Major cuts in Medicare Advantage postponed until after election

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

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]

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

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

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

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

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

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..

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?

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

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

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

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

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

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"

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.

More on the concept expressed by Goodhart's law

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

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?

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

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..

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 12.5 to 25 mg as measured in head-to-head studies by ambulatory BP measurement is consistently inferior to that of all other drug classes. Because outcome data at this dose are lacking, HCTZ is 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

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

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?

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

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?

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

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"

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

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?

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

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

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.

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

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

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,

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

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

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"?

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 policy  leader recommending price controls out of ignorance of basic economics or being aware of the likely outcomes and make that recommendation anyway?

 addendum: Minor editorial change made 5/3/15

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

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.