated BMI and still have a low percentage of body fat. Look at any NBA game and you can see poster guys for that.

The BMI as an indicator of body fat also can also fail at the lower end. As humans age , often weight may not change but body composition does, with muscle mass decreasing and body fat increasing so that you may not gain weight but have a high percentage of body fat. Sarcopenia, or muscle loss, is a major element of old age fragility and so far the only way shown to mitigate that is resistance exercise.Aerobic exercise does not seem to help mitigate the apparently inexorable loss of the fast twitch muscle fibers whose loss is most marked in the age related decline in strength.

Nomal weight obesity (NWO) is a recently minted term that is meant to refer to the condition in which the BMI is in the generally accepted normal range but by some (perhaps less than widely accepted) standard of percentage of body fat, the person is deemed to have "too much". Hence they suffer (well, we haven't really shown yet that they suffer) from NWO. My term would be too much fat (TMF) because we have used BMI to operationally define obesity (as bad an indicator as it may be) and some may think we have at least the appearance of a contradiction in terms. People with this entity may be the some of the same people we used to call flabby.

Researchers from Mayo Clinic have published an article that correlates this NWO with risk for the metabolic syndrome. (You may remember this entity as something perhaps no longer believed in by endocrinologists but still by cardiologists. See here for comments regarding that schism). So, it appears that NWO or TMF would be a risk factor for a risk factor (metabolic syndrome) which is a risk factor for heart disease and diabetes, just to name two.

Tip of hat to Dr. Michel Accad's blog Alertandoriented for alerting me to this "novel" risk factor. Here is a press release for the May0 Clinic article.

The Mayo clinic researchers recommend that a shift from focusing on BMI and perhaps monitoring percentage of body fat or least waist measurements since the "real" definition of obesity is too much fat.

Data from CDC show that 35% of American are obese (as defined by BMI >= 30. Using NHANES data from 2003-2004 we see that 66% of Americans are either overweight or obese.That leaves 34% with a normal BMI but Mayo docs tell us about half of those are really obese after all leaving something around 17-20% of us who do not have too much fat. We now know that there are fat people that don't even look fat., a secret epidemic of fat people who don't look fat. (OK, some of them probably have a bulging tummy).A nation of reverse Lake Wobegon, where most everyone is worse than average.

There are new risk factors cropping up all the time. Risk and pre-risk and proto-risk abound. The cardiologist Dr. Thomas Giles, remarked that we are all pre-dead. Prompt and massive public health funding is the only answer,maybe as part of the stimulus package.

Britain's NHS computer system said to be on verge of failure

See here for a news item and commentary about what seems to be shaping up as a giant governmental boondoggle in Great Britain, their computerization of their medical system.

We are repeatedly told that an electronic medical records system and more prevention will save much money greatly increase quality of care and possibly save the U.S. health care system in the process.The above quoted article could serve to disabuse the thoughtful about the metaphysical certainty of saving the country's health with computers and this great posting by DrRich might cast some doubt on the thesis that prevention will save money.

Can we believe guidelines formulated by "expert panels"

The blog, California Medicine Man, written by Dr. John S. Ford, expresses concerns about the recommendations that flow in ever increasing numbers from panels of experts. He expresses some of the same thoughts I have had for some time. My spider antenna quivers when I see a supplemental issue of a journal devoted to a specific topic which contain a panel's recommendation for a given therapy.

He mentions a 2007 supplement to The American Journal of Medicine that discusses hyponatremia and specifically treatment with a new class of medicines that I have briefly blogged about before .

I previously wrote in regard to this particular supplement:

The supplement is sponsored by the drug company that makes conivaptan ( trade name Vaprisol).This is an antagonist to renal vasopressin receptors and is a member of the "vaptan family" which so far has three other members. Vaprisol is approved by the FDA for treatment of euvolemic and more recently hypervolemic hyponatremia and is given IV. It is contraindicated in hypovolemic hyponatremia wherein further volume depletion from the ensuing aquaresis could be disastrous.

The way things work is that when a drug company assembles a "panel" to make recommendations about one of its products and pays to have the results published, usually the opinions tend to be somewhat favorable as was the case with this publication. I have no experience with any of the vaptans but I would be very interested in what the hospitalists (or any of the die hard internists who still treat people in the hospital) bloggers have to say about the role of vaptans in hyponatremic states.

However, as interesting as this new medication may be and as useful as it may or may not be, Dr. Ford's major point was :

The problem is that even before checking out this particular drug's usefulness, I'm already starting from a position of mistrust. With such an undeniable "appearance of impropriety" how can I truly rely on these experts to give me the unvarnished truth? It's one thing to report hard facts. It's something entirely different to render an opinion which is what a guideline is.

Ten years ago, we did not know about medical ghost writing and all the other subtle and so not so subtle techniques used by drug companies to influence physician's behavior but now we do and we cannot go back to an early era of relative innocence and less critical reading of whatever is written about medications and guidelines. From one point of view it is a good thing that physicians have had to become much more critical and skeptical about what we told and that applies to guidelines and not just those apparently encouraged by certain drug company interests. On the other hand, it is so much easier to just do what the experts tell us to.

American College of Physicians recommends against fighting with specialists over Medicare money

I have been a bit critical of some of ACP's positions and proposals but this time I agree. See here for a news item on their stance on food fighting and a rather long series of comments.

For a tactical point of view, ACP may have weight and influence disadvantages with professional associations of surgeons and some other specialists and might loose anyway. Sometimes proponents of taking money away from the "procedurists" to give to the primary care physicians actually say the procedure docs make "too much money" and their income should be limited. The wage and price controls imposed by CMS in 1990 has caused many problems for health care not the least of which is a shortage of primary care physicians.Extend that process and target specialists and we will likely see shortages for non primary care docs as well. For that matter, would we have physician groups going to Washington and begging for more money if there were not wage and price controls in Medicare?

Yes, it is true that the procedure docs have fared less badly as CMS has turned the cost control screws and the procedure doc dominated RUC has played no small role in that but to argue that they haven't been screwed enough and to limit their income will push things along so that everybody's ship will sink.

Tom Daschle history with lobbying firm damages credibility as future head of HHS

Tom Daschle has held a position as "policy advisor" with a prominent Washington law firm with well known lobbying activities.

The Washington Law firm, Alston and Bird, has a number of clients in the health care industry. See here for some details and here for a list of health care clients which include CVS Caremark, several drug companies and the American Orthotic and Prosthetic Association. The lobbying targets included HHS, FDA,CMS ( Medicare and Medicaid) and CDC.

Mr.Daschle was not a registered lobbyist in his position at Alston and Bird but was characterized as a " special public policy advisor" so an argument can be ( and has been) raised by the administration that since Mr. Daschle was not technically designated as lobbyist his appointment would violate no policy or promises regarding a lobbyist free administration.Even so, the administration says Mr. Daschle will recuse himself from any HHS work that might conflict with any previous activity he may have had while at Alston.

His wife is a lobbyist whose firm, Baker Donelson, has worked with Schering-Plough in efforts to extend patent rights for one of its medications. ( Will Mr.Daschle recuse himself also based on his wife's lobby activities?) At this writing she may have left that firm to set up her own lobbying firm and she was best known for her lobbying expertise in the aviation industries not in health care matters.

Moreover, Daschle's chief of staff at HHS will be Mark B. Childress and he did official lobbying work for another Washington Law firm, (Foley Hoag). Administration spokesmen have indicated that Mr. Childress will recuse himself from matters at HHS that he previously dealt with in his former lobbying life. See here for some details.

The list goes on. The nominee for the post of Deputy secretary of HHS is Bill Corr, who has also has been a registered lobbyist with some activity in health related activities.See here for details on that nomination. It is promised that he too will recuse himself should an issue arise at HHS for which he has a lobbying history.

It seems that whatever issue will be on the table at HHS there will be a lot of recusal going on.

The Public Citizen blog "Becoming 44" expressed their doubt of Daschle's suitability for the HHS post this way:

...the assurance that Daschle will recuse himself from any work presenting a conflict is hard to digest. He would, if formally nominated and confirmed, be the leader of the entire enterprise.

While we do not know which specific Alston health care clients Daschle worked for, it is highly likely that many of them would be affected by the regulatory decisions made by the director of HHS.

Daschle is also an advocate of the proposed Federal Medical Board and will play a dual role being the point man for President Obama's plans for health care change about which I have blogged before. Whatever concerns one may have regarding Daschle's appointment to HHS would apply to his role as architect of what appears to be a very powerful governmental body whose decisions may well have considerable impact on everyone's medical care and on the financial bottom line of many organizations, a list of which include many of the clients of Alston and Bird.

Concentrated benefits and diffuse costs-no need for docs to fight each other over the pie

Alex de Tocqueville is quoted as saying:

The American republic will endure until the day congress discovers it can bribe the public with public's money.

Well, he was partly right. He implies that day will not be a good thing and that discovery would lead to much mischief and worse but he greatly underestimated how long a country could slog along with the congress doing that very thing as a major-perhaps the major- activity.He underestimated the economic power of a free country.

The notion of concentrated benefits and diffuse cost was given much academic credibility and stature by the works of Nobel prize winner, James Buchanan,who developed what has become known as Public Choice theory.

Here from an interview in Canada is the way Buchanan explained the concept.

We have a system of taxation that is fairly general, so the cost of something is borne by everybody. On the other side of the budget account, concentrated spending benefits go to particularized groups. Through trading among these groups, coalitions are built up to benefit from that spending but the costs are spread out through taxation. That spending is very concentrated and brings pressure to bear on your political leaders, who are pressured to pass special interest, sometime called "pork barrel" legislation. You can get a coalition of senators from particular states in my country, for example, who want to construct highways or dams or ports which may well be very inefficient. The taxes would be paid by the people over the whole country, but the benefits would go to the few people in those particular locations,

We talk about special interest groups, the founding fathers talked about factions.James Madison worried a lot about the matter of factions.

The economic stimulus-recovery package proposes some 20 billion dollars to provide electronic medical records to "most" American in the next five years. A feeding frenzy is likely underway to share in this opportunity.Maybe the benefits will accrue to the patient and things will be much easier for the physicians and quality will soar and costs will plummet or maybe the major beneficiaries will be the vendors of the systems to provide the EMRs, who needless to say are ramping up their lobbying efforts as I write.

With a economic stimulus package that supplies only 7% of the stimulus to be spent by the end of 2009 and only 110 of the 355 billion by the end of 2010 ( GBO figures) we will see the hoped-for stimulation after many economists believe the recession will be over anyway. So what is this about anyway? See this interpretation from the blog, Austrian Economists by Steve Horwitz) which argues that much of what is said to be a stimulus are usual suspects,i.e. the off- the- shelf ideas that were waiting for a crisis to get passed and not have any arguable stimulatory effect at all and certainly not in the relevant time frame.

Thomas Sowell describes the current plan this way:

Out of $355 billion newly appropriated, the Congressional Budget Office estimates that only $26 billion will be spent this fiscal year and only $110 billion by the end of 2010. Using long, drawn-out processes to put money into circulation to meet an emergency is like mailing a letter to the fire department to tell them that your house is on fire.

(Warning :"Irony and sarcasm alert")
Everyone who knows how things work in Washington and have the means to do so are scrabbling around to get their piece of the pie that is alleged to be a stimulus. For some recipients it will be a stimulus or at least a nice windfall. With that in mind, I have to think that this suggestion by a primary care doctor to increase primary care payments by taking money away from others in the health care business is not only doomed to failure but primary care docs' efforts would be better spent by doing what everyone else is doing in Washington, i.e. elbowing for the pie.It is a time honored technique.

Universal health care-a religion or a bureaucracy

There are a number of conscientious, well meaning physicians who strongly believe that the problems of the current U.S. health care system can be solved by having a universal payer (aka the government) or at a minimum that such a system would improve things significantly. There are other conscientious, well meaning physicians who have also spend much time thinking and writing about the alternatives who believe exactly the opposite. Those in the second camp might think those in the former group are members of the church of universal health advocacy, a view expressed in this posting from Cato's blog.

I have quoted Thomas Sowell before. In this entry I wrote about his exposition of two very different visions and the explanatory power of that formulation.

Sowell's "Visions" are world views- or simply put- the way folks see how things work and how things are largely because people are the way they are. Sowell speaks of two such views-the constrained or Tragic view versus the unconstrained or Utopian view.

The Cato blogger would seem to fit into the first category and at least some of the advocates of a single governmental health care payer into the second.

For those who view the world through the Tragic view lenses, humans are basically limited creatures with those limitations involving their knowledge, virtue and wisdom and therefore social arrangements must take these inherent limitations in mind. The Utopians think differently believing that these limitations are due to the flaws of society and its arrangements and they can be overcome and that they should be overcome by better plans and putting better people in charge,often the same people who advocate for those putatively beneficial changes.


In the Utopian view, social inequalities such poverty,uninsured patients,drug addiction, not owing a home, racial or gender imbalances are seen as resulting from faults in society and therefore demand that social targets be developed and plans be made to rectify the social problems. The tragic Visionist would be concerned with the self interested motives of the people who are tasked with carrying out the programs and also with the unforeseen and unintended consequences that such projects seem to routinely bring about. The self interest and unintended consequences have been amply discussed and documented by the Public Choice school of thought authors. Utopian view physicians would celebrate the introduction and insertion of the concept of social justice into the new medical professionalism.

In the Tragic view, man is constrained by his moral limitations and his egocentricity. The social challenge is how to work with those limitations rather than engage in energy wasting and ultimately futile efforts to change human nature.In this view, one deals with trade-offs and not solutions. Benefits to society derive from actions largely unintended but emerging from market actions which derive from the pressures of the incentives for individual gain which include the monetary and the psychic.

If the tragic vision folks might see the Utopians as being faith based in their advocacy of a single payer I wonder if the reverse is also true. That is, do the utopians view the tragic world view's advocacy of individual freedom and market solutions also as a faith based initiative.

As Sowell has suggested advocates of both views typically frame their arguments by cherry picking facts that seem to conform with their vision and and the two camps rarely actually discuss or debate issue but rather talk past each other and cannot often even agree on what the terms of the discourse really are.

Forces gathering to blame the patient

There seems to be much blame to go around for the health care "crisis"-the physician,the hospitals,the insurance companies,the managed care companies, the pharmacy management companies, the Medicare payment system and most recently the patient.

Several factors, influences,movements, and lines of thought leading to the blame-the- patient notion include.

1)Basic human emotions-These tended to boil up in many of us as house officers, when fatigue and frustrations peak and we thought why are we wasting our time (and possibly sleep time) on someone who basically has brought the illness or its severity on themselves. Charges against the patient included; alcohol excess, or negligence, not wearing a seat belt or eating too much and not exercising or smoking or using illicit drugs.

A variation of this theme appears from time to time in comments and blog entries by emergency room docs who lament their interactions with citizens of unsavory character who often populate the ERs.

2.The P4P movement in which physicians are rewarded or not based on group outcomes. Their report card may look bad and their compensation may decrease based on numbers of their patients having the audacity to ignore advice or stubbornly refuse to live according to the healthy life style of the day and thereby arguably not meet their goal for HbA1C, blood pressure or something. If the physician's rating or income suffers from missed appointments or a patient's failure to have a given procedure so may the attitude of the physician towards the patient.

Drs JF Whatan and Daniel Salmasy writing in a JAMA Commentary entitled "Improving the Quality of Health Care.Who is responsible for what" (2009;301(2),215-217 (subscription required for full text of the article) point out the obvious but increasingly ignored fact that physicians have a obligation at an individual patient level but are increasingly judged by group or population level data. They quote Aristole who captured this issue

The doctor does not treat ‘man’ except accidentally; he treats Callius or Socrates or someone else described in this way, who is accidentally ‘man’. So, if someone has grasped the principles of the subject without having any experience, and thus knows the universal without knowing the individuals contained in it, he will often fail in his treatment; for it is the individual who has to be treated.

3.The collectivist-utilitarian mind set that says if the government (or society- even though the two are not the same) is going to pay for your heath care then you should loose your seat at the public trough if you do not comply with the rules it makes to keep you health.

This view has been expressed by several commentators.This one by an internist ( Dr. Chris Rangel on his bloghttp://www.rangelmd.com/index.php/2009/01/10/holding-patients-accountable-with-government-health-care/) explains it this way.

..the state has a practical interest in keeping the workforce healthy and reducing the economic burdens from people who become sick and disabled as a result of unhealthy or risky lifestyles (the reason seat belt and helmet laws). This is a utilitarian principle. Such policies benefit all citizens.

In counterpoint to all of forces blaming the patient or assigning societal obligations to her, I remember the comments of Dr. Lawrence J. Hergott in a JAMA article (JAMA Feb7,2007,vol.297,#5,p 477)

May I never see in the patients anything but a fellow creature in pain.
Not as someone who deserves his dyspnea because of cigarette use defying years of advice to quit, not as someone whose ascites is his just due from profligate use of alcohol, not as someone who should not be in this country at all, not as someone who would not be having the myocardial infarction at all if he had done what his doctors told him to do and not as someone who is taking "scarce medical resources" from someone who deserves them more or for whom the treatment could be more cost effective but as a fellow human whose is in need of what physicians spent so many years of their lives preparing themselves to be able to offer.

Proposal to spend 1.1 billion to save money and lives

There is a bill before the House of Representatives that would fund a project to study comparative effectiveness of new medications and medical devices. I believe this is House Bill S-3408 offered in 2008.

Advocates claim not only would money be saved but so would lives. Interestingly, the governmental Congressional Budget Office has apparently said that this type plan will not really save much ( see here for a 2007 GBO report on the issue of costs and benefits from a comparative effective research center) and I wonder how would such a program save lives.

The British agency ( called NICE) that is in charge of approving or limiting certain treatments for certain conditions in Great Britain arguably has cost lives by disallowing certain treatments. See here for a 2008 NEJM article touching on some of the pros and cons of this British agency including certain of the denials of care that attracted more than a little press coverage.

I believe the argument for its life-saving function might run like this: By limiting certain treatments that are not cost effective we can shift the money to other treatments which will save more lives, i.e. more lives saved for the buck., a utilitarian claim of the greatest good for the greatest number. In the NEJM article we find this quote from the chair of NICE which captures that line of thinking fairly well: If we spend a lot of money on a few patients, we have less money to spend on everyone else. We are not trying to be unkind or cruel. We are trying to look after everybody."

Looking out for everybody is a tough job but cost effectiveness analysts claim they are up to the task as apparently did Dr. David Eddy in a series of articles in JAMA over ten years ago that proposed that type of planning and control within the context of health care entities such as HMOs, a topic I wrote about here expressing my opposition to Eddy's philosophy.

See here for a op-ed expressing concern about the current House bill by Dr. Scott Gottlieb.

The NEJM author summed it up this way " .. such an institute could help to improve quality and slow escalating costs only if it were able to make tough calls and remain independent of political and financial interests."

When big bucks are involved remaining independent seems very unlikely.

Abnormal cardiac function. limits exercise-you've got to be kidding me

The blog, "ACP Internist" has an occasional feature called "Medical News of the Obvious". A recent news item in the AMA morning E mailed report stated " Study Indicates abnormal heart function may impeded ability to exercise"seems to break new ground in that regard but actually what the referenced article demonstrated was significant and not what we really knew all alone. Just a somewhat sloppy headline by the reporter.

The article entitled "Left Ventricular Function and Exercise Capacity" involving over 2800 patients studied at Mayo Clinic (see here for abstract, subscription needed for full text) has this paragraph for a conclusion:

In this large cross-sectional study of those referred for exercise echocardiography and not limited by ischemia, abnormalities of left ventricular diastolic ( my bold) function were independently associated with exercise capacity.

Diastolic function , until fairly recently, has not been regularly measured and this article gives strong data indicating that patients with diastolic dysfunction (such as many of the elderly and hypertensive patients with normal ejection fractions and smallish, poorly compliant left ventricles) may well have exercise limitation on a cardiac basis. This would seem a bit obvious simply from a consideration of the physiology of cardiac function but this study does provide much data documenting the relationship between exercise capacity and diastolic dysfunction. In evaluating a complaint of exertional dyspnea a cardiac cause is not excluded by a normal ejection fraction.

Why would the Med-Fed board be immune to "regulatory capture" and undue influence

Tom Daschle is promoting the idea of a Federal Health Board that would in his words:

" set standards for benefits and quality for federal program and insurance." he continues:

Just as the Federal Reserve ensures certain standards, transparency and performance for our banking industry, the Fed Health would ensure harmonization across public programs of health-care protocols, benefits, and transparency. Ultimately, the Fed Health would offer a public framework within which a private health-care system could operate more effectively and efficiently.

See here for some more of his comments on the virtues of his plan.

If I were arguing for such a board, this last analogy I would want to make is reference the agency that was said to ensure standards and transparency and performance of the banking section. If the proposed Fed-Med lived up to the Federal Reserve's performance in regard to credit and loans, no one would be able to get medical care even though the government had just thrown billions into the health care industry to "shore it up'"

Thanks goodness, we had the Federal Reserve Bank and the FDIC and the SEC as well as several banking regulatory agencies or we would have a had a frightening financial meltdown.

While there are many folks and organizations that rightfully share the blame for recent financial meltdown there is a strong case that can be made by a major element being regulatory failure. See here for a discussion of that.

One of the reasons that can lead to regulatory failure ( but not the only one) is the phenomenon of regulatory capture.

Wikipedia explains the term "regulatory capture" this way:

Regulatory capture is a term used to refer to situations in which a government regulatory agency created to act in the public interest instead acts in favor of the commercial or special interests that dominate in the industry or sector it is charged with regulating.

A national board with the power and influence that a Med-Fed would have will attract what economists called rent-seekers like flies to honey or some similar Dan Rather simile.(Basically we are talking about the efforts to cut one's self a bigger piece of the pie)
Medical equipment manufacturers, drug companies, rehab centers, managed care companies might all see the opportunity to score big.Medical Associations, hospital organizations etc etc- just about anyone and anything that wanted a bigger piece.

The Interstate Commerce Commission is often highlighted as the poster child for a regulatory agent that did more favors for the alleged regulated entity than acting in some nebulous public interest. However, the history of the FDA strikes closer to medical home. See here for the most recent expose of how that agency failed to monitor potential conflicts of interests in investigators who contributed to research used to support the approval of medications. Further, it is hard to forget their track record in the matter of telithromycin. OK some of that is more properly the typical bureaucratic way of doing things and not actual capture. It took the FDA about a year to re-analyze the Vytorin data and conclude that folks on that med and doing ok need not stop and that lower cholesterol is really better.Wow,only a year and somehow a federally mandated organization will- according to Daschle- be able "harmonize benefits and health care protocols" presumably for everything.

The health care protocol idea is being promoted by David Snow, CEO of Medco. Medco is the same organization that,as explained in this Sept 30, 2003 NYT report,that was accused by the federal government of destroying medical prescriptions,not filling prescription bottles with the ordered number of pills,lying about contacting physicians,coercing pharmacists and paying bribes to get contracts. DrRich has commented on Mr Snow's recommendations suggesting that an additional benefit would be solving the country's shortage in primary care physicians.(Warning for readers offended by frontal irony and sarcasm).

Clearly there is no end to the postive benefits for statins-the list goes on and on

I have written several times before expressing my amazement at the ever growing list of positive medical benefits that the statin group of drugs are said to bestow.

Here is a reference to a review that concluded there can be a significant reduction in the onset of atrial fibrillation with statin use. Here is reference to another review that analyzed the course of over 30,000 patients and found a 43% reduction in death following heart surgery for those given pre-op statins. And it seems good not just to prevent death, here is reference to an article from Canada that found a reduction in post-op delirium of almost fifty percent from statin use.

Of course, there are always doubters. Intrigued by observational reports that statin users were at lower risk from sepsis and were less likely to die from sepsis if they developed it, a group from Canada did their own investigation and failed to confirm a mortality benefit and offered the argument that, at least, in some of the observations studies that concluded a benefit in disease X, Y or Z from statin use that we were seeing our old friend , the healthy user effect.

With case controls studies and observational data analyses, all sorts of correlations will emerge, some of which will suggest negative effects of a medication. You have to wonder how many data dredging exercises with negative results never see the light of a published page . However,some have been reported in regard to statins. For example, a study from France raised the possibility of tendon damage from statin use. See here for earlier comments on that.There was also concern expressed about a possible association with statin use and risk of Parkinson Disease.

There is at least one disease in which statins may not be beneficial.This report suggest adding statins to inhaled steroids for asthma did not seem to help.

Sometimes, the magnitudes of the reported benefit are neuron boggling such as this report of a case control study that demonstrated an 83% reduction in death from COPD in statin users. The sicker COPD patients have lower and often quite low LDL levels and would be very unlikely candidates to have been treated with a statin in the first place and the healthier patients with airways obstruction were more likely to be treated to lower their LDL. We may have here not only a "healthy user " effect but an "unhealthy nonuser effect" which is one of the problems of working with "coarse grained data". When something seems to good to be true...

I like to call observational studies coarse-grained instruments with bias and confounding being the basis for the coarseness as well as often a dearth of patient specific data These hidden variables may lead to an association that is not real. We can only be confident that the calculated confidence interval takes only random variation in the data into account . It does not fix everything. Various types of bias and confounding are beyond its command,a point rarely made in the press blurbs about various benefits and harms of medical interventions.

Case study.How price controls in Medicine has worked out

Legislation was passed in 1991 and put into place in 1992 that effectively imposed on a major component of medical practice in the U.S. controls on physicians charges. Controls had already (1984) been placed on hospital charges for Medicare patients in the form of a Prospective Payment System. There were three major elements in the legislative action regarding Medicare fees for physicians.

1.The billing known as "CPR", or customary,prevailing and reasonable was replaced with a relative value formula for determining the maximal prices that could be charged for Medicare patients.

2.The billing practice known as balanced billing was abolished

3.To control growth in Medicare spending a system called Medicare Volume Performance standard was enacted which reduced reimbursement to physicians based on the degree to which total Medicare services increased. So if more surgery, x-rays and other procedures were done, the total amount spent on Medicare doctors fees was reduced to try and keep the global budget from growing.

The predictable effects of these price controls have been seen. Demand for services has increased, quality has decreased.We have seen gaming of the system and politicalization of health care. The type of medical practice that has come to be known as primary care has particularly felt the impact. FP and IM physicians have found it increasingly difficult to deal with the reduced fees . Primary care docs-whose fees were smaller to begin with-have tended to attempt to increase their output by seeing more patients to try and compensate for the decreased compensation per patient encounter by either spending less time per patient encounter and/or employing mid-level health care workers to see patients.The now only recently talked about role of the RUC played a key role in shaping the payment system controls so that primary care docs were the major losers and the procedure heavy specialist did relatively better.

What other profession has its charges limited by federal government enforced price controls? Of course, not all of medical fees are controlled. Private insurers ,however, tend to follow the fee setting of Medicare. While cosmetic plastic surgeons and cosmetic dermatologists and concierge docs can operate outside of this system and pediatricians may play in different ballpark, the effect of the price controls is determinative of much of what is wrong and worsening in American medicine.

The "Medical Home" suggested by the American College of Physicians will be operating in the same environment of price controls and is either naive or is a "wink-wink--nudge-nudge" suggestion that even they do not believe. P4P will only make things worse.

I wonder how many college students would seriously consider medicine as a career if they knew government price controls had been in place since 1992 and there was little if any hope of the situation changing.

Although price controls can be blamed for much of the perfect storm that is causing havoc in American medicine, at least two other factors are at work: 1)the phenomenon of spending other people money 2)the mind boggling developments in technology and therapeutics of the last several decades. Both of these have amplified the increased demand for medical services and it is not surprising that the "other people" ( government and other third party payers) have moved to enact measures to control costs which most notably are managed care and now P4P. The "measurement and forced compliance" managerial paradigm has been transplanted into medical care as the corporate and government players move to control medical costs in part by controlling medical practice in accordance with the current management fad of the day.

So, how have price controls in medicine worked out over the last 15 years? Exactly like you would expect : increased demand, shortages in primary care physicians and more recently general surgeons and decreased quality and ever increasing dissatisfaction among physicians and many patients.

The economic stiumlus package for electronic medical records-We are from the government and we are here to help

The following comments by Arnold Kling as quoted in the blog EclectEcon might be worth thinking about as we read about the amount of money ( 20 billion) that is planned for providing the means for most U.S. citizens to have an electronic medical record by 2014 according to the stimulus or recovery plan of the new administration.

It is true that markets have been overwhelmed by today's information problems, and consequently resources are unemployed. However, the ultimate solution of where resources belong is not known by government officials any more than it is known by private investors. A large "fiscal stimulus" is, ultimately, a major transfer of power away from the trial-and-error process of entrepreneurial markets and instead toward the bureaucratic planning process. It is not clear to me that technocrats have suddenly acquired the wisdom that would justify such a transfer. In fact, while they may have an air of certitude, they may know even less than usual about the best future direction for economic resources.

Here is the entire lecture by Dr. Kling.

doctor-nurses versus doctor-doctors-The AMA makes it clear where it stands

We already have doctors, folks who survive four years of medical school and then from three to six years in residencies and fellowships and pass a daunting battery of tests along the way.

We already have folks who complete a defined educational program in nursing and we have some nurses who then go past that level of education and take extra training to become advanced practice nurses. State laws vary in how much autonomy such folks have but the very name "mid-level " providers informs us that they are not at the same level as physicians.

So one wonders what would be the reason for existence of a new professional one that is a doctorate level nurse. Here we are talking about a clinical doctorate- not the PhD s that some nurses obtain in nursing educations. There is a so-far-fairly small- movement in the land which proposes that this new category of clinical practitioner is what the health crisis needs . The argument goes that there are not enough primary care physicians and too many nurses leave nursing for more rewarding careers and this doctor-nurse position will fill that need and we are told by the apparently self appointed spokesperson for that movement that:

A nurse practitioner with a DNP has achieved many of the competencies [of physicians]but through nursing education they will have the same skills in identifying a disease state and treating it but it is a different hybrid of care.

Apparently this doctor-nurse position will be rewarding and attractive to nurses even though the argument that primary care is becoming less and less attractive .


Dr. Mary Mundinger is the Dean of the Columbia University School of Nursing and holds a doctorate in Public Health (not the DNP degree she is proposing) and in this era of increasing awareness of real and perceived conflicts of interests, one has to notice that she is a director for United Health Group holding -as of Dec.11,2007- 32,000 shares.

The AMA has taken spoken out in opposition to this new clinical professional. In this era of increasing awareness of real and perceived conflicts of interests, one has to notice that the DNP would be competition for physicians.

So what is behind this doctor-nurse movement? Is it ,as Dr. Mundinger suggests,, the paucity of primary care docs and the purported exodus of RNs from nursing or can we see what is really going on if we follow the cynical but venerable follow-the-money rule. Here is DrRich's take from his June 17,2008 blog entry.

Having taken such careful pains to make primary care medicine so exquisitely unattractive to present and future physicians as to assure that the growing “PCP shortage” will become the next real medical crisis, the healthcare system is now grooming its solution to this manufactured crisis, namely, the doctor-nurses. These doctor-nurses will fulfill all the criteria the healthcare system desires for its practitioners of primary care medicine (no matter what healthcare reforms we may end up with). They will be “doctors” who are duly “certified” in primary care medicine by respected testing organizations, who have just enough training to diagnose and treat the average patient (i.e., the ones with high blood, low blood, fat blood and sugar), and who will cheerfully, unquestioningly (and with far better compliance than MDs - what with their traditions, attitudes, etc. - can ever hope to offer), follow whatever guidelines are handed down to them by the experts. And they will do it all for less pay and with less lip than the now-obsolete physician PCPs. These new practitioners of primary care medicine will be a perfect fit.

If you accept this analysis you can appreciated that Dr. Mundinger could have a conflict of interest as she is a board member of a organization that could profit from the care and feeding of this new breed of health care professional,namely (at least for a while) they will work cheaper.

Reports of potentially serious error in VA's computerized health records

The electronic medical record system at the VA system has for the most part received very high marks from various observers and users. However, problems with that system have recently hit the news after this report by a congressional committee.

Systems have problems and that should be no surprise but two particularly troublesome aspects have also come to light. One, there is the suggestion that this problem may have been keep secret (i.e. were not disclosed to the patients involved) and two the comments of a VA spokesman suggest that the patient should help the staff keep up with the treatment, etc. He is quoted as saying:

"VA believes that veterans are active partners in their health care, and encourages patients to always follow up with their health care teams to ensure that their treatment options meet their understanding and their health care needs."

Next time you are in the hospital semi- delirious with sepsis or a stroke be sure that dose of heparin or antibiotic is correct and conforms with what your physician ordered and that your needs are being meet.

Lilly pays big settlement in Zyprexa case

For marketing an off label use of Zyprexa, Lilly has agreed to to pay 1,42 billion .
The medication has FDA approval for treatment of schizophrenia and bipolar disease but it is alleged that Lilly vigorously promoted its use to control agitation in the demented elderly as well as in children with certain behavior disorders.A number of physicians, academic and otherwise, took part in various of these promotional activities.One promotional campaign was cutely named "Viva Zyprexa".

In 2007,sales for Zyprexa reached 4.8 billion with total Lilly drug sales of 18.6 billion.

As interns, we carried around black bags that were given to us on graduation from medical school.Lilly gave out those bags and they came with our names on the bag and I think a reflex hammer and tuning fork inside.Big pharma was known as the "ethical drug industry" back then.How the adjective became part of their designation I don't know. It seemed similar to the House Ways and Means Committee always being referred to as the Powerful Ways and Means.The later adjective still applies, not so much for the former one.

I have written about the Zyprexa saga before and in that blog quoted Dr. Patricia Illingworth:

"some commonly accepted principles of business ethics are fundamentally incompatible with medical ethics"

I believe that is true but what ethics precept could Lilly have possibly adhered to in regard to the Zyprexa promotional activities.

Organized Medicine jumps into the "lets Jump start" the economy bandwagon

Dr. Nancy H. Nielsen, president of the AMA, said at a recent press conference

" Health care reform is a key component to jump starting our national economy.....quality,affordable health care is..good for business."

For some reason, I am reminded of the old quote that "what's good for general Motors is good for the country" That quote , of course, has taken on new meaning in the bailout or bridge loan requested by GM. Now we have what's good for health care is good for the economy.

With the degree of direness indicted by the media regarding the financial mess some have suggested that health care issue might have to be put on the back burner for a while.The recent ad campaign by AMA and others ( PhRMa, Blue Cross- to name two) might appear to be an effort to put it back up front, to exactly what ends is not made clear. What is that big pharma and the AMA suggest that will reform health care and somehow also jump-start things? Stay tuned, the ads to come may clarify their goals.

If vague generalities can help jump-start the economy we are off to a good start.Everyone is lining up in Washington for their share of the "recovery" package. We should not be surprised that the AMA does not want to be left out .