Dr. Ezekiel Emanuel seems to make exactly that point in this WSJ opinion piece.
Quoting Dr. Emanuel :
"Here is the specific problem: Insurance companies worry that young
people, especially young men, already think they are invincible, and
they are bewildered about the health-care reform in general and
exchanges in particular. They may tune out, forego purchasing health
insurance and opt to pay a penalty instead when their taxes come due.
The consequence would be a
disproportionate number of older and sicker people purchasing insurance,
which will raise insurance premiums and, in turn, discourage more
people from enrolling. This reluctance to enroll would damage a key
aspect of reform."
Dr. Emanuel goes on with this bit of wishful thinking.
"... The president connects with young people, too, so he needs to use that
bond and get out there to convince them to sign up for health insurance
to help this central part of his legacy....
Second, we need to make clear as a society that buying insurance is part
of individual responsibility. If you don't have insurance and you need
to go to the emergency room or unexpectedly get diagnosed with cancer,
you are free- riding on others."
Question for the day. How often have mammoth ,disruptive and costly social programs succeed on the basis of exhorting people to do the "right thing"? Is this a sign of desperation on the part of the diminishing number of vocal advocates for Obamacare that they resort to a plea for some to act mainly in the interest of others?
Plans and schemes that ignore the persistent and widespread tendency of humans to act in their own self interest have seldom enjoyed lasting success.
Mises and Hayek in their efforts in the Socialist Calculation debate emphasized that central planing would fail because of two problems;the knowledge problem and the incentive problem. Planning would fail in the absence of the guidance from prices derived from the free market and because of the inherent persistent characteristic of humans to act in their own self interest. The history of the 20th century should have made clear to all but the clueless that depending on the transformation of human nature for something to work was not a viable plan.
h/t to Dr. Paul Hsieh for his insightful, recent commentary in PJ Media ("Is Obamacare's Fatal Flaw taking effect?") in which he discusses Emmanuel's essay as well as other developments strongly suggesting that Obamacare is unraveling before it is fully implemented as increasing number of former supporters seem to be jumping ship.See here.
Friday, May 24, 2013
Monday, May 13, 2013
James Madison on Obamacare
"It will be of little avail to the people that the laws are made by those they elected, if laws be so voluminous that they cannot be read, or so incoherent that they cannot be understood."
James Madison, Federalist no. 62.
According to this source while the House bill and the Senate version contained over 2,000 pages a PDF file of the final law has "only" 906 pages.I could find no link attempting to quantify its incoherence.
Thursday, April 25, 2013
To discuss "high value" medical care do we need to begin with what is value
Apparently in the history of economics for a while the early thinkers in the field were a bit perplexed by what was known as the diamond-water paradox.Why was is that diamonds were worth so much more that water even though water was necessary for life.
The story goes that in the late 1800s three economists working independently devised what became known as the subjective marginal theory of value. Their notion was that value was not inherent in an object but value was in the eye and mind of the valuer.There is no such thing as value without a valuer.Further the valuers made their evaluation at the margin. (Economist like to talk about margins a lot) A man living by a lovely stream of potable water would pay little or nothing for a glass while a person lost in the desert without supplies would pay almost anything for a drink.The early economists were considering things from the view point of mankind in general for whom water was essential for life but the value of a given increment of water was evaluated by individual people each with their own set of values and needs and circumstances which could change over time.It was the value at the margin, the marginal value, and it was subjective.
The American College of Physicians (ACP) has announced a program called" High value,cost conscious care" ( HVCC). See here for some details.
Value is not inherent in things but is subjective but there may be objective proxy-measures of value such a market value. However, these measures in turn depend on the subjectivity of the individuals who make the choices. I have no reason to believe that the leaders of ACP have anything but good intentions in this initiative but I wonder if their notion of value is stuck somewhere in the early 19th century.
Here is a quote from ACP that seems to say we can have our cake and eat it too.
"[ the initiative is] to help physicians and patients understand the benefits, harms, and costs of an intervention and whether it provides good value, and to slow the unsustainable rate of health care costs while preserving high-value, high-quality care."
My question is in regard to how will "good" or "high "value be determined. It seems like the history of the notion of value in the world of economics has lead to the widely accepted concept that value is subjective.Does this now say that after all value can really be objectively determined? So the advocates and practitioners of cost effectiveness would seem to say. I should add in fairness that the authors of the quoted Annals article do state that in the final analysis a subjective judgement in required.At the end of the analytic process someone or some group makes a subjective judgment.Is the benefit greater than the risks or does treatment x cost "too much".Too much in the judgment of whom. Will the value be decided by the patient to whom the risk and benefits accrue or will the value be decided by a group of medical experts after making a cost effectiveness "determination".
In the March 7,2013 issue of the NEJM there is a thoughtful commentary by Dr. Lisa Rosenbaum entitled "The Whole Ball Game-Overcoming the Blind Spots in Health Care Reform" which addresses certain aspects of the notion of value in health care. She says:
"Value in health care, however,depends on who is looking , where they look and what they expect to see....". Are we fooling ourselves if we believe that efforts to reign in health care cost can be done by only eliminating things of low value?"
That quote seems to express the notion of subjective value- that individuals subjectively evaluate a given event ( test or treatment ) from her own point of view which may or may not coincide with a determination of value by practitioners of cost effectiveness and cost benefit analysis who after they carry out the various elements of their statistical package make their own subjective evaluation cloaked though it may be in the robes of a purported objective analysis. Is the real bottom line here the accounting bottom line of the third party payers?
5/30/14. several minor corrections made in spelling and punctuation.
The story goes that in the late 1800s three economists working independently devised what became known as the subjective marginal theory of value. Their notion was that value was not inherent in an object but value was in the eye and mind of the valuer.There is no such thing as value without a valuer.Further the valuers made their evaluation at the margin. (Economist like to talk about margins a lot) A man living by a lovely stream of potable water would pay little or nothing for a glass while a person lost in the desert without supplies would pay almost anything for a drink.The early economists were considering things from the view point of mankind in general for whom water was essential for life but the value of a given increment of water was evaluated by individual people each with their own set of values and needs and circumstances which could change over time.It was the value at the margin, the marginal value, and it was subjective.
The American College of Physicians (ACP) has announced a program called" High value,cost conscious care" ( HVCC). See here for some details.
Value is not inherent in things but is subjective but there may be objective proxy-measures of value such a market value. However, these measures in turn depend on the subjectivity of the individuals who make the choices. I have no reason to believe that the leaders of ACP have anything but good intentions in this initiative but I wonder if their notion of value is stuck somewhere in the early 19th century.
Here is a quote from ACP that seems to say we can have our cake and eat it too.
"[ the initiative is] to help physicians and patients understand the benefits, harms, and costs of an intervention and whether it provides good value, and to slow the unsustainable rate of health care costs while preserving high-value, high-quality care."
My question is in regard to how will "good" or "high "value be determined. It seems like the history of the notion of value in the world of economics has lead to the widely accepted concept that value is subjective.Does this now say that after all value can really be objectively determined? So the advocates and practitioners of cost effectiveness would seem to say. I should add in fairness that the authors of the quoted Annals article do state that in the final analysis a subjective judgement in required.At the end of the analytic process someone or some group makes a subjective judgment.Is the benefit greater than the risks or does treatment x cost "too much".Too much in the judgment of whom. Will the value be decided by the patient to whom the risk and benefits accrue or will the value be decided by a group of medical experts after making a cost effectiveness "determination".
In the March 7,2013 issue of the NEJM there is a thoughtful commentary by Dr. Lisa Rosenbaum entitled "The Whole Ball Game-Overcoming the Blind Spots in Health Care Reform" which addresses certain aspects of the notion of value in health care. She says:
"Value in health care, however,depends on who is looking , where they look and what they expect to see....". Are we fooling ourselves if we believe that efforts to reign in health care cost can be done by only eliminating things of low value?"
That quote seems to express the notion of subjective value- that individuals subjectively evaluate a given event ( test or treatment ) from her own point of view which may or may not coincide with a determination of value by practitioners of cost effectiveness and cost benefit analysis who after they carry out the various elements of their statistical package make their own subjective evaluation cloaked though it may be in the robes of a purported objective analysis. Is the real bottom line here the accounting bottom line of the third party payers?
5/30/14. several minor corrections made in spelling and punctuation.
Thursday, April 18, 2013
High value health care-who gets to decide?
In the 1 Feb 2011 issue of the Annals of Internal Medicine,an ACP committee offers up a entry entitled
High-Value, Cost Conscious Health Care: Concepts for clinicians to Evaluation, and Costs of Medical Intervention" with Douglass K. Owens, the lead author.
They begin with their definition of value which is " an assessment of the benefit of a intervention relative to expenditures." So balancing benefit and cost is considered value.
As a possible counterpoint I quote the following from the blog, "Politics & Prosperity" :
The Annals authors then make what they believe to be critical distinction -the distinction between cost and value. So that a high cost item may or may not provide high value and low cost may have little benefit , therefore low value.The price ( or cost?) of things in micro-economic theory results from the subjective valuation of things by people.
The authors then redefine rationing (or in the authors words " more appropriately define) to mean "restricting the use of effective, high-value care". So that if an intervention that is "determined" to be low value is restricted this would not be considered rationing. One can see what power this puts in the hands of those who determine what is high and low value.We will not have rationing-in the ACP definition- if we only eliminate those interventions that some one ( government? an ACP committee, United health Group ?) has determined to be low value. You think the power to define the words we use and the power to control the narrative is not important.
If a treatment is both better and cheaper than an alternative there is no problem in deciding between the two. More complexity emerges when an alternative provides more benefits but also costs more. What to do here gets to the core issue. How much is health worth.?In the authors terms- what is the choice of the " cost effectiveness threshold".
Owens et al in regard to determining how much health care is worth say that we need cost effective analysis which they say requires "specialized expertise and training" attributes that just happen to be apparently possessed by the authors themselves. Note we are moving from comparative effectiveness analysis to cost effectiveness analysis which is an entirely different matter. The authors tell us that such analysis is expensive and is "typically performed by investigators". In this way the value of competing interventions to patients and to society can be determined. Determining the "value to society"-no hubris there.
But here is the money quote in which he authors admit the obvious.
"The choice of a cost effectiveness threshold is itself a value judgment and depends on several factors, including who the decision maker is."
After all of the gathering of various costs and developing estimates of the quality adjusted life years (QALY) and the aggregation of costs and aggregation of estimated benefits and using various analytic tools , a value judgment has to be made. Ultimately it is a human value judgment- not simply the objective analysis or simply solving a set of equations. The big question question is who will decide; whose judgment will settle the issue..Seemingly, the authors have assumed or gratuitous announced they ( or similar experts with special training and expertise) should be the ones whose subjective evaluation is determinative.
High-Value, Cost Conscious Health Care: Concepts for clinicians to Evaluation, and Costs of Medical Intervention" with Douglass K. Owens, the lead author.
They begin with their definition of value which is " an assessment of the benefit of a intervention relative to expenditures." So balancing benefit and cost is considered value.
As a possible counterpoint I quote the following from the blog, "Politics & Prosperity" :
The theory of subjective value, which is a cornerstone of microeconomics, says that
value is not inherent in things. There may be objective proxy-measures of value—like market value—but these depend primarily on the subjectivity of the individuals who make the choices. The prices of things, in other words, result from people’s subjective valuations of things.The often quoted,Harvard Business School professor, M.E. Porter defines as: Value =outcome/cost. See here for my earlier comments on Porter,value and its determination.
The Annals authors then make what they believe to be critical distinction -the distinction between cost and value. So that a high cost item may or may not provide high value and low cost may have little benefit , therefore low value.The price ( or cost?) of things in micro-economic theory results from the subjective valuation of things by people.
The authors then redefine rationing (or in the authors words " more appropriately define) to mean "restricting the use of effective, high-value care". So that if an intervention that is "determined" to be low value is restricted this would not be considered rationing. One can see what power this puts in the hands of those who determine what is high and low value.We will not have rationing-in the ACP definition- if we only eliminate those interventions that some one ( government? an ACP committee, United health Group ?) has determined to be low value. You think the power to define the words we use and the power to control the narrative is not important.
If a treatment is both better and cheaper than an alternative there is no problem in deciding between the two. More complexity emerges when an alternative provides more benefits but also costs more. What to do here gets to the core issue. How much is health worth.?In the authors terms- what is the choice of the " cost effectiveness threshold".
Owens et al in regard to determining how much health care is worth say that we need cost effective analysis which they say requires "specialized expertise and training" attributes that just happen to be apparently possessed by the authors themselves. Note we are moving from comparative effectiveness analysis to cost effectiveness analysis which is an entirely different matter. The authors tell us that such analysis is expensive and is "typically performed by investigators". In this way the value of competing interventions to patients and to society can be determined. Determining the "value to society"-no hubris there.
But here is the money quote in which he authors admit the obvious.
"The choice of a cost effectiveness threshold is itself a value judgment and depends on several factors, including who the decision maker is."
After all of the gathering of various costs and developing estimates of the quality adjusted life years (QALY) and the aggregation of costs and aggregation of estimated benefits and using various analytic tools , a value judgment has to be made. Ultimately it is a human value judgment- not simply the objective analysis or simply solving a set of equations. The big question question is who will decide; whose judgment will settle the issue..Seemingly, the authors have assumed or gratuitous announced they ( or similar experts with special training and expertise) should be the ones whose subjective evaluation is determinative.
I am not speaking against comparative effectiveness research (CER). It is important that we be able to say, for example, if carotid stenting gives better results that carotid endarterectomy and in what groups of patients.Presuming to be able to determine which is the better value if the higher price intervention gives superior results than the less costly alternative is another matter altogether and in my opinion falls into what I call type 2 hubris.See here for the woefully under utilized Gaulte classification of hubris in which type 2 is the type that some self defined exceptional persons never outgrow their sense of hypertrophied self worth and instead enlarges to know what is best for everyone .
The authors of the article clearly admit the exercise ultimately is a value judgment. The authors modestly admit that folks with their skillful use of utilitarian statistics of the aggregate are best able to make those judgments.
Econ 101 courses often talk about economics as involving the allocation of scarce resources to competing ends and scarcity leading to trade offs. People in their everyday lives make trade offs that involve some type of formal or more likely informal balancing of costs and benefits. Mark Pennington in his book "Robust Political Economy" said :
"Utilitarianism,however,extends the principle of making trade-offs within a person's life to the trade-offs between lives, and thus fails to respect the discreteness of individual lives."
John Rawls criticized utilitarianism as being inattentive to the separateness of persons and being guilty of treating people as means for the achievement of various social ends. The utilitarianism of cost effectiveness based decisions regarding health care is in opposition to both the egalitarianism of Rawls and the libertarian views of Nozick but dovetails nicely with the notion of physician as steward of society's medical resources and the medical progressives' overarching principle that medicine is too important and complicated to be left to the individual patient with his individual separate life and his physician.
(Note: I have written before on the Owens article discussing in why that approach will deliver much less than they claim and have also commented on the bogus nature of the concept of Quality adjusted life year (QALY) which was actually recognized by the father of utilitarianism and other questionable assumptions involved in cost benefit analysis.)
Sunday, April 07, 2013
Another chapter in the story of Obamacare and crony capitalism
Since many states have not and may not ever establish insurance exchanges,a key component of ACA,the federal government is moving ahead to put in place a federal insurance exchange.
The key to that is the "hub" which will be a gigantic computer system which will house information on everyone in the country. Data will be imputed from CMS (Center for Medicare and Medicaid Services),the IRS,Homeland Security and the Justice Department as well as various state agencies.
A Maryland company QSSI ( Quality Software Services Inc ) has been awarded the contract. QSSI is now owned by a division of United Health Group known as Optum.See here.
Now consider the revolving door part. Steve Larsen now works for Optum.Mr. Larsen with a resume of variously working for state insurance agencies (including being Maryland's Insurance Commisioner) and health insurance companies and then HHS most recently lead a group at HHS charged with setting up rules for insurance coverage for the exchanges.His new job is- according to the Optum web site-executive vice president in charge of "government solutions". See here for more details about the contract with QSSI and concern about possible cahoots by expressed by folks in both the Senate and House.
Soon after Obamacarewas rammed through passed by Congress folks at ACP and AMA offered praise in part because of their claim that social justice was forwarded.More realistically its passage and efforts aimed at subsequent implementation seems a embarrassing monument to crony capitalism and rent seeking.
The key to that is the "hub" which will be a gigantic computer system which will house information on everyone in the country. Data will be imputed from CMS (Center for Medicare and Medicaid Services),the IRS,Homeland Security and the Justice Department as well as various state agencies.
A Maryland company QSSI ( Quality Software Services Inc ) has been awarded the contract. QSSI is now owned by a division of United Health Group known as Optum.See here.
Now consider the revolving door part. Steve Larsen now works for Optum.Mr. Larsen with a resume of variously working for state insurance agencies (including being Maryland's Insurance Commisioner) and health insurance companies and then HHS most recently lead a group at HHS charged with setting up rules for insurance coverage for the exchanges.His new job is- according to the Optum web site-executive vice president in charge of "government solutions". See here for more details about the contract with QSSI and concern about possible cahoots by expressed by folks in both the Senate and House.
Soon after Obamacare
Thursday, March 28, 2013
Here is a shocker- Bogus "commission" recommends abolition of physician fee for service
Fee for service has increasingly become the bogus reason for all of what is wrong with health care in the U.S. Now a group of self designated experts deliberated and concluded what they all likely believed at the onset namely that we must eliminate fee for service (ffs) in medical care.Reference here is to the "National Commission on Physician Payment Reform". See here for the report.
One could get a idea regarding their likely recommendations by considering some who are on the commission. Here are some of the participants:
Dr. Troyen Brennan who wrote with Dr. Don Berwick about replacing the physician patient dyad in their 1996 book, "New Rules" was formerly a VP at Aetna and now an executive VP at CVS Caremark. Here is a quote from Drs.Berwick and Brennan from that book:
Guess how the author of that paragraph would feel about fee for service for physicians.
Dr. Judy Bigby is Secretary of HHS for Massachusetts.
Dr. Lisa Lotts is a VP at Well Point.
Somehow the image of a commission of prominent foxes gathering to make recommendations regarding hen house security comes to mind.
One thing most of the fee for service critics propose is that physicians become part of Accountable Care Organizations (ACOs) and therefore they will be compensated for "quality and not volume of care". Does anyone really believe that physician employees of a ACO will not have volume requirement?
Dr John Goodman in this blog commentary says it better than I can in regard to fee for service and ACOs.
"There is absolutely no support for the notion that ACOs will do anything ― anything ― to reduce costs or improve quality (see this recent NCPA blog, “Question: Why Did Anyone Ever Believe in ACOs?”). It is nothing more than a wish dressed up with high-falutin’ language (sustainable, cost-effective, high-quality, interoperable, coordinated, etc.) In fact, virtually all of the evidence indicates just the opposite ― that the elements of ACOs (disease management, pay-for-performance and so on) are useless or worse."
And here is the money quote:
" ... the problem in health care is not fee-for-service, but third-party payment. Almost everything we do during the course of a day is done on a fee-for-service basis and none of it results in high inflation or poor quality. Quite the opposite. The only difference in health care is that someone else is paying the bill, so there is no constraint on the consumer or the provider of services."
Exactly-health care is largely paid for with some one else's money and those some one elses are doing all they can to limit that spending and increase their bottom lines and demonizing ffs and promoting the new bigger and better HMO ( now renamed as ASOs) seems to be their current tactic.
Sadly, the major medical professional organizations are complicit in this push into the ACOs which cannot possibly fix the health care problems but can put many more nails in the coffin of the fiduciary duty of the physician to the patients. How much individual patient advocacy are you going to see in a large organization in which the physician are the employees? To what extent will physicians trained in the era in which the world medical view is that physicians are stewards of society's resources and that their actions should be controlled by utilitarian based cost effectiveness analysis and directives be dedicated advocates for their patients?
One could get a idea regarding their likely recommendations by considering some who are on the commission. Here are some of the participants:
Dr. Troyen Brennan who wrote with Dr. Don Berwick about replacing the physician patient dyad in their 1996 book, "New Rules" was formerly a VP at Aetna and now an executive VP at CVS Caremark. Here is a quote from Drs.Berwick and Brennan from that book:
“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.”
Guess how the author of that paragraph would feel about fee for service for physicians.
Dr. Judy Bigby is Secretary of HHS for Massachusetts.
Dr. Lisa Lotts is a VP at Well Point.
Somehow the image of a commission of prominent foxes gathering to make recommendations regarding hen house security comes to mind.
One thing most of the fee for service critics propose is that physicians become part of Accountable Care Organizations (ACOs) and therefore they will be compensated for "quality and not volume of care". Does anyone really believe that physician employees of a ACO will not have volume requirement?
Dr John Goodman in this blog commentary says it better than I can in regard to fee for service and ACOs.
"There is absolutely no support for the notion that ACOs will do anything ― anything ― to reduce costs or improve quality (see this recent NCPA blog, “Question: Why Did Anyone Ever Believe in ACOs?”). It is nothing more than a wish dressed up with high-falutin’ language (sustainable, cost-effective, high-quality, interoperable, coordinated, etc.) In fact, virtually all of the evidence indicates just the opposite ― that the elements of ACOs (disease management, pay-for-performance and so on) are useless or worse."
And here is the money quote:
" ... the problem in health care is not fee-for-service, but third-party payment. Almost everything we do during the course of a day is done on a fee-for-service basis and none of it results in high inflation or poor quality. Quite the opposite. The only difference in health care is that someone else is paying the bill, so there is no constraint on the consumer or the provider of services."
Exactly-health care is largely paid for with some one else's money and those some one elses are doing all they can to limit that spending and increase their bottom lines and demonizing ffs and promoting the new bigger and better HMO ( now renamed as ASOs) seems to be their current tactic.
Sadly, the major medical professional organizations are complicit in this push into the ACOs which cannot possibly fix the health care problems but can put many more nails in the coffin of the fiduciary duty of the physician to the patients. How much individual patient advocacy are you going to see in a large organization in which the physician are the employees? To what extent will physicians trained in the era in which the world medical view is that physicians are stewards of society's resources and that their actions should be controlled by utilitarian based cost effectiveness analysis and directives be dedicated advocates for their patients?
Tuesday, March 19, 2013
"physicians as stewards of society's medical resources" is not just bogus but is a dangerous concept
The "physician as a steward" idea is implicit in Medical Professionalism as defined and promoted by a number of physicians who I label medical progressives and notably by the ABIM Foundation. In their own words they are advocates for " a just and cost effective distribution of finite resources." See here for source of quote.
I argue that the physician-steward is a bogus and dangerous concept.
To consider physicians as stewards is to consider the medical care resources as a collective entity.
This is to say that Individually possessed resources or assets should be considered as part of a collective pool owned by everyone and that all have an equal right to some share of the pool.That is the core concept implicit in the physician as a steward phrase.
In regard to a private property system the rights of the owner in general terms are clear. He has the right to use his property,exclude others from use of the property and dispose of the property through sale,gift or inheritance.
In contrast , the rights are in a common ownership system are vague and indeterminate. It is not clear how one can be said to "own" something if no one in principle is excluded from making a claim .
Once the common ownership idea is accepted it then seems to make sense to talk about allocating resources and to consider some one or some group or groups as the appropriate allocators. With common ownership it simply would not work for all of society to willy-nilly feed on the medical commons as soon the resources would be depleted Rather there needs to be a rational plan so that just and cost effective distribution can take place.
The first thing wrong with considering medical resources as collectively owned is that they are not collectively owned in any real ,literal or legal sense in a free or even semi free society. U.S.medical resources are not like a grassy field in which all of the town folks sheep can come to graze.
While a grassy field for the villager's sheep to graze can be defined by a specific surveyor description, the "medical commons" is a extremely large,always changing, amorphous array,the elements of which defy enumeration. Various entities own various elements of this array-society owns none even though various government entities own some but the government is not society.It is an amorphous abstraction.
The skills,and knowledge of thousands of physicians and others involved in health care are aggregated and then allocate. Further, to speak of allocation means some one or some elite group will do the allocating not individual physician patient units.You know the "dyads" that Drs.Berwick and Brennan wanted to eliminate as the decision making unit in matters of health care.(See here for what Berwick and Brennan has to say about that.)
The dangerous element of the concept is that when medical decisions are made on the basis of cost effectiveness as judged by some third party the individual is at risk of being harmed in the name of some aggregate benefit allegedly exceeding the aggregated cost. It is the utilitarian enterprise -the greatest good for the greatest number. there will be winners and losers and as long as the "utility" of the winners exceeds the utility lost by the losers we have a cost effective outcome. As since society as a whole is better off it must be fair by definition. Never mind that individuals may be sacrificed to some abstract aggregate benefit .
This utilitarian approach is not just opposed by libertarians but the egalitarian thinker, John Rawls says of utilitarianism that individual rights may be breached in its effort to bring about the happiness or utility of the greatest number and objects to utilitarian decisions because it ignores the separateness and distinctness of individuals.
The ABIM foundation and committees of the ACP both are promoting cost effectiveness analysis. Note this is not comparative effectiveness analysis but recommending the technique to determine for example if two treatments are both effective that the one with a more favorable cost effective ratio be used.
The idea that medical data analysis technocrats should be the allocators or at least advisers to the actual allocators is what one would expect from the medical progressives whose major tenet appears to be that medical decisions and too complex to be made by the individual physician patient dyads and is also a died-and- gone- to- heaven moment for the third party payers who could not be more pleased that is the medical profession itself ( or certain elements of it) who are advocating cost effectiveness .
Social justice was the Trojan horse on which cost effectiveness allocation of finite resources and guideline adherence rode. Operationally it seems that to the ABIM Foundation social justice is mainly all about fair and cost effective allocation of resources. In that scheme there will be two tiers of physicians.
There will be the highly trained cost effectiveness analysts who will determine what is just and cost effective and the worker bee physicians who by adhering to the allocators' guidelines will be promoting social justice in their stewardship role.
I argue that the physician-steward is a bogus and dangerous concept.
To consider physicians as stewards is to consider the medical care resources as a collective entity.
This is to say that Individually possessed resources or assets should be considered as part of a collective pool owned by everyone and that all have an equal right to some share of the pool.That is the core concept implicit in the physician as a steward phrase.
In regard to a private property system the rights of the owner in general terms are clear. He has the right to use his property,exclude others from use of the property and dispose of the property through sale,gift or inheritance.
In contrast , the rights are in a common ownership system are vague and indeterminate. It is not clear how one can be said to "own" something if no one in principle is excluded from making a claim .
Once the common ownership idea is accepted it then seems to make sense to talk about allocating resources and to consider some one or some group or groups as the appropriate allocators. With common ownership it simply would not work for all of society to willy-nilly feed on the medical commons as soon the resources would be depleted Rather there needs to be a rational plan so that just and cost effective distribution can take place.
The first thing wrong with considering medical resources as collectively owned is that they are not collectively owned in any real ,literal or legal sense in a free or even semi free society. U.S.medical resources are not like a grassy field in which all of the town folks sheep can come to graze.
While a grassy field for the villager's sheep to graze can be defined by a specific surveyor description, the "medical commons" is a extremely large,always changing, amorphous array,the elements of which defy enumeration. Various entities own various elements of this array-society owns none even though various government entities own some but the government is not society.It is an amorphous abstraction.
The skills,and knowledge of thousands of physicians and others involved in health care are aggregated and then allocate. Further, to speak of allocation means some one or some elite group will do the allocating not individual physician patient units.You know the "dyads" that Drs.Berwick and Brennan wanted to eliminate as the decision making unit in matters of health care.(See here for what Berwick and Brennan has to say about that.)
The dangerous element of the concept is that when medical decisions are made on the basis of cost effectiveness as judged by some third party the individual is at risk of being harmed in the name of some aggregate benefit allegedly exceeding the aggregated cost. It is the utilitarian enterprise -the greatest good for the greatest number. there will be winners and losers and as long as the "utility" of the winners exceeds the utility lost by the losers we have a cost effective outcome. As since society as a whole is better off it must be fair by definition. Never mind that individuals may be sacrificed to some abstract aggregate benefit .
This utilitarian approach is not just opposed by libertarians but the egalitarian thinker, John Rawls says of utilitarianism that individual rights may be breached in its effort to bring about the happiness or utility of the greatest number and objects to utilitarian decisions because it ignores the separateness and distinctness of individuals.
The ABIM foundation and committees of the ACP both are promoting cost effectiveness analysis. Note this is not comparative effectiveness analysis but recommending the technique to determine for example if two treatments are both effective that the one with a more favorable cost effective ratio be used.
The idea that medical data analysis technocrats should be the allocators or at least advisers to the actual allocators is what one would expect from the medical progressives whose major tenet appears to be that medical decisions and too complex to be made by the individual physician patient dyads and is also a died-and- gone- to- heaven moment for the third party payers who could not be more pleased that is the medical profession itself ( or certain elements of it) who are advocating cost effectiveness .
Social justice was the Trojan horse on which cost effectiveness allocation of finite resources and guideline adherence rode. Operationally it seems that to the ABIM Foundation social justice is mainly all about fair and cost effective allocation of resources. In that scheme there will be two tiers of physicians.
There will be the highly trained cost effectiveness analysts who will determine what is just and cost effective and the worker bee physicians who by adhering to the allocators' guidelines will be promoting social justice in their stewardship role.
Monday, March 11, 2013
Social Justice quote for the day from F.A. Hayek
Since the medical progressive leadership has at least nominally enshrined the pursuit of social justice as a ethical requirement for all physicians I think it is appropriate to at least look at what various prominent philosophers have had to say about the concept of social justice. Such a look is justified if for no other reason that the various polemics promoting a social justice imperative for physicians were bereft of any consideration of the impressive body of thought which rejects social justice as a meaningful concept.
FA Hayek's writings are prominence in that regard .The following quote is from his lengthy treatise "Law,Legislation and Liberty" Volume 2,The Mirage of Social Justice"
"[I]n...a system in which each is allowed to use his knowledge for his own purposes the concept of `social justice' is necessarily empty and meaningless, because in it nobody's will can determine the relative incomes of the different people, or prevent that they be partly dependent on accident. `Social justice' can be given a meaning only in a directed or `command' economy (such as an army) in which the individuals are ordered what to do; and any particular conception of `social justice' could be realized only in such a centrally directed system...In a free society in which the position of the different individuals and groups is not the result of anybody's design--or could, within such a society, be altered in accordance with a generally applicable principle--the differences in reward simply cannot meaningfully be described as just or unjust." (pp. 69-70)
One Sociology text book version of what the concept of social justice typically involves is the following:
Why the views of classical liberalism should be excluded from medical ethics without discussion and the standard welfare state progressive's notion of social justice be included is by no mean clear nor was a cogent argument for that presented in either the New Professionalism on the new ACP ethics.
FA Hayek's writings are prominence in that regard .The following quote is from his lengthy treatise "Law,Legislation and Liberty" Volume 2,The Mirage of Social Justice"
"[I]n...a system in which each is allowed to use his knowledge for his own purposes the concept of `social justice' is necessarily empty and meaningless, because in it nobody's will can determine the relative incomes of the different people, or prevent that they be partly dependent on accident. `Social justice' can be given a meaning only in a directed or `command' economy (such as an army) in which the individuals are ordered what to do; and any particular conception of `social justice' could be realized only in such a centrally directed system...In a free society in which the position of the different individuals and groups is not the result of anybody's design--or could, within such a society, be altered in accordance with a generally applicable principle--the differences in reward simply cannot meaningfully be described as just or unjust." (pp. 69-70)
One Sociology text book version of what the concept of social justice typically involves is the following:
- Historical inequities insofar as they affect current injustices should be corrected until the actual inequities no longer exist or have been perceptively "negated".
- The redistribution of wealth, power and status for the individual, community and societal good.
- It is government's (or those who hold significant power) responsibility to ensure a basic quality of life for all its citizens.
Why the views of classical liberalism should be excluded from medical ethics without discussion and the standard welfare state progressive's notion of social justice be included is by no mean clear nor was a cogent argument for that presented in either the New Professionalism on the new ACP ethics.
Friday, March 08, 2013
Is medical practice moving from "What can I do for you" to "What can't I do for you"?
In a society in which individuals are more or less free to interact with one another and seek each other's services and goods the following phrase is routine; "What can I do for you?" or "how can I help you?"
I have said that said many times to a patient at the beginning of an office visit.
It seems to me that that phrase captures an important aspect of the mind set of the clinician as she relates to her patients. What can I do for you, how can I help you, what are you concerned about all speak to the role of the physician in her fiduciary duty to the patient.
Why is it that clinicians seems to be concerned with what they can do for patients and so often health policy wonks emphasize how we as physicians can limit what patients receive? To talk of the need to limit resource use is to assume that a vaguely defined or undefined too much is being done for patients which translates further to a third party ( either a third party payer or a third party self appointed expert) deciding that the individual decisions of doctors and patients about clinical management issues results in "overuse" of resources.There is a body of thought that maintains physicians are not only obligated to serve the best interests of their individual patient but somehow they are ethically obligated to be the stewards of resources that somehow in other than a metaphorical sense are owned by society.
Overuse seems to lie in the eye of the third party payer. Could it be that many in the health policy arena and many of the self appointed thought leaders of major medical professional organizations believe that patient treatment is too important to leave to the myopic lens of doctor and patient and that their selfish interests are no basis for appropriate medical decisions and that the experts' enduring wisdom should over ride the archaic physician patient dyad.Perhaps first advice and "education" would be enough to disabuse the practicing physician and her relentlessly self centered patient from doing too much. However if discussions about cost savings did not prevail more carrots and sticks might be required.
Of course "what can I do for you" is not an boundless,open ended agreement to do all and everything a patient may request. If a patient concerned about difficulty with word finding and misplacing his car keys possibly indicating early dementia you might reasonably refuse to comply with his request for a referral for a brain biopsy. The physician can give informed and reasoned advice about how to proceed taking into account the views and wishes and concerns of the individual patient.
The new initiative lead by the ABIM Foundation (does anyone else wonder why a organization ostensibly tasked to test the competence of internists needs a foundation ) labelled Choosing Wisely appears to be a list of "thou shall not s"- sort of a hundred commandments. OK, they are currently phrased not as absolutes but are presented as the much softer and gentler opportunities to have a discussion with your patient not as rules not to be broken.Suggestions first, guidelines later and then perhaps extra payment for compliant socially conscious stewards of society's resources namely the physicians (make that health care professionals) and reduced payment for the recalcitrant and selfish.
Of course some tests and treatments are ordered and carried out in instances in which no patient benefit is obtained and in some cases harm may done but for numerous medical professional organizations to proclaim that numerous tests and procedures should not be done ( however gently this is currently presented) seems to me to be efforts to change to mind set from the traditional what can I do for you to what I can not allow you to have.
I have seen few comments ( see here for one) in anyway critical of the specific recommendation of the Choosing Wisely campaign but there should be thoughtful analysis of each of them before there is any widespread acceptance.Remember evidence based medicine. What is the evidence behind for example no pap tests before age 21.Are there randomized clinical trials ? Is it based on expert opinion? Are we told about potential conflicts of interests of the authors of the recommendations? Are there published systematic reviews or cost effectiveness analysis for each of the recommendations or for any?
Any of the numerous ( current count is 130 but stay tuned) recommendations made by various medical professional organization may well pass the tests of coherence and correspondence with valid evidence but you have to be skeptical of some many recommendations appearing seemingly so quickly and their manner of presentation appears more authority based or expert based than evidence based.
No one is in favor of tests and procedures that are of no benefit and/or are harmful.No one is against Mom and apple pie or in favor of the nation going broke from run away medical costs, but to rush to publish 100 plus prohibitions under the banner of preventing harm or waste may end up itself doing much more harm than good and even costing more if each specific recommendation is not based on sound evidence based analysis. Making recommendations that might affect the health and lives of thousands of people is serious and heady business and time after time we have seen well meaning medical recommendations turn out to be very bad advice ( remember HRT for just about all post menopausal women and then for none and then again for some). Doctor,were you wrong then or are you wrong now?
American Board of Internal Medicine President Christine Cassel, MD, said such rules of thumb (those suggested by various medical professional organizations regarding certain tests and procedures) seek to change the mindset of physicians and patients alike that "more is better," which can lead to wasteful spending and sometimes harm to the patient.
"What you're talking about is a culture change," Dr. Cassel told Medscape Medical News in a recent published interview. Let's hope the hoped for cultural change does not include discarding the fiduciary role.Yet I believe it is significant that neither the New Medical Professionalism nor the New medical ethics of the ACP talks about the fiduciary responsibility of the physician to the patient.I believe that de-
emphasizing the fiduciary role of the physician and claiming a role of resource steward for physicians is
conceptually dangerous and to the extent it is incorporated into day to day medical thinking destructive to the traditional physician patient relationship doling damage to both physicians and patients.
For each of the recommendations published by the Choosing Wisely campaign physicians and their patients need to know what is the nature of the evidence? For some probably the evidence is strong and convincing for others maybe not so much.Let's not replace "more is better" with" less is better" because neither is a universal all encompassing decision rule and clinical decisions should not be based on empty catch phrases such as "less is more" and the vacuous "the right treatment for the right patient at the right time".
I have said that said many times to a patient at the beginning of an office visit.
It seems to me that that phrase captures an important aspect of the mind set of the clinician as she relates to her patients. What can I do for you, how can I help you, what are you concerned about all speak to the role of the physician in her fiduciary duty to the patient.
Why is it that clinicians seems to be concerned with what they can do for patients and so often health policy wonks emphasize how we as physicians can limit what patients receive? To talk of the need to limit resource use is to assume that a vaguely defined or undefined too much is being done for patients which translates further to a third party ( either a third party payer or a third party self appointed expert) deciding that the individual decisions of doctors and patients about clinical management issues results in "overuse" of resources.There is a body of thought that maintains physicians are not only obligated to serve the best interests of their individual patient but somehow they are ethically obligated to be the stewards of resources that somehow in other than a metaphorical sense are owned by society.
Overuse seems to lie in the eye of the third party payer. Could it be that many in the health policy arena and many of the self appointed thought leaders of major medical professional organizations believe that patient treatment is too important to leave to the myopic lens of doctor and patient and that their selfish interests are no basis for appropriate medical decisions and that the experts' enduring wisdom should over ride the archaic physician patient dyad.Perhaps first advice and "education" would be enough to disabuse the practicing physician and her relentlessly self centered patient from doing too much. However if discussions about cost savings did not prevail more carrots and sticks might be required.
Of course "what can I do for you" is not an boundless,open ended agreement to do all and everything a patient may request. If a patient concerned about difficulty with word finding and misplacing his car keys possibly indicating early dementia you might reasonably refuse to comply with his request for a referral for a brain biopsy. The physician can give informed and reasoned advice about how to proceed taking into account the views and wishes and concerns of the individual patient.
The new initiative lead by the ABIM Foundation (does anyone else wonder why a organization ostensibly tasked to test the competence of internists needs a foundation ) labelled Choosing Wisely appears to be a list of "thou shall not s"- sort of a hundred commandments. OK, they are currently phrased not as absolutes but are presented as the much softer and gentler opportunities to have a discussion with your patient not as rules not to be broken.Suggestions first, guidelines later and then perhaps extra payment for compliant socially conscious stewards of society's resources namely the physicians (make that health care professionals) and reduced payment for the recalcitrant and selfish.
Of course some tests and treatments are ordered and carried out in instances in which no patient benefit is obtained and in some cases harm may done but for numerous medical professional organizations to proclaim that numerous tests and procedures should not be done ( however gently this is currently presented) seems to me to be efforts to change to mind set from the traditional what can I do for you to what I can not allow you to have.
I have seen few comments ( see here for one) in anyway critical of the specific recommendation of the Choosing Wisely campaign but there should be thoughtful analysis of each of them before there is any widespread acceptance.Remember evidence based medicine. What is the evidence behind for example no pap tests before age 21.Are there randomized clinical trials ? Is it based on expert opinion? Are we told about potential conflicts of interests of the authors of the recommendations? Are there published systematic reviews or cost effectiveness analysis for each of the recommendations or for any?
Any of the numerous ( current count is 130 but stay tuned) recommendations made by various medical professional organization may well pass the tests of coherence and correspondence with valid evidence but you have to be skeptical of some many recommendations appearing seemingly so quickly and their manner of presentation appears more authority based or expert based than evidence based.
No one is in favor of tests and procedures that are of no benefit and/or are harmful.No one is against Mom and apple pie or in favor of the nation going broke from run away medical costs, but to rush to publish 100 plus prohibitions under the banner of preventing harm or waste may end up itself doing much more harm than good and even costing more if each specific recommendation is not based on sound evidence based analysis. Making recommendations that might affect the health and lives of thousands of people is serious and heady business and time after time we have seen well meaning medical recommendations turn out to be very bad advice ( remember HRT for just about all post menopausal women and then for none and then again for some). Doctor,were you wrong then or are you wrong now?
American Board of Internal Medicine President Christine Cassel, MD, said such rules of thumb (those suggested by various medical professional organizations regarding certain tests and procedures) seek to change the mindset of physicians and patients alike that "more is better," which can lead to wasteful spending and sometimes harm to the patient.
"What you're talking about is a culture change," Dr. Cassel told Medscape Medical News in a recent published interview. Let's hope the hoped for cultural change does not include discarding the fiduciary role.Yet I believe it is significant that neither the New Medical Professionalism nor the New medical ethics of the ACP talks about the fiduciary responsibility of the physician to the patient.I believe that de-
emphasizing the fiduciary role of the physician and claiming a role of resource steward for physicians is
conceptually dangerous and to the extent it is incorporated into day to day medical thinking destructive to the traditional physician patient relationship doling damage to both physicians and patients.
For each of the recommendations published by the Choosing Wisely campaign physicians and their patients need to know what is the nature of the evidence? For some probably the evidence is strong and convincing for others maybe not so much.Let's not replace "more is better" with" less is better" because neither is a universal all encompassing decision rule and clinical decisions should not be based on empty catch phrases such as "less is more" and the vacuous "the right treatment for the right patient at the right time".
Thursday, February 21, 2013
The language of academic medicine has become the language of the collective
One of the many changes that have occurred in medicine over the last 40 years ( my professional lifetime) has been the framing of certain aspects of medical care into the language of the collective. I have written before abut the bogus nature of the concept of the "Medical commons" (see here for critique of the medical commons bogus analogy ) but that is only a small example of the dominant themes found in medical literature and not just just in the policy wonk journals and editorials such as those found in the NEJM but also in throw away comments found in the boiler plate like introductions to what otherwise are serious medical research papers. How many medical journal articles have you seen that begin with commenting that disease x, y or z is an important pubic health problem? Defining everything as a public health problem cries out for public health solutions. Are there any health issues that are simply a matter between the patient and his physician?
The concept of social justice as an ethical imperative of physicians which has though the efforts of a small group of prolific academic writers,certain foundations with deep pockets and medical insurance industry shills has become the de facto default position of medical academia and the self proclaimed thought leadesr and will become standard catechism for the present and future generations of medical students.Aspects of this con job (better word?) has aspects of the features of the classic Baptist and Bootlegger phenomenon. As some members of the medical academia promote this view and move out of and into the medical insurance upper level management and various government positions of power it become difficult to identify who are really the baptists and who is conning whom. Yet,I continue to believe that many of those who advocate social justice and believe that physicians should be the stewards of society's medical resources do so with sincerity and in the belief that these are meaningful terms and worthy goals while at least a few of us believe that allegiance to bogus concepts usually does not work out very well.
Ask not what you can do for your patient but what you can do for the greater good of the group,ACO or payment panel which you and your patients by random chance have become part of.After all if you do what is cost effective the group will benefit and through some type of metaphysical fairy dust so will your patient even if she or he is deprived on a beneficial test of procedure or medication because he/she is part of the group.Rather than comments like the preceding being shouted down with a John McEnroe like " you've gotta be kidding" we see that that type commentary in the NEJM offered by a well known medical economist.See here for the comments of Victor Fuchs and my criticism.
Since few would doubt that academia in general is populated by a preponderance of liberals, progressives and egalitarians ( See here for some survey data) why be surprised that medical academia is no exception? The question is why is it that only fairly recently has the rhetoric of medical publications so strongly reflected that mind set appearing not just in editorials and commentaries and in health policy publications but regularly in the boilerplate introductions to otherwise ordinary presentations of a medical studies.
The concept of social justice as an ethical imperative of physicians which has though the efforts of a small group of prolific academic writers,certain foundations with deep pockets and medical insurance industry shills has become the de facto default position of medical academia and the self proclaimed thought leadesr and will become standard catechism for the present and future generations of medical students.Aspects of this con job (better word?) has aspects of the features of the classic Baptist and Bootlegger phenomenon. As some members of the medical academia promote this view and move out of and into the medical insurance upper level management and various government positions of power it become difficult to identify who are really the baptists and who is conning whom. Yet,I continue to believe that many of those who advocate social justice and believe that physicians should be the stewards of society's medical resources do so with sincerity and in the belief that these are meaningful terms and worthy goals while at least a few of us believe that allegiance to bogus concepts usually does not work out very well.
Ask not what you can do for your patient but what you can do for the greater good of the group,ACO or payment panel which you and your patients by random chance have become part of.After all if you do what is cost effective the group will benefit and through some type of metaphysical fairy dust so will your patient even if she or he is deprived on a beneficial test of procedure or medication because he/she is part of the group.Rather than comments like the preceding being shouted down with a John McEnroe like " you've gotta be kidding" we see that that type commentary in the NEJM offered by a well known medical economist.See here for the comments of Victor Fuchs and my criticism.
Since few would doubt that academia in general is populated by a preponderance of liberals, progressives and egalitarians ( See here for some survey data) why be surprised that medical academia is no exception? The question is why is it that only fairly recently has the rhetoric of medical publications so strongly reflected that mind set appearing not just in editorials and commentaries and in health policy publications but regularly in the boilerplate introductions to otherwise ordinary presentations of a medical studies.
Thursday, February 14, 2013
update on more Obamacare and central planning bad news
There is an increasing stream of news almost hourly on the detrimental effects of Obamacare and to adequately review and highlight even the more flagrant examples would overwhelm my limited staff (me).
However from time to time I'll offer a few . Here are some for today.
1.The absurd nonsense of the Obama Administration health czars' (the designation czar is alarmingly correct) "compromise" on the contraceptive mandate.See here for Cato's commentary on that in an article that explains Obamacare's shell game regarding the mandate.
A related story is that offered by David Catron at The American Spectator, see here. Catron tells a story about a lobbyist for big Pharma who is now the appointee for a major position at HSS,the Barr Laboratories who make the morning after pill and pricing rules dictated by HHS.Crony Contraceptives is the appropriate title of the commentary.Is this another Cui Bono instance?
2.The revelation of the egregious conditions at the Stafford Hospital in the UK ( see here for many details ) which can serve as a multiple poster child for the horrors of central planning gone bad,how really bad P4P can turn out and to illustrate once again the primacy of the economic principle that incentives matter. However,it may be that with the NHS 's program for reform,everything will work out especially since apparently Dr. Don Berwick may be chosen to lead the reformation of the system whose praises so loudly he sung some time ago.
3.This article from Cato by Michael Cannon explains that Obamacare from its beginning treated legal immigrants and citizens who were in a certain income bracket differently.The immigrants were granted a subsidy for health insurance under an insurance exchange while the citizen would get his health care from Medicaid.The health care obtained under Medicaid is widely regarded as inferior.How is that for social justice?
However from time to time I'll offer a few . Here are some for today.
1.The absurd nonsense of the Obama Administration health czars' (the designation czar is alarmingly correct) "compromise" on the contraceptive mandate.See here for Cato's commentary on that in an article that explains Obamacare's shell game regarding the mandate.
A related story is that offered by David Catron at The American Spectator, see here. Catron tells a story about a lobbyist for big Pharma who is now the appointee for a major position at HSS,the Barr Laboratories who make the morning after pill and pricing rules dictated by HHS.Crony Contraceptives is the appropriate title of the commentary.Is this another Cui Bono instance?
2.The revelation of the egregious conditions at the Stafford Hospital in the UK ( see here for many details ) which can serve as a multiple poster child for the horrors of central planning gone bad,how really bad P4P can turn out and to illustrate once again the primacy of the economic principle that incentives matter. However,it may be that with the NHS 's program for reform,everything will work out especially since apparently Dr. Don Berwick may be chosen to lead the reformation of the system whose praises so loudly he sung some time ago.
3.This article from Cato by Michael Cannon explains that Obamacare from its beginning treated legal immigrants and citizens who were in a certain income bracket differently.The immigrants were granted a subsidy for health insurance under an insurance exchange while the citizen would get his health care from Medicaid.The health care obtained under Medicaid is widely regarded as inferior.How is that for social justice?
Monday, February 11, 2013
Social Justice quote for the day-by Thomas Sowell
Thomas Sowell makes the distinction between what he says is the traditional conception of justice and social justice.See here for the essay from which the following quote was taken.
" Traditional concepts of justice or fairness, at least within the American tradition, boil down to applying the same rules and standards to everyone. This is what is meant by a "level playing field"-- at least within that tradition, though the very same words mean something radically different within a framework that calls itself "social justice." Words like "fairness," "advantage" and "disadvantage" likewise have radically different meanings within the very different frameworks of traditional justice and "social justice."
John Rawls perhaps best summarized the differences when he distinguished "fair" equality of opportunity from merely "formal" equality of opportunity. Traditional justice, fairness, or equality of opportunity are merely formal in Professor Rawls' view and in the view of his many followers and comrades. For those with this view, "genuine equality of opportunity" cannot be achieved by the application of the same rules and standards to all, but requires specific interventions to equalize either prospects or results. As Rawls puts it, "undeserved inequalities call for redress." "
Libertarians and conservatives on one hand and egalitarians on the other all claim to be supporters of equal opportunity but they mean different things by the same words.The first group is talking about what Rawls calls formal opportunity and the second what he calls genuine opportunity.Egalitarians urge corrective actions to transform a situation which has what they consider ethically inadequate formal opportunity to their real deal of genuine opportunity.Libertarians not conversant with the egalitarian nomenclature consider the egalitarian's support of corrective actions to be a concern for and emphasis on outcomes while the egalitarians think of the outcome as an improved and the appropriate opportunity.Debates in which the two parties have different meanings for the same words usually do not get resolved.
The Charter (The Physician's Charter)( see here for article ) authored by a surprisingly small group (but apparently well funded, see here) internists in 2002 claims that to be properly professional in the new millennium a physician must strive for social justice raising that goal to the same level as the key traditional medical ethical precepts of patient autonomy and beneficence for the patient . This notion of justice is not the traditional concept of justice to which many in this country,including no doubt many physicians accept. Audacity is too weak a word to describe their assertions. Unbelievable is too weak a word to describe the apparent success their effort has had as least as judged by the nominal acceptance of that view by a large number of American medical professional organizations.
Who were the physicians who lead the social justice movement in the medical profession? This is a topic for a later commentary.
Thursday, February 07, 2013
Foundation gave $ 2.5 million to ABIMF to promote Choosing Wisely
The Robert Wood Johnson Foundation in 2012 gave the American Board of Internal Medicine Foundation (ABIMF) $ 2.5 million to further the promotion of "professionalism" which as explicated in the Physician 's Charter ( see here) includes social justice and the wise stewardship of limited medical resources. In this instance the grant was to promote the stewardship theme. RWJ's website announcement is found here.
Specifically the grant was to promote ABIM's Choosing Wisely Campaign.In the words of the RWJ Foundation web site:
"To (1) leverage and expand the reach of the 2012 Choosing Wisely campaign of the ABIM Foundation to raise awareness about avoiding unnecessary care; (2) spur physicians, patients and other health care stakeholders to think and talk about medical tests and procedures that may be unnecessary; and (3) prepare providers, patients and other stakeholders to decrease unnecessary health care utilization."
It is no surprise that RWJ Foundation would have warm feelings for the Charter as the link between the two foundations go back at least to 2002 which was the date of the Charter's publication '
One of the authors of the Physician's Charter was Dr. Risa Lavizza-Mourey who since 2002 has been the President and CEO of RWJ . See here for a listing of the Charter's authors.
The apparent successful campaign to promote social justice and the stewardship notion has amazed me but it seems less amazing considering the value of having friends with very deep pockets. ( RWJ foundation has about 7.5 billion in assets). The person who invited Dr. Lavizza-Mourey to be a co-author in the Charter project (if that is what really happened,I have no insider information) really knows how to get things done. A Google search was not successful when I attempted to learn how much money over the past 10 years RWJF has given to ABIMF to promote the Charter. If anyone can help with that, please let me know.
You have to wonder how that $2.5 million will be spent and if this ABIMF initiative will be as successful as the promotion of the Charter seems to have been. There are still many physicians who believe that the promotion of social justice as an basic ethical imperative of physicians is harmful at best and destructive at worse to the physician patient relationship and usurps the fiduciary duty of the physician to the patient.
With the money behind the promotion of the social justice-stewardship of society's resources program,we have to be a bit discouraged.
Avoiding unnecessary tests and treatments for patients does not necessitate evoking concepts of social justice and mythical caretakers of society's resources- the traditional medical ethical concepts of beneficence and non-malfeasance take care of that. Of course,choose wisely in patient management advice but do so because it is right for the individual patient not on the basis of some fairy tale of collective resources being preserved.
addendum.2/11/2013.I apologize to the CEO of RWJ Foundation for misspelling her name on the initial publication of this post.It is now corrected.
Specifically the grant was to promote ABIM's Choosing Wisely Campaign.In the words of the RWJ Foundation web site:
"To (1) leverage and expand the reach of the 2012 Choosing Wisely campaign of the ABIM Foundation to raise awareness about avoiding unnecessary care; (2) spur physicians, patients and other health care stakeholders to think and talk about medical tests and procedures that may be unnecessary; and (3) prepare providers, patients and other stakeholders to decrease unnecessary health care utilization."
It is no surprise that RWJ Foundation would have warm feelings for the Charter as the link between the two foundations go back at least to 2002 which was the date of the Charter's publication '
One of the authors of the Physician's Charter was Dr. Risa Lavizza-Mourey who since 2002 has been the President and CEO of RWJ . See here for a listing of the Charter's authors.
The apparent successful campaign to promote social justice and the stewardship notion has amazed me but it seems less amazing considering the value of having friends with very deep pockets. ( RWJ foundation has about 7.5 billion in assets). The person who invited Dr. Lavizza-Mourey to be a co-author in the Charter project (if that is what really happened,I have no insider information) really knows how to get things done. A Google search was not successful when I attempted to learn how much money over the past 10 years RWJF has given to ABIMF to promote the Charter. If anyone can help with that, please let me know.
You have to wonder how that $2.5 million will be spent and if this ABIMF initiative will be as successful as the promotion of the Charter seems to have been. There are still many physicians who believe that the promotion of social justice as an basic ethical imperative of physicians is harmful at best and destructive at worse to the physician patient relationship and usurps the fiduciary duty of the physician to the patient.
With the money behind the promotion of the social justice-stewardship of society's resources program,we have to be a bit discouraged.
Avoiding unnecessary tests and treatments for patients does not necessitate evoking concepts of social justice and mythical caretakers of society's resources- the traditional medical ethical concepts of beneficence and non-malfeasance take care of that. Of course,choose wisely in patient management advice but do so because it is right for the individual patient not on the basis of some fairy tale of collective resources being preserved.
addendum.2/11/2013.I apologize to the CEO of RWJ Foundation for misspelling her name on the initial publication of this post.It is now corrected.
Wednesday, February 06, 2013
Will Obamacare encourage more business to "go protean" ?
What does "go protean" mean? See here for this WSJ article on the phenomenon. Basically a business would outsource many of its functions to other corporate entities, not to individual contractors, which is often what out sourcing means.
Quoting WSJ:
" Like a protozoan single-cell organism, the protean corporation has the ability to "shape shift," rapidly adapting to internal and external forces in the market and the company. At the heart of a true protean corporation is a tiny number of core employees surrounded by a large cloud of resources, generally contracted or outsourced talent that does most of the work."
To get under the fifty employee ACA head count threshold, a business might ofter that some of its employees form a corporation and then contract with that business to do whatever functions at that business. Now you have one corporation doing business with another and there is no longer the employer-employee relationship which is one that is controlled and regulated in many ways by local and federal governmental entities (e.g.OSHA,Fair Employment laws of various kinds,Etc)
H/T to Michael Cannon at Cato who closed his commentary on this issue with this:See here for his entire comments.
"Keeping the core company below 50 full-time employees will allow such companies to avoid the employer mandate. But it will also drive up Obamacare’s cost, because most of the workers in the new corporate entity will be eligible for government subsidies through the health insurance “exchanges.” This will drive up the cost of Obamacare wherever those subsidies exist."
The list of unintended consequences of Obamacare continues to grow.The protean corporation scheme may or may not catch on,and the IRS or some other governmental entity may or may not have some regulatory counter move and since folks respond to incentives we can expect to see more ways for businesses to avoid or minimize the effects of Obamacare and counter moves by the government.The IRS has already issued proposed rules to restrict some of the self protective actions of businesses in regard to how full time employees are counted and how to calculate full time equivalents.
Quoting WSJ:
" Like a protozoan single-cell organism, the protean corporation has the ability to "shape shift," rapidly adapting to internal and external forces in the market and the company. At the heart of a true protean corporation is a tiny number of core employees surrounded by a large cloud of resources, generally contracted or outsourced talent that does most of the work."
To get under the fifty employee ACA head count threshold, a business might ofter that some of its employees form a corporation and then contract with that business to do whatever functions at that business. Now you have one corporation doing business with another and there is no longer the employer-employee relationship which is one that is controlled and regulated in many ways by local and federal governmental entities (e.g.OSHA,Fair Employment laws of various kinds,Etc)
H/T to Michael Cannon at Cato who closed his commentary on this issue with this:See here for his entire comments.
"Keeping the core company below 50 full-time employees will allow such companies to avoid the employer mandate. But it will also drive up Obamacare’s cost, because most of the workers in the new corporate entity will be eligible for government subsidies through the health insurance “exchanges.” This will drive up the cost of Obamacare wherever those subsidies exist."
The list of unintended consequences of Obamacare continues to grow.The protean corporation scheme may or may not catch on,and the IRS or some other governmental entity may or may not have some regulatory counter move and since folks respond to incentives we can expect to see more ways for businesses to avoid or minimize the effects of Obamacare and counter moves by the government.The IRS has already issued proposed rules to restrict some of the self protective actions of businesses in regard to how full time employees are counted and how to calculate full time equivalents.
Sunday, February 03, 2013
Social Justice quote for the day from Anthony De Jasay
The Hungarian economist Anthony De Jasay in his commentary posted in the Library of Economics and Liberty takes on the issue of social justice and wonders if the adjective really fits the noun and if what sense it is justice.See here for his entire comments.
"Justice is a property of acts. Just acts conform to certain rules, unjust ones violate them. A state of affairs is just if it is the outcome of just acts. If we want to claim that a state of affairs, say, a particular distribution of material advantages, is an injustice, it is incumbent upon us to show that it results from unjust acts. Otherwise, talk of injustice is just talk. This is where the problem of the identification of social justice as supposedly a branch of the general body of justice must be faced.
Stripped of rhetoric, an act of social justice (a) deliberately increases the relative share (though it may unwittingly decrease the absolute share) of the worse-off in total income, and (b) in achieving (a) it redresses part or all of an injustice. (Note that “income” is used in a broad sense to include stocks and flows of all material goods or claims on same that are transferable). This implies that some people being worse off than others is an injustice and that it must be redressed. However, redress can only be effected at the expense of the better- off; but it is not evident that they have committed the injustice in the first place. Consequently, nor is it clear why the better-off should be under an obligation to redress it, even though if they do not, no one else is left to do it."
So, if the better off did nothing wrong, where is the justice in forcing them to pay; would it not actually be an injustice to force them to redress something for which they were not responsible? John Rawls's contractarian theory seeks to support a negative answer to that question arguing that they, quoting Jasay," have agreed in a hypothetical but prima facie sane contract to bear the burden in their own interest". In this formulation redistribution would be the remedy for an unjust situation and there need not have been any unjust acts committed. Comments regarding this hypothetical,fictitious social contract are deferred to a later posting.
Jasay's comments resonate with FA Hayek's characterization of the modifier "social" as a weasel word which like a weasel sucking a egg allegedly without collapsing it can suck the meaning out of the word it modifies. Question for the day: Has the Physician Charter (Medical Professionalism in the New Millenium) sold the medical profession a bill of goods for the next thousand years based on a weasel word?
"Justice is a property of acts. Just acts conform to certain rules, unjust ones violate them. A state of affairs is just if it is the outcome of just acts. If we want to claim that a state of affairs, say, a particular distribution of material advantages, is an injustice, it is incumbent upon us to show that it results from unjust acts. Otherwise, talk of injustice is just talk. This is where the problem of the identification of social justice as supposedly a branch of the general body of justice must be faced.
Stripped of rhetoric, an act of social justice (a) deliberately increases the relative share (though it may unwittingly decrease the absolute share) of the worse-off in total income, and (b) in achieving (a) it redresses part or all of an injustice. (Note that “income” is used in a broad sense to include stocks and flows of all material goods or claims on same that are transferable). This implies that some people being worse off than others is an injustice and that it must be redressed. However, redress can only be effected at the expense of the better- off; but it is not evident that they have committed the injustice in the first place. Consequently, nor is it clear why the better-off should be under an obligation to redress it, even though if they do not, no one else is left to do it."
So, if the better off did nothing wrong, where is the justice in forcing them to pay; would it not actually be an injustice to force them to redress something for which they were not responsible? John Rawls's contractarian theory seeks to support a negative answer to that question arguing that they, quoting Jasay," have agreed in a hypothetical but prima facie sane contract to bear the burden in their own interest". In this formulation redistribution would be the remedy for an unjust situation and there need not have been any unjust acts committed. Comments regarding this hypothetical,fictitious social contract are deferred to a later posting.
Jasay's comments resonate with FA Hayek's characterization of the modifier "social" as a weasel word which like a weasel sucking a egg allegedly without collapsing it can suck the meaning out of the word it modifies. Question for the day: Has the Physician Charter (Medical Professionalism in the New Millenium) sold the medical profession a bill of goods for the next thousand years based on a weasel word?
Friday, February 01, 2013
Obama admistration defines "affordable" in a way denying subsidies to some lower income families
What does the affordable in the Affordable Care Act mean? It means exactly what the IRS says it means and now the IRS has had its say in that regard. See here for the NYT news report on this IRS ruling.
Quoting the NYT article:
"In deciding whether an employer’s health plan is affordable, the Internal Revenue Service said it would look at the cost of coverage only for an individual employee, not for a family. Family coverage might be prohibitively expensive, but federal subsidies would not be available to help buy insurance for children in the family."
Affordable means affordable coverage for the individual employee not for his or her family. If the employee share of the employer subsidized coverage exceeds 9.5% of the family's annual income then the family would be eligible for a federal subsidy.But,the percentage applies only to the cost of coverage for the employee and not for the entire family and the cost of family coverage is significantly higher than for single coverage. So if the company insurance does not include the family many employees will be faced with costly insurance with no government subsidy.
This interesting brand of social justice administered by the IRS was countered by the Secretary of HHS exempting folks screwed over by this ruling from any penalty (or tax as Justice Roberts might say) resulting from this IRS ruling.
Many, if not most large, companies which already provide health insurance do so for the entire family not just the employee so no one has a good estimate regarding how many would be affected.The Times article claimed millions.
Speaking of affordable,the IRS has released educational material explaining how the penalty (they apparently have not read Justice Robert's decision that made the penalty a tax) for failure to buy health insurance.First, they say that in 2016 the cheapest insurance allowable (bronze plan) will cost $ 20,000 for a family of five.See here for news article.
Next they reveal in typical IRS language how the "penalty will be computed.
"(ii) For each month in 2016, under paragraphs (b)(2)(ii) and (b)(2)(iii) of this section, the applicable dollar amount is $2,780 (($695 x 3 adults) + (($695/2) x 2 children)). Under paragraph (b)(2)(i) of this section, the flat dollar amount is $2,085 (the lesser of $2,780 and $2,085 ($695 x 3)). Under paragraph (b)(3) of this section, the excess income amount is $2,400 (($120,000 - $24,000) x 0.025). Therefore, under paragraph (b)(1) of this section, the monthly penalty amount is $200 (the greater of $173.75 ($2,085/12) or $200 ($2,400/12))."
If you had wondered about the role of the IRS in health insurance ,that quote should give a flavor.What did you expect?
Quoting the NYT article:
"In deciding whether an employer’s health plan is affordable, the Internal Revenue Service said it would look at the cost of coverage only for an individual employee, not for a family. Family coverage might be prohibitively expensive, but federal subsidies would not be available to help buy insurance for children in the family."
Affordable means affordable coverage for the individual employee not for his or her family. If the employee share of the employer subsidized coverage exceeds 9.5% of the family's annual income then the family would be eligible for a federal subsidy.But,the percentage applies only to the cost of coverage for the employee and not for the entire family and the cost of family coverage is significantly higher than for single coverage. So if the company insurance does not include the family many employees will be faced with costly insurance with no government subsidy.
This interesting brand of social justice administered by the IRS was countered by the Secretary of HHS exempting folks screwed over by this ruling from any penalty (or tax as Justice Roberts might say) resulting from this IRS ruling.
Many, if not most large, companies which already provide health insurance do so for the entire family not just the employee so no one has a good estimate regarding how many would be affected.The Times article claimed millions.
Speaking of affordable,the IRS has released educational material explaining how the penalty (they apparently have not read Justice Robert's decision that made the penalty a tax) for failure to buy health insurance.First, they say that in 2016 the cheapest insurance allowable (bronze plan) will cost $ 20,000 for a family of five.See here for news article.
Next they reveal in typical IRS language how the "penalty will be computed.
"(ii) For each month in 2016, under paragraphs (b)(2)(ii) and (b)(2)(iii) of this section, the applicable dollar amount is $2,780 (($695 x 3 adults) + (($695/2) x 2 children)). Under paragraph (b)(2)(i) of this section, the flat dollar amount is $2,085 (the lesser of $2,780 and $2,085 ($695 x 3)). Under paragraph (b)(3) of this section, the excess income amount is $2,400 (($120,000 - $24,000) x 0.025). Therefore, under paragraph (b)(1) of this section, the monthly penalty amount is $200 (the greater of $173.75 ($2,085/12) or $200 ($2,400/12))."
If you had wondered about the role of the IRS in health insurance ,that quote should give a flavor.What did you expect?
Subscribe to:
Posts (Atom)