Dr. Don Berwick addresses leaders of ACP, Tells them top-down government mandates won't work

Some would find that headline hard to believe. I do.While I believe the message I am surprised by the messenger.

It is hard to believe that the head of large government entity (CMS), which is noted for its top down mandates would express such a view. It is hard to believe that someone who heaped praise on the British National Health Service,also well known for its well known history of mandates, would hold such a view.

It is hard to believe that someone who has said that a health care system must,he emphasized the word "must", involve redistribution would say that. To achieve redistribution there must,now I emphasize the word "must", involve government mandates.


Berwick's address to the American College of Physicians Board of Governors was discussed in a blog entry by Bob Doherty,ACP's man in Washington, in his blog "The ACP Advocate Blog" See here for that entry.

There is much in Dr. Berwick's writings that strongly suggests his high regard for "rules with authority" and low opinion for the traditional doctor-patient relationship . The following is a quote from the book,"New Rules" which he co-authored with Dr. Troyen Brennan.

"Today, this isolated relationship is no longer tenable or possible… Traditional medical ethics, based on the doctor-patient dyad must be reformulated to fit the new mold of the delivery of health care...Regulation must evolve. Regulating for improved medical care involves designing appropriate rules with authority...Health care is being rationalized through critical pathways and guidelines. The primary function of regulation in health care, especially as it affects the quality of medical care, is to constrain decentralized individualized decision making.”


He advocates regulation,rules with authority, constraint of individualized decision making and reformulating medical ethics. Clinical decisions, in this view, should not be in the hands of the patient and his physician. These views are clearly those of someone who believes in authoritative control over those clinical decisions, so if he believes that government top down rules won't work then he must envision some other,non-governmental system of controls.

Indeed, he has talked about vertically integrated medical systems which can seek out cost effective treatments and coordinate care referring to such things as accountable care organizations,and medical homes.So could he possibly think that they will be the source of the mandates rather than the federal government? The promotion of such organizations was a major theme of a recent article in the Annals of Internal Medicine by three member of the current White House staff which I blogged about here.

With the passage of the health care remake bill and the birth of scores of federal entities with the power to issue mandates and the unprecedented power given to the secretary of HHS to make mandates what else could possible happen but that medicine as it will be practiced will be medicine by federal mandate?

Mr. Doherty's interpretation of what Dr. Berwick has written is that Berwick believes that change must come from the bottom up. It is true that Dr. Berwick has earned an excellent reputation for working towards and catalyzing grass roots innovations to improve patient care and much of his rhetoric is consistent with that effort and promotion of that idea.

However, he is not leading a organization devoted to grass roots solutions but rather one whose history and thrust and machinery has and will continue to issue and enforce orders from the top.

Have we heard from Dr. Berwick any plans to dismantle the current CMS system of command and control?What will be the relationship of these vertical organizations to the central control systems of CMS and those created by the health care bill? Will they be the administrative arms of the central controllers?

Whatever vertically integrated entities emerge and regardless of the relationship of the accountable care-type organizations to the government particularly troubling to me is that the "bottom" of Berwick's bottom up solutions is not all the way down, namely to the level of the individual patient and the individual doctor as he has made it clear that the traditional doctor-patient relationship needs to be replaced."This relationship is no longer tenable or possible".

It is hard to say it better and simpler than the following questions posed by Dr. Edmund D. Pellegrino (JAMA,May 24/31/1995,Vol. 272,no 20)

" Is medical ethics a social, historical, or economic artifact? Or are there some universal , enduring principles?

Was the traditional physician-patient relationship with the strong and controlling fiduciary duty to the patient's welfare merely an artifact of an earlier economic time which was largely free of the third party payer hegemony? Fee-for-service and the traditional physician fiduciary duty are the two major enemies to centralized (private or public) control over medical care.

Avandia just barely hanging on and now Actos accused of increasing risk of bladder cancer

The TDZ's seem always to be in the news,the bad news. First, Rezulin was taken off the market because of liver toxicity.Next, the issue of Avandia increasing the risk of heart attack arose and arose and arose and seemingly the issue will never be settled. Now Actos is being accused of increasing the risk of bladder cancer.

Most recently the FDA has taken action to strictly limit its use and make it fairly difficult for a new patient to be prescribed that drug. In Europe, apparently it will be taken off the market and folks currently taking that medication will have to be switched to something else.

An interesting action taken by the FDA is to require GSK to commission an independent "re-adjudication" of the RECORD study. This was the clinical trial with 4447 patients in which rosiglitazone (Avandia) was compared with the combination of metformin and a sulfonylurea and concluded that results was inconclusive in regard to what everyone was interested, namely cardiovascular outcomes. Somehow the FDA expects more analysts looking at the data will turn the inconclusiveness into some conclusions. More likely it won't but then maybe everyone can move on and worry about some other adverse effect of something else.

FDA's reasoning seems to be that if these new adjudicators can get an answer then the TIDE trial ( still another trial that the optimists think will settle the issue) will not have to be taken off of hold. The FDA put TIDE on full clinical hold.

Several years ago when one attended the infomercials with food ( AKA drug company sponsored CME -dinners) several speakers could talk about little else but the PPAR receptors and after much time and money was aimed at doing something really good therapeutically with those receptors little was accomplished. See here for some comments by a research insider about the PPAR story.

Early on in the Avandia kerfuffle I went on and on about the issue of "small"increases in relative risk and how is relatively easy to tell a big thing from a little thing but how difficult it is for epidemiology to tell a little thing from nothing at all. The original Nissen and Wolski paper talks about a relative risk of 1.43. With risks of 3 and 4 there is typically little to argue about. With RRs less than 2 it seems we go round and round for a long time before the combatants run out of stream.

What is fate of physician-patient relationship in a Don Berwick designed health care system ?

The following quote from the book Dr. Berwick authored with Dr. Troyen A. Brennan,which is frighteningly entitled , "New Rules" answers the headline question. (see here for a review of that book published in the NEJM)

H/T to the blog " Black Ribbon Project"

“Today, this isolated relationship is no longer tenable or possible… Traditional medical ethics, based on the doctor-patient dyad must be reformulated to fit the new mold of the delivery of health care...Regulation must evolve. Regulating for improved medical care involves designing appropriate rules with authority...Health care is being rationalized through critical pathways and guidelines. The primary function of regulation in health care, especially as it affects the quality of medical care, is to constrain decentralized, individualized decision making.”

I have expressed my concern abut Dr. Berwick views before and one such commentary was re-e-published by Kevin,M.D. with my permission. One of the replies to that entry on his web site accused me of taking his remarks " out of context". While it is true that remarks and words and phrases can be cherry picked to give an impression contrary to the speaker's intentions I offer a friendly, rhetorical challenge to anyone who can propose a context in which Berwick's words could be said and not mean anything other than their obvious meaning. OK, I can think of one and it is trivial. The author precedes that paragraph with the words "I do not believe the following".

Berwick's and Brennan's views dovetail with the ground work constructed by the "New Professionalism" (see here for the details of that project ) which implores physicians to somehow balance their duty the patient with some nebulous responsibility of stewardship to take proper care of society's limited medical resources and strive for social justice. Dr. Troyen Brennan was the chair of the Professionalism project. In fact Dr. Brennan name crops up more than once in a narrative of the transformation of medicine in which medical care is taken from the hands of individual physician and into the control of various organizations.

In 2002, Dr. Brennan's new Professionalism was revealed to the world in the Annals of Internal Medicine ( see the above link). (OK, it wasn't just Brennan's,others played a role.)Physicians were admonished to work for the good of society and not just be concerned with the parochial concern for their own patients.

In 2006 Brennan and Berwick published the book, "New Rules". The operative word is "rules".

In an Article in 2007 (JAMA,Vol 208,#6,p 670) Drs J. Cohen, ,S. Cruess, and C. Davidson report their " discovery " that individual docs basically could not resolve the ethical dilemma posed by balancing their efforts for the patient's welfare with their duty to work for the good of the herd. ( see here for my comments on that article) What was needed was a "Medical Societal alliance" which could be made manifest through large vertically integrated organization such as something called an "Accountable care organization (ACO). Note, the old medical ethics had no major, crisis -level conflicts it was the New Ethics that posed the problem that the author purport to remedy with their nebulous alliance between collective abstractions.

Another article in JAMA in 2007 carried this theme further. The article was written by the then President of the American College of Physicians, Dr. Christine K. Cassel and the then executive vice-president of Aetna Insurance, Dr. Brennan. (JAMA ,June 13, 2007, Vol 297, no. 22, p. 2518, "Managing Medical resources.Return to the Commons")

They speak of an abstract hypothetical " medical commons" and how the current emphasis by the physician on the welfare of the individual patient will spoil the commons much as the farmer who selfishly grazes his cattle on public land without regard for depleting the resource will destroy the resource.Physicians are implored to "reconstitute the medical commons" and think in terms of resource conservation and allocation so at the end the greatest medical good can be done for the greatest number of patients.They admit there is not currently such a commons. There never has been so I am unsure how a return is possible.

The medical commons figure of speech seems bizarre and lame.While a grassy knoll for the villager's sheep can be defined by a specific surveyor description, the "medical commons" is a extremely large amorphous array,the elements of which defy enumeration, and is every changing, with some elements growing ,others contracting and innovations cropping up constantly. Various entities own various elements of this array-society owns none.The skills,and knowledge of thousands of physicians are aggregated and then allocated as if somehow society own them.There is no easily defined entity called "medical resources". Rather,it is an amorphous abstraction.Further, to speak of allocation means some one or some elite group will be the "allocator in chief ". Decisions will not be made by thousands of individual physician-patient pairs, since those individual physician-patient pairs plans to spend money are the worse nightmare an officer of a health care insurance company could have. Is anyone surprised that an officer on a large medical insurance company would propose a plan to eliminate the pesky problem of physician-patient "dyads" scheming to spend the insurance company's money simply because the two agreed such expenditure would be in the patient's interest?

The old follow-the-money strategy continues to have explanatory power. but why would the leadership of the ACP take part in that philosophical sham?

Is more primary care really not the answer to all that ails U.S. medicine after all?

A recent WSJ article reports a Dartmouth Atlas study (DA study) that seems to cast at least a little doubt on the thesis that the key to good health care is lots of primary care docs. See here. See here for a more detailed discussion from the blog ACP Internist about the findings of the DA article.

So ,why are the indicators of good care used by the Dartmouth folks not better in an area where more primary doctors are available? The authors make several suggestions? I offer another. Maybe use of aggregate data often makes things less rather than more clear. A similar argument has been raised by some economists in their criticism of the major role of aggregate demand in Keynesian economics namely that the aggregation obscures more than it clarifies.

OR maybe the indicators purported to be of quality care are little more than something chosen because it was easy to measure and the data were available.

I think the real bottom line in regard to this Dartmouth publication is found in the authors' hypothesis that perhaps primary care is really the answer to much of what ails medicine only if that primary care is integrated into a larger system of other health care providers. This is the it-takes-a-village-to- provide -health- care type thinking. Can you say Accountable Care Organization (ACO)?

For the centrally managed health care that Obamacare portends to succeed at least one obstacle has to be overcome. That obstacle is the thousands of individual primary care docs out there practicing outside of the control of an organization such as an HMO,giant clinic or ACO. The Dartmouth publication could be part of a emerging argument similar to that put forth in a recent article in the Annals of Internal Medicine written by members of the administration urging physicians to get on board with the [Obamacare] program. See Dr. Rich's recent commentary about that article and what the message of that was.

What follows is a quote from the White House authored Annals Internal Medicine Study followed by a quote from one of the authors of the DA study.

"These reforms will unleash forces that favor integration across the continuum of care. Some organizing function will need to be developed to track quality measures, account for and manage shared financial incentives, and oversee care coordination…"


"Our findings suggest that the nation's primary care deficit won't be solved by simply increasing access to primary care, either by boosting the number of primary care physicians in an area or by ensuring that most patients have better insurance coverage," said David C. Goodman, MD, MS, lead author and co-principal investigator for the Dartmouth Atlas Project. "Policy should also focus on improving the actual services primary care clinicians provide and making sure their efforts are coordinated with those of other providers, including specialists, nurses and hospitals."

So, an "organizing function" is needed and someone/ something needs to make sure efforts are coordinated.

The message is that medical care is too important,too complicated, too whatever to be left to the individual patient and his physician.

Here is an earlier quote from the DA folks from there website.

"The availability of excellent primary care is central to high performing health care and favorable patient outcomes. Unfortunately in many regions of the country, residents cannot find the care they want and need."

Attorneys like to find expert witnesses making apparent contradictory statements so they can ask the old classic: Were you wrong then or are you wrong now?

Annals Internal Medicine publishes Obamacare advocacy commentary -I am shocked,shocked

The Annals of Internal Medicine published an article ( see here for full text) authored by three current or former members of the Obama administration .It is difficult to consider it anything other than advocacy for the health care law ( The bill is now generally known as ACA or Affordable Care Act.) The article, first appearing on line, lead to a flurry of negative comments from readers See here.

The authors are: Dr.Ezekial Emanuel,brother of Rahm Emanuel who is President Obama's chief of staff,Nancy-Ann Deparle ,Counselor to the President, and Dr. Robert Kocher. Kocher who recently resigned from the President's Council of Economic Advisers to return to the McKenzie group, was the lead author.

The article begin with this incredible statement, " It guarantees access to health care to all Americans."

However, it is well recognized "all" will not be covered. There is a group of people too prosperous for Medicaid but who are not required to buy insurance because their income is too low to trigger the mandatory insurance purchase mandate.This has been well covered even in the mainstream press so it is difficult to imagine that Dr. Kocher and his co-authors were not aware of that fact.The Congressional Budget Office estimates 17 million Americans would remain uninsured.

Dr. Kocher joined (and is now departed from) the President's National Economic Council after having lead a team from the business consultant company, the Mckensey Group, to study health care systems in various countries.See here for the publication co- authored by Kocher.

The attribution section of the Annals article ( the part that explained which author did what in the preparation of the article) makes it clear that the principle author was Dr. Kocher., who since the Mckensey article, is considered an "expert" in health care cost and cost controls.

A recent town hall meeting between voters and Senator Max Baucus lead to an exchange in which the senator told the audience that he had not read the health care bill and that was left to the experts.

Said Baucus: "I don't think you want me to waste my time to read every page of the health care bill. You know why? It's statutory language. We hire experts."

From the glaring factual error in the Annals article it seems that at least one expert hasn't read the bill either.

The Little Book of Obamacare Horrors-a guide for the worried (most folks)

Go here to read a publication from the folks at the NCPA telling the readers much they need to know about PPACA.

It is a welcome counterpoint to the rosy and in parts misleading picture painted in this publication from CMS.

For example, CMS talks about the changes in Medicare Advantage in the following way in a section astoundingly labeled as "Improvement to Medicare Advantage". ..." The new law levels the playing field by gradually eliminating Medicare Overpayments to insurance companies." Contrast that characterization with the following from the NCPA booklet:

Loss of Medicare Advantage Coverage. About half of the enrollees in Medicare Advantage (MA) plans (7½ million people) are likely to lose their coverage and will be forced to return to conventional Medicare. If you are able to keep your MA plan, expect higher premiums and fewer benefits. ...Of the 15 million people expected to enroll in Medicare Advantage programs, 7½ million will lose their plans entirely, according to Medicare’s chief actuary, and the remainder will face higher premiums and lower benefits.

The playing field seems to be leveled by forcing several million elderly folks out the MA plans many of whom may have to sign up for a Medicare supplemental insurance which is conveniently offered by AARP who just happened to have championed the health deconstruction-reconstruction bill. The follow-the-money rule has such great explanatory power.The CMS publication's section on MA would be more appropriately titled
"Throwing Medicare Advantage patients under the bus".

The entire NCPA publication is important reading but here is one interesting aspect of the bill that I was not aware of:

The government will require you to give your employer your most recent income tax return. Both at work and in the newly created health insurance exchanges, out-of-pocket premiums will be limited to a percent of your income. In order to enforce that requirement, however, your employer or the operator of the exchange will have to know what your income is. Note: Under the new law, the income-based premium limits are not based on the wages your employer pays you. They are based on your family income — including nonwage income (dividends, interest, trust income, etc.), your spouse’s income (from all sources) and, if your children are dependents, their incomes as well.

Wow, what if you might not want your boss to know how much your spouse makes or how much you made on investments? Too bad. It all just gets better and better. (Well, I won't give Fred a raise, looks how much his wife makes.)

The NCPA booklet is great source for important details of the PPACA. For an insightful,succinct summary statement it is hard to beat this slightly paraphrased comment from the blog "Nostrums by Doc D".
The plan is to take 500 billion from Medicare, spend it on something else and then call it a savings and a quality improvement to Medicare. Compared to that game plan, the business model of the Underwear Gnomes appears brilliant.

Yet another valid criticism of pay-for-performance (P4P)

DB of "DB's Medical Rants" takes another opportunity to direct some of his typical well thought out criticism against the dangerous concept of pay for performance for physicians. See here.

The thoughts he expresses fall into the category of still-another-reason why P4P is a bad idea.

He refers to the concepts popularized by Daniel Pink in his book "Drive" which include intrinsic motivation and the notion that contingent rewards lead to a loss of autonomy and loss of motivation.As noted by a commentary to DB's entry, Pink seems to rely heavily on the work of Alfie Kohn which can be found in his book,"Punished by Rewards".

The basic idea as it applies to physicians is the following. To offer rewards to someone for tasks that they already find interesting and enjoyable and who are to a large degree driven by their intrinsic motivation to perform at a high level a job that they believe to be important will tend to destroy motivation and eats away at the autonomy which is a major element in that job satisfaction.

Fundamentally P4P ,while touted as a means of improving some nebulous "quality" is a method of control of physicians' activities and succeeds in that control if and only if physicians comply which because of the hegemony of third party payer has become, outside of retainer practices, a fait accompli.

The Initiative to Transform Medicine-The push for social justice goes on and on

Should medical student applicants be chosen less for their demonstrated ability to master large amounts of knowledge and solve problems and more for their social consciousness and desire to push forward with social justice?

That appears to be the suggestion of a panel of experts from the AMA in a project called the Initiative to Transform Medicine (ITM) who believe an altruism deficiency underlies the migration to certain more lucrative medical specializations at the expense of forsaking primary care causing a shortage of primary care doctors.See here for the AMA page regarding that initiative and from there a link to the recommendations of that panel.Yes, I realize this is not breaking news but I only now heard about it.

See here for a good summary and exposition of reasons more convincing than a sudden attack of selfishness, greed and hypertrophied self interest as to why fewer medical students choose primary care .Yes, it does depend to a significant degree on income, but there is more to it.

(h/t) to John Goodman's blog entry authored by Linda Goodman.

The suggestion made by the panel that social awareness or social consciousness should be weighed more heavily than ability to master a formidable load of knowledge and problem solving ability in selecting students for primary care residency training reflects a lack of awareness of what is required in primary care and a demeaning characterization of primary care medicine. Often more problem solving skill is demonstrated in sorting out a patients diagnoses from a myriad of often non-specific complaints that is evident in the specialists subsequent handling of the case which arrive in his office with the label already properly applied. Internists were once thought of as being at the top of the problem solving food chain but now those limit their practice to outpatients seem to be considered merely as members of the category of primary care provider.

I believe the shift of medical students from primary care to specialties is due less to some alleged "altruism gap" than to the combination of three other gaps; 1) an income differential gap, 2) a life style differential gap, and 3) a practice hassle gap.

The above referenced link contains a useful, succinct summary how the income gap came about. This is a story often told in the medical blogs of the Resource Based Relative Value Scale and the now infamous RUC and the role that once obscure group played in protecting the income of procedure oriented physicians versus those who do not do procedures.

In addition to the altruism deficiency the panel "determined" another weakness of physicians as they are trained today.

Physicians are generally not prepared to be advocates for patients on issues related to social justice (for example, elimination of health care disparities, access to care) and to be citizen leaders inside and outside of the medical profession. This also includes engaging in advocacy on public health issues.

Apparently in the view of this group of self designated experts, one of the many requirements of physician training is to prepare them to work for social justice, which must involve redistribution of wealth. Perhaps lessons in community organizing could be added to the curriculum. I suppose libertarians need not apply. Neither should anyone who thinks Thomas Jefferson had it right when he said;

"To take from one because it is thought that his own industry and that of his father's has acquired too much, in order to spare to others, who, or whose fathers have not exercised equal industry and skill, is to violate arbitrarily the first principle of association -- the guarantee to every one of a free exercise of his industry and the fruits acquired by it."

(h/t to Wealth is not the Problem blog)

The general philosophical basis of the ITM is the same as that underlying to the creation of The New Medical Professionalism,which seriously weakens the fiduciary duty of the physician and inserts a nebulous duty to society to the physician 's obligations .See here.

Will health care law make Medicare more fiscally viable by making care less available?

Two recently released projections of what Obama Care (PPACA aka ACA) will do paint different pictures.
The paper by the Medicare Trustees take the provisions as written,assume that the provisions will be met and conclude that Medicare will remain fiscally viable for a longer period time than would obtain that if the bill were not passed.

The Chief Medicare actuary, however,claims that it is highly improbable that the cuts to Medicare providers, that are necessary to make Medicare more solvent, will ever happen. Congress , so far, repeatedly postponed the looming SGR formula cut so that now to belatedly enact them would bring about a 30% cut in Medicare fees for physicians. This would cause an even greater exodus from Medicare on the part of physicians, particularly primary care docs-internists and family physicians, at a time when some 31 millions folks will have recently obtained health insurance and will be seeking primary care.At least some of these will have plans that will pay more than Medicare.Further with the cuts to Medicare Advantage more senior will be looking for primary care docs in the traditional Medicare program.

So, if Congress would re-grow a spine and invoke the cuts to Medicare it may well be the case that Medicare patients will struggle to find primary care and lines will form. If they don't, the allegedly effect of making Medicare more solvent will not occur.In any event lines will form. Shortages are one foreseeable consequence of price controls and University of Chicago Law School professor, Richard Epstein, has characterized the health care bill as a giant mishmash ( my paraphrasing ) of price controls.

If the cuts do occur it is projected (by the Medicare Trustees) that Medicare reimbursements will fall below those of Medicaid by 2019. How many internists will participate in Medicare with that level of reimbursement? How many internists accept Medicaid patients now? The leadership at AMA and ACP should have second thoughts for sponsoring a plan that would so seriously reduce access to care by the Medicare population.See here for John Goodman's comments about Medicare projections.

President Obama in a recent radio address and Paul Krugman in a recent column ( see here) and a spokesman for the American College of Physicians in a recent blog all heralded the projected increased soundness of Medicare.We were not told much if anything specifically about the report of the Medicare's chief actuary regarding the implausibility of the cuts to Medicare actually happening and thereby the savings evaporating.The wink-wink-nudge-nudge dance and the attempts try to find the right shade of pig lipstick continue.

Value,quality,rent seeking -Does value equal quality/cost

I suspect we will be hearing more and more about paying for "quality" since the recess appointment of Dr. Donald Berwick to be the head of CMS. His views on central planning of medical care are the subject of much discussion. The following is a lightly re-edited version of a commentary I wrote several years ago on "measuring" quality and value.

Dr. RobertWachter, Professor of Medicine at UCSF , tells us that "value=quality/cost" and we have a moral obligation to "solve" equations for various clinical services. I reference his comments in the ACP observer as he replies to a letter to the editor commenting on the interview he gave discussing the overseas out-sourcing of medical services.(ACP Observer,July/August/2006 pg4) Dr. Wachter says in part:

Health care will be judged by its value: i.e.quality/cost...It is immoral not to seek ways to provide high quality care at more affordable costs"

It seems to me that this "equation" presupposes an intrinsic theory of value in which value is considered to be something that can be objectively measured and is an intrinsic property of a good or service much like the specific gravity of a liquid or the density of a compound.

Since the Austrian School of economics popularized the subjective theory of value most mainstream economists reject the intrinsic value theory.

The same service may be more or less valued by a given person as her circumstances and desires change. No two individuals need value the same thing to the same degree though they may.Value to most economists is not an intrinsic measurable number but rather value is subjective and is in "the eye of the beholder". Thomas Sowell ( pg 51,Knowledge and Decisions,Basic Books, 1966) puts it this way:

"Value being ultimately subjective, it varies not only from person to person but from time to time with the same person, and varies according to how much of the given good he already has."

Advocates of the subjective value theory would argue that to define value with the above equation is to erroneously claim that value (or in this case "quality" which along with "cost" determines "value") is an objectively measured entity. Are the medical quality experts( as best I can tell this is a self proclaimed designation) who are able to or claim to be able devise means to measure quality merely substituting their preferences-dressed up as objective measurements-for the value judgments of others?

Wachter continues saying:

"Patients, payers and policy makers now expect us to tap into actual clinical data to assess a physician's quality of care.I suspect once we truly figure out how to do that..."

I take this to mean that exactly how to measure the quality of care has not yet been "figured out". Somehow, I think that compliance with guidelines and adherence to protocols will play a big role in this-it has so far- and I doubt if patients will be asked what it is they value. I agree that payers and policy makers want quality data to use as a cost containment tool, the gatekeeper concept now largely abandoned, but patients want a physician who will spend time with them,care about their problem and be more interested in doing what the doc and patients agree on as the right course for that person and not adherence to some guideline that the patient has probably never heard of and does not take the particulars of his situation into account.

I believe "quality" which is now the main rhetorical tool of the cost-containment movement has become a classic bait-and-switch term. Everyone, docs and patients alike,would naturally say we want to give/receive good care or "quality" care. But the quality guidelines so often turn out to be what some self-appointed quality guru, committee or task force says is an quality indicator and are often no more than simplistic, easy-to-count, check-off list items, some of which may have counterproductive or harmful effects.

I have no doubt there are many well-intentioned physicians working hard to improve medical care- if you will improve quality- but much of the quality movement and arguably its major motive force is to contain costs.


The movement to contain costs derives from so much of medical care being paid for with other people's money. We are not instructed about the moral imperative of providing high quality legal services, or haircuts or home repairs at more affordable costs because the people who use these services pay for them themselves.

Some may rejoice in the passage of Obama care as a golden opportunity to improve the quality of medical care while the more cynical think of the legislation with unparalleled power placed in the hands of various governmental agencies as the mother of all opportunities for what economists call rent seeking in which various interested parties ( now known a stake holders) seek special privilege.

Donald Berwick and Great Britain's Prime Minister talk about different NHS s

While Dr. Don Berwick, Obama's recess appointee to head CMS, speaks of Britain's NHS in glowing if not poetic and outlandishly laudatory terms,Britain's Prime Minister who has actually studied a report about NHS failings presents a different portrait . See here for the white paper on the NHS.

Here is one except from that report:

... the NHS has achieved relatively poor outcomes in some areas. For example, rates of mortality amenable to healthcare, rates of mortality from some respiratory diseases and some cancers, and some measures of stroke have been amongst the worst in the developed world.


"Worst in the developed world" Berwick began his remarks celebrating the 60th anniversary of the NHS with this:

"I am romantic about the NHS; I love it. All I need to do to rediscover the romance is to look at health care in my own country."

His expressed infatuation for the single payer,centrally planned health system of Great Britain is obvious.What is less obvious is how he (or anyone) could reconcile those views with his self admitted radical views of patients primacy.

Dr.RW takes on this daunting task in his recent blog posting (see here) and using in part material from a 2007 IHI publication (see here) he provides insight into Berwick's thinking about reconciling conflicting aims.

Everyone ,physicians,patients,anyone who might become a patient should read about the "goals" that Berwick's organization advocates for a health care system.Then consider on what planet or in what alternative reality those aims could be actually accomplished by governmental central planning.It makes Will Roger's quote " Boil the oceans" ( to get rid of German U-boats ) seem practical.

Dr RW says this about their formulation:

'Grandiose, nebulous and intrusive are adjectives that come to mind." I think he is too kind.

Wall Chart of PPACA is so complex that no one who supported the bill could have possibly known what they supported

Go here to see the labyrinth of provisions, regulations, deadlines,subsides and cross subsidies from the hundreds of thousands of words from PPACA that will transform American medicine. Read through it and try and see who gains and who loses. I suggest the countless details defy a comprehensive analysis. It will be years before the the unintended consequences can begin to be sorted out.Did the advocates for Obama care from AMA and ACP and other medical organizations who claim a victory for "social justice" have a clue about what the bill really contained? I suggest they understood even less that some of legislators who admitted they had not even read the bill.Further, many of the operational particulars have not yet been defined.That is a work in progress by the numerous governmental agencies who are now beset upon by the various lobbying interests(known euphemistically as stakeholders ).

Perusing the chart makes me wonder why there is so so much detail,why so many elements and provisions are there ,why laws are crafted to be so long and so opaque and why are so many agencies and governmental entities are necessary to carry out any stated goal.

Angelo Codevilla's essay on the ruling class provides one answer:

"[O]ur ruling class’s standard approach to any and all matters, its solution to any and all problems, is to increase the power of the government – meaning of those who run it, meaning themselves, to profit those who pay with political support for privileged jobs, contracts, etc."

Simply put, it has to be long and detailed and governmental agencies have to empowered to make many discriminatory decisions so that the folks in power can ensure who is that profits and who it is that picks up the tab. A statute's mind-boggling length and opacity serves to obscure what is happening.

Senator Baucus apparently really knew what the health care bill was all about even though he likely could not detail exactly what all the provisions were when he said in his exuberant candor after the bill was passed:

"Too often, much of late, the last couple three years, the mal-distribution of income in America is gone up way too much, the wealthy are getting way, way too wealthy and the middle income class is left behind," he said. "Wages have not kept up with increased income of the highest income in America. This legislation will have the effect of addressing that mal-distribution of income in America."

Right, it was all about redistribution of wealth which it just so happens is Dr. Don Berwick's desire as well as regards health care in America expressed in this quote from Berwick:

"...and that any health care funding plan that is just, equitable, civilized, and humane must – must – redistribute wealth from the richer among us to the poorer and less fortunate.


H/T to the Blog We Stand Firm

So did AMA and ACP have a seat at the medical legislative table or were they on the menu?

An essay that is receiving much attention as it should is available here .The author is Angelo M. Codevilla, a professor emeritus from Boston University. His characterizations of the" Ruling Class" and the "Country Class" is in the least thought provoking. I quote from the section labeled " Dependence Economics" with my bolding added:

"By taxing and parceling out more than a third of what Americans produce, through regulations that reach deep into American life, our ruling class is making itself the arbiter of wealth and poverty. While the economic value of anything depends on sellers and buyers agreeing on that value as civil equals in the absence of force, modern government is about nothing if not tampering with civil equality. By endowing some in society with power to force others to sell cheaper than they would, and forcing others yet to buy at higher prices -- even to buy in the first place -- modern government makes valuable some things that are not, and devalues others that are. Thus if you are not among the favored guests at the table where officials make detailed lists of who is to receive what at whose expense, you are on the menu.
Eventually, pretending forcibly that valueless things have value dilutes the currency's value for all. Laws and regulations nowadays are longer than ever because length is needed to specify how people will be treated unequally. For example, the health care bill of 2010 takes more than 2,700 pages to make sure not just that some states will be treated differently from others because their senators offered key political support, but more importantly to codify bargains between the government and various parts of the health care industry, state governments, and large employers about who would receive what benefits (e.g., public employee unions and auto workers) and who would pass what indirect taxes onto the general public."

Treating people differently seems to be the essence of "social justice" for which supporters of Obamacare claim a victory.

While the leaders of AMA and ACP ( and other medical organizations as well) announced proudly they had a seat at the adults' table with the Obama administration in planning health care reform , for most of the medical profession, I think the designation of "on the menu" is more appropriate as it is for many citizens who were "happy with their doctors and health care plans". Maybe sometimes folks just thought they had a seat at the table or , even worse, maybe they got what they wanted.

More medical blogs express concern about Donald Berwick's suitability for CMS head

For a while it seemed only a few medical blogs were expressing concern about Dr. Donald Berwick's suitability to be the head of CMS. See here for one of Dr. RW Donnell's posting on that topic and here for one by Dr. Doug Perednia of the new blog Road to Hellth. Now others are joining it.

The prolific and widely read Dr. David Gorski has submitted a detailed discussion about Dr. Berwick expressing in part concern about Berwick's apparent support for unscientific alternative medicine .See here for the commentary. Additionally, Gorski makes the case, based on quotes from Berwick, that in some regards his views appear to be naive and out of touch with real world physician-patient encounters and relationships. Quoting Gorski:

Berwick strikes me as a very well-meaning person with some good ideas about how to make our health care system less rigid and more responsive to patients’ needs, both medical and nonmedical. Unfortunately, he also appears to be naive to the point of my wondering whether he has any clue what it’s like to practice medicine in the real world or even in the idealized world of academics.

I agree.A number of Berwick's comments appear very naive,unrealistic, and something more expected from someone not actually caring for patients than a physician with any recent background in patient care.As best I can tell he had not been practices medicine for a while.

There is a major disconnect between Berwick's expressed adulation of the NHS and his statement that rationing must be done with his views of patient centerness which he self describes as radical.

Dr. Kimball Atwood,a tireless opponent of non-scientific alternative medicine expressed similar views to Gorski in his essay on the blog Health Care Renewal. See here. Quoting Atwood:

"In February of 2009, Dr. Berwick gave a 'keynote' address at the IOM and Bravewell Collaborative-sponsored Summit on Integrative Medicine and the Health of the Public. He shared the podium with Mehmet Oz, Dean Ornish, Senator Tom Harkin, and other advocates of pseudoscientific health claims. I wrote about the conference at the time, mainly to call attention to its misleading use of the term "integrative medicine": literature emanating from the Summit characterized it as "preventive" and "patient-centered," whereas the only characteristic that distinguishes it from modern medicine is an inclusion of various forms of pseudomedicine. I noticed that Dr. Berwick was on the speaker roster, which I found disappointing: I imagined that he had either gone over to the Dark Side or, perhaps, was sufficiently naive about the topic to have been duped; or, more likely, that he had cynically accepted the offer to further his ambitions."

Dr. Donald Berwick's medical utopia - a top down, technocratic, authoritarian pipe dream

Apart from some apparently radically contradictory expressed views on patient "centerness " and patients being in control ( see here for a discussion of some of his inconsistency) the newly appointed head of CMS, Dr. Donald Berwick, has made it clear what sort of medical system he would have for the United States.

What he wants is well explained in this commentary from National Review Online as is the authors' reasoning of why that sort of authoritarian central planing never seems to work. The following is from that article:

Ideologues on the left favor a single-payer system for, well, ideological reasons of material egalitarianism. But for technocrats like Berwick, who shape the liberal policy consensus, the single-payer system is the most efficient way to manage health care. Top-down control, in their minds, ensures that every participant in the system serves the broader public good: hospitals and doctors only perform the tests and procedures they need to; private companies make enough money to get by, without excessive profits; and “integrators” mandate best practices for all parties based on the best available evidence.

From Berwick's extensive writing and speeches we see that he favors a system in which data is dispassionately collected,adroitly and in an unbiased manner analyzed and in the most scientifically validated method a cost benefit analysis is performed so that the proper testing, procedures and medications are dispensed in a fair, equitable, humane and compassionate manner. Mandated best practices would impose order on the chaotic unplanned, helter-skelter mess we have today. By the same token someone should impose order on the chaotic, unplanned mess that is our "grocery delivery"system. Getting food is even more important that health care. By that I mean the thousands of groceries across the country in which most of us find, most of the time, everything we want. and if we don't, we go to the store down the street.Contrast that with the iconic empty grocery shelves of the USSR which fixed the chaotic market with best practice central planning.

It is difficult to imagine that someone still thinks central planning is more efficient that market mechanisms.Most anti-markets theorists decry what they believe to be the lack of morality of markets while agreeing that markets are most efficient.

So what could be wrong with this technocratic approach? The NRO essay suggests the following for starters:

Even if you believe that technocrats could better organize our health-care system, Berwick’s approach only works if the narrow interests of Congressmen, labor unions, general hospitals, the AARP, etc., have no influence on the writing of law. No one who watched Democrats make the Obamacare sausage can harbor any illusions on this score.

In other words,it would work only if we change human nature and the folks in government ( both the legislative and the executive branches) miraculously are no longer vulnerable to the incentives and pressures and biases and,yes even self interest, that is the plight of the rest of humanity. Technocratic administration in theory and technocratic administration in practice could not be more different.

A second point from NRO's critique:

Technocrats may believe they can marshal statistics and analysis to optimize the health-care system, but they are not omniscient. Their analyses rely on too many assumptions and on unreliable data. This is why government programs always result in colossal amounts of waste, fraud, and abuse.

So, how well did the central planning work out in the USSR? Hint: There is no USSR anymore.Starvation and near starvation characterized both the Russian and Chinese central planning of farming.

Berwick longs for a situation in which "leaders with plans" can roll up their sleeves and get this chaotic,leaderless medical system on the right road. I can think of little worse that putting self anointed leaders with plans in charge of medical care or,for that matter, grocery distribution.

Who Funds Don Berwick's foundation?And why did he not give that info to Senate Democrats?

H/T to Keithhennessey.com for calling attention to the fact that Dr. Donald Berwick did not reply to Senate Democrats questions regarding who funded his foundation, the Institute for Healthcare Improvement (IHI).See here.

The mainstream medical organizations seem to have nothing but praise both for Dr. Berwick's work and his institute.

If you visit the IHI website you will not learn about who funds the organization.You will learn that the IHI has quite a few vice-presidents for what that is worth.

I have no reason to believe that their activities are anything but those representing a sincere effort to improve medical care although I freely admit that I have not spent much time analyzing or learning about exactly what they have done. But the question remains- why are the donors' name(s) not made public.

This commentary, from the American Spectator (AS) appears to have answered some of the questions regarding funding and raises the issue of the dread conflict of interest (COI) in regard to Berwick and the IHI.

I was impressed with how lucrative it is have Berwick's job at the IHI and how well a number of their vice-presidents are compensated. If the facts are as they are claimed to be in the AS article, it seems like we have once again validated the Mafia rule of "follow the money" because managed care organizations and insurance companies contribute to the IHI. Could it be they may well profit from research on quality which just happens to find that less care is better and/or that there is much overuse and misuse in medical care.

Here is a quote from the NHS speech Dr. Berwick delivered:

In the United States, these hundreds of insurance companies have a strong interest in not selling health insurance to people who are likely to need health care. Our insurance companies try to predict who will need care, and then to find ways to exclude them from coverage through underwriting and selective marketing. That increases their profits. Here, you know that that is not just crazy; it is immoral.

There is a interesting contrast here.Very critical remarks about the U.S.health insurance industry are made by someone who, according to the American Spectator Article, received 2.36 million annually since 2008 in compensation from an institute which is to a significant amount funded by health insurance companies.

Why are these companies paying someone so well to travel the world and bad mouth them?

All of this is really the dogs barking while the caravan moves on.Obama has in place a staunch single payer advocate. A single payer is becoming more will likely to happen sooner rather than later if the debacle with Masscare is a precursor of what will happen to the insurance industry with Obamacare.

New Head of CMS,Donald Berwick-friend of central planning and redistribution of wealth ?

President Obama has appointed Dr. Donald Berwick as head of CMS during Congress's recess .If you like central planning and the notion of redistribution of wealth, you should love Dr. Berwick at least if you believe he was sincere in his speech praising the National Health Service in Great Britain.But is there another side to his philosophy?

He said that we need "leaders with plans" to design and reform the U.S. health care system. He said that"excellent health care is by definition redistribution". See here for a portion of speech praising the British NHS for in which the "redistribution " quote appears.

He has expressed his "love" for the NHS which is well known for its particular form of rationing medical care. This poses an interesting and puzzling contrast with the following statement from his paper from Health Affairs (vol.28,no.4):

Evidence-based medicine sometimes must take a back seat. First, leaving choice ultimately up to the patient and family means that evidence-based medicine may sometimes take a back seat. One e-mail correspondent asked me, "Should patient ‘wants’ override professional judgment about whether an MRI is needed?" My answer is, basically, "Yes." On the whole, I prefer that we take the risk of overuse along with the burden of giving real meaning to the phrase "a fully informed patient." I contemplate in this a mature dialogue, in which an informed professional engages in a full conversation about why he or she—the professional—disagrees with a patient’s choice. If, over time, a pattern emerges of scientifically unwise or unsubstantiated choices—like lots and lots of patients’ choosing scientifically needless MRIs—then we should seek to improve our messages, instructions, educational processes, and dialogue to understand and seek to remedy the mismatch. For the same reason, I wish we would abandon the word "noncompliance." In failing to abide by our advice or the technical evidence, the patient is telling us something that we need to hear and learn from. Honestly, how many of us have ever faithfully taken a full ten-day course of a prescribed antibiotic or never consciously skipped a statin dose? Are we fools who did that? Or did we choose that because of some sensible, local considerations of balance, convenience, or even symptom information that the doctor never had?

I would have liked to have heard his attempt to reconcile those views some of which sound like advocacy for ground up versus a top down control mechanisms with his affinity for the rationing activities of the NHS and his preference for leaders with plans to design the health care system but the recess appointment eliminates the need for Senate confirmation and the hearings that precede it.So we may never hear that.

Does Berwick believe the patient should call the shots or should the "leaders with plans" be the decision makers? It is hard to believe that in his beloved NHS a patient can get an MRI if she wants one or for that matter get certain cancer treatments? Perhaps he can miraculously merge those views which appear to be contradictory and the result of his leadership at CMS in the era of Obama care will be health care that is " generous, hopeful, confident, joyous and just " which are the words he used to characterize the NHS. What does it even mean to describe a health care system with as many problems as have been documented in the NHS as hopeful and joyous?

Another virtue of Obamacare-massive job stimulus for lobbyists

There is benefit to make a law ambiguous-at least to the bureaucrats whose rule making will give that law operational meaning. There is benefit to a law which delegates to federal agencies the power to flesh out what a exhaustingly long and dense morass of legalese really means-at least to the lobbyists who represent the special interests who will benefit from the"proper interpretation" and implementation of the statute.

Such it is with PPACA aka Obamacare. Hat Tip to the The blog "Thinkmarkets .

" these reams of regulation are an epitome of vagueness...In the murk and the wide-open discretion given to bureaucrats lie gems for lobbyists. The White House and Congressional Democrats-even as they chided business lobbies-maximized the bill's scope and vagueness, laying the groundwork for massive growth in the crony system that intermingles government with private interests".

"Void for vagueness" is a legal concept that seems to particularly apply to criminal law and perhaps only to criminal law. In non criminal law vagueness seems to have become a virtue so that both sides in regard to particular legislation might think they have passed what they wanted and after passage the real meaning of the law is authored by various regulatory agencies and then the regulations themselves are often couched in another layer of vagueness allowing much interpretive leeway to those agencies.

A possible job for Retired Doc

Ever since I retired I have had my eyes open for a suitable job opportunity. This might work. Thanks to the Carpe Diem blog for the reference. An older white guy might be even better as a candidate .

The best name yet for Obamacare-TNRKMA (turkey ma)

High fives to the endlessly insightful blog of John Goodman for what I believe is the best designation yet for PPACA which is also known as Obamacare.

I quote his introduction to the new name,TNRKMA.(The Thing that Nobody Really Knows Much About.)

'...what should we actually call this thing? That is, the Thing that Nobody Really Knows Much About (TNRKMA). At this blog, we have followed the convention of calling it “ObamaCare,” but that could be considered derisive. There is always “health reform,” but this bill will almost certainly be reformed many, many times, even before all of the original provisions are enacted.

On balance, I’m inclined to go with the acronym, TNRKMA — which is pronounced “Turkey Ma” (mother of all turkeys), with the N silent, or simply “Turkey,” for short.'

I tend to prefer the simpler designation, "turkey".Read his entire blog here.