We cannot trust drug company studies so we need a government panel,one that is not biased

I read the medical blog "The Last Psychiatrist" (TLP) regularly.Sometimes I think I understand it.I keep going back because at some level I just know he has a lot to say even if some(much) of it escapes me.

In this entry (see here) he takes on a recent commentary by Dr. Daniel Carlat.Dr Carlat gained some degree of name recognition when he renounced his lucrative life as a drug company paid speaker and has become an outspoken critic of many of the drug companies practices including those involving paid physician spokesmen.

TLP quotes Carlat making the point that people respond to incentives and with financial incentives at work how can you trust someone's analysis of the value of a given medication.How can you trust what a drug company's research or spokesman says?

Here is the passage from The Last Psychiatrist that really nails it: (my bolding)

This is the same error people make about the need for government intervention, e.g. that the "free markets" have failed and more regulation is obviously needed. Even if one were to agree on principle that people can't be trusted, the mistake is in forgetting that government is people. These people are subject to the same biases, cognitive errors and general prejudices as the guys at Goldman Sachs, albeit currently it in the opposite direction. We can argue that we prefer the government's biases, but one cannot argue that the government is less biased, self serving, or corruptible.

This may originally have been a country of laws, not men, but that's not the country most modern people want; they want to be able to alter the laws to suit the times. Fine, it's your country. But understand that if the laws are subordinate to men, then the enforcers of those laws will always have more power than you. Has anyone tried to get an anti-Depakote study published in J Clin Psych in the past decade?

It's excellent that Daniel Carlat thinks doctors like himself cannot be trusted to read and interpret their own studies, and that some other group of-- doctors? lawyers? what?-- with special bias-immunity rings need to be assembled to protect us. But those people are still people. This is why the NIH, with their incestuous grant reviewers, crazy politics and flavors of the decade philosophies is so dangerous-- they're just as biased as Pfizer except you think they are objective.

He captures the basic thoughts of the "Public Choice" school of thought. The people who comprise the government are just like the people not of the government in that they too are biased,self-serving and corruptible and respond to incentives and constraints just like everyone else.

His closing paragraph make it clear

People would do well to remember that at one point in our nation's history, "government" was George Bush. When you argue that government needs to be more involved, you are arguing that George Bush needs to be more involved. I do not trivialize this discussion by offering Barack Obama as an equivalent example of the government you want so desperately to supervise your lives.

See what Baucus bill has to offer in 2015 (just one little part)

A very grateful tip of the hat to Health Care Renewal for information about one of the things that lies in store after the next presidential election in regard to payment to the likely-to- be- far- fewer- physicians who are still seeing medicare patients. See here.

Page 80-81 of the Baucus bill has the following:

"Beginning in 2015, payment [under Medicare] would be reduced by five percent if an aggregation of the physician's resource use is at or above the 90th percentile of national utilization." Thus, in any year in which a particular doctor's average per-patient Medicare costs are in the top 10 percent in the nation, the feds will cut the doctor's payments by 5 percent."

The Washington Times (see here) has this to say:

This provision makes no account for the results of care, its quality or even its efficiency. It just says that if a doctor authorizes expensive care, no matter how successfully, the government will punish him by scrimping on what already is a low reimbursement rate for treating Medicare patients. The incentive, therefore, is for the doctor always to provide less care for his patients for fear of having his payments docked. And because no doctor will know who falls in the top 10 percent until year's end, or what total average costs will break the 10 percent threshold, the pressure will be intense to withhold care, and withhold care again, and then withhold it some more. Or at least to prescribe cheaper care, no matter how much less effective, in order to avoid the penalties.

This proposal is just another in the long list of "perverse incentives" that John Goodman speaks of here. This is another example of a situation in which the interests of the physician will be pitted against the best interest of the patient. In a way the proposed provision is blatantly straight forward; its aim is to save money and to do so without pretending that there will be an increase in quality plus there will always be 10% of docs who will have their fees reduced.

PPIs blunt effect of clopidogrel-yes they do,no they don't

Patients and physicians alike had to be a bit worried when this study suggested that PPIs decrease the efficacy of clopidogrel and could lead to more cardiovascular events. But the story continues and the results of the COGENT study discussed here said "no" : presumably offering some reassurance that the putative PPI inhibition of the desired beneficial pharmacological effect of clopidogrel is not really a problem.

What if the articles were published in reverse order?

Does the fact that COGENT was a randomized trial with placebo versus omeprazole in patients on clopidogrel and the Medco data study was more of a data dredge mean that we have no need to worry? Or does the fact that the COGENT trial was stopped ( the sponsor,Cogentus, filed for bankruptcy) before the planned number of patients were enrolled limit the power of the trial to find a real difference mean that we should question how much we should really be reassured? Can anyone tell me if the prematurely stopped COGENT trial was adequately powered to show a difference as great as that reported in the Medco study?

The villian is fee for service-of that we can all agree?

Health care costs too much and it will cost more and we are told that a major cause of this is the fee for service system (apparently obesity is the other cause) that rewards volume and not quality.So to bend the cost curve ( I presume they mean bend it downward),we must do away with physician fee for service and pay for quality. Quality is nebulous and floating and if Congress has its way the definition will be whatever the secretary of HHS says it.

What does this really mean?

I think Dr. Wes nails it cleanly here when he says"

"Perhaps I'm too cynical, but I think the subliminal message coming from Washington so far is really this: doctors should be happy becoming salaried employees of larger health systems. This way, the government can pay the health system a bundled fee and the doctors can fight for their share of the kitty."

The larger health care systems, the vertically integrated systems, that some allege will save us from the old-fashioned and very harmful fee for service is a topic that I spent some effort ranting about two years ago.
see here. Not only will it save money but it will further the ubergoal of social justice. Those systems offer a chance to employ the utilitarian ethics to the cost curve bending exercise.

Dr. Richard Cooper's views get aired on major economic blog

Arnold Kling is one of the economists whose blogs I have begun to read lately ( lately being since the stock market tanking in 2008 scared the heck out of me ) In this entry he gives well deserved blog time to the thoughts of Dr. Richard Cooper who- is among other things (quite a few other things)-an outspoken and well spoken critic of the Dartmouth studies on regional variation in Medicare expenditures, a study that Mr. Peter Orszag and others in the Obama administration seemed to have taken as gospel truth.

Dr. Cooper points out several flaws in the widely quoted Dartmouth studies and their conclusions and the purported remedies based on that work. I have blogged about Dr. Cooper's views before. He argues , in part, that just looking at Medicare expenditures, which is what Dartmouth did, gives a false impression of what is really going on. One should examine total costs and when one does a different picture emerges, one in which more expenditures does correlate with better outcomes which is certainly a conclusion more consistent with common experience.

So what do tires and a tariff on Chinese tires have to do with health care?

The United States has moved to impose a tariff on imported tires from China.See here for WSJ article.

With the stock market swoon of 2008 and dire predictions of another great depression blaring from just about every "news" source and while I watched some significant percent of my retirement assets drop, I morbidly began to try and educate myself about the great depression. One thing I learned was that tariffs are not a good thing from an economic point of view.

While admittedly much ( but not all ) of what I read was more to the Austrian and Monetarist economic sides of the aisle there seemed to be agreement about at least two factors that took a severe recession and made it great; monetary actions of the Federal Reserve in reducing the money supply and the Smoot-Hawley tariff.

As best I can tell, economists of almost every stripe agree that free trade is a good thing and tariffs are not. A tariff is a tax on imports. The following is a quote from a text book on Macroeconomics by Paul Krugman and Robin Wells. Dr. Krugman has made it very clear than he is not of the Austrian School of economics and seems to be more in agreement with at least some of what Keynes said.

[A tariff] raises the domestic price above the world price,leading to a fall in trade and domestic consumption and an increase in domestic production. Domestic producers and the government gain , but domestic consumer loses more than offset the gain leading to a dead weight loss. ("Dead weight loss" is a term of art in economic circles and you can read about here without a graph or here replete with a graph and cogent comments by a real economist-Dr.Mark Perry of University Of Michigan- who discusses the issue in the context of the recently imposed tariff.)

Since the President has access to a number of highly educated and intelligent economists who would, if asked, would be likely to tell him that from an economic of view a tariff is not a good thing to impose,it seems unlikely his actions are being done in a belief that it will the economy. Perhaps political motivations are more likely.What could that be?

The United Steelworkers union supports the action. Could the tariff move be another gift to the unions from which the Obama administration might reasonably expect support for their health care reconstruction plans, particularly in regard to putting pressure on the Blue Dog Democrats who may have reason to worry about reelection and whose vote may be crucial to the health care bill passage.

Is Roflumilast the next drug for obstructive lung disease?

The answer seems to be a firm "maybe".

Remember aminophylline.Once a mainstay in the treatment of asthma and COPD exacerbations as well for longer term therapy in the form of various oral preparations, it now generally considered a third line medications almost about as likely to be used as the 12th man on the NBA bench in a close game.

Interestingly, one of the purported ways that aminophylline was thought to exert a therapeutic effect was its inhibition of PDE3 and PDE4. Now a new drug, roflumilast, is being studied to treat obstructive pulmonary diseases is also a phosphodiesterase inhibitor.

Recently four phase 3 clinical trials were published in the Lancet.See here for a brief summary.

The four trials involved 4500 patients;two lasted six months and two for one year. A decrease in exacerbations was shown as was a slight increase in some parameters of lung function.These statistically significant outcomes occurred in patients who were already taking a long acting beta agonist or an anticholinergic ( Tiotropium). Nausea was the most common side effect.

Why are placebos thought to be getting stronger?

I read the blog Wired from time to time to make some slight attempt to keep up with really cool innovations and products in the land of the wired.In doing so I came across an excellent essay on placebos. See here .

Here is one sample from the article:

"Two comprehensive analyses of antidepressant trials have uncovered a dramatic increase in placebo response since the 1980s. One estimated that the so-called effect size (a measure of statistical significance) in placebo groups had nearly doubled over that time." [Unfortunately, no references are given in the article].

If the placebo effect is getting stronger, why would that be?

One thought is that the direct to consumer drug company advertising has had effect(s) greater than simply promoting sales for a given medication.Perhaps it could generate greater belief in the effectiveness of pills in general which has stirred up a greater expectation of something good happening to people who take medications.Drug company advertising is just one force pointing in that direction;so do the activities of various disease promotion organizations (some of which are thought by some cynics to really be put-up jobs by the drug companies) and the general trend that seems to make almost everything a medical problem.

The "expectation effect" is a topic of relevance to the placebo effect. A patient can expect the announced beneficial effect of a pill and this has been shown in some experimental settings to increase the release of endogenous opioids. This article from Scientific American gives some detail and background regarding this issue.Areas of the brain that deal with weighting of events and threats seem to be activated by placebo through this mechanism of anticipation. Some studies have indicated that subjects who sign up a drug study may experience beneficial effect even while they are put on the waiting list.

Harriet Hall offers a detailed discussion of various issues related to the placebo effect here in the May 20th 2009 issue of the blog "Skeptic".

She outlines 4 possible ways placebo might work;

1.Expectation
2.Motivation (folks want to get better and often sign up for clinical trials)
3.Conditioning ( maybe all of us have become somewhat conditioned to believing pills make us better is in no small measure due to the effect of drug company and disease promotion groups advertising )
4.release of feel good substances such as endogenous opioids.

Do resident work hour restrictions transform professionals to shift workers?

The answer according to Dr. John D. Rybock,from Johns Hopkins School of Medicine, is "yes". Dr. Rybock in a letter to the editor published in the August 27,2009 issue expresses the opinion that the duty-hour rules of 2003 have "taken away their(residents) control" and prevent them from making decisions that characterize a professional.

In regard to limiting work hours he says:
"We now force them to leave a patient with whose treatment they are intimately involved or to cease the observation of an instructive surgical procedure midstream.It did not take long for this system to produce residents who would either walk away when their time" had expired or else lie in order to violate the rules.Although we added "professionalism" as a training goal, we began giving our trainees the choice between abandoning a patient and lying."

As pointed out in another letter to the editor in the same issue of NEJM: It has now been six years since the implementation of the 2003 ACGME regulations and there still is no consensus or clear cut evidence on whether the work-duty hours changes have improved safety and the debate continues on the effect on residents' medical education.

I continue to be amazed at how much impact the pronouncements of the IOM have and how there seems to be so little questioning and criticism of their recommendations.The IOM recommendations regarding further limitation of work hours seems to be taken seriously by ACGME.

An editorial in the NEJM presented the voice of reason.(Blanchard,MS, et al, To nap or not to Nap.Residents' work hour revisted .NEJM 2009,360,2242-4). That editorial recommended careful studies on the impact on the new IOM recommendations regarding patient safety and other relevant end points before widespread implementation of further restrictions.

Closer and closer to a new oral anticoagulant (dabigatran)

Actually, there already is a new oral anticoagulant available in Europe and Canada at least for the application of clot prophylaxis in hip and knee surgery patients.Dabigatran is an oral direct thrombin inhibitor that is taken twice a day and requires no blood test monitoring .In Canada, the trade name is Pradax and in Europe,Pradaxa.


Data from the large RELY trial were presented in Barcelona in August 2009. Some details can be found here and the entire article is available on the NEJM web site for free.

18,000 patients with non-valvular atrial fibrillation were randomized into three groups:warfarin titrated to an INR of 2-3, dabigatran 110 mg twice a day and 150 mg twice a day.The lower dabigatran does was associated with a slightly lower rate of bleeding while the higher dose and warfarin had similar rates. With a median followup of 2 years there was no increase in abnormal liver function tests in either dabigatran group.

Liver function test is an important issue as an earlier another oral thrombin inhibitor (ximelagatran) was withdrawn from the market after it had been approved in several European countries because of liver problems.

One possible bump in the road to FDA approval is the finding of a small increase in heart attacks in both dabigatran groups. I can't guess how an anticoagulant could cause an increase in heart attacks but perhaps warfarin is better at reducing risk of myocardial infarctions. Even so, with the battles and bad press that the FDA has had in recent years with real or purported increase risk of myocardial infarctions with certain prescription drugs an anticipated 2010 approval might be overly optimistic.

Now for something complety different-we should spend more on health care

"We are not spending enough of health care" is the point made by economist Mark Perry (economist at the University of Michigan) and the WSJ. See here for Dr. Perry's blog and see here for the WSJ article by Craig Karpel.

Here are some snippets:

The 2.4 trillion spent on health care in the United States is not buried in the ground but paid to other Americans.One man's cost is another man's stream of income. This is a basic economic fact that we take for granted in every area except in health care. I believe Uwe Rheinhardt asked the question "Why is it good when someone buys a car but bad when they buy medicine?" I guess part of the answer maybe because so much of the latter is paid for by the government.

In the midst of what some have labeled "the great recession" while hundred of thousands of jobs were lost the health care section actually added jobs to the tune of 19,000 in July 2009.

About 400,000 non US residents came to the US for health care in 2008.

Economists Robert E. Hall and Charles Jones wrote the following in a 2007 article that examined the "optimal health care spending" in the U.S." (my bolding)

"Viewed from every angle, our results support the proposition that both historical and future increases in the health spending share are desirable. . . . [W]e believe it likely that maximizing social welfare in the United States will require the development of institutions that are consistent with spending 30 percent or more of GDP on health by the middle of the century." ( quote is from the WSJ article, I don't have the original citation)

Ambiguity in Legislative language in HR 3200 may be there for a reason

Everyone with any interest in the proposed health care legislation should go here to read DrRich's latest blog entry in which he tell us what the ambiguity in the house bill is really all about.

I have blogged briefly before on the ambiguity and cognitively impenetrable nature of HR 3200 and suggested that is was not due to ineptitude of the authors of the bill and their inability to clearly put in words what they were proposing. As DrRich points out it is ambiguous for a reason.

The reason is that the lack of meaning will be supplied by the rule making processes of the various government agencies and this will be an unending process as opposed to a one time rule setting.

Ambiguity is a topic that has been discussed from time to time in the law journals. See here for a recent article from the Stanford Law Review.

Legal scholars talk about the willful insertion of ambiguous language into statutes as opposed to the inadvertent insertion of ambiguity. The first category sometimes is used to effect a compromise between opposing factions of a legislative body.In other cases the lack of clarity leads to interpretation (or more accurately definition) by an administrative or regulatory agency which could be the real reason for the ambiguity at least in some instances.

If a proposed statute is so ambiguous that its meaning cannot be determined by careful reading of the statutory language then public support or public denunciation of the proposal will likely turn on the rhetorical expertise and the persuasive power of the opponents to fabricate catch phrases and sell them to the public.

In regard to house bill 3200 DrRich's point is that no one knows what the specific effects of passage will be because as written the bill is without operational meaning and that will be supplied by government technocrats after the bill is passed and signed into law.

Here is how Dr.Rich summarizes it:

"This is legislation designed to create a legal framework under which huge cadres of unelected, politically-appointed policy mavens and bureaucrats will determine - by publishing hundreds of thousands of pages of regulations, rules, and guidelines - what our new healthcare system will look like. And until those regulations and guidelines are actually created - and this “creation” will be a never-ending process rather than an act - anybody claiming to know the precise nature of our new healthcare system under HR 3200 is engaging in one of the following: lying, projecting one’s own wishful thinking, or extrapolating on the perceived behaviors and beliefs of those who (one surmises) will finally get to make up all the rules."

I can't say it any better than that.

Who benefits from the world class ambiguity of section 1233 of House Health Care bill ?

Does section 1233 ( of the current version of the House bill dealing with Health Care "reform") make end of life counseling mandatory or voluntary or does the section's multi-layered and seemingly un-dissectable ambiguity enable the Secretary of HHS to determine what it "really means"?

Dr.RW discusses aspects of this general issue here quoting two sources with significant insight content from Kathleen Parker and Wesley Smith. Smith's quote is particularly noteworthy;

The bill might not create punishments [ in regard to quality measurement that the Secretary may enact concerning physicians who fail to counsel] , but the regulations that would be created in the shadows outside the direct democratic process could.

So the question arises is the bill written is such a way as no one really knows what it means which in turn raises the question "Are the bill's authors (whoever they are) merely bad at statute composition and are unable to clearly delineate what is to become law or is the ambiguity really quite artfully, purposely inserted so that HHS technocrats can do pretty much what they want"?

In another posting Dr. RW offers this comment:

Although a good palliative care service can save an institution money its focus is on what's best for the individual patient. Sometimes those goals are in conflict, sometimes not, but an excellent palliative care team will manage the conflict appropriately by putting the individual patient first, no matter the impact on the medical commons. When an end of life counseling provision is part of a bill with a clear agenda to control costs some degree of skepticism is appropriate.

How many other sections of the House bill suffer (or benefit) from this same type of opaque wording?

One more time, so how is the Massachusetts health care plan working?

Here is one view offered by one of my favorite economists, Arnold Kling. Some proponents of certain elements of the administration's health care reform plan ( really the Democrats House of Representatives plan) amazingly claim that the plan for Mass-care is working just fine and would serve well as an example of what should be done on a national level

As Kling explains: ( the italics were added by me):

So, the reform is "working" by mandating a shift in compensation from take-home pay to health insurance ( i.e forcing employers to offer insurance) and by draining money from the Federal taxpayers ( yes, the federal government is bailing them out)

In sum, the plan costs much more than projected, waiting times for physician appointments have skyrocketed, and the Federal Government is having to help pay for it . Who will pay for the cost overruns if and when a similar plan is put into place for the entire country?

What might Hayek have said about Ezekiel Emanuel's "fair distribution of life years"

I do not claim to be an expert on the incredibly insightful writing of Friederick Hayek and certainly do not really know what he would said in regard to the system of allocation of health care that Dr. Emanuel and his co-authors at the NIH have proposed.(See here for their Jan 2009 Lancet article in which they describe and advocate for their "life years" system) but this quote from Hayek seems appropriate:


--> “…the conception of a ‘value to society’ is sometimes carelessly used even by economists… there is strictly speaking no such thing and the expression implies [a] sort of anthropomorphism or personification of society…Services can have value only to particular people (or an organization), and any particular service will have very different values for different members of society. To regard them differently is to treat society not as a spontaneous order of free men but as an organization whose members are all made to serve a single hierarchy of ends (Law, Legislation and Liberty, vol. 2., p.75).

The "Complete Lives System"-why so little comment from the medical blogger world?

I missed this when it was published earlier this year in the Lancet and it was called to my attention in the blog "Junkfood Science". Here is the article in which Sandy Szwarc so correctly analyzes the Lancet in this entry of her blog which, by the way, seems to get better all the time.

The title of the Lancet article is Principles for allocation of scarce medical interventions.
I may have missed it but the medical ethics blogs that I regularly read seemed to have missed this or ignored it for some reason and the medical blogs generally have had little to say, with John Goodman (see here) and Sandy Szwarc being notable exceptions.

The basic premise seems to be that since someone or some entity must allocate scare medical resources there should be a "morally" acceptable method for such allocation. The authors, which include Dr. Ezekiel J Emanuel, brother of President Obama's Chief of Staff, and "Special Advisor for Health Policy" to the president presents a detailed proposal of how this allocation should be done. (Using the passive voice here serves the purpose or not having to say that the government will do the allocation.)

The authors begin with a critical review of the currently in existence allocation systems and finding flaws in each proceed to devise their own "hybrid" supposedly salvaging the good and casting out the less desirable elements of the various systems.

Expectedly, this "morally acceptable" allocation process would allocate less to the elderly and those with incurable illnesses. Perhaps unexpectedly, their process would place, for example, a fifteen year person allocation-wise above an infant because they say more social expenditures have been made on the adolescent and society need to get its money's worth.

The underlying theme is that individuals exist for the good of the collective ( state, society, pick one) and in health care decisions the greater good of society, now apparently denominated in "life years", trump the individual every time.

The authors describe their system:

This system incorporates five principles ... youngest-first, prognosis, save the most lives, lottery, and instrumental value. As such, it prioritises younger people who have not yet lived a complete life and will be unlikely to do so without aid. Many thinkers have accepted complete lives as the appropriate focus of distributive justice: “individual human lives, rather than individual experiences, [are] the units over which any distributive principle should operate.”Although there are important differences between these thinkers, they share a core commitment to consider entire lives rather than events or episodes, which is also the defining feature of the complete lives system.

They explain further in regard to the old folks issue.

Unlike allocation by sex or race, allocation by age is not invidious discrimination; every person lives through different life stages rather than being a single age. Even if 25-year-olds receive priority over 65-year-olds, everyone who is 65 years now was previously 25 years. Treating 65-year olds differently because of stereotypes or falsehoods would be ageist; treating them differently because they have already had more life-years is not.

The blog Freerepublic.com summarizes the system in this way.

Infants get minimal treatment, because the State has not invested anything yet in their education. Old people get minimal treatment because their working lives are over.

So if you discriminate because someone is old that is ageism and invidious but if you treat differently because they have lived longer ( i.e. have had more life years) it is not. Talk about contrived nonsense.

Here is another quote that I find chilling.

the complete lives system assumes that, although life-years are equally valuable to all, justice requires the fair distribution of them.” (my bolding)

If you like social justice that sentence should really please you. Not only should most things be distributed fairly but now apparently how many "life-years" you get.

If you like distributive justice you will find a lot to like here. If you are old enough for Medicare or economically unfortunate enough to rely on Medicaid, you might be a little worried that the President's Advisor on health matters thinks this way.

It should be noted ,however, that Emanuel seems to believe that a two-tier system is ethically acceptable and he wrote the following about in 1996 :

... The fundamental challenge to theories of distributive justice for health care is to develop a principled mechanism for defining what fragment of the vast universe of technically available, effective medical care services is basic and will be guaranteed socially and what services are discretionary and will not be guaranteed socially. Such an approach accepts a two-tiered health system-some citizens will receive only basic services while others will receive both basic and some discretionary health services. Within the discretionary tier, some citizens will receive few discretionary services, other richer citizens will receive almost all of available services, creating a multiple-tiered system.

Link for the complete article for the above excerpt is here.

So, even though justice demands a fair distribution of life years, you can opt out of that distribution system by being rich enough.

After reading Dr. Emanuel's writings that seem to give his ethical blessing to a multiple-tiered system, my inner libertarian was somewhat relieved. Yet the chilling nature of the notion that life-years should be distributed fairly frightens the hell out of me.

Should the symbol of Massachusetts Health Plan be the canary or the dead parrot?

An argument can be made for either candidate.

The canary,as in the canary in the coal mine, served as a early warning system for respirable hazards in the mines, and the experiment in Massachusetts in mandated health insurance can serve to demonstrate what might happen if the Mass. plan goes national as may occur with plans now being written in Congress. So far we have seen costs significantly higher than the plan's advocates claimed,significantly decreased access to care and most recently efforts underway to control costs cost by radically overhauling payment systems for medical care. The latest is a capitation plan which would turn the (at least) public portion of Mass-care into a big HMO with features that make regular managed care look like your overly generous uncle.

Economist Arnold Kling comments on the events in Massachusetts and the first comment in reply to his entry explains why capitation did not work when tried in the 1990s. Sandy Swarc at Junkfood Science has this detailed review of how badly capitation worked out and the implications and effects that a capitation system has on medical ethics.I have written before about the destructive effects of a HMO-capitation system on the physician-patient relationship and the attempts to redo medical ethical principles to be "better suited" for the statistical morality of group outcome data and payments directives based on them in which the physician is directed to care for the group's outcome and not be mired in the outdated belief in the primacy of the fiduciary duty to the individual patient.

The dead parrot also might be considered a mascot or symbol because of analogy to a classic Monty Python routine seen here. In this sketch the customer is complaining that the parrot he recently purchased is dead while the store clerk steadfastly maintains that the bird is sleeping or resting. The opponents of the Mass-care point to the rising costs and decreasing access to care as a failure while the advocates deny the bird is dead and scramble to devise more fixes to salvage a spiraling failure with more government controls and less patient choice and opportunity for physicians to use their judgment and care for their patients.

Can we really save the economy by spending more?

The Director of the CBO believes we can't at least not in the context of the spending involved in the health care bill. The administration's purposed health care re-do seems to go like this. Since the country will ultimately go broke if we continue top spend more and more on health care cost must be contained. This is expressed in the jaunty jargon of health care policy wonks as "bending the health care cost curve". To bend this curve the administration is recommending that we spend more on health care by making sure that all (well almost all) of everyone in the county have health care insurance. So how will this keep the country from going bankrupt?

Simple we will rely on the magic three: comparative effectiveness research (cer),prevention and use of electronic medical record (EMR) systems. Actually that appeard to be the gist of the original taking points points more recently there are varous tax increase proposals being formulated. Combining providing care for almost all with these three ( plus some as yet undecided upon package of increased taxes) will bring about a "budget neutral " economic miracle.Everyone (almost) will have health care and it won't cost anymore and the quality will be better and by not relentlessly increasing health care cost we will save the country from bankruptcy. QED.

Douglas Elmendorf, Director of the Congressional Budget Office testified before Congress and reminded everyone that the notion of there-is-no-such-thing-as-a free-lunch may still apply. He said in part:

".. bills crafted by House leaders and the Senate health committee do not propose "the sort of fundamental changes" necessary to rein in the skyrocketing cost of government health programs, particularly Medicare. On the contrary, Elmendorf said, the measures would pile on an expensive new program to cover the uninsured. (Quote is taken from this Washington Post article and the bolding is mine.)

New physician payment Rules for CMS,different slicing of a shrinking pie

New physician payment rules from CMS have been proposed, can be found here and will likely go into effect January 2010. The Obama administration has found money to increase the pay of primary care doctors a bit ( about 6-8%) by taking it away from other doctors. Radiologists and cardiologists will be paid less. DrRich comments on the understandable reaction of the cardiology leadership here. In the coming months we may get to see how effective the lobbying efforts of organized cardiology will be in their damage control.

Sandy Szwarz in this entry from her blog Junkfood Science sees more in this proposal that the simple pay-this-doctor-less-to-pay- this- doctor-more. She speaks of the vision of things to come. I quote from her posting:

The core of the new CMS proposals (described in section 1413-P33) was a new method for determining fees for services based on their costs (called “resource-based practice expenses”) and their relative value, as determined by a survey called the Physician Practice Information Survey (PPIS). This survey compiled the returned questionnaires from 3,656 physician and professional groups and had been conducted in 2007-8 by The Lewin Group, the contractor for the American Medical Association and the government.

It does not go unnoticed that the Lewin Group is part of Ingenix which is part of United Health Group.See here for some details of the flawed data used by Ingenix and some of the legal actions against them. It is not clear if the Lewin Group derived data used to determine the new pay scales are also flawed.

I recommend that everyone read the rest of her essay to get a flavor of the type of changes and emphasis we can expect in Medicare as the "reform" plays out.Look for emphasis on "lifestyle medicine"as a key element in the prevention part of purported ways to save money.

As suggested by Ms. Szwarz the plan is basically to cut funds to providers and hospitals and institute a covering of "quality" measures so the claim can be made-see we spent less and quality improved.Look, when we pay the bills , we get to say what quality is.

The change (aka "reform") of health care that is promoted by the administration promises to increase coverage and decrease costs while increasing quality by the magic of the triple whammy consisting of electronic medical records, comparative effectiveness research and prevention. It is instructive to look at what comparative effectiveness research has to say about the extensive efforts that have been made to prevent coronary artery disease by attacking multiple risk factors. This is what the Cochrane Group has to say about that.

In many countries, there is enthusiasm for "Healthy Heart Programmes" that use counseling and educational methods to encourage people to reduce their risks for developing heart disease. These risk factors include high cholesterol, excessive salt intake, high blood pressure, excess weight, a high-fat diet, smoking, diabetes, and a sedentary lifestyle. This updated review of all relevant studies found that the approach of trying to reduce more than one risk factor - multiple risk factor intervention - advocated by these Programmes do result in small reductions in blood pressure, cholesterol, salt intake, weight loss, etc. Contrary to expectations, these lifestyle changes had little or no impact on the risk of heart attack or death. Possible explanations for this are that the small risk factor changes are not maintained long-term or are not real but caused by some of the studies being poorly conducted. This review is based on the findings from 39 trials conducted in several countries over the course of three decades. Its authors discourage more research on the topic: "Our methods of attempting behaviour change in the general population are very limited. Different approaches to behaviour change are needed and should be tested empirically before being widely promoted. For example, the availability of foods and better access to recreational and sporting facilities may have a greater impact on dietary and exercise patterns respectively, than health professional advice."

As primary care physicians' practices have changed in large part due to the tightening of the reimbursement screws one of the effects has been the increased use of ER by the primary care doctors' patients ( in off hours and weekends) and/or those folks who cannot find a primary care doc to begin with. With this change one would think the increasing importance of the role of the ER docs should be evident to all including the policy wonks at CMS. Apparently they do not as their new pay schedule gives these figures for the ER physician and the chiropractor:EM docs are valued at $ 38.36 per hour versus chiropractors valued $65.33 a hour.

Is fee for service really the culprit for health care costs?

Fee for service is said to be a major cause of the high health care costs that we are told must be brought under control to save the economy.Dr. Donald J. Boudreaux,Chair of the Economics Department at George Mason University, argues that is not correct.Rather a major cause is the fact that much of medical care is paid for with someone else's money. Go here to read his entire commentary.