Say it isn't so Joe, Medical "thought leaders" might have conflict of interests

 The issue of possible conflicts of interest (COI) has arisen in regard to both the National Quality Forum,  (NQF) and the popular UpToDate.

 This article in the Journal Of Medical ethics discusses that issue in regard to the popular UpToDate which on its web site describes its self as "premier evidence-based clinical decision support resource". The journal article has this to say regarding several sections of UpToDate comparing it to another rival medical resource:

"All articles from the UpToDate articles demonstrated a conflict of interest. At times, the editor and author would have a financial relationship with a company whose drug was mentioned within the article. This is in contrast with articles on the Dynamed website, in which no author or editor had a documented conflict. We offer recommendations regarding the role of conflict of interest disclosure in these point-of-care evidence-based medicine websites."  It should be noted that the journal authors did not review all of sections but selected ones that involved subjects for which treatment was controversial and/or involved recommendations for specific treatments that wee provided by a single supplier.

Much more has been written about possible COI regarding the NQF.

Details regarding Dr. Charles Denham can be found in this article in "Modern Health Care. Quoting that article:
"

"Dr. Charles Denham, co-chair of NQF's Safe Practices Committee in 2010, received $11.6 million from San Diego-based CareFusion to promote the company's ChloraPrep line of skin-preparation products. Denham's committee at the NQF also recommended surgeons use ChloraPrep products to prevent surgical infections, the NQF said."

Dr.Christine Cassel,currently CEO of NQF left little doubt about her assessment of Denham actions saying simply "He lied" when he mislead the NQF regarding his possible COI and business interests. Dr. Cassel was not affiliated with NQF at the time of the allegedly kickback  related activities.

Ironically enough now Dr Casell has the spotlight on her in regard to possible COI  regarding her role at NQF. ProPublica takes up that issue here. I say ironically because one aspect of Dr.Cassel's academic reputation has been in the field of medical ethics.Dr. Cassel has written and lectured extensively on medical ethics, authored or co-authored several publications in the field including "Ethical Dimension in Health Professions" and completed a fellowship in bioethics.

 So what is it that Pro Publica finds of concern in regard to Dr. Cassel's role at NQF. It is in regard to other compensated positions that she holds.For example Dr. Cassel is a board member for Premier Inc with a reported compensation  of  $ 235,000 and stock.Does a board member of a corporation not have a fiduciary duty to the corporation.?

Since she has earned the title of expert in the field of medical ethics it seems astonishing to me that she apparently does not consider it an ethical breach to play a leadership role in the NQF and to  receive compensation  from two organizations that could profit ( or loose) based on some recommendations made by that organization. Two ethicist interviewed by Pro Publica seem to disagree and Dr Roy Poses ( see here) who is absolutely untiring in his efforts to point out issues of COI in health care has this to say regarding Dr. Cassel's dual roles:


"However, in my humble opinion, the issue here goes even beyond a blatant and undisclosed conflict of interest.  That a top steward of a big for-profit health care corporation could simultaneously be the top leader of an influential non-profit health care quality improvement organization suggests that increasingly US health care is run by an insular group of insiders whose influence gets ever larger because of their collective power, not necessarily because of their dedication or ability to improving health care.

 As ProPublica put it,
Rosemary Gibson, an author and senior adviser to The Hastings Center, a research group dedicated to bioethics in the public interest, said she wasn’t surprised at Cassel’s outside compensation. So much money permeates decision-making in Washington, she said, that participants have become oblivious.'The insiders don’t see it,' Gibson said. 'It’s like a fish in water.'

Update: 2/27/2014 Dr Cassel has resigned from her posts at Premier and  Kaiser.

Obamacare may decrease employment but at least more folks can "pursue their dreams"

The situation involving recent projections about job loss and Obamacare from the Congressional Budget Office and the White House's reaction to it falls under the joint headings "you can't make this stuff  up" and  You gotta be kidding me"
Yes, the White House really said that now people will be able to pursue their dreams,which is one way of considering  having no job,and those blessed with less work can spend more time with their family as well as having the opportunity to retire early.


See here for Avik Roy's comments regarding the CBO projection of 2.5 millions job losses and the administration's reaction it which should have destroyed any feeble residue of credibility that Obamacare apologists  may still retain.

 No,CBO is not saying that 2.5 millions folks will be fired but rather there will be "a decline in the number of full time equivalent workers of about 2.0 million in 2017 , rising to about 2.5 million in 2014."

Basically the CBO says Obamacare will decrease employment by the millions.Here is Avik Roy's explanation of how that might be brought about.

"The new, larger estimate of the law’s negative impact on the labor force derives from three factors: (1) Obamacare’s employer mandate, which will discourage hiring and reduce wages offered by employers; (2) Obamacare’s $1 trillion in tax increases, which will discourage work and depress economic growth; and (3) the law’s $2 trillion in subsidies for low-income individuals, which will discourage many from remaining in the labor force."

If you were wondering  what the tax increase would be spent you should be reassured that it will all not be wasted as some of it will go to mitigate losses that insurance companies might experience because the plan is not working out quite as projected.See here for what Humana will get so far.In Obamacare's quirky version of social justice all the redistribution does not seem to go to the most disadvantaged making it seem a bit more like crony capitalism.

Are employee wellness programs just silly or can they be hazardous to health?

Leah Binder, writing in Forbes on line ( see here) argues that the answer is "maybe" at least as regards what she calls badly designed programs. She draws from a book from Al Lewis and Kiv Khanna entitled "Surviving workplace wellness".

Practicing internal medicine and pulmonary disease in the late 1970s I had not heard the term "wellness" until I was approached to consult for a large petrochemical company who believed they had a problem with some type of occupational lung disease at one of their facilities. ( The term risk factor was new to me as well)

Later while working part time at that company I sat in on a presentation from a consulting firm who was selling employee wellness programs.They showed slides with huge alleged savings from the detection of early disease in the employees. One cynical older HR person said yes that maybe be true but if we save those lives while folks are working will  we not  be shelling out more money in longer retirement payment because if we have both a health insurance program and a retirement program we will be paying now or paying later.

That argument aside Lewis and Khanna make a persuasive and humorous case for shelving most of what passes for employee wellness programs, which by the way are encouraged by Obamacare giving us reason 962 for never having passed the biggest crony capitalism con job  windfall ever.

The authors tell us that the "sum of value created when an employer plays doctor" can be put in a very small footnote,

stop smoking
eat better
get off your butt

Their analysis resonate with  the impression I had years ago .The difference is they have data to support their conclusions.

So how's that health care insurance for "nearly everyone" working out for you?

Advocates of Obamacare in defense  of it in spite of all the flaws and the ever increasingly list of unintended and intended- but not advertized- consequences ( eg tax payer subsidies for insurance companies  that might loose money on the exchanges) typically fall back on the twin refrains of "health care will be available for nearly everyone" and social justice is being promoted.

Of course, those folks are conflating health care with having insurance but ignoring that for a moment it looks more and more unlikely that the nearly everyone )(usually estimated to be about 30 million) will  actually get the insurance cards . So far  fewer of the uninsured are actually shining up on the exchanges.McKinsey did a study and their analysis indicates that the vast majority of those who are signing up were already insured and only about 11% were moving from the uninsured group to the insured group. See here for some details of that study. If McKinsey's analysis is even close to be correct the 30 million claim will not likely be reached.

As far the social justice argument let me repeat that Rawls defended inequality if it benefited the most disadvantaged in society but while some of that is happening with Obamacare , a significant number are forced into paying more for insurance and often buying benefits which they can never use.

So the plan seemed to be that the young, healthy would sign  up in sufficient numbers to fund the scheme  and the uninsured would rush to the website and sign up since getting those 30 million insured was the purported reason for the legislation in the first place. So far it seems that neither of those things are actually happening in sufficient numbers to   prevent the so called death spiral.More aspects of the Obamacronycare law come to light, one of the most recent  one being the news that HHS is writing or rewriting the details of subsides to bail insurance companies to make them even more generous.

And this quote from Coyote Blog which comments on the fact that many people who are now getting subsidies had insurance before:


"So, we know that 80% of the people are getting subsidized on the exchanges, and now we know that 70-90% of those previously had a unsubsidized policy beforehand.   This means that what the exchanges are doing is NOT insuring the uninsured, but converting people previously responsible for their own health care into government dependents.  The more cynical out there will argue that was the whole point in the first place."


And for  what party will folks dependent on the government likely  vote?

Can widely accepted guidelines be dangerous?

Projections assuming the wide acceptance of peri operative beta blocker guidelines in Europe suggests the answer is a frightening yes..See here for details of what seems to be a candidate for  the mother of all iatrogenic disasters. The authors of that referenced article suggest deaths may be in the hundreds of thousands.Extrapolations are fraught with great mis -estimates but even with assumptions of much less adherence to the guidelines there have to be a large number of patients that died or experienced non fatal strokes in a terribly misguided effort to save lives. Hubris of the medical planners and the danger of excessive faith in the truth producing power of meta analysis and the dangers of guidelines enforcement  are among the windmills at which I  repeatedly joist. 

I shamelessly quote a slightly re-edited comments which I made in 2007 following the disappointing results of the POISE trial that cast an unfavorable light on the use of peri operative beta blockers in non cardiac surgery which demonstrated an increased risk of stroke in the treatment arm of the trial.


"quality measures  often drive care and influence the way physicians care for their patients. If a physician should exert great care in deciding what to do for an individual patient it would seem a greater level of concern and contemplation should be expended in writing "rules" that will influence the care of many patients.

I do not mean to imply that physicians who author quality rules take their responsibility lightly but events such as the beta-blocker saga should perhaps make us insist on a very high standard of proof of efficacy and safety be shown before we presume to tell others physician what they should do particularly when those rules are "enforced" by economic carrots or sticks. Further if an intervention is to prevent something, i.e to decrease the risk of a bad outcome, the level of certainty should be higher than in the circumstance when the physician is treating a certain medical condition.  I increasingly wonder if those sweeping recommendations should be based to a large degree on meta analyses. In a seriously ill, patient you often have to act, even to use treatments that lack super solid proof of efficacy; when you are in the prevention mode, you had better have a much greater level of certainty.

The individual physicians not only have a fiduciary duty to do what it right for the patient but they are held to a legal duty. At least physicians were taught that duty before the days of the New Professionalism as promoted by the ACP with their new ethic and the ABIM Foundation and the Robert Wood Johnson Foundation.See how often you find the word "fiduciary" in the new ethics or the New Professionalism.

The individual physician deals with the stroke patient and has to answer to him and the family, and perhaps to the family's attorney while the quality rule writers have to answer to whom. Apparently no one. Being a  public health expert or a guideline author seems to confer immunity for having to say you are sorry.  The individual physician strives to do what is the right thing for his patient and hopes that what he does is right, the quality rule makers seem presume to know what is good for everyone. Obviously, they frequently do not. Oh well, you can't make an omelet unless...

When guidelines were operationally what they claim to be now suggestions,their benefit and their potential harm was limited. Enter the ever increasing hegemony of the third party payers (government or private insurers ) which  has morphed guidelines into requirements with greatly increased power to do good or harm but with seeming impunity.

(edited on 4/24/24 to correct several spelling and grammar issues)

Are cuts in Medicare (mainly Medicare Advantage) more of the magical social justice of Obamacare?

As this Forbes article by Scott Gottlieb explains,Medicare Advantage programs are in the cross hairs of the Obama administration as ACA continues to roll out benefits for some and just roll over others.

Obamacare is partly funded by cuts to Medicare Advantage,a program popular among low income seniors,particularly those who may not be able to afford the medicare supplements plans.More of these plan members are being shifted to Medicaid, a health care delivery "system" generally perceived as something less than typical care that one obtains under Medicare. If social justice means redistributing stuff around so that the most disadvantaged are benefited. you have to wonder how diminishing the health care for one group of lower income folks to enable another group of low income folks to have insurance cards( not health care but cards) is any type of justice at all. Cuts to Medicare Advanatage had been postponed so that they kick in after the 2012 election, will they be postponed again with the administration's eye on the 2014 elections?

Quoting Dr. Gottlieb:

"The net effect of all of these cuts is already expected to shrink the program. The Obama Administration is disproportionately shifting these cuts onto so-called Medicare “special needs” plans. These are Medicare Advantage plans that are specifically designed to enroll patients with certain serious and costly chronic illnesses like diabetes and heart disease. Many of these patients are low income, and dually eligible for both Medicare and Medicaid. "

 We are seeing more strange social justice in the situation in which the program at least nominally designed to help the most sick of those in Medicare Advantage will be cut the most (that is unless the administration decides to post pone it again in the run up to the next elections).

John Goodman also covers this issue here.

"About one of 20 seniors on Advantage had to switch plans because their old coverage was cancelled, but the damage has been particularly acute in a category called special needs plans, or SNPs. More than 1.5 million people were covered by about 500 of these plans in 2013, but the consultants at Avalere Health report that 13% were wiped out."

Being old and sick and poor is becoming more dangerous for some to help pay for insurance cards for some others who may also be sick and poor.   

As 2014 sees Obamacare ramp up,another tip of the crony hat to its "architect" is in order

Of course no one person wrote the bill,it took a small village of cronies to put it together being as careful as they could to make sure that the health insurers were among  the beneficiaries as well as a few other crony beneficiaries.

A health care "reform" bill was constructed that forced large numbers of the uninsured to buy health insurance and included safeguards ( particularly Section 1341 and section 1342) for the insurance industry to minimize losses should the overall strategy ( to get 40% of the newly enrolled to be young and healthy) not work out as projected.

The statute was crafted by the senate finance committee lead by Max Baucus. According to Baucus much credit should be given to one of his staffers,Liz Fowler. Quoting Mr. Baucus;

"“I wish to single out one person, and that one person is sitting next to me. Her name is Liz Fowler. Liz Fowler is my chief health counsel. Liz Fowler has put my health care team together. Liz Fowler worked for me many years ago, left for the private sector, and then came back when she realized she could be there at the creation of health care reform because she wanted that to be, in a certain sense, her profession lifetime goal."

From 2001 to 2005 Ms.Fowler was Baucus's top health care adviser.She left in 2006 to become Vice President of the nation's largest health care insurer  (Well Point) and returned to play a major role in crafting Obamacare in 2008.That's right, an executive at the nation's largest health care insurer helped write the bill that forced folks to purchase the product that company sold. But it gets even better. She was then hired by the Obama administration to help implement the bill and subsequently left to become a vice president at a pharmaceutical company about which Glen Greenwald ( see here) said the following:

"The pharmaceutical giant that just hired Fowler actively supported the passage of Obamacare through its membership in the Pharmaceutical Researchers and Manufacturers of America (PhRMA) lobby. Indeed, PhRMA was one of the most aggressive supporters - and most lavish beneficiaries - of the health care bill drafted by Fowler. Mother Jones' James Ridgeway proclaimed "Big Pharma" the "big winner" in the health care bill. And now, Fowler will receive ample rewards from that same industry as she peddles her influence in government and exploits her experience with its inner workings to work on that industry's behalf, all of which has been made perfectly legal by the same insular, Versailles-like Washington culture that so lavishly benefits from all of this."

Also of interest is she is now also a member of the Institute of Medicine.See here. The IOM is touted as being a disinterested organization of health care experts who will recommend what is right for the health of the nation and its citizens and whose members are not driven by any special interests.

Of course, none of this is a state secret.Many have written about it including Bil Moyers,Mother Jones, the Huffington Post to name a few.

And yet what do we hear from the physician's organizations, particularly the AMA and the American college of Physicians? Why do not they speak out denouncing this massive pork barrel project.? I cannot accept ignorance or naivete as credible explanations.these organizations have their people in Washington who know what is going on.Surely AMA and ACP do not sponsor, condone or take part in crony capitalism.

Even the Daily Kos,which is very pro Democratic Party,says in headlines " Thank you Max Baucus and Liz Fowler for turning the AHC into a Rube Goldberg machine".. (see here.) while ACP continues its defense of the legislation.

Even recently one of their blogs defended  Obamacare as providing affordable insurance coverage to "nearly  all Americans" and of course, furthering  social justice. Apparently " nearly all" means all but 31 million, not counting those who recently lost their insurance.  Social justice typically means redistribution to benefit the most disadvantaged.Yes, some of that occurs with AHC as some folks do gain an insurance card (but not necessarily medical care)but it is hard not to realize how much redistribution might occur from the taxpayers to the insurance companies and Big Pharma. These increasingly lame defenses of Obamacare is getting embarrassing.

The great linguistic coup of 21 th century medical ethics

George H. Smith in his book "The System of Liberty" in the chapter entitled "Liberalism,Old and New" discusses how the concept of liberalism and its advocates were victims of a linguistic coup in the latter part  of the nineteenth century.

 The classic liberals thought of freedom as the absence of coercion.They championed the notion of a limited government whose function was to secure the rights of individuals.Enter a group of thinkers who proposed a " new liberalism" , one that would,in their view, correct this inadequate,limited definition of freedom.To the newcomers liberty without equality was freedom in name only  and true freedom involved equal opportunity and power to enjoy one's life. They wanted to replace the idea of "negative freedom" of the classical liberals with what would become  the focus  of  the welfare state.True freedom in their view was more than mere removal of compulsion or coercion.  The new liberals were paternalistic and believed  the state should do much more than secure the people from internal and external predators but rather protect them from the effects of their own uncoerced actions.The classic liberals defended their position in part by asserting that the new liberalism was old wine in new bottles, with the wine being advocacy for a paternalistic government.The new liberals continued to dispense rhetoric that supported liberty but they had redefined the word liberty.

The new liberals won the day and the old or classic liberals lost much influence  but re-appeared in the 20th century with a new label, libertarian. The new liberals were simply known as liberals and later referred to by some as progressives.

I argue analogously that the traditional ,classical medical ethics and its advocates ( physicians themselves) were victims of a similar linguistic coup. Throughout most of the 20th century and earlier the core of medical ethics was primacy of patient welfare and respect of the autonomy of the patient,the later gradually replacing an older paternalism of medicine.Physicians were considered to have a fiduciary duty to the patient.

At the end of the 20th century and the early years of the 21th century a new medical ethics emerged,one in which -while  its proponents claimed nothing had really changed-there was a radical sea-change in regard to the duties of the physician.This was accomplished by nothing more rhetorically solid based  or intellectually justified  than a simple gratuitous assertion.The notion of social justice was simply declared to be part of medical professionalism and medical ethics.The degree to which this bogus concept has been accepted and endlessly repeated in medical publication is a tragic shame.The victims of this linguistic coup are the physicians themselves but to a greater degree the patients are the real losers as they have lost their advocates at a time when they may need them the most.

Obamacare's noble lie meets the iatrogenics of the statute's reality

 Matt Welch, writing in Reason.com ( see here) offers the following concise summary of what is fundamental to making ACA work.

"The estimated scores of millions of eventual health plan cancellations that Americans will soon face are not some weird unintended consequence of Obamacare. They are fundamental to making the law work as written. The Affordable Care Act relies on previously uninsured young people to overpay for coverage they don’t need, and for previously insured adults to pay for health contingencies they will never face, be it childbirth for men or pediatric dental care for grandparents. That is what is supposed to allow more people to be covered and to keep overall rates in check. Since making people’s health insurance more expensive is not particularly popular, Obama lied about it, and not only when he claimed you could keep your plan and your doctor."

It is making some people pay for other people's stuff or in other words social justice. The possibly fatal flaw in Obamacare  is that the payer class is literally getting the bill for this redistribution and they know the bill is being sent to them. This violates the principle rule of redistributional politics which is to focus the benefits and diffuse the cost and don't let those who are paying the cost realize what is happening. Now with Obamacare lots of folks are realizing that are paying for it and they don't like it.

The noble lie,sometimes referred to as Plato's noble lie refers to the situation in which the elite knowingly expresses an untruth  in order to advance an agenda.

The "ball don't lie" expression  is a basketball phrase referring to the  situation in which a foul is called in error and the player awarded the free throws misses. The injustice of the foul is negated by the missing of the free throws.

Jordan Bruneau writing in the blog "Mises Daily" comments on the iatrogenics of Obamacare. The term iatrogenics enlarges the concept of medically induced harm to the more general meaning of unintended negative consequences which harms the very people the act was intended to help. For example, by the end of 2013 there may well be more people losing their health insurance than the previously uninsured who gained a insurance card.Obamacare is the latest poster child of iatrogenics.Rent control,various anti poverty programs and the war on drugs are among some of the numerous government programs that illustrate this principle of negative unintended consequences.

Obamacare was devised with major crony, special interest influences in mind   but poorly crafted,sold to the public by markedly minimizing the projected costs and misleading the public about its negative consequences,rolled out with numerous politically expedient  exemptions to friends of the administration and then  a monumental website failure, and  was soon recognized by millions of people that the law resulted in their loss of insurance and/or significantly more expensive health insurance costs in spite of several ad hoc ,possibly illegal,likely ineffective and possible counterproductive fixes by an increasingly panicking administration .

The ineptitude of the entire project  in its public relations fiasco,its ignoring of the fundamental rule of distributional politics, its ignoring of the rule of law as it executes the law by political expediency   and its world class disjointed complexity resulting in  quotidian unintended consequences brings to mind the following Hayek quote:

 “The curious task of economics is to demonstrate to men how little they really know about what they imagine they can design.”

What happens when health care is based on spending other people's money?

Dr. Paul Hsieh answers the question posed in the title in his recent commentary in Forbes. See here.

He outlines four important ominous consequences of basing health care on spending other people's money.

Everyone should read this excellent article in its entirety but let me briefly highlight and comment on the first in the list.

"Doctors will be increasingly expected to save money' for the system ' ."

This is already happening.Various medical professional organizations are re-writing traditional medical ethics, pushing the fiduciary duty of the physician to the patients in the memory hole and substituting the bogus concept of the physician as a steward of society's medical resources. I have ranted about this before but the caravan rolls on and increasingly  the rhetoric  in various medical forums emphasizes saving money for the system. The medicine of the collective is replacing the medicine of the individual. This is being promoted in part by what I have called the progressive medical elite who, to a frightening degree, seem to occupy the leadership position in many influential medical organization . Their unspoken mantra is that medical care is too complex and too important to be left to the individual patient and his physician. Wise leaders with ideas need to be in charge. Of course, it is promoted by the third party payers, private and public who may well consider the medical professional  elite in this ethical paradigm shift as useful idiots.

The notion of "the system" [in regard to medical care] while a rhetorically useful notion for a certain agenda, is basically fallacious aggregating elements that do not belong together. In short, there is no system for health care just as there is no car delivery system or a home building system. It makes no sense to speak of the situation in which someone buys a new car as a cost to the car supply system or a person buying a home as a cost to the home supply system.All of these are transactions in which there are buyers and sellers and exchanges take  place.Mr Jones gets a CT  of  the abdomen.. This is not a cost to any system. It is a cost to Jones and/or his insurance company while to the providers of care it is a payment.. One person's cost is another person's income.To call this a cost to a system is nonsense.Unless all the health care is provided, operated and owned by  a single entity, usually the government., then the services provided  could be considered  a cost to the system.

Who gains from acceptance of this bogus notion of physicians as stewards of some mythical collectively owned medical resources? The third party payers and the medical elite progressives who stand to gain from their position of prestige  as experts and rule makers gain and the rest of us lose.

so why don't we really know about breast cancer screening? Is it really turtles all the way down?

The more I read and the more I think about what I read and the more things seem to change but really stay the same I develop a  renewed sense of just how damn hard is it to figure out what to do or what advice to give in regard to cancer screening as well as other so called preventive measures.

The  verbal scuffles following the USPSTF recommendations on mammograms settled little. The best commentary I have read on this matter is from the amazingly prolific Dr. Roy Poses and is found in this paragraph from his recent blog posting:

One would think that a big point of discussion about breast cancer screening would be why after eight trials enrolling a total of about 350,000 patients reported over 20 years we still cannot answer the big clinical questions. A related point for discussion in the US is why only one, and the earliest trial was conducted here. If we here in the US think breast cancer screening is such a major concern (and we should think so), why have we been unable to mount a single important trial of it since the HIP trial conducted more than 30 years ago?

The big clinical questions of which he spoke were:
does screening mammography improve survival
does it improve quality of life
do the benefits outweigh the risk and harms

Yeah, so how come we don't know after all those studies and trials and analysis and meta-analysis.

Part of the evidence that the USPSTF panel used in formulating its recommendations came from a recent meta-analysis. I always cringe a bit when a meta-analysis seems to play an important role in a decision. I am reminded of an commentary by Dr. Steve Goodman regarding what seemed to be dueling meta-analysis regarding the very topic of breast cancer screening.

This is what I said about that before with slight editorial reconfiguration:

[An] important Annals of Internal Medicine Articles and related editorial by Dr. Steve Goodman of Johns Hopkins made it clear to me that meta-analyses (MAs) were basically themselves observational studies in which the studies themselves were subjects. He discussed two major MAs on the value of mammograms, one which concluded they were effective and valuable and the other concluded the opposite.The major difference between the studies was their choice of studies to include and to exclude. Both sets of authors maintained their criteria for exclusion were valid and yet they were quite different and resulted in opposite conclusions. Quoting Goodman:

... this controversy shows that the justification for why studies are included or excluded from the evidence base can rest on competing claims of methodological authority that look little different from the traditional claims of medical authority that proponents of evidence-based medicine have criticized.

I have no doubt that the panelists did their work according to generally accepted evidence based medicine "rules of the game". But along the way both within and apart  from the meta-analyses used in their calculus there are many gaps in which subjectivity and yes even personal bias come upon the scene. When human beings approach problems , gather evidence and analyze it is not evidence turtles all the way down, judgment turtles crawl in.I quote Goodman again:

"Controversies like this one about mammography are
likely to appear more frequently as we move toward reassessing
the evidence base after each new study appears
(15). Such reassessments will guarantee that we are often in
a gray zone between moderate and strong evidence, where
scientific judgment can make a critical difference. We must
learn to navigate within this gray zone better. Judgment
determines what evidence is admissible and how strongly
to weigh different forms of admissible evidence. When
there is consensus on these judgments and the data are
strong, an illusion is created that the evidence is speaking for itself and that the methods are objective. But this episode
should raise awareness that judgment cannot be excised
from the process of evidence synthesis and that the
variation of this judgment among experts generates uncertainty
just as real as the probabilistic uncertainty of statistical
calculations."

I am even more cynical-there may not be any way to navigate this grey zone better. There are many more trade offs than there are solutions.

ACA and " improvisational government"

 Daily, both in the main stream press and in the blogger world, more and more ACA bad news is reported and dissected. But the cancelled policies and the sticker shock, and the shrinking of provider networks  and insurance policy formularies may not be the most frightening aspect of the Affordable Care Act.

"... the most harrowing aspect of Obamacare is that it vests political executives and government administrators with sweeping discretionary power, free of conventional checks and balances. It gives federal officials the authority to set insurance prices without any of the economic and legal standards that govern regulation of public utilities...

Collaterally, Obamacare is introducing a new form of government​—​improvisational government, characterized by continuous ad hoc revisions of statutory law by executive decree. This is a reversion to a primitive form that long antedates our Constitution and rule-of-law traditions. Transported to the modern world, it leaves the private sector in a state of constant uncertainty and subjection."

The above quote is from Chris Demuth writing in the Weekly Standard.. See here for the entire article. Forget Rule of Law, Obamacare is being administered by the rule of men often with the driving motivation being political, minimizing or delaying the bill's harmful effects until after the 2014 election. H/T to the economist John H. Cochrane,aka the Grumpy Economist. See here.

ACA could be described as the "improv health care bill".If provision X of ACA stipulates that this or that be enacted as of a date certain, no problem provision X can be postponed ( until after the next election) . If folks are having their insurance policies cancelled, no problem just postpone those cancellations or more recently pressure the insurers to provide free care. for awhile at least.See here for the latest edict from HHS.If the letter of the law of ACA provides subsidies only under the exchanges that states establish, no problem, just provide subsidies for the federally established exchanges as well regardless of what the plain language of section 1311 might say. See here for a recent update on the legal aspects of that issue.

Section 3, clause 5 of the US Constitution  ( [the President shall] " take care that the laws be faithfully executed" might as well never be written.

 The talking point of the administration has changed from " if you like your insurance,you can keep it" to" if you are unhappy with some aspect of ACA we'll change it".

The increasingly  strident defenses raised by die hard ACA advocates ring less and less credible as they continue to claim that ACA provides affordable health care to almost everyone. More and more folks being stung with higher payments and fewer benefits makes the "affordable" claim much weaker and does "almost all " now mean everyone but maybe 31 millions.( For the CBO estimate for those not insured under ACA,see here.). With July 4,2012 census estimate of the US population being about 313.93 million, just under 10% of the population would not be covered, not to mention an unknown number of the young and healthy who choose to pay the fine tax rather than insurance premium as well as those who have lost insurance and choose not to buy or cannot afford a policy to replace it.


".. constant uncertainty and subjection" was not was Madison had in mind but that seems to be the promise of Obamacare.

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.









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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).