Individual risk assessment- Is that a concept that resists meaning?

Following the Annals of Internal Medicine's publication of the latest recommendations of the USPTSP regarding breast cancer screening, was an editorial by Dr. Karla Kerlikowske discussing the need for "individual risk assessment" of breast cancer.See here for excerpt, subscription required for full text

Previously it was a commentary in the same journal regarding breast cancer and the need for "better" (more accurate?) risk assessment in the context of whether women in the 40-49 age group should be advised to get a mammogram. I wrote this entry making the claim that at the core it is debatable if the concept of individual risk risk makes any sense at all as opposed to speaking of the risk of an event in a group of people.

Dr. Kerlikowske begin her final paragraph with this sentence:

We can improve primary and secondary breast cancer prevention effectiveness by implementing risk assessment in primary care and mammography facilities and providing tailored recommendations for prevention based on individual risk.

So what is this thing called individual risk and how do we determine it?

What follows is a re-write of my 2007 blog entry on this issue with the addition of skeptical comments by my brother, Jarrad ,who is a radiologist considering retirement.

Risk assessment for various medical conditions has become an everyday part of the activities of primary care physicians. Risk assessment involves the identification of something called risk factors, personal characteristics or test findings that are associated with increased incidence of a given disease. This term was coined by the researchers in the Framingham study when they spoke of factors that were associated with an increased risk of coronary artery disease. As the "practice model" of internist practices changes from hospital based consultation type to office outpatient, more attention is given to preventive medicine which is a world of risk factor identification and risk assessment exercises as well as recitation of various guidelines and targets or as Jarrad says treating folks who have no demonstrable diseases.

Here is an example of risk assessment using the equation from the National Cholesterol Panel's (NCEP) web site.A 67 year old non-smoking man, Mr. Jones,with a history of hypertension under control and systolic blood pressure of 120, with a total cholesterol of 170 and an HDL cholesterol of 75 would have a risk estimate of 9 % according to their risk equation.

This means that if we consider the 10 year health outcomes of 100 men from the Framingham data base with this particular set of characteristics, 9 would have a coronary event. (A so-called hard end point of either a myocardial infarction or coronary death.) Of course, we do not know who the 9 will be until the event occurs and we cannot tell Mr. Jones if he will be one of the nine or not raising the question of in what sense is this number "his" individual risk.

What does this" risk "of 9% for Mr Jones mean? Maybe the following mind experiment will shed some light on that. Let's pretend we can clone Mr. Jones and we do so 100 times and consider the question of what will be the outcomes of these 100 Joneses. Will 9% have a coronary artery event or will it be the case that either all will be fine or all will have a coronary event. (My gratitude again to Dr. Goodman and his memorable article in the Annals of Internal Medicine for this line of though that I blogged about here.)

If we believe in medical determinism- that clinical outcomes are determined by a causal chain of events-we believe that either all will be fine or all will have a heart attack. They will all be fine if they and the original Mr. Jones do not posses the factor(s) that sum up or interact to bring on an event or all will have an event if Mr. Jones had-as will all his clones have-whatever factor(s) known and unknown which determine a coronary artery event. If we believe in a cosmic dice roll then some 9% will have an event and medical science will never know ahead of the event who will because it is simply random.

Another consideration is that while we have placed Mr. Jones in this set of men with these particular features , we could have -if we had the data available-place him into a different set or as a member of as many sets as the imagination allows. We might consider him as a member of a set defined by his age, his c-reactive protein value, his performance on a stress test, his calcium score on a heart CT scan and his triglyceride level and if we consider the event rate in a group of men with these features we may well arrive a different value which could be 22%. So what is his risk- 9% or 22% or any of the multitude of other numbers that we could construct in a similar manner and are any of these numbers his individual risk? With the  publication of the 2013 Guidelines from AHA and ACC we have a  new prediction tool.Is the new tool better than Framigham and how do we make that determination? What if the expert panel who uses their new rule give recommendations and risk level cut points that differ from what the old expert panel with their predictions and rules? Doctor,were you wrong then or are you wrong now?

That type of consideration led the imminent German statistical theorist, Richard Von Mises to say in his book " Probability,Statistics and Truth" that it is only possible to speak of probability in terms of a collective (or in more modern terms -a set or a group) and that to say, for example, that a given person has the probability 0.10 of dying in the next year is nonsense. Yet, isn't this is exactly what we do when we we punch in a person's numbers into the Framingham equation and announce to the patient that his risk of a cardiac event in the next 10 years is 9%. ?

Jarrad,offers this: "But wait,if you believe that "determination" of individual risk is nonsense why is it that seemingly there are a number of very useful prediction models used by physicians for such things as risk or likelihood of pulmonary embolus given several clinical variables?In what way does the use of those prediction model equation differ from telling Mr. Jones that he has a risk of 9 % of a heart attack in the next ten years?"

Well,  I'm not sure but  one thing is usually those prediction models classify patients into low, moderate and high risk of the disease at issue and based on that certain further testing is or is not done and those strategies seemed to have been shown to work out reasonably well in clinical trials.Further the determination of risk in general terms ( low, medium, high) has at times been proven to be of clinical value in diagnosing pulmonary embolism or whatever, but telling someone their risk is 9% of a future disease is not per se an actionable item.We can link the numbers to some recommendations for statins or whatever but.... I am not sure there is any practical or useful outcome from that. Trying to figure out the best way to clinically manage someone with a given clinical picture is one thing, advising someone to take or not take statins or  bisphophonates based on some "determination" of her risk based on some expert panel's judgment is another matter entirely.Although I spent a number of years doing just that sort thing for many hours per week,now I am much less certain about the validity of the entire enterprise and whether I was doing my patients good or harm.

Obamacare's chief economist does not raise the important "and then what" question.

In a recent interview Dr. Jonathan Gruber,a MIT economist whose name is closely linked to ACA gave a broad outline of who gains and who looses as the legislation becomes operational. See here for details of the interview in the New Yorker article.

Here is the brief overview.

80% of folks are basically "left alone", as they will keep their employer sponsored medical insurance.
3% loose as they will no longer have their individual policies.
14% are winners as they will now be able to obtain medical insurance.

Since there seem to be many more winners than loosers, from a utilitarian perspective, the greatest good for the greatest number has been achieved  and ACA must be considered a success .After all, you know to make an omelet..

So, he seems to say " not much here to see, move one"

   However, there is much more to it than recitation of the alleged head counts of the various Gruber categories.

Economists such as Walter Williams and Thomas Sowell in talking about the economic way of thinking emphasize the importance of asking "and then what ". For example, if some one praises rent controls as providing affordable housing for the disadvantaged, the then-what question might lead to a discussion of how such measures typically result in a shortage of available housing , lower quality of the housing and possible black market behaviors and non-price based rationing.

Had Gruber asked the and-then what question in regard to ACA he might have begun a discussion about how much policies would cost in each subset-would the 80% be paying more or less and would the coverage be better or worse or unchanged. Or even as some reports indicate  (even one by the CBO) that significant numbers of the " left alone" 80% might loose their employer provided health care insurance although not necessarily for reasons directly related to ACA..See here.

The and then-what question could lead to consideration of the issue: will there be enough physicians to care for the significantly increased numbers of folks who have an insurance card. Will insurance companies be reimbursing health care providers at their current rate? Will insurance plans offer significantly less choice as to providers? Further, rules issued from HHS have put providers on the hook for service charges not paid by insurance after a policy holder defaults on their monthly premiums.See here. How far will the rule makers at HHS go as they are continually modifying the law go to minimize any lose insurance companies might incur in the exchanges? See here for a detailed analysis of some of the efforts from HHS to minimize those potential loses.Basically HHS rules changed the 90 grace period to a 30 day period during which insurance companies were at risk for reimbursement of of services rendered .

This day to day, or week to week, ad hoc, de facto central planning  which  "readjusting" of the provisions of Obamacare  as they were written continues in the rule making offices of HHS regularly shredding what is left of the rule of law. The lobbying and crony capitalism continues long after the president signs the law. The article 11 , section 3 part of the Constitution ( " he shall  take care that the laws be faithfully executed" ) might just as well never have been written.

How will the $ 700 billion cut in Medicaid funding which in part pays for Obamacare impact the care Medicare recipients receive? How will the $170 Billion cut in Medicare Advantage impact the quality of care of care of folks on those plans?

Gruber's discussion ignores the secondary effects and only looks at the head counts of those who keep insurance,those who loose it and those who gain it ignoring the cost and quality of coverage and access to care issues that are the unintended consequences.

You can easily see why the " and then what" question is something ACA apologists would rather not dealt with.

The dangerous shift from the medical ethics of the individual to the ethics of the collective

The long running,thoughtful  blog "DrWes" discusses an important issue .See here.

The author is Dr.Westby G. Fisher,a cardiac electrophysiologist from Illinois.
Quoting Dr. Fisher:

"Doctors are currently witnessing the profession of medicine moving from the ethic of the individual to the ethic of the collective. The passage of the Affordable Care Act has solidified this treatment ethic and, as a consequence, often creates conflicts between the treating physician and their individual patients.

Nowhere is this shift to the ethic of the collective clearer than our expanding attempt to determine treatment "appropriateness" using a look-up chart of euphemistically-scored clinical scenarios owned and trademarked as "Appropriateness Criteria®" or "AUC®" by our own medical professional organizations."

A important-perhaps critical-step in this shift was the effort to change medical ethics. At least nominally this has occurred. I believe this conceptual sea change  was largely brought about -at least in the United States- about by a relatively small number of physicians who I describe as the progressive medical elite. Influential folks in the American College of Physicians and the American Board of Internal Medicine and its foundation , the ABIM Foundation, are among those who have lead the charge.I have written about this development more than once. See here  details on this sea change in ethics.

These new ethics and a movement labelled medical professionalism  push the fiduciary duty of the physician to the patient past the back burner and attempts to shove that notion into the memory hole. This duty has ( had?) been the fundamental core of the physician patient relationship. Try and find the word "fiduciary" in the most recent rendition of medical ethics from ACP or in the white paper on Medical Professionalism.

The first encounter I had with this notion of treat the collective not the patient was in a series of articles in JAMA in 1995 written by  Dr. David Eddy in which he promised to show the medical world how to increase quality while conserving costs. The answer was simply to allocate resources in a medical collective ( such as an HMO) using some version of cost benefit analysis so as there would be achieved the greatest benefit to the greatest number, i.e. utilitarianism.Letters to the editor raised the issue of the upending of traditional  medical ethics, the tort system which did not and does  not recognize a utilitarian defense of harming the individual patient  to benefit some statistical aggregate  and the basic human tendency to act in one own perceived best interest and those of their family and not that of some possibly hypothetical collective.The dogs barked and the caravan moved on and currently we see that this duty to the collective notion has hijacked traditional medical ethics and I fear is doing the same to medical education.

ACA's IPAB and Platonic Medicine led by Platonic guardians

 A recent commentary by one of favorite bloggers,Dr. Robert Centor, spoke favorably about IPAB, one of many,many provisions of ACA.See here.I made a brief reply to his entry. I recalled my earlier blog entry and if Dr.Centror's comments stir up much furor  I want to add this earlier blog post to the kerfuffle.Originally published  6/22/11 and now submitted with little editing:
----
I had been sketching out some comments about what I was going to call "Platonic Medicine" referring to the "leaders with ideas" who will lead the way to transform medicine based on the underlying premise that "medicine is too complex and important to be left to the individual physician and the individual patient" and therefore it should be controlled and directed by the wise medical elite who will determine the collective utility of a given approach and its value.I have commented before about Don Berwick's advocacy of that view.

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

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

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

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

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

 Consider the following: The federal government establishes a body, which is politically appointed and whose decisions will direct impact hundreds  of  millions of dollars of health care expenditure.Will it be likely or unlikely that interested parties,the usual suspects in the health care "system",will do everything they can to influence the composition  and decision of that board.

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

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

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


"we ought to consider setting all payer-rates for providers." He continues "but the country's antigovernment mood renders such a discussion unlikely,at least for now".

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

Finally, another chilling quote from Mr. Jost:

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

Yeah, it just might be.

some of the week that was in the commentary regarding the magestic unfolding of Obabacare

1. Don Boudreaux , economist from George Mason University, blends the history of the Plymouth Colonies,Thanksgiving, the purported right to health care, ACA  and the incentive problem with his typical trenchant style , See here.

Referring to a recent article suggesting a significant increase in the numbers of Medicaid patients resulting from implementation of Obamacare would aggravate the already problematic doctor shortage , Professor Boudreaux said :

"This historical experience [ referring to the Plymouth colony's failed experiment in communal ownership] contains a lesson for health care.  The problems highlighted in your report – a surge in health-care consumption along with a shortage of health-care resources – is a predictable result of turning health care into a common-property resource.  Consumers have fewer incentives to consume it wisely while physicians and other health-care providers have fewer incentives to supply it in quantities sufficient to meet all of the demands for their services."

 The colonists in Massachusetts figured it out in the 1600s what  finally hit the leaders in the USSR when that  failed economic experiment imploded in the early 1990s.

Communal ownership of health care resources is a theme that the medical professional elite has put forth for some time, perhaps beginning with the lame analogy between health care resources and the so called  tragedy of the commons the coining of which is typically  attributed to  Garrett Hardin in a 1968 article.Later Dr Howard Hiatt wrote in the New England Journal of Medicine in 1975 : " the total resources available for medical care can be viewed as analogous to the grazing areas on Hardin's common."

 The absurdity of this analogy was dealt with in some detail here but the notion of medical care as a common property issue has flourished in the medical policy literature and gave birth to the meme
popular in progressive medical thought leader circles that physicians have an ethical duty to be stewards of the [mythical]  medical resources.To promote this stewardship theme and to to conserve these limited common resources  appears to be the reason for existence of the American Board of Internal Medicine Foundation  with its" choosing wisely" campaign which in turn is well funded from the Robert Wood Johnson Foundation.It should not go unnoticed that one of the authors of the New Medical Professionalism which promotes social justice as a ethical imperative  is current leader of the RWJF amd she was at the time of that pronouncement was sent forth.

2.The related topic of appropriateness guidelines is discussed by Dr. Westby Fisher in his blog "DrWes" . He traces the origin of that movement to the Rand Corporation in the broader theme of  the tension between the medicine of the individual and the medicine of the collective..See here.

quoting Dr.Fisher:

"Doctors are currently witnessing the profession of medicine moving from the ethic of the individual to the ethic of the collective. The passage of the Affordable Care Act has solidified this treatment ethic and, as a consequence, often creates conflicts between the treating physician and their individual patients.
Nowhere is this shift to the ethic of the collective clearer than our expanding attempt to determine treatment "appropriateness" using a look-up chart of euphemistically-scored clinical scenarios owned and trademarked as "Appropriateness Criteria®" or "AUC®" by our own medical professional organizations."

I did not realize that the organizations of cardiologists were as aggressive as the ACP and the ABIMF in their efforts to institutionalize guideline medicine  and  minimize the individual physician patient decision making process.

3.Dr. Robert Centor, one of my all time favorite medical bloggers, opened the can of worms of IPAB , a topic that had become somewhat dormant. He expressed support for IPAB and this was meet by several letter writers voicing the opposite view.See here. For those of us who believe that Public Choice theory is largely correct and worry about regulatory capture and cronyism  ,there is much to worry about with IPAB.

 4.More and more economists and others have been writing about what they believe to be the very  real possibly of the insurance exchanges,critical to the viability of Obamacare,entering into some type of Greek tragedy death spiral. Seth Chandler,a law professor who is a specialist in insurance law at the University of Houston Law school does a great job of very detailed and nuanced analyses of many of the incredibly complicated and complex details of that law and of the still emerging regulations that further define its operational meaning makes predictions iffy since may change tomorrow. See here for Prof.Chandler's blog.
Even NPR seemed to recognize that some called a death spiral could actually happen.

Do the new medical professionalism and new ethics conflict with the notion of "rule of law"?

Both the new medical Professionalism and the current rendition of the ethics of the American College of Physicians have added to the long standing ethical precepts of  patient welfare and patient autonomy the ambiguous notion of "social justice".I use the term "ambiguous" because in neither proclamation do the authors clarify exactly what they mean by social justice.Later writings by the ABIM foundation,an organization closely linked to the ACP seem  to equate social justice to conservation of medical resources which seems to me to be at best an idiosyncratic use of the term.

Although many  would consider social justice to be something along the lines of  " trying to help the less fortunate " or at least a sincere concern for the disadvantaged, many equate social justice to re distributional justice and that  seems to be a widely accepted meaning. Against the first informal definition few would raise objections but there is a long history of political economic thought in opposition to the second including principles prominent  in the founding of the United States and dates back at least to John Locke and others typically characterized as classic liberals.

So what does the quest for social justice have to do with the rule of law?

According to some,most notably,  F A Hayek, social justice in the sense of distributive justice is inherently incompatible with the rule of law.Basically this is because the progressive philosophical position which include efforts to bring about social justice favors  efforts to redistribute resources or services to lessen inequality along some purported  axis while the rule of law proposes treating everyone the same and promotes the rule of law as opposed to the rule of man. The progressives  oppose treating everyone the same because treating unequals equally likely results in no lessening  of the inequality which is the "polar star" of the progressives much as liberty could be said to be the polar star of the classic liberal thought, now referred to as libertarianism.

Hayek speaks of social justice a being "devoid of specific meaning " but "fraught with insinuations" that are dangerous and erroneous. He believed that people who use the term do not know themselves what the mean by the term.

To Hayek justice referred to a process while the progressives  (on modern liberals) consider justice as a result. Hayek favored a society in which coercion was limited as much as possible  and believed human freedom was dependent on general rules that carved out domains of activity that were exempt from government power.

The classic liberal view point  strands in clear opposition to the  view espoused by the modern liberal  also known as progressive. If there is a cogent argument for the proposition that a physician must adhere to the progressive view and act accordingly to be considered ethical it has not been made. Rather certain organizations- most prominently The American College of Physicians and the American Board of Internal Medicine Foundation- have gratuitously asserted that support of social justice is a fundamental precept of medical ethics and medical professionalism.These advocates have attempted to make a political goal ( redistribution and social justice) an ethical requirement of physicians.

Dr Thomas Huddle of the University of Alabama Medical  School said:

"Advocacy on behalf of societal goals... is inevitably political".
and
" civil virtues are outside of the professional realm" and " the profession of medicine ought not to require any political stance".

Dr Huddle co-authored the following along with Dr. Robert Centor:

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

So, in answer the the question posed by the title-yes. Would physicians hung up on the archaic notion of the rule of law be considered unethical?

 Minor changes ,word order and spelling, made on 7/31/14 and again on 8/15/14 and 8/31/14.

More emerging aspects of the great kaleiscope of the Obamacare debacle

1. Contrary to the silly claim made in the even sillier comparison between Obamacare and Katrina  that " at least Obamacare  did not kill anyone ", well it just might. See here. for economist John R Graham's discussion about ACA and the median voter. He references the WSJ article about Edie  Sunby whose medical insurance policy was cancelled after the insurer has paid out 1.2 million dollars for treatment of her rare cancer.Apparently her options to purchase insurance now does not include plans that provide care at the specialized institutions necessary for her treatment.Maybe that is not a matter or life and death but then again..

2. Reports suggest that the health care insurance policy cancellations seen so far are just the tip of a very large iceberg .Is the 100 million more cancellations  projection from AEI just predictable  anti-Obamacare spin and Casandra talk or are they on to something.Seth Chandler from the University of Houston, in his new blog, provides a detailed and nuanced analysis. His bottom line seems to be is maybe 15 million is a more realistic guesstimate.See here. Professor Chandler's legal analysis may well be correct in saying that many small employers will be impacted by the law and the fall out would be more policies cancelled. The big but here is that so far in regard to Obamacare the administration has seen fit to delay execution of various aspects of the law when that is the politically advantageous thing to do.There is an election in 2014 and one does not have to be excessively cynical to think that they will do everything they can to postpone what ever they can to try and salvage the 2014 election.


3. Has Obamacare violated the primary rule of redistributional politics? The rule is: diffuse the cost and focus the benefits of  any redistribution scheme. With ACA many folks are getting the bill and realizing who is paying for it.See here for comments regarding this rule violation from the blog Pileus who raises the question has the Obama administration's hubris been so great as to think they need not heed this fundamental law. Speaking of law violation it may be that the administration plan of "fixing" the clown car health care website by putting more programmers and very smart people on the project  violate Brooks's law that states:"adding manpower to a late software project makes it later".

4.This is not a new thought but it needs to be repeated. Obamacare is the biggest example of crony capitalism ever. Think about it. Everyone  (almost except ,for example, the Amish) is forced to buy the health care insurer's product,and if someone can't afford the government will provide a subsidy. And if that was not enough ACA provides various safeguards to the insurers that minimize any losses they may incur in the exchanges in the form of reinsurance and risk corridors. See here for details of that.What do you expect when a former VP from Wellpoint was hired by the Obama administration to help write and then to help implement the law. See here for details about Elizabeth Fowler and what executive position she now has in a health care related company.

5.I wonder if many members of the American College of Physicians have embraced the college's program for helping patients sign up for the exchanges.Maybe it is more successful than the government website.See here.

6.United Health cuts thousands of physicians from its roster , See here. This is mostly from their Medicare Advantage Programs which have already or will soon experience cuts from Medicare. You may remember that this funding mechanism for Obamacare was postponed until after the last national  election to avoid the wrath of medicare voters being manifest as votes for Republicans.

Medical Insurance cancellations-A feature not a bug of Obamacare

Those who believe it is a feature argue something like the following:

Part of the funding for Obamacare was supposed to come from forcing young,healthy people to purchase more expensive insurance so that older,less healthy folks could have their insurance subsidized. This was an essential part of the redistribution of the law thought necessary for the economic viability of the insurance exchanges. It was thought to be politically expedient to claim that no one would loose their insurance and no one would loose their doctor so  the plan could be sold to the public.With the outcry from many of those who in fact did loose their plans, it became politically expedient to postpone or pretend to postpone those cancellations for at least some of those people until the next Congressional election,whether the President has the legal authority to do so or not .

Those who believe it to be a bug and therefore fixable argue the following;

Well, I guess no one actually believes that but the House of Representative has passed a bill with the apparent assumption being that it is a bug and we can fix the problem by not allowing insurance companies to cancel policies  because those polices do not meet the law requirements .But if the cancellations are a feature and necessary for the success of the insurance exchanges, the administration cannot allow that bill to become law and the President has threatened to veto .I wonder if any of the representatives who voted for the abolition of the  cancellations or the Senators who are proposing something similar think they are fixing a bug or realize the entire economic survival or the bill is at stake or do they just think that is politically expedient.

"The curious task of economics..."

More Obamacare "Social justice": cutting subsidies for charity medical care

Dr John Goodman's website explains what is happening. See here. Less money will be paid by the government to hospitals that provide medical care to indigent patients.

A number of well known hospitals ( e.g. Parkland in Dallas,Grady in Atlanta, etc) provide much medical care to indigent patients. The federal government through the Centers for Medicare and Medicaid have provided significant subsidies under a program referred to disproportionate share payments.

One of the mechanisms devised to fund the health care transformation known as ACA is to make significant cuts in this program.

Quoting from a recent  ( see here) NYT article:

“We were so thrilled when the law passed, but it has backfired,” said Lindsay Caulfield, senior vice president for planning and marketing at Grady Health in Atlanta, the largest safety-net hospital in Georgia.
 
 As Obamacare unfolds we are seeing more than a little backfiring.

 And this quote from my favorite Louisiana economist, Dr. Don Boudreaux writing in his blog  " Cafe Hayek"

" In the 18th century, Adam Smith launched the discipline of economics by explaining that intentions are not results, and that the complexity of a real-world economy nearly always overwhelms and confounds the hubris-intoxicated “man of system” who aims to improve matters through government intervention."

The most generous interpretation of the comments from spokespeople from AMA and ACP when they lauded ACA as a fountainhead of social justice  is that they were enamored with the purported intentions of ACA and naively believed that intentions equaled results.   

The cuts in subsidies for safety-net hospitals like Memorial — those that deliver a significant amount of care to poor, uninsured or otherwise vulnerable patients — are set to total at least $18 billion through 2020.  The government has projected that as much as $22 billion more in Medicare subsidies could be cut by 2019, depending partly on the change in the numbers of uninsured nationally. - See more at: http://healthblog.ncpa.org/tattering-the-safety-net/#sthash.O6he8bDl.dpufThe cuts in subsidies for safety-net hospitals like Memorial — those that deliver a significant amount of care to poor, uninsured or otherwise vulnerable patients — are set to total at least $18 billion through 2020.  The government has projected that as much as $22 billion more in Medicare subsidies could be cut by 2019, depending partly on the change in the numbers of uninsured nationally. - See more at: http://healthblog.ncpa.org/tattering-the-safety-net/#sthash.O6he8bDl.dpufThe cuts in subsidies for safety-net hospitals like Memorial — those that deliver a significant amount of care to poor, uninsured or otherwise vulnerable patients — are set to total at least $18 billion through 2020.  The government has projected that as much as $22 billion more in Medicare subsidies could be cut by 2019, depending partly on the change in the numbers of uninsured nationally. - See more at: http://healthblog.ncpa.org/tattering-the-safety-net/#sthash.O6he8bDl.dpufThe cuts in subsidies for safety-net hospitals like Memorial — those that deliver a significant amount of care to poor, uninsured or otherwise vulnerable patients — are set to total at least $18 billion through 2020.  The government has projected that as much as $22 billion more in Medicare subsidies could be cut by 2019, depending partly on the change in the numbers of uninsured nationally. - See more at: http://healthblog.ncpa.org/tattering-the-safety-net/#sthash.O6he8bDl.dpuf

Recent Bits and pieces about Obamacare

 Here are few items of possible interest regarding ACA, some fairly trivial,others more significant.


1. Bob Doherty of the ACP blog ACP Advocate takes the difficult-to-defend position that Obamacare is not paternalistic or maybe not at least part of it..See here. Let''s see- we have a law that forces folks to buy a product they may not want and fines them if they don't because it is really for their own good.What definition of paternalism does Mr. Doherty have in mind?  He may have been better off to use the Seinfeld defense and say "not  that there is anything wrong with it".

2.Does Obamacare violate the iron principle of  politics?  See here. That rule is: focus the benefits and diffuse the cost.  In Obamacare we are now seeing focused costs, e.g on . those folks with insurance policies that are now being cancelled and have to pay more for policies that offer coverage they neither want nor need.'The poster child for this type thing is the widely circulated comment to the effect that I was in favor of Obamacare until I got the bill. The authors of the above referenced link wonder if the hubris level of the current administration is so high that they (he?) believed that they could violate that law with impunity.

3.John Goodman asks if the Obamacare bureaucracy become a virtual "deep state" See here. The term refers to the situation that once existed in Turkey in which army had become so powerful if was uncontrollable and unstoppable.Quoting Goodman:

The healthcare bureaucracy’s status as a “deep state” is an important factor explaining why ObamaCare is unfathomable. Politicians have little control over this deep state, so they simply grant it more and more power. Philip Klein of the American Spectator went through the law and counted over 700 stipulations which contained the term “the Secretary shall“, over 200 cases of “the Secretary may“, and 139 cases of “the Secretary determines.”
Of course, it is now clear that Secretary Sebelius did not make any serious determinations. Rather, they have been made by many unidentified career agents of healthcare’s deep state, who spend their days responding to lobbyists’ “concerns” about this rule or that regulation, while drafting thousands of pages of impenetrable regulatory guidance.
- See more at: http://healthblog.ncpa.org/the-deep-state-in-american-health-care/#sthash.tSeR6xUi.dpuf

"The healthcare bureaucracy’s status as a “deep state” is an important factor explaining why ObamaCare is unfathomable. Politicians have little control over this deep state, so they simply grant it more and more power. Philip Klein of the American Spectator went through the law and counted over 700 stipulations which contained the term “the Secretary shall“, over 200 cases of “the Secretary may“, and 139 cases of “the Secretary determines.”

Of course, it is now clear that Secretary Sebelius did not make any serious determinations. Rather, they have been made by many unidentified career agents of healthcare’s deep state, who spend their days responding to lobbyists’ “concerns” about this rule or that regulation, while drafting thousands of pages of impenetrable regulatory guidance."


4.Does anyone know how many folks will ultimately loss their current health care coverage? If item 3 is true there may be no way to predict unless and until the controlling rules are made by some apparatchik within HHS.No one knows but  here is one recent speculative analysis that projects losses much greater than those affecting holders of individual policies as it may impact holders of some employer plans.Projections are fragile because the Secretary of HHS ( or someone there ) may issue an exception to some and not others at any time.









-

The healthcare bureaucracy’s status as a “deep state” is an important factor explaining why ObamaCare is unfathomable. Politicians have little control over this deep state, so they simply grant it more and more power. Philip Klein of the American Spectator went through the law and counted over 700 stipulations which contained the term “the Secretary shall“, over 200 cases of “the Secretary may“, and 139 cases of “the Secretary determines.”
Of course, it is now clear that Secretary Sebelius did not make any serious determinations. Rather, they have been made by many unidentified career agents of healthcare’s deep state, who spend their days responding to lobbyists’ “concerns” about this rule or that regulation, while drafting thousands of pages of impenetrable regulatory guidance.
- See more at: http://healthblog.ncpa.org/the-deep-state-in-american-health-care/#sthash.tSeR6xUi.dpuf

The healthcare bureaucracy’s status as a “deep state” is an important factor explaining why ObamaCare is unfathomable. Politicians have little control over this deep state, so they simply grant it more and more power. Philip Klein of the American Spectator went through the law and counted over 700 stipulations which contained the term “the Secretary shall“, over 200 cases of “the Secretary may“, and 139 cases of “the Secretary determines.”
Of course, it is now clear that Secretary Sebelius did not make any serious determinations. Rather, they have been made by many unidentified career agents of healthcare’s deep state, who spend their days responding to lobbyists’ “concerns” about this rule or that regulation, while drafting thousands of pages of impenetrable regulatory guidance.
- See more at: http://healthblog.ncpa.org/the-deep-state-in-american-health-care/#sthash.tSeR6xUi.dpuf

The healthcare bureaucracy’s status as a “deep state” is an important factor explaining why ObamaCare is unfathomable. Politicians have little control over this deep state, so they simply grant it more and more power. Philip Klein of the American Spectator went through the law and counted over 700 stipulations which contained the term “the Secretary shall“, over 200 cases of “the Secretary may“, and 139 cases of “the Secretary determines.”
Of course, it is now clear that Secretary Sebelius did not make any serious determinations. Rather, they have been made by many unidentified career agents of healthcare’s deep state, who spend their days responding to lobbyists’ “concerns” about this rule or that regulation, while drafting thousands of pages of impenetrable regulatory guidance.
- See more at: http://healthblog.ncpa.org/the-deep-state-in-american-health-care/#sthash.tSeR6xUi.dpuf

Modern legislation as "emergent phenomena" AFTER the bill is passed

One of George Will's more valuable insights is that Congress does not pass legislation anymore but rather passes "intentions". I would add to that the modifier ""purported" to make the designation "purported intentions". Some and often much of actual meat of the bill or the devilish details are filled in later by various bureaucrats and government appointees in various agencies committees and Cabinet posts. The Affordable Care Act and the Dodd-Frank bills are recent egregious examples of that phenomenon.


Many of the actual operational details of both bills are still being written by various governmental entities several years after the President signed them into law.These details are emergent phenomena of the actions and interactions of various agencies as they write the regulations that define bills with varying degrees of influence from various interested parties politely referred to now as stakeholders.

Of course, even as Congress passes intentions some very specific items do end up in legislative acts that favor one or another special interest For example, the big hospital lobby was rewarded for their support of ACA by an exemption for a number of years (I think until 2020) from the edicts of IPAB and also the outlawing of new physician owned hospitals eliminating one source of competition .There may well be other nuggets of pork in the hundreds of pages of ACA that benefit Big Hospitals. The more complex,arcane and opaque the legislation the better is it ,both from the point of view of the law and rule makers and the special interests and their lobbyist wise guys.

Nancy Pelosi was only partially right in her famous statement that we have to pass the bill (ACA) to see what is in it.Actually we only got to see some things in broad general terms and some specifics that typically favor some interest group but have to wait varying periods of time for important elements of the bill that will be written by various governmental entities. Two years later for ACA the details are still gradually being determined and issued as bureaucratic edicts which for the most part are immune from appeal.


Since the much of real meat of the health care legislation is still being written meaning what ACA would do was unknown at the time of the commentary leading up to its passage. How could anyone rationally support the bill.How could medical organizations such as AMA and ACP lobby for the bill when the details that constitute the real effects of the bill were unknown and unknowable.They could likely only support the purported intention of the bill.

The legislative process is a push and pull of various interests and coalitions and horse trading and lobbying and the final bill emerges but the emerging is only begun as some of the particulars will only emerge from the push and pull of various administrative and regulatory entities as they plod along with their various administrative bureaucratic characteristics as they too are influenced by specific lobbying forces.The wheels and levers of crony capitalism do not stop when the president signs the bill.

Thomas Sowell in in his 1980 masterpiece Knowledge and Decisions warns against "characterizing process by their hoped-for results rather than their actual mechanics". Praise for ACA from AMA and ACP because it purportedly furthered social justice lacks basis as no one could know what the end result would be for social justice or anything else as many of the real defining characteristics of the bill were unknown at the time ( and in many regards remains so today).One can argue that giving insurance cards to 30 million people will result in a struggle to find a physician for everyone and in that struggle (as in most struggles) the poor will lose out as it will be the folks with more money and contacts,education and social skills who are in the front of the waiting lines . Giving 15 million people more Medicaid cards out may not be doing any favors to those folks as currently there are far too few physicians who will accept Medicaid patients. Further, as Dr. Scott Atlas has pointed out some studies show that Medicaid patients receive health care inferior to that received by patients who have no health insurance at all.

Dr Donald Berwick,the short lived director of CMS, said that good health care was by definition redistribution. ACA will result in redistribution.Will the poor and uninsured be the recipients of the redistribution or will the recipients more likely be big pharma,big hospitals, big health care insurance and big health care IT?

Are the cancelled health care policies really "substandard" or is that another misleading statement?

The spin being spun by the ACA apologists regarding the hundreds of thousands of medical insurance policies that have been cancelled is that those policies were "substandard" and those misguided policy holders will be much better off because they will be forced to buy the good kind of insurance they should have had anyway if they knew what was best for them and or if those " fly by night" insurance companies had not screwed them over. One commentator had the audacity to suggest that the administration should be bragging about it.

See here for a thoughtful refutation of that simplistic dismissal of what is a really big deal for thousands of Americans who liked their policy but cannot keep them as promised. One site described President Obama's often quote comment in that regard as simply  "misleading" and another as the president simply " misspoke" .The entire run up and sales job for the passage of ACA could generously be described as misleading while one health care blogger suggests that fraudulent  is a more apt descriptor.

Another critique of the "substandard policy" excuse is offered by the economist, Tyler Cowen here.

It is an empirical question as to whether their new, to be purchased plan is better or worse that the cancelled plan. Many opponents of ACA have the quaint view that the individual should make that decision while many proponents of ACA believe that such decisions are better made by experts.The issue is who should make that decision as to what type health insurance a person should purchase. Prior to ACA that decision process also included the prior question of should you buy any at all, most folks have been relieved of having to make that decision.

John Goodman has this excellent summary of what has happened so far  and how the public was mislead about what what going to happen .

Peter Boettke has this excellent commentary in which he has an opportunity to bring out the money quote by FA Hayek. which is :

"The curious task of economics is to demonstrate to men how little they really know about what they imagine they can design."
 
Certainly, that would apply to the web site and I afraid  to most of the rest of Obamacare.

Goodman and other economists pointed out from close to day one the problems with ACA  while  the general public was largely kept in the dark by the unrelenting repetition of the major talking points  (you can keep your health care plan, your doctor, etc) by the administration and the echo chamber of the main stream press and the complicit actions of big insurance and the progressive medical elite who manage  the major medical professional organizations. (AMA, ACP etc).

The politicalization of medical ethics

The politicization of medicine is a topic raised and discussed cogently by Dr. Thomas Huddle. See here for an abstract of his article.

First, with the publication of the Charter, Professionalism in the New Millennium in 2002 the notion of social justice was injected into the listing of attributes and behaviors that physicians should exhibit to act professionally.

Subsequently a commitment to social justice was declared to be an ethical imperative in the American College of Physicians'  (ACP) ethics manual. Other professional organizations followed suit pledging at least rhetorical support of the inclusion of social justice into their ethical propositions.

 Dr Huddle, who teaches at University of Alabama Medical School at Birmingham, says in part:

"Advocacy on behalf of societal goals... is inevitably political".

" civil virtues are outside of the professional realm" and " the profession of medicine ought not to require any political stance".

Requiring a commitment to social justice is clearly  political and requires physicians to take a particular political stance .Advocacy for social justice is one feature of the modern liberal or progressive political stance.Such advocacy is not typically part of the conservative political viewpoint or the libertarian ( aka classical liberal) position.

The notion of justice upon which which the country was founded  was that of the justice embodied in the rule of law,i.e. treating everyone equally under the law. The foundational notion of the social justice line of thinking is essentially that treating folks who are unequal equally is unfair and unjust and therefor there must be societal  effort to mitigate inequality by redistributional efforts of the state.

The physicians who authored the Charter and the ACP's new ethics would appear to be of the progressive persuasion while there are many physicians in the country who are not. A small group of what I have labeled as the medical progressive elite have seemingly captured the conversation and are attempting to  profoundly alter traditional medical ethics.To the extent that they and similar minded individuals set the agenda of major medical professional organizations and medical students education they may have succeed. but I wonder how many practicing physicians are even aware of the views that they pretend to be a settled issue.

ABIM Foundation reveals how physicians can further social justice

Older physicians,inculcated as they were with outmoded,no longer applicable in the new millennium, ethical principles might have wondered how they should put into practice the newest addition to the ethical pillars of medical practice.The new addition, of course is social justice.

Social justice is part  of the new professionalism and also of the new latest version of Medical Ethics as conceived  by the America College of Physicians.

Fortunately-for those puzzled doctors-there is an organization whose professed reason for existence is to "advance medical professionalism and physician leadership in quality assessment and improvement". We will be instructed about professionalism and also how to strive for social justice.When social justice was proclaimed as the third pillar of professionalism we were given a broad charge, ambiguous and lacking in operational details. Put simply- how do practicing doctor "do" social justice.

In the July 19,2013 edition of the Medical Professionalism blog we get the answer. We physicians are to bring about social justice through "just distribution of resources and stewardship of resources".

 As enlightening as this may be ,some of the older physicians wonder what is their definition of "just".  My intuition is that later we well be told ( we may well have been told that already) that just distribution is  the distribution that results from a cost effectiveness driven set of guidelines which just happens to be the same way that operationally the rank and file docs can be said  to act as stewards of resources.

Here is another quote from the ABIMF's blog that attempts to elucidate the notion of just distribution
  ( my bolding):

" While meeting the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources. They should be committed to working with other physicians, hospitals, and payers to develop guidelines for cost effective care. The physician’s professional responsibility for appropriate allocation of resources requires scrupulous avoidance of superfluous tests and procedures. The provision of unnecessary services not only exposes one’s patients to avoidable harm and expense but also diminishes the resources available for others."

Physician are admonished to strive for a fair and cost effectiveness allocation of medical resources.Presumably the allocation must be both. While the methods of cost effectiveness analysis are well known and explicit- though not without serious criticism- the term "fair" is as ambiguous,vague and without obvious operational details as is the term social justice and is as subject to varying meanings.

 Philosophers have thought much and written a great deal on justice and on fairness.There is much that two of the 20th century's most  noted philosophers disagree about but John Rawls and Robert Nozick seem in general agreement that utilitarianism did not conform with their notions of justice and fairness.  The utilitarian approach does not respect the separateness of individuals and it may treat individuals as pawns in some social scheme allegedly bringing about some hypothetical, aggregate good or utility.Utilitarian theory is basic to cost effectiveness analysis as benefits and costs are aggregated over a group of people and it is the group analysis that trump a given individual's benefit or loss.

The philosophical mavens at the ABIM Foundation presume to instruct physicians on proper professionalism by advocating cost effectiveness analysis and the "appropriate guidelines " that follow. So, in the formulation declared to the ethical law of the medical land physicians are to strive for social justice by being committed to develop guidelines for cost effective  medical care.

 Then the question is raised: is cost effectiveness allocation of medical resources socially just?Is the  recently crowned new ethical precept,social justice, actually  achieved by allocating medical resources by guidelines derived from cost effectiveness studies? The third party payers would be joyous if that link were accepted. That is a topic for later comments.I am still trying to get my thinking around the notion that cost effectiveness furthers social justice.

addendum: Minor editorial changes done on 6/8/14 correcting a few typos and punctuation issues.

Don Berwick on the NHS ..."unique example for all to learn from and emulate""-after examing the Mid Staffordhire horror show

Here is the entire sentence from which part of this posting's title derives:

"You are stewards of a globally important treasure: the NHS. In its form and mission, guided by the unwavering charter of universal care, accessible to all, and free at the point of service, the NHS is a unique example for all to learn from and emulate."

 That quote is from a letter from Dr. Berwick to officials of the NHS as part of the report from the committee he chaired to investigate the egregious treatment of patients at a NHS hospital,the Mid Staffordshire.

See here for Greg Scandlen comments in a  blog entry entitled "The Real Don Berwick"

In Scandlen's commentary there is a description of the horrible things to which patients were subjected and excerpts from the committee's report.

I cannot resist one other quote, this one from Paul Krugman.

"In Britain, the government itself runs the hospitals and employs the doctors. We've all heard about how that works in practice .Those stories are false."

The following is  from Berwick's  book written with the current Vice president of CVS Caremark (Troyen Brennan)

 "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.

So how did those appropriate rules with authority work out for those victims of the NHS? Was there too much residual "decentralized decision making"

Maybe one lesson to learn from the NHS tragedy is when no one is accountable or responsible, some really terrible things can happen. Berwick's committee did find that no one was really at fault."NHS staff were not to blame".

OK,one more quote, this time John McEnroe's  "you gottta be kidding me"

Another lesson all can learn from the NHS is how incredibly bad their electronic record system worked. See here for a report of what some have called the biggest IH foul up ever.

Obamacare-"Law of the Land"except those parts that the administration Postpones or exempts the favored from

As opposition to Obamacare grows even as deadlines loom for its implementation,the dwindling numbers of defenders issue increasingly strident and lame defenses.

Members of the administration as well as Paul Krugman  blatantly proclaim Obamacare is the "law of the Land" and is no longer a political matter. The administration that has done much damage to the rule of law in the way it has selectively enforced, or postponed  or issued exemptions to the law has the audacity now to claim it is the law. As least those parts they it deems to be politically expedient."No longer a political matter"- really, the way it has been arbitrarily administered has been nothing but politics.

The ACP Advocate blog has recently  questioned the ethics of physicians who would refuse to help their patients to sign up for the plan and of those physicians who bring their anti-Obamacare views into the examination room. No, the blog did not say it was unethical but just raised the issue and used the term "borderline unethical".(I wonder if saying they were unethical would be libel per se.Further, the blog writer, Bob Doherty ,ACP's  Executive VP and governmental affairs man in Washington, challenged the claim that Obamacare will damage the physician-patient relationship  with the astonishing counter claim that  Obamacare might actually strengthen the physician-patient relationship.See here for that blog entry and a series of  related commentaries.

 I argue that this relationship is not a function of insurance or its lack  but rather it is based on the patient's belief that the doctor is acting in the best interests of the patient, treating him with respect, respecting his autonomy  and maintaining confidentiality. To the degree that Obamacare encourages physicians to join ACOs there may well be a tendency for the patient's trust to diminish as has been the case in some HMOs if and when the patients sense that the organization's interests  clash with his own and that his physician's income depends of adhering to the policies of the HMO-ACO-vertically integrated health care entity. Does anyone believe that HMOs have strengthened the physician-patient relationship?

I find it interesting that a ACP sponsored blog raises the issue of physician-patient relationship in  in regard to Obamacare.IMO it has been the efforts of ACP,along with  the ABIM foundation, to promulgate the new medical ethics and the "professionalism for the new millennium" that has damaged the physician-patient relationship by sneaking into medical ethics the concept of the physician having a co-duty to the patient and to society to the determent of the traditional physician's fiduciary duty.

ACP proposed ( and now seems to assume it is accomplished) a major change in medical ethics ( adding social justice and physician obligation to conserve "society's resources" ) and then with an apparent straight  face claimed there was really nothing new there at all. See here for a detailed discussion of this disingenuous tactic.

The new medical ethics and professionalism is good news for the viability of the ACOs

If most physicians believed and acted as if they were the fiduciary agent of their patient ( as was once their primary ethical imperative ) the new highly touted Accountable Care Organizations (ACOs) would be doomed to failure. They may fail anyway because the new ethics is not a sufficient condition for ACO and maybe not be necessary either but it sure won't hurt.

The new ethics has paved the ethical road for bigger medicine -in the form of ACOs and other vertically integrated health care entities..What was needed to be done was to change the role of the physician from steadfast advocate for the patient, which often put him in opposition to the insurance company,to a more compliant worker working with the suits to "conserve society's medical resources" and thereby enhance the bottom line of the organization.

   To accomplish that, long standing  medical ethical principles had to revised. These venerable precepts were welfare of the patient and preservation of patient autonomy. The new ethics architects did not launch a honest frontal attack on primacy of patient welfare but rather sneaked in a new element , namely social justice and added to the concern for the individual patient's welfare a co duty to preserve society's resources.

A facile veneer of ethical sounding verbiage serves to justify a localized, utilitarian statistical approach to clinical decision making in which the aggregate "good" or statistically defined utility-perhaps measured in quality adjusted life years- will trump the utility or good of any given individual patient.

This approach was raised to its most specious,arrogant level by a well known medical economist,Victor Fuchs writing in the New England Journal of Medicine. See here for my previous comment regarding Dr. Fuch's sophistry.

Fuchs tells his readers about a dilemma.

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


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

 Here, Fuchs conflates the good of group as indicated by some aggregate number with the good of each individual in a particular situation in which a particular individual may not enjoy the benefit and may actually be harmed. In fact cost effectiveness analysis involves aggregate data. With any outcome in a group some may benefit and  some may be harmed.Years earlier, Dr David Eddy offered the same basic recipe for " increasing quality while decreasing costs" but, unlike Fuchs had the honesty to admit in such an arrangement there would be winners and losers. Fuchs maintains,apparently with a straight face,everyone wins.

The old medical ethics clashed with what is needed from physicians to make the collective a financial success. The medical progressive elite believe they have solved that problem by changing medical ethics .Many in the older generations of physicians do not buy in to the
stewards of society's resources concept but as waves of younger docs hear nothing else from the day they enter med school, the concept of fiduciary duty to the patient will be of fleeting historical interest.Certainly, that will be the case if the activities of the ABIM Foundation with its generous funding from the Robert Wood Johnson Foundation has its way.

If you wonder how big and bigger medicine will affect patient care see this excellent discussion by  Dr.Paul Hsieh.

Public Choice Theory informs us that Obamacare is a bad idea

You will not find defenders of Obamacare (aka ObamaCONcare) evoking Public Choice Theory (PCT).In some instances this is out of ignorance of the ideas contained therein and in other instances a wise, tactical decision was made not to have to face those ideas as they relate to Obamacare.

In a nutshell here is what PCT is all about;it is based on certain views concerning human nature namely:

1)Humans tend to respond to incentives.2)Humans  frequently tend to act in what they believe to be in their own best interests.3)Humans have definite cognitive limitations.

PCT does not claim that people always act on the basis of some cost benefit analysis nor that sometimes folks do not act in ways that seem to be altruistic.

These aspects of human nature apply to businessmen,butchers,bakers and con men but they also apply to elected public officials,politicians,and bureaucrats.Accordingly this second group will from time to  time act- most of time probably- in their own interests and not in some effort to bring about some abstract public good and that politicians just might respond to the incentives of campaign contribution in return for sponsoring some legislative act that benefits some special interest group at the expense of the public at large.

There are two others aspects of PCT worth briefly mentioning.

PCT explains that although private and public actors both respond to incentives (and constraints) the set of incentives and constraints are not the same for the two groups.Secondly, for the PCT analyst the unit of analysis is the individual- not society or the group or the community. Society does not make decisions,individuals do -realizing necessarily that the individual does not make decisions in a vacuum.

James Buchanan and Gordon Tullock are credited with the explication and promulgation of PCT but were not the first nor alone  alone in their efforts .From one point of view, their work restored and re-invigorated views that were part of the common wisdom and discourse of the English speaking inhabitants of the British colonies in the later part of the 18 Th century. For much of the twentieth century journalists,historians and high school civic texts as well as college courses treated governmental action and public officials actions as not being self interested and assumed those acts were done in the public interest and typically carrying out the voters' will. Buchanan and Tullock said lets rethink those assumptions. As Buchanan said it is about politics without romance. Political actors acting in their individual self interest replace the wishful thinking which envisioned benevolent,wise selfless officials carrying out whatever society wanted which they were able to discern with near omnipotent wisdom.

The Founding Fathers realized the dark side of human nature  and were very aware of the risks involved with investing power with the government.The government needed enough power to protect individual rights but the power could be used to restrict liberty as well. The Madisonian project was to devise a system of government that could constrain the power of the government that it needed to have to protect individual liberty.

Obamacare from the PCT perspective is a bad idea in part because it invests  governmental entities with too much power.Further the power is concentrated in a few governmental entities and in regard to their edicts there are few if any avenues of appeal.Think HHS Secretary,IPAB,the IRS and the US Preventive Services Task Force.

The power given to the Secretary of HHS is a prime example.The absurd number of times the statute says "The Secretary [of HHS] shall determine" illustrates the concentration of power in a single politically appointed governmental official and is a dangerous transfer of power from the legislative to the administrative. The corrupt political ends to which a number of those decisions, i.e exempting friends of the administration from certain aspects of the law, serve to illustrate illustrate Acton's axiom of " power corrupts".

And then here is the matter of the IRS.Politicians feign shock and horror regarding the revelation of IRS acting in an illegal and politically motivated way and will hold hearings to investigate. The same thing has happened with previous administrations, both democrat and republican. Does anyone really believe that giving the IRS a major role in the administration of Obamacare is a good idea?

The still revolving door of Health care "reform"- yet another chapter

Dr. Roy Poses writes about the odyssey of Nancy DeParle from the health care industry to the health care legislative reform con job known as ACA and back to the health care business-this time with  a venture capital firm which invests in health care related enterprises. See here for his recent blog commentary.

quoting Poses:

"...Ms DeParle came from roles as a steward of multiple large health care corporations to lead the health care reform efforts of the executive branch.  In that capacity, she helped to create and enact legislation that she would later say created many "new investment opportunities."  Now, as the legislation is going into operation, she has spun over to private equity to take advantage of these opportunities. "

A similar tale can be told in regard to the person Sen. Max Baucus credited as playing a key role in the cooking of the legislative meat of Obamacare. I have commented on  that before. See here.

Once again a well deserved kudo to Dr. Roy Poses for  his tireless efforts to shine as much light as he can on corruption,rent seeking and crony capitalism in the world of health care.

What could possilby go wrong with meta-analysis and guidelines (think pre-op beta blockers)

Epidemiology 101 describes reasons for a correlation, namely :" causation,bias,confounding and chance".But fraud should also be on the list. Reports indicate that fraud played a major role in a Dutch study which in turn determined the outcome of at least one meta-analysis and from that a major recommendation for pre-op beta blockers in non cardiac patients.And now it seems that rather than prevent peri-operative deaths the beta-blockers might have lead to more deaths.

 The European Society of Cardiology issued a strong recommendation for the use of peri-operative use of beta-blockers in 2009. Their analysis that lead to that recommendation was apparently heavily influenced by the DECREASE trial that showed a significant decrease in perioperative heart attacks in the treatment group. On the other hand ,the POISE trails showed that the control group had fewer deaths. When the two were combined and included in the meta-analysis and sprinkled with magic statistical fairy dust benefits were shown to be greater than the risks. When the fraud issue was raised and another Meta-analysis was done excluding the DECREASE data the risks were greater than benefits and more deaths occurred in the treatment arm.

See here for details and for more links.

As tragic as however- many- deaths occurred as a result of these guidelines there is reason for great optimism moving forward. Surely we will not need to worry about this sort of thing happening with the advent and proliferation of Accountable Care Organizations (ACOs) which will be catalyzed by the great crony capitalism victory social justice generating Accountable Care Act.We look forward to have wise "leaders with ideas " leading the way  in good Don Berwicken fashion who will be immune to the multitude of Kahneman-Tversky type cognitive biases to which the hapless individual medical practitioners and their selfish patients are so susceptible.

What is  the big deal here anyway-surely fraud is rare in medical studies.I hope so too but  there are other reasons to be wary of meta-analysis and should sweeping guidelines be based on meta-analysis that are driven by one study. The x-files Aent Mulner believed the "truth is out there somewhere"-maybe  but it is elusive and premature conclusions that are magnified by being enshrined in guidelines-particularly those that fortified in a P4P setting-can do more than a little harm.When the wisdom of the day is 180 degrees from the wisdom yesterday you can hear the plaintiff attorney asking :"Doctor, were you wrong then or are you wrong now ?"

The perfect system of medical compensation is not an option

Quoting the increasingly insightful Arnold Kling;

"Keep in mind that there is no perfect system for compensating doctors. For example, if you pay them a fixed amount of money per patient, then their incentive is to see a lot of healthy patients and avoid the sick ones. If you pay them a fixed salary, their incentive is to work short hours. If you pay them for “quality care,” that means that a central bureaucracy, comparable to IPAB, has to define the meaning of quality."    

 and I add "folks will treat to the test" and the quality measure will lose whatever value it had as a measure.

So as usual it is "people respond to incentives" all the way down.


Currently the medical progressive elite and various rent seeking special interests seem to control the narrative and hence the anti fee-for- service propaganda blitz.

The medical elite policy wonks need to listen to the real docs

Here are two real docs telling a story that seems to be lost to many of the medical elite who smoke the progressive pipe and sing the manta "medicine is too complex and important to be left in the hands of the individual physician and patient". See this commentary  from the blog In my Humble Opinion and these remarks from a practicing ophthalmologist in Texas which was featured on Dr. G.Keith Smith's website,Surgerycenterofoklahoma.

Will Obamacare bring social justice(as claimed by AMA and ACP) or "Shatter the Backbone of the Middle Class"?

Obamacare was lauded by some democratic senators and some medical organizations ( e.g. the AMA and ACP) as finally delivering  long awaited social justice to health care in the U.S. Labor unions supported Obama's candidacy as well as the bill. Now as some of the devilish details are oozing out of the hundreds of pages of dense legislative verbiage,labor union leaders are realized they may well not get the really good deal they believe they had been promised. 

Now three unions are demanding that the administration make changes in the interpretation of the statute ( can you say "waivers") to lessen any negative impact on various unions health care plans.See here for details.

One brief quote from a letter  to Democratic leaders in the House and Senate that was signed by Jimmy Hoffa :

 " We have a problem; you need to fix it. The unintended consequences of the ACA are severe. Perverse incentives are already creating nightmare scenarios."

Perhaps Obamaconcare might be a more appropriate name as more and more folks are realizing they were conned.

How/why/when did physicians get tasked with being "stewards of resources"?

 Let's take at look at the the strange journey of physician's ethics from fiduciary duty to the patient to stewards of society's medical resources.


When I trained as an internist in the late 60s and early 70s,medical ethics seemed very straight forward and was so uncontroversial that is was rarely the topic for discussion.The physician had a fiduciary duty to the patient and he was to place the patient's interests first and do what was right for the patient and to do no harm to the patient.

It was a time when the hegemony of the third party medical payers (insurance companies and CMS) was not an issue. It was the era of "retail medicine" in which indemnity insurance followed the patients and the payments for physician's services were dispensed according to what was said to be "customary,reasonable and prevailing". Insurance companies did not determine which hospital a physician used,which consultants to be used for referrals nor what medications were approved for use.Physicians who vigorously advocated for their patients as it involved some hospital practice were not summoned before a kangaroo court on charge of being "disruptive".

As time passed there appeared on the scene a perfect storm of forces and events that accelerated medical costs.There were new diagnostic tests (mainly imaging procedures),new therapies,patients were spending what they considered to be other people's money and physicians believed they were ethically bound to do what they thought was right for the patient which often included more rather than fewer tests .


As medical care costs and expenditures increased, third party payers including large corporations who provided health insurance ( those who were self insured) took measures to control costs. There were larger deductibles and co-payments and more scrutiny by insurance companies on what exactly they would pay for. There were guidelines and pre approval rules for testing.The concept of gate keeper was born. These counter measures probably mitigated price increases a bit but costs continued to rise and continue they would as basically this was folks spending someone else's money and the fingers on the cost guns were in the hands of hundreds of thousands of physicians many in sole or small group practices whose actions continued to be largely outside of the control of the third part payers.

The problem was how to control the activities on these physicians who had been inculcated for many decades with the ethical imperative of do what is right for the patient. For one trained in that ethical environment, cost to " the system", be it United Health Care,Exxon, or Medicare,was not a major priority in their value or decision making calculus.

So various variations of carrots and sticks were employed by the third party payer.Pay for performance grew up as a type of bribe to docs to follow the cost cutting guidelines which went by the wink,wink,nudge, nudge name of quality guidelines.

Although carrot and stick techniques have a proven history of changing behaviors to some degree,what would be even better is to have at the triggers of medical cost initiation e.g physicians (or some alternative "health care provider", i.e NPs, PAs)  who  really believe their duty lies at least to a significant operational degree in cost saving and to preserving the medical collective's resources.

Enter the concept of physicians as stewards of society's resources.

I have not developed a detailed chronology of that part of the literature which deals with medical policy matters to be able to date with any precision when and how this concept arose. I have written before on some of the earlier papers in the mainstream medical literature.


In 1988 Hall and Berenson writing in the Annals of Internal Medicine said that "the traditional ideal" [the prime duty to the patient ] was "not compatible with the role that existing insurance contracts and manged care arrangements define for physicians." Their comments were not subtle when they said :

"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."

Note:Berenson and Hall  glibly justify that ethical sea change because the role that insurance contracts define for the physicians. Here we might pause and remember that one of the defining characteristics of a profession is that members are bound by a ethical code that is largely self defined.

Over the next 20 years far from that proposal being dismissed out of hand as medical ethical heresy which is how many physicians at the time would have characterized it, it has become part of the generally accepted medical ethical package nestled in professionalism statements by many professional medical organizations and has become part of medical education .

The fiduciary duty to the patient seem to have been demolished ( or at least made secondary) with unsuccessful   attempts by physicians of the old school to battle  the propaganda juggernaut . The dogs bark and the caravan moves on.

We have traveled a long way since the Berenson article.Now we read of a suggestion that "cost-consciousness and stewardship of resources be elevated by the ACGME and the ABMS to the level of a a new seventh general competency." In other words, residents should be schooled and graded on their mastery of the skill set necessary to be good stewards of [society's] resources. ( reference, The Idea and Opinions Section, Annals of Internal Medicine,20 Sept 2011,Vol.155 no.6, by Dr. Steven E. Weinberger,of the American College of Physicians.

Interestingly, in the 1999 Ethics Statement of the council of Medical Specialty Societies (CMSS) there was no mention of physicians as stewards of medical resources but rather the document talked about physicians as stewards of medical knowledge.(As best I can determine the 1999 Ethic statement is the most recent)

A CFO of a HMO or now a ACO could not devise a better ethical precept- at least for their bottom line-  than for physicians to be ethically bound to "conserve medical resources".

Operationally to be a good steward one need only adhere to the organization's guide lines which may be derived from aggregate data and the statistical utilitarianism of outcome research or at times the opinion of self designated experts. Just ask the economist Fucks how to resolve the ethical conflict for the physician facing with the good of his patient or the good of the group. Who better to give ethical advise to physicians than an economist? See here for comments on Fuchs' "solution".

So we have gone from the primacy of the welfare of the individual patient and the fiduciary duty of the physician to the patient to a Two Master concept of professionalism.

Dr. Accad of the blog,Alert and Oriented, has commented that "Medicine is dominated by the collectivist Ideology".  I agree and one striking manifestation of that dominance chiefly driven by medical academia, is the acceptance of the concept of the physician as medical resource steward. What place does/will the traditional physician-patient relationship have in this formulation?


The medical ethicist Dr. Edmund Pellegrino in 1995 asked ...can physicians change the ethics of the profession at will ( as proposed by Berenson and Hall or Berwick and Brennan)) or is there a more fundamental and universal foundation for the ethics of medicine found in the special nature of the physician-patient relationship?

Pellegrino is quoted from an article entitled "Guarding the Integrity of Medical Ethics-Some Lessons from Soviet Russia" . The subversion of medical ethics that occurred in Russia suggested to Pellegrino two lessons.

1) corruption will afflict any health system not designed with care of the patient as the its primary driving force. 2) medical ethics must be independent of political exigency. "... a morally responsive profession is an indispensable safeguard for the sick against the statistical morality of utilitarian politics, even in democracies."

How did it happen? How did the ideological certitude that we had as residents in the 1970s in regard to our ethical obligations morph into the divided loyalties and the two master concept that now seem destined to become codified in the training program? Following the Mafia rule, we look to the third party payer who are the obvious beneficiaries of the stewardship concept but what did they do to achieve that change? Did the academic medical progressives pave the way with their rhetoric and lobbying?

Language can be used as a tool of change. Dr. Thomas Szazz, one of my favorite iconoclasts, said "Define or be defined". Physicians, once a profession that defined its ethics now has been and is being defined by a relatively small group of academic physicians . Patients are now designated as consumers of health care or customers,Both terms leave no room for discussion of the physician patient relationship.Physicians are redefined as stewards of resources.

New terms have been slipped into discussion about health care. These include "professionalism" which seems to be a pattern of behaviors and a system of values that has been unilaterally grafted onto the top of medical ethics largely as the results of a group ( not necessarily an organized group per se but they are active in some internists organizations) of internists whose views are basically liberal ( not in the sense of classical liberalism) or more accurately  progressive. Then the term professionalism was used as a vehicle to dictate a series of given policies which according to the definers are the necessary characteristics of physician's professionalism , This include a striving for social justice and to be "stewards of medical resources". The operational meaning of the later terms is to conserve resources by following guidelines that to some degree and sometimes derived in part from cost effectiveness and cost comparative studies.

So here is how is worked. Physicians not only have to adhere to the usual medical ethical principles but they must also behave according to the new guidelines of professionalism ( which were conceived and promoted by a small group of like minded internists) which include being stewards of resources which practically means following guidelines.

So back to the title. The how was largely through the perhaps well intentioned persistent and well funded efforts ( think the Robert Wood Johnson Foundation et al) of the progressive medical elite subset of physicians to flim flam physicians to accept the 180 degree turn in professional ethics,the why was the increasing concern of the  third payers for the  increasing cost of medical care fueled in part by folks spending other people's money .The when is not identifiable  as one specific  date or event but rather more like the process of frog boiling over the post 25 to 30 years.

Addendum: 7/8/13 An apology is in order. On 7/7/13 I was drafting this posting and I hit post instead of save . As as result a rough form was published . The above is a rushed effort to smooth the edges.

Obamacare in action substitutes "Rule by Rulers" for Rule of Law

 The term "Rule of Law" may be discussed in at least three  different contextual frameworks. The formal or so called thin interpretation states that law must be prospective,well known, and have the features of equality and certainty. The law must be clear and apply to everyone. The substantive or so called thick interpretation says that the law protects individual rights. In the functional approach rule of law is defined by contrast with rule of man. FA Hayek talks about the rule of law as contrasted with arbitrary government edicts or proclamations.

Whatever framework you prefer, the manner in which Obamacare so far has been administered by the government exemplifies rule by arbitrary governmental order or as Michael Cannon phrased it in his Cato commentary "Rule by Rulers" (see here). Quoting Mr. Cannon:

"...the IRS’s unilateral decision to delay the employer mandate is the latest indication that we do not live under a Rule of Law, but under a Rule of Rulers who write and rewrite laws at whim, without legitimate authority, and otherwise compel behavior to suit their ends. Congress gave neither the IRS nor the president any authority to delay the imposition of the Patient Protection and Affordable Care Act’s employer mandate. In the section of the law creating that mandate, Congress included several provisions indicating the mandate will take effect in 2014. In case those provisions were not clear enough, Section 4980H further clarifies:

(d) EFFECTIVE DATE.—The amendments made by this section shall apply to months beginning after December 31, 2013.

It is hard to see how the will of the people’s elected representatives – including President Obama, who signed that effective date into law – could have been expressed more clearly, or how it could be clearer that the IRS has no legitimate power to delay the mandate."

Read all of Cannon's essay in which he lists some of the various ways that the current administration  has behaved like "rulers" exercising powers  not delegated by the statute to protect Obamacare's image and to lessen any negative impact it may have on their supporters (think unions) and on elections (think Medicare advantage and the 2014 mid term congressional and fallout from the disruption of the employer mandate.)


So both houses of congress pass a law,with great fanfare the President signs the law and then SCOTUS declares most  the law is constitutional. And now an administrative agency simply ignores the letter and intent of the law and postpones a portion of it even though it has no statutory authority to do so. Will Madisonian checks and balances kick it to  play and somehow order the IRS to obey the law? I think not- most of the times legality or  fear of  judicial action does not impede the current trend of ruling by rulers.More and more no one complains and the courts are not called upon. The barking dogs in the blog world and the non Main Stream Media bark away (along with the occasional legislator) and the ruler caravan moves on.


Addendum: 7/5/2013 It just gets more and more unclear as more analyses are offered. See here for a detailed discussion about the issue of what exactly is being postponed.Does the administration really have the authority to do whatever they think they did?Does anyone have legal standing to bring legal action to force the administration of a statute? And even if the courts found for the plaintiff ( if one could be found) could the court really force the executive to do anything?  I'll bet that James Madison thought his checks and balances and "sufficient virtue" of the American people would have worked out better.

Addendum: 7/8/2013. More delays in Obamacare. In this posting from the Washington Post  we learn that some elements of Obamacare will be on the "honor system", at least for a while.Somehow I have a problem thinking about the IRS overseeing a honor system arrangement.