Here is the entire sentence from which part of this posting's title derives:
"You are stewards of a globally important treasure: the NHS. In its form
and mission, guided by the unwavering charter of universal care,
accessible to all, and free at the point of service, the NHS is a unique
example for all to learn from and emulate."
That quote is from a letter from Dr. Berwick to officials of the NHS as part of the report from the committee he chaired to investigate the egregious treatment of patients at a NHS hospital,the Mid Staffordshire.
See here for Greg Scandlen comments in a blog entry entitled "The Real Don Berwick"
In Scandlen's commentary there is a description of the horrible things to which patients were subjected and excerpts from the committee's report.
I cannot resist one other quote, this one from Paul Krugman.
"In Britain, the government itself runs the hospitals and employs the doctors. We've all heard about how that works in practice .Those stories are false."
The following is from Berwick's book written with the current Vice president of CVS Caremark (Troyen Brennan)
"Today, this isolated relationship[ he is speaking of the physician patient relationship]
is no longer tenable or possible… Traditional medical ethics, based
on the doctor-patient dyad must be reformulated to fit the new mold
of the delivery of health care...Regulation must evolve. Regulating
for improved medical care involves designing appropriate rules with
authority...Health care is being rationalized through critical
pathways and guidelines. The primary function of regulation in health care, especially as it affects the quality of medical care, is to constrain decentralized individualized decision making.
So how did those appropriate rules with authority work out for those victims of the NHS? Was there too much residual "decentralized decision making"
Maybe one lesson to learn from the NHS tragedy is when no one is accountable or responsible, some really terrible things can happen. Berwick's committee did find that no one was really at fault."NHS staff were not to blame".
OK,one more quote, this time John McEnroe's "you gottta be kidding me"
Another lesson all can learn from the NHS is how incredibly bad their electronic record system worked. See here for a report of what some have called the biggest IH foul up ever.
Thursday, September 19, 2013
Tuesday, September 17, 2013
Obamacare-"Law of the Land"except those parts that the administration Postpones or exempts the favored from
As opposition to Obamacare grows even as deadlines loom for its implementation,the dwindling numbers of defenders issue increasingly strident and lame defenses.
Members of the administration as well as Paul Krugman blatantly proclaim Obamacare is the "law of the Land" and is no longer a political matter. The administration that has done much damage to the rule of law in the way it has selectively enforced, or postponed or issued exemptions to the law has the audacity now to claim it is the law. As least those parts they it deems to be politically expedient."No longer a political matter"- really, the way it has been arbitrarily administered has been nothing but politics.
The ACP Advocate blog has recently questioned the ethics of physicians who would refuse to help their patients to sign up for the plan and of those physicians who bring their anti-Obamacare views into the examination room. No, the blog did not say it was unethical but just raised the issue and used the term "borderline unethical".(I wonder if saying they were unethical would be libel per se.Further, the blog writer, Bob Doherty ,ACP's Executive VP and governmental affairs man in Washington, challenged the claim that Obamacare will damage the physician-patient relationship with the astonishing counter claim that Obamacare might actually strengthen the physician-patient relationship.See here for that blog entry and a series of related commentaries.
I argue that this relationship is not a function of insurance or its lack but rather it is based on the patient's belief that the doctor is acting in the best interests of the patient, treating him with respect, respecting his autonomy and maintaining confidentiality. To the degree that Obamacare encourages physicians to join ACOs there may well be a tendency for the patient's trust to diminish as has been the case in some HMOs if and when the patients sense that the organization's interests clash with his own and that his physician's income depends of adhering to the policies of the HMO-ACO-vertically integrated health care entity. Does anyone believe that HMOs have strengthened the physician-patient relationship?
I find it interesting that a ACP sponsored blog raises the issue of physician-patient relationship in in regard to Obamacare.IMO it has been the efforts of ACP,along with the ABIM foundation, to promulgate the new medical ethics and the "professionalism for the new millennium" that has damaged the physician-patient relationship by sneaking into medical ethics the concept of the physician having a co-duty to the patient and to society to the determent of the traditional physician's fiduciary duty.
ACP proposed ( and now seems to assume it is accomplished) a major change in medical ethics ( adding social justice and physician obligation to conserve "society's resources" ) and then with an apparent straight face claimed there was really nothing new there at all. See here for a detailed discussion of this disingenuous tactic.
Members of the administration as well as Paul Krugman blatantly proclaim Obamacare is the "law of the Land" and is no longer a political matter. The administration that has done much damage to the rule of law in the way it has selectively enforced, or postponed or issued exemptions to the law has the audacity now to claim it is the law. As least those parts they it deems to be politically expedient."No longer a political matter"- really, the way it has been arbitrarily administered has been nothing but politics.
The ACP Advocate blog has recently questioned the ethics of physicians who would refuse to help their patients to sign up for the plan and of those physicians who bring their anti-Obamacare views into the examination room. No, the blog did not say it was unethical but just raised the issue and used the term "borderline unethical".(I wonder if saying they were unethical would be libel per se.Further, the blog writer, Bob Doherty ,ACP's Executive VP and governmental affairs man in Washington, challenged the claim that Obamacare will damage the physician-patient relationship with the astonishing counter claim that Obamacare might actually strengthen the physician-patient relationship.See here for that blog entry and a series of related commentaries.
I argue that this relationship is not a function of insurance or its lack but rather it is based on the patient's belief that the doctor is acting in the best interests of the patient, treating him with respect, respecting his autonomy and maintaining confidentiality. To the degree that Obamacare encourages physicians to join ACOs there may well be a tendency for the patient's trust to diminish as has been the case in some HMOs if and when the patients sense that the organization's interests clash with his own and that his physician's income depends of adhering to the policies of the HMO-ACO-vertically integrated health care entity. Does anyone believe that HMOs have strengthened the physician-patient relationship?
I find it interesting that a ACP sponsored blog raises the issue of physician-patient relationship in in regard to Obamacare.IMO it has been the efforts of ACP,along with the ABIM foundation, to promulgate the new medical ethics and the "professionalism for the new millennium" that has damaged the physician-patient relationship by sneaking into medical ethics the concept of the physician having a co-duty to the patient and to society to the determent of the traditional physician's fiduciary duty.
ACP proposed ( and now seems to assume it is accomplished) a major change in medical ethics ( adding social justice and physician obligation to conserve "society's resources" ) and then with an apparent straight face claimed there was really nothing new there at all. See here for a detailed discussion of this disingenuous tactic.
Thursday, September 12, 2013
The new medical ethics and professionalism is good news for the viability of the ACOs
If most physicians believed and acted as if they were the fiduciary agent of their patient ( as was once their primary ethical imperative ) the new highly touted Accountable Care Organizations (ACOs) would be doomed to failure. They may fail anyway because the new ethics is not a sufficient condition for ACO and maybe not be necessary either but it sure won't hurt.
The new ethics has paved the ethical road for bigger medicine -in the form of ACOs and other vertically integrated health care entities..What was needed to be done was to change the role of the physician from steadfast advocate for the patient, which often put him in opposition to the insurance company,to a more compliant worker working with the suits to "conserve society's medical resources" and thereby enhance the bottom line of the organization.
To accomplish that, long standing medical ethical principles had to revised. These venerable precepts were welfare of the patient and preservation of patient autonomy. The new ethics architects did not launch a honest frontal attack on primacy of patient welfare but rather sneaked in a new element , namely social justice and added to the concern for the individual patient's welfare a co duty to preserve society's resources.
A facile veneer of ethical sounding verbiage serves to justify a localized, utilitarian statistical approach to clinical decision making in which the aggregate "good" or statistically defined utility-perhaps measured in quality adjusted life years- will trump the utility or good of any given individual patient.
This approach was raised to its most specious,arrogant level by a well known medical economist,Victor Fuchs writing in the New England Journal of Medicine. See here for my previous comment regarding Dr. Fuch's sophistry.
Fuchs tells his readers about a dilemma.
"How can a commitment to cost-effective care ( as physicians have been "committed" to that since the Physician charter and the New Professionalism) be reconciled with a fundamental principle of primacy of patient welfare"
He argues that if all the physicians in a given health care collective(as in Accountable care Organizations) practice cost effective medicine, the resources saved can be used for the benefit of the defined population which includes the patients of the physician who seemingly may face a conflict. So, if all the physicians act in the same way all patients benefit.
Here, Fuchs conflates the good of group as indicated by some aggregate number with the good of each individual in a particular situation in which a particular individual may not enjoy the benefit and may actually be harmed. In fact cost effectiveness analysis involves aggregate data. With any outcome in a group some may benefit and some may be harmed.Years earlier, Dr David Eddy offered the same basic recipe for " increasing quality while decreasing costs" but, unlike Fuchs had the honesty to admit in such an arrangement there would be winners and losers. Fuchs maintains,apparently with a straight face,everyone wins.
The old medical ethics clashed with what is needed from physicians to make the collective a financial success. The medical progressive elite believe they have solved that problem by changing medical ethics .Many in the older generations of physicians do not buy in to the
stewards of society's resources concept but as waves of younger docs hear nothing else from the day they enter med school, the concept of fiduciary duty to the patient will be of fleeting historical interest.Certainly, that will be the case if the activities of the ABIM Foundation with its generous funding from the Robert Wood Johnson Foundation has its way.
If you wonder how big and bigger medicine will affect patient care see this excellent discussion by Dr.Paul Hsieh.
The new ethics has paved the ethical road for bigger medicine -in the form of ACOs and other vertically integrated health care entities..What was needed to be done was to change the role of the physician from steadfast advocate for the patient, which often put him in opposition to the insurance company,to a more compliant worker working with the suits to "conserve society's medical resources" and thereby enhance the bottom line of the organization.
To accomplish that, long standing medical ethical principles had to revised. These venerable precepts were welfare of the patient and preservation of patient autonomy. The new ethics architects did not launch a honest frontal attack on primacy of patient welfare but rather sneaked in a new element , namely social justice and added to the concern for the individual patient's welfare a co duty to preserve society's resources.
A facile veneer of ethical sounding verbiage serves to justify a localized, utilitarian statistical approach to clinical decision making in which the aggregate "good" or statistically defined utility-perhaps measured in quality adjusted life years- will trump the utility or good of any given individual patient.
This approach was raised to its most specious,arrogant level by a well known medical economist,Victor Fuchs writing in the New England Journal of Medicine. See here for my previous comment regarding Dr. Fuch's sophistry.
Fuchs tells his readers about a dilemma.
"How can a commitment to cost-effective care ( as physicians have been "committed" to that since the Physician charter and the New Professionalism) be reconciled with a fundamental principle of primacy of patient welfare"
He argues that if all the physicians in a given health care collective(as in Accountable care Organizations) practice cost effective medicine, the resources saved can be used for the benefit of the defined population which includes the patients of the physician who seemingly may face a conflict. So, if all the physicians act in the same way all patients benefit.
Here, Fuchs conflates the good of group as indicated by some aggregate number with the good of each individual in a particular situation in which a particular individual may not enjoy the benefit and may actually be harmed. In fact cost effectiveness analysis involves aggregate data. With any outcome in a group some may benefit and some may be harmed.Years earlier, Dr David Eddy offered the same basic recipe for " increasing quality while decreasing costs" but, unlike Fuchs had the honesty to admit in such an arrangement there would be winners and losers. Fuchs maintains,apparently with a straight face,everyone wins.
The old medical ethics clashed with what is needed from physicians to make the collective a financial success. The medical progressive elite believe they have solved that problem by changing medical ethics .Many in the older generations of physicians do not buy in to the
stewards of society's resources concept but as waves of younger docs hear nothing else from the day they enter med school, the concept of fiduciary duty to the patient will be of fleeting historical interest.Certainly, that will be the case if the activities of the ABIM Foundation with its generous funding from the Robert Wood Johnson Foundation has its way.
If you wonder how big and bigger medicine will affect patient care see this excellent discussion by Dr.Paul Hsieh.
Tuesday, August 27, 2013
Public Choice Theory informs us that Obamacare is a bad idea
You will not find defenders of Obamacare (aka ObamaCONcare) evoking Public Choice Theory (PCT).In some instances this is out of ignorance of the ideas contained therein and in other instances a wise, tactical decision was made not to have to face those ideas as they relate to Obamacare.
In a nutshell here is what PCT is all about;it is based on certain views concerning human nature namely:
1)Humans tend to respond to incentives.2)Humans frequently tend to act in what they believe to be in their own best interests.3)Humans have definite cognitive limitations.
PCT does not claim that people always act on the basis of some cost benefit analysis nor that sometimes folks do not act in ways that seem to be altruistic.
These aspects of human nature apply to businessmen,butchers,bakers and con men but they also apply to elected public officials,politicians,and bureaucrats.Accordingly this second group will from time to time act- most of time probably- in their own interests and not in some effort to bring about some abstract public good and that politicians just might respond to the incentives of campaign contribution in return for sponsoring some legislative act that benefits some special interest group at the expense of the public at large.
There are two others aspects of PCT worth briefly mentioning.
PCT explains that although private and public actors both respond to incentives (and constraints) the set of incentives and constraints are not the same for the two groups.Secondly, for the PCT analyst the unit of analysis is the individual- not society or the group or the community. Society does not make decisions,individuals do -realizing necessarily that the individual does not make decisions in a vacuum.
James Buchanan and Gordon Tullock are credited with the explication and promulgation of PCT but were not the first nor alone alone in their efforts .From one point of view, their work restored and re-invigorated views that were part of the common wisdom and discourse of the English speaking inhabitants of the British colonies in the later part of the 18 Th century. For much of the twentieth century journalists,historians and high school civic texts as well as college courses treated governmental action and public officials actions as not being self interested and assumed those acts were done in the public interest and typically carrying out the voters' will. Buchanan and Tullock said lets rethink those assumptions. As Buchanan said it is about politics without romance. Political actors acting in their individual self interest replace the wishful thinking which envisioned benevolent,wise selfless officials carrying out whatever society wanted which they were able to discern with near omnipotent wisdom.
The Founding Fathers realized the dark side of human nature and were very aware of the risks involved with investing power with the government.The government needed enough power to protect individual rights but the power could be used to restrict liberty as well. The Madisonian project was to devise a system of government that could constrain the power of the government that it needed to have to protect individual liberty.
Obamacare from the PCT perspective is a bad idea in part because it invests governmental entities with too much power.Further the power is concentrated in a few governmental entities and in regard to their edicts there are few if any avenues of appeal.Think HHS Secretary,IPAB,the IRS and the US Preventive Services Task Force.
The power given to the Secretary of HHS is a prime example.The absurd number of times the statute says "The Secretary [of HHS] shall determine" illustrates the concentration of power in a single politically appointed governmental official and is a dangerous transfer of power from the legislative to the administrative. The corrupt political ends to which a number of those decisions, i.e exempting friends of the administration from certain aspects of the law, serve to illustrate illustrate Acton's axiom of " power corrupts".
And then here is the matter of the IRS.Politicians feign shock and horror regarding the revelation of IRS acting in an illegal and politically motivated way and will hold hearings to investigate. The same thing has happened with previous administrations, both democrat and republican. Does anyone really believe that giving the IRS a major role in the administration of Obamacare is a good idea?
In a nutshell here is what PCT is all about;it is based on certain views concerning human nature namely:
1)Humans tend to respond to incentives.2)Humans frequently tend to act in what they believe to be in their own best interests.3)Humans have definite cognitive limitations.
PCT does not claim that people always act on the basis of some cost benefit analysis nor that sometimes folks do not act in ways that seem to be altruistic.
These aspects of human nature apply to businessmen,butchers,bakers and con men but they also apply to elected public officials,politicians,and bureaucrats.Accordingly this second group will from time to time act- most of time probably- in their own interests and not in some effort to bring about some abstract public good and that politicians just might respond to the incentives of campaign contribution in return for sponsoring some legislative act that benefits some special interest group at the expense of the public at large.
There are two others aspects of PCT worth briefly mentioning.
PCT explains that although private and public actors both respond to incentives (and constraints) the set of incentives and constraints are not the same for the two groups.Secondly, for the PCT analyst the unit of analysis is the individual- not society or the group or the community. Society does not make decisions,individuals do -realizing necessarily that the individual does not make decisions in a vacuum.
James Buchanan and Gordon Tullock are credited with the explication and promulgation of PCT but were not the first nor alone alone in their efforts .From one point of view, their work restored and re-invigorated views that were part of the common wisdom and discourse of the English speaking inhabitants of the British colonies in the later part of the 18 Th century. For much of the twentieth century journalists,historians and high school civic texts as well as college courses treated governmental action and public officials actions as not being self interested and assumed those acts were done in the public interest and typically carrying out the voters' will. Buchanan and Tullock said lets rethink those assumptions. As Buchanan said it is about politics without romance. Political actors acting in their individual self interest replace the wishful thinking which envisioned benevolent,wise selfless officials carrying out whatever society wanted which they were able to discern with near omnipotent wisdom.
The Founding Fathers realized the dark side of human nature and were very aware of the risks involved with investing power with the government.The government needed enough power to protect individual rights but the power could be used to restrict liberty as well. The Madisonian project was to devise a system of government that could constrain the power of the government that it needed to have to protect individual liberty.
Obamacare from the PCT perspective is a bad idea in part because it invests governmental entities with too much power.Further the power is concentrated in a few governmental entities and in regard to their edicts there are few if any avenues of appeal.Think HHS Secretary,IPAB,the IRS and the US Preventive Services Task Force.
The power given to the Secretary of HHS is a prime example.The absurd number of times the statute says "The Secretary [of HHS] shall determine" illustrates the concentration of power in a single politically appointed governmental official and is a dangerous transfer of power from the legislative to the administrative. The corrupt political ends to which a number of those decisions, i.e exempting friends of the administration from certain aspects of the law, serve to illustrate illustrate Acton's axiom of " power corrupts".
And then here is the matter of the IRS.Politicians feign shock and horror regarding the revelation of IRS acting in an illegal and politically motivated way and will hold hearings to investigate. The same thing has happened with previous administrations, both democrat and republican. Does anyone really believe that giving the IRS a major role in the administration of Obamacare is a good idea?
Sunday, August 18, 2013
The still revolving door of Health care "reform"- yet another chapter
Dr. Roy Poses writes about the odyssey of Nancy DeParle from the health care industry to the health care legislative reform con job known as ACA and back to the health care business-this time with a venture capital firm which invests in health care related enterprises. See here for his recent blog commentary.
quoting Poses:
"...Ms DeParle came from roles as a steward of multiple large health care corporations to lead the health care reform efforts of the executive branch. In that capacity, she helped to create and enact legislation that she would later say created many "new investment opportunities." Now, as the legislation is going into operation, she has spun over to private equity to take advantage of these opportunities. "
A similar tale can be told in regard to the person Sen. Max Baucus credited as playing a key role in the cooking of the legislative meat of Obamacare. I have commented on that before. See here.
Once again a well deserved kudo to Dr. Roy Poses for his tireless efforts to shine as much light as he can on corruption,rent seeking and crony capitalism in the world of health care.
quoting Poses:
"...Ms DeParle came from roles as a steward of multiple large health care corporations to lead the health care reform efforts of the executive branch. In that capacity, she helped to create and enact legislation that she would later say created many "new investment opportunities." Now, as the legislation is going into operation, she has spun over to private equity to take advantage of these opportunities. "
A similar tale can be told in regard to the person Sen. Max Baucus credited as playing a key role in the cooking of the legislative meat of Obamacare. I have commented on that before. See here.
Once again a well deserved kudo to Dr. Roy Poses for his tireless efforts to shine as much light as he can on corruption,rent seeking and crony capitalism in the world of health care.
Tuesday, August 06, 2013
What could possilby go wrong with meta-analysis and guidelines (think pre-op beta blockers)
Epidemiology 101 describes reasons for a correlation, namely :" causation,bias,confounding and chance".But fraud should also be on the list. Reports indicate that fraud played a major role in a Dutch study which in turn determined the outcome of at least one meta-analysis and from that a major recommendation for pre-op beta blockers in non cardiac patients.And now it seems that rather than prevent peri-operative deaths the beta-blockers might have lead to more deaths.
The European Society of Cardiology issued a strong recommendation for the use of peri-operative use of beta-blockers in 2009. Their analysis that lead to that recommendation was apparently heavily influenced by the DECREASE trial that showed a significant decrease in perioperative heart attacks in the treatment group. On the other hand ,the POISE trails showed that the control group had fewer deaths. When the two were combined and included in the meta-analysis and sprinkled with magic statistical fairy dust benefits were shown to be greater than the risks. When the fraud issue was raised and another Meta-analysis was done excluding the DECREASE data the risks were greater than benefits and more deaths occurred in the treatment arm.
See here for details and for more links.
As tragic as however- many- deaths occurred as a result of these guidelines there is reason for great optimism moving forward. Surely we will not need to worry about this sort of thing happening with the advent and proliferation of Accountable Care Organizations (ACOs) which will be catalyzed by thegreat crony capitalism victory social justice generating Accountable Care Act.We look forward to have wise "leaders with ideas " leading the way in good Don Berwicken fashion who will be immune to the multitude of Kahneman-Tversky type cognitive biases to which the hapless individual medical practitioners and their selfish patients are so susceptible.
What is the big deal here anyway-surely fraud is rare in medical studies.I hope so too but there are other reasons to be wary of meta-analysis and should sweeping guidelines be based on meta-analysis that are driven by one study. The x-files Aent Mulner believed the "truth is out there somewhere"-maybe but it is elusive and premature conclusions that are magnified by being enshrined in guidelines-particularly those that fortified in a P4P setting-can do more than a little harm.When the wisdom of the day is 180 degrees from the wisdom yesterday you can hear the plaintiff attorney asking :"Doctor, were you wrong then or are you wrong now ?"
The European Society of Cardiology issued a strong recommendation for the use of peri-operative use of beta-blockers in 2009. Their analysis that lead to that recommendation was apparently heavily influenced by the DECREASE trial that showed a significant decrease in perioperative heart attacks in the treatment group. On the other hand ,the POISE trails showed that the control group had fewer deaths. When the two were combined and included in the meta-analysis and sprinkled with magic statistical fairy dust benefits were shown to be greater than the risks. When the fraud issue was raised and another Meta-analysis was done excluding the DECREASE data the risks were greater than benefits and more deaths occurred in the treatment arm.
See here for details and for more links.
As tragic as however- many- deaths occurred as a result of these guidelines there is reason for great optimism moving forward. Surely we will not need to worry about this sort of thing happening with the advent and proliferation of Accountable Care Organizations (ACOs) which will be catalyzed by the
What is the big deal here anyway-surely fraud is rare in medical studies.I hope so too but there are other reasons to be wary of meta-analysis and should sweeping guidelines be based on meta-analysis that are driven by one study. The x-files Aent Mulner believed the "truth is out there somewhere"-maybe but it is elusive and premature conclusions that are magnified by being enshrined in guidelines-particularly those that fortified in a P4P setting-can do more than a little harm.When the wisdom of the day is 180 degrees from the wisdom yesterday you can hear the plaintiff attorney asking :"Doctor, were you wrong then or are you wrong now ?"
Friday, August 02, 2013
The perfect system of medical compensation is not an option
Quoting the increasingly insightful Arnold Kling;
"Keep in mind that there is no perfect system for compensating doctors. For example, if you pay them a fixed amount of money per patient, then their incentive is to see a lot of healthy patients and avoid the sick ones. If you pay them a fixed salary, their incentive is to work short hours. If you pay them for “quality care,” that means that a central bureaucracy, comparable to IPAB, has to define the meaning of quality."
and I add "folks will treat to the test" and the quality measure will lose whatever value it had as a measure.
So as usual it is "people respond to incentives" all the way down.
Currently the medical progressive elite and various rent seeking special interests seem to control the narrative and hence the anti fee-for- service propaganda blitz.
"Keep in mind that there is no perfect system for compensating doctors. For example, if you pay them a fixed amount of money per patient, then their incentive is to see a lot of healthy patients and avoid the sick ones. If you pay them a fixed salary, their incentive is to work short hours. If you pay them for “quality care,” that means that a central bureaucracy, comparable to IPAB, has to define the meaning of quality."
and I add "folks will treat to the test" and the quality measure will lose whatever value it had as a measure.
So as usual it is "people respond to incentives" all the way down.
Currently the medical progressive elite and various rent seeking special interests seem to control the narrative and hence the anti fee-for- service propaganda blitz.
Wednesday, July 31, 2013
The medical elite policy wonks need to listen to the real docs
Here are two real docs telling a story that seems to be lost to many of the medical elite who smoke the progressive pipe and sing the manta "medicine is too complex and important to be left in the hands of the individual physician and patient". See this commentary from the blog In my Humble Opinion and these remarks from a practicing ophthalmologist in Texas which was featured on Dr. G.Keith Smith's website,Surgerycenterofoklahoma.
Wednesday, July 17, 2013
Will Obamacare bring social justice(as claimed by AMA and ACP) or "Shatter the Backbone of the Middle Class"?
Obamacare was lauded by some democratic senators and some medical organizations ( e.g. the AMA and ACP) as finally delivering long awaited social justice to health care in the U.S. Labor unions supported Obama's candidacy as well as the bill. Now as some of the devilish details are oozing out of the hundreds of pages of dense legislative verbiage,labor union leaders are realized they may well not get the really good deal they believe they had been promised.
Now three unions are demanding that the administration make changes in the interpretation of the statute ( can you say "waivers") to lessen any negative impact on various unions health care plans.See here for details.
One brief quote from a letter to Democratic leaders in the House and Senate that was signed by Jimmy Hoffa :
" We have a problem; you need to fix it. The unintended consequences of the ACA are severe. Perverse incentives are already creating nightmare scenarios."
Perhaps Obamaconcare might be a more appropriate name as more and more folks are realizing they were conned.
Now three unions are demanding that the administration make changes in the interpretation of the statute ( can you say "waivers") to lessen any negative impact on various unions health care plans.See here for details.
One brief quote from a letter to Democratic leaders in the House and Senate that was signed by Jimmy Hoffa :
" We have a problem; you need to fix it. The unintended consequences of the ACA are severe. Perverse incentives are already creating nightmare scenarios."
Perhaps Obamaconcare might be a more appropriate name as more and more folks are realizing they were conned.
Sunday, July 07, 2013
How/why/when did physicians get tasked with being "stewards of resources"?
Let's take at look at the the strange journey of physician's ethics from fiduciary duty to the patient to stewards of society's medical resources.
When I trained as an internist in the late 60s and early 70s,medical ethics seemed very straight forward and was so uncontroversial that is was rarely the topic for discussion.The physician had a fiduciary duty to the patient and he was to place the patient's interests first and do what was right for the patient and to do no harm to the patient.
It was a time when the hegemony of the third party medical payers (insurance companies and CMS) was not an issue. It was the era of "retail medicine" in which indemnity insurance followed the patients and the payments for physician's services were dispensed according to what was said to be "customary,reasonable and prevailing". Insurance companies did not determine which hospital a physician used,which consultants to be used for referrals nor what medications were approved for use.Physicians who vigorously advocated for their patients as it involved some hospital practice were not summoned before a kangaroo court on charge of being "disruptive".
As time passed there appeared on the scene a perfect storm of forces and events that accelerated medical costs.There were new diagnostic tests (mainly imaging procedures),new therapies,patients were spending what they considered to be other people's money and physicians believed they were ethically bound to do what they thought was right for the patient which often included more rather than fewer tests .
As medical care costs and expenditures increased, third party payers including large corporations who provided health insurance ( those who were self insured) took measures to control costs. There were larger deductibles and co-payments and more scrutiny by insurance companies on what exactly they would pay for. There were guidelines and pre approval rules for testing.The concept of gate keeper was born. These counter measures probably mitigated price increases a bit but costs continued to rise and continue they would as basically this was folks spending someone else's money and the fingers on the cost guns were in the hands of hundreds of thousands of physicians many in sole or small group practices whose actions continued to be largely outside of the control of the third part payers.
The problem was how to control the activities on these physicians who had been inculcated for many decades with the ethical imperative of do what is right for the patient. For one trained in that ethical environment, cost to " the system", be it United Health Care,Exxon, or Medicare,was not a major priority in their value or decision making calculus.
So various variations of carrots and sticks were employed by the third party payer.Pay for performance grew up as a type of bribe to docs to follow the cost cutting guidelines which went by the wink,wink,nudge, nudge name of quality guidelines.
Although carrot and stick techniques have a proven history of changing behaviors to some degree,what would be even better is to have at the triggers of medical cost initiation e.g physicians (or some alternative "health care provider", i.e NPs, PAs) who really believe their duty lies at least to a significant operational degree in cost saving and to preserving the medical collective's resources.
Enter the concept of physicians as stewards of society's resources.
I have not developed a detailed chronology of that part of the literature which deals with medical policy matters to be able to date with any precision when and how this concept arose. I have written before on some of the earlier papers in the mainstream medical literature.
In 1988 Hall and Berenson writing in the Annals of Internal Medicine said that "the traditional ideal" [the prime duty to the patient ] was "not compatible with the role that existing insurance contracts and manged care arrangements define for physicians." Their comments were not subtle when they said :
"We propose that devotion to the best interests of each individual be replaced with an ethic of devotion to the best interests of the group for which the physician is personally responsible."
Note:Berenson and Hall glibly justify that ethical sea change because the role that insurance contracts define for the physicians. Here we might pause and remember that one of the defining characteristics of a profession is that members are bound by a ethical code that is largely self defined.
Over the next 20 years far from that proposal being dismissed out of hand as medical ethical heresy which is how many physicians at the time would have characterized it, it has become part of the generally accepted medical ethical package nestled in professionalism statements by many professional medical organizations and has become part of medical education .
The fiduciary duty to the patient seem to have been demolished ( or at least made secondary) with unsuccessful attempts by physicians of the old school to battle the propaganda juggernaut . The dogs bark and the caravan moves on.
We have traveled a long way since the Berenson article.Now we read of a suggestion that "cost-consciousness and stewardship of resources be elevated by the ACGME and the ABMS to the level of a a new seventh general competency." In other words, residents should be schooled and graded on their mastery of the skill set necessary to be good stewards of [society's] resources. ( reference, The Idea and Opinions Section, Annals of Internal Medicine,20 Sept 2011,Vol.155 no.6, by Dr. Steven E. Weinberger,of the American College of Physicians.
Interestingly, in the 1999 Ethics Statement of the council of Medical Specialty Societies (CMSS) there was no mention of physicians as stewards of medical resources but rather the document talked about physicians as stewards of medical knowledge.(As best I can determine the 1999 Ethic statement is the most recent)
A CFO of a HMO or now a ACO could not devise a better ethical precept- at least for their bottom line- than for physicians to be ethically bound to "conserve medical resources".
Operationally to be a good steward one need only adhere to the organization's guide lines which may be derived from aggregate data and the statistical utilitarianism of outcome research or at times the opinion of self designated experts. Just ask the economist Fucks how to resolve the ethical conflict for the physician facing with the good of his patient or the good of the group. Who better to give ethical advise to physicians than an economist? See here for comments on Fuchs' "solution".
So we have gone from the primacy of the welfare of the individual patient and the fiduciary duty of the physician to the patient to a Two Master concept of professionalism.
Dr. Accad of the blog,Alert and Oriented, has commented that "Medicine is dominated by the collectivist Ideology". I agree and one striking manifestation of that dominance chiefly driven by medical academia, is the acceptance of the concept of the physician as medical resource steward. What place does/will the traditional physician-patient relationship have in this formulation?
The medical ethicist Dr. Edmund Pellegrino in 1995 asked ...can physicians change the ethics of the profession at will ( as proposed by Berenson and Hall or Berwick and Brennan)) or is there a more fundamental and universal foundation for the ethics of medicine found in the special nature of the physician-patient relationship?
Pellegrino is quoted from an article entitled "Guarding the Integrity of Medical Ethics-Some Lessons from Soviet Russia" . The subversion of medical ethics that occurred in Russia suggested to Pellegrino two lessons.
1) corruption will afflict any health system not designed with care of the patient as the its primary driving force. 2) medical ethics must be independent of political exigency. "... a morally responsive profession is an indispensable safeguard for the sick against the statistical morality of utilitarian politics, even in democracies."
How did it happen? How did the ideological certitude that we had as residents in the 1970s in regard to our ethical obligations morph into the divided loyalties and the two master concept that now seem destined to become codified in the training program? Following the Mafia rule, we look to the third party payer who are the obvious beneficiaries of the stewardship concept but what did they do to achieve that change? Did the academic medical progressives pave the way with their rhetoric and lobbying?
Language can be used as a tool of change. Dr. Thomas Szazz, one of my favorite iconoclasts, said "Define or be defined". Physicians, once a profession that defined its ethics now has been and is being defined by a relatively small group of academic physicians . Patients are now designated as consumers of health care or customers,Both terms leave no room for discussion of the physician patient relationship.Physicians are redefined as stewards of resources.
New terms have been slipped into discussion about health care. These include "professionalism" which seems to be a pattern of behaviors and a system of values that has been unilaterally grafted onto the top of medical ethics largely as the results of a group ( not necessarily an organized group per se but they are active in some internists organizations) of internists whose views are basically liberal ( not in the sense of classical liberalism) or more accurately progressive. Then the term professionalism was used as a vehicle to dictate a series of given policies which according to the definers are the necessary characteristics of physician's professionalism , This include a striving for social justice and to be "stewards of medical resources". The operational meaning of the later terms is to conserve resources by following guidelines that to some degree and sometimes derived in part from cost effectiveness and cost comparative studies.
So here is how is worked. Physicians not only have to adhere to the usual medical ethical principles but they must also behave according to the new guidelines of professionalism ( which were conceived and promoted by a small group of like minded internists) which include being stewards of resources which practically means following guidelines.
So back to the title. The how was largely through the perhaps well intentioned persistent and well funded efforts ( think the Robert Wood Johnson Foundation et al) of the progressive medical elite subset of physicians to flim flam physicians to accept the 180 degree turn in professional ethics,the why was the increasing concern of the third payers for the increasing cost of medical care fueled in part by folks spending other people's money .The when is not identifiable as one specific date or event but rather more like the process of frog boiling over the post 25 to 30 years.
Addendum: 7/8/13 An apology is in order. On 7/7/13 I was drafting this posting and I hit post instead of save . As as result a rough form was published . The above is a rushed effort to smooth the edges.
When I trained as an internist in the late 60s and early 70s,medical ethics seemed very straight forward and was so uncontroversial that is was rarely the topic for discussion.The physician had a fiduciary duty to the patient and he was to place the patient's interests first and do what was right for the patient and to do no harm to the patient.
It was a time when the hegemony of the third party medical payers (insurance companies and CMS) was not an issue. It was the era of "retail medicine" in which indemnity insurance followed the patients and the payments for physician's services were dispensed according to what was said to be "customary,reasonable and prevailing". Insurance companies did not determine which hospital a physician used,which consultants to be used for referrals nor what medications were approved for use.Physicians who vigorously advocated for their patients as it involved some hospital practice were not summoned before a kangaroo court on charge of being "disruptive".
As time passed there appeared on the scene a perfect storm of forces and events that accelerated medical costs.There were new diagnostic tests (mainly imaging procedures),new therapies,patients were spending what they considered to be other people's money and physicians believed they were ethically bound to do what they thought was right for the patient which often included more rather than fewer tests .
As medical care costs and expenditures increased, third party payers including large corporations who provided health insurance ( those who were self insured) took measures to control costs. There were larger deductibles and co-payments and more scrutiny by insurance companies on what exactly they would pay for. There were guidelines and pre approval rules for testing.The concept of gate keeper was born. These counter measures probably mitigated price increases a bit but costs continued to rise and continue they would as basically this was folks spending someone else's money and the fingers on the cost guns were in the hands of hundreds of thousands of physicians many in sole or small group practices whose actions continued to be largely outside of the control of the third part payers.
The problem was how to control the activities on these physicians who had been inculcated for many decades with the ethical imperative of do what is right for the patient. For one trained in that ethical environment, cost to " the system", be it United Health Care,Exxon, or Medicare,was not a major priority in their value or decision making calculus.
So various variations of carrots and sticks were employed by the third party payer.Pay for performance grew up as a type of bribe to docs to follow the cost cutting guidelines which went by the wink,wink,nudge, nudge name of quality guidelines.
Although carrot and stick techniques have a proven history of changing behaviors to some degree,what would be even better is to have at the triggers of medical cost initiation e.g physicians (or some alternative "health care provider", i.e NPs, PAs) who really believe their duty lies at least to a significant operational degree in cost saving and to preserving the medical collective's resources.
Enter the concept of physicians as stewards of society's resources.
I have not developed a detailed chronology of that part of the literature which deals with medical policy matters to be able to date with any precision when and how this concept arose. I have written before on some of the earlier papers in the mainstream medical literature.
In 1988 Hall and Berenson writing in the Annals of Internal Medicine said that "the traditional ideal" [the prime duty to the patient ] was "not compatible with the role that existing insurance contracts and manged care arrangements define for physicians." Their comments were not subtle when they said :
"We propose that devotion to the best interests of each individual be replaced with an ethic of devotion to the best interests of the group for which the physician is personally responsible."
Note:Berenson and Hall glibly justify that ethical sea change because the role that insurance contracts define for the physicians. Here we might pause and remember that one of the defining characteristics of a profession is that members are bound by a ethical code that is largely self defined.
Over the next 20 years far from that proposal being dismissed out of hand as medical ethical heresy which is how many physicians at the time would have characterized it, it has become part of the generally accepted medical ethical package nestled in professionalism statements by many professional medical organizations and has become part of medical education .
The fiduciary duty to the patient seem to have been demolished ( or at least made secondary) with unsuccessful attempts by physicians of the old school to battle the propaganda juggernaut . The dogs bark and the caravan moves on.
We have traveled a long way since the Berenson article.Now we read of a suggestion that "cost-consciousness and stewardship of resources be elevated by the ACGME and the ABMS to the level of a a new seventh general competency." In other words, residents should be schooled and graded on their mastery of the skill set necessary to be good stewards of [society's] resources. ( reference, The Idea and Opinions Section, Annals of Internal Medicine,20 Sept 2011,Vol.155 no.6, by Dr. Steven E. Weinberger,of the American College of Physicians.
Interestingly, in the 1999 Ethics Statement of the council of Medical Specialty Societies (CMSS) there was no mention of physicians as stewards of medical resources but rather the document talked about physicians as stewards of medical knowledge.(As best I can determine the 1999 Ethic statement is the most recent)
A CFO of a HMO or now a ACO could not devise a better ethical precept- at least for their bottom line- than for physicians to be ethically bound to "conserve medical resources".
Operationally to be a good steward one need only adhere to the organization's guide lines which may be derived from aggregate data and the statistical utilitarianism of outcome research or at times the opinion of self designated experts. Just ask the economist Fucks how to resolve the ethical conflict for the physician facing with the good of his patient or the good of the group. Who better to give ethical advise to physicians than an economist? See here for comments on Fuchs' "solution".
So we have gone from the primacy of the welfare of the individual patient and the fiduciary duty of the physician to the patient to a Two Master concept of professionalism.
Dr. Accad of the blog,Alert and Oriented, has commented that "Medicine is dominated by the collectivist Ideology". I agree and one striking manifestation of that dominance chiefly driven by medical academia, is the acceptance of the concept of the physician as medical resource steward. What place does/will the traditional physician-patient relationship have in this formulation?
The medical ethicist Dr. Edmund Pellegrino in 1995 asked ...can physicians change the ethics of the profession at will ( as proposed by Berenson and Hall or Berwick and Brennan)) or is there a more fundamental and universal foundation for the ethics of medicine found in the special nature of the physician-patient relationship?
Pellegrino is quoted from an article entitled "Guarding the Integrity of Medical Ethics-Some Lessons from Soviet Russia" . The subversion of medical ethics that occurred in Russia suggested to Pellegrino two lessons.
1) corruption will afflict any health system not designed with care of the patient as the its primary driving force. 2) medical ethics must be independent of political exigency. "... a morally responsive profession is an indispensable safeguard for the sick against the statistical morality of utilitarian politics, even in democracies."
How did it happen? How did the ideological certitude that we had as residents in the 1970s in regard to our ethical obligations morph into the divided loyalties and the two master concept that now seem destined to become codified in the training program? Following the Mafia rule, we look to the third party payer who are the obvious beneficiaries of the stewardship concept but what did they do to achieve that change? Did the academic medical progressives pave the way with their rhetoric and lobbying?
Language can be used as a tool of change. Dr. Thomas Szazz, one of my favorite iconoclasts, said "Define or be defined". Physicians, once a profession that defined its ethics now has been and is being defined by a relatively small group of academic physicians . Patients are now designated as consumers of health care or customers,Both terms leave no room for discussion of the physician patient relationship.Physicians are redefined as stewards of resources.
New terms have been slipped into discussion about health care. These include "professionalism" which seems to be a pattern of behaviors and a system of values that has been unilaterally grafted onto the top of medical ethics largely as the results of a group ( not necessarily an organized group per se but they are active in some internists organizations) of internists whose views are basically liberal ( not in the sense of classical liberalism) or more accurately progressive. Then the term professionalism was used as a vehicle to dictate a series of given policies which according to the definers are the necessary characteristics of physician's professionalism , This include a striving for social justice and to be "stewards of medical resources". The operational meaning of the later terms is to conserve resources by following guidelines that to some degree and sometimes derived in part from cost effectiveness and cost comparative studies.
So here is how is worked. Physicians not only have to adhere to the usual medical ethical principles but they must also behave according to the new guidelines of professionalism ( which were conceived and promoted by a small group of like minded internists) which include being stewards of resources which practically means following guidelines.
So back to the title. The how was largely through the perhaps well intentioned persistent and well funded efforts ( think the Robert Wood Johnson Foundation et al) of the progressive medical elite subset of physicians to flim flam physicians to accept the 180 degree turn in professional ethics,the why was the increasing concern of the third payers for the increasing cost of medical care fueled in part by folks spending other people's money .The when is not identifiable as one specific date or event but rather more like the process of frog boiling over the post 25 to 30 years.
Addendum: 7/8/13 An apology is in order. On 7/7/13 I was drafting this posting and I hit post instead of save . As as result a rough form was published . The above is a rushed effort to smooth the edges.
Thursday, July 04, 2013
Obamacare in action substitutes "Rule by Rulers" for Rule of Law
The term "Rule of Law" may be discussed in at least three different contextual frameworks. The formal or so called thin interpretation states that law must be prospective,well known, and have the features of equality and certainty. The law must be clear and apply to everyone. The substantive or so called thick interpretation says that the law protects individual rights. In the functional approach rule of law is defined by contrast with rule of man. FA Hayek talks about the rule of law as contrasted with arbitrary government edicts or proclamations.
Whatever framework you prefer, the manner in which Obamacare so far has been administered by the government exemplifies rule by arbitrary governmental order or as Michael Cannon phrased it in his Cato commentary "Rule by Rulers" (see here). Quoting Mr. Cannon:
"...the IRS’s unilateral decision to delay the employer mandate is the latest indication that we do not live under a Rule of Law, but under a Rule of Rulers who write and rewrite laws at whim, without legitimate authority, and otherwise compel behavior to suit their ends. Congress gave neither the IRS nor the president any authority to delay the imposition of the Patient Protection and Affordable Care Act’s employer mandate. In the section of the law creating that mandate, Congress included several provisions indicating the mandate will take effect in 2014. In case those provisions were not clear enough, Section 4980H further clarifies:
Read all of Cannon's essay in which he lists some of the various ways that the current administration has behaved like "rulers" exercising powers not delegated by the statute to protect Obamacare's image and to lessen any negative impact it may have on their supporters (think unions) and on elections (think Medicare advantage and the 2014 mid term congressional and fallout from the disruption of the employer mandate.)
So both houses of congress pass a law,with great fanfare the President signs the law and then SCOTUS declares most the law is constitutional. And now an administrative agency simply ignores the letter and intent of the law and postpones a portion of it even though it has no statutory authority to do so. Will Madisonian checks and balances kick it to play and somehow order the IRS to obey the law? I think not- most of the times legality or fear of judicial action does not impede the current trend of ruling by rulers.More and more no one complains and the courts are not called upon. The barking dogs in the blog world and the non Main Stream Media bark away (along with the occasional legislator) and the ruler caravan moves on.
Addendum: 7/5/2013 It just gets more and more unclear as more analyses are offered. See here for a detailed discussion about the issue of what exactly is being postponed.Does the administration really have the authority to do whatever they think they did?Does anyone have legal standing to bring legal action to force the administration of a statute? And even if the courts found for the plaintiff ( if one could be found) could the court really force the executive to do anything? I'll bet that James Madison thought his checks and balances and "sufficient virtue" of the American people would have worked out better.
Addendum: 7/8/2013. More delays in Obamacare. In this posting from the Washington Post we learn that some elements of Obamacare will be on the "honor system", at least for a while.Somehow I have a problem thinking about the IRS overseeing a honor system arrangement.
Whatever framework you prefer, the manner in which Obamacare so far has been administered by the government exemplifies rule by arbitrary governmental order or as Michael Cannon phrased it in his Cato commentary "Rule by Rulers" (see here). Quoting Mr. Cannon:
"...the IRS’s unilateral decision to delay the employer mandate is the latest indication that we do not live under a Rule of Law, but under a Rule of Rulers who write and rewrite laws at whim, without legitimate authority, and otherwise compel behavior to suit their ends. Congress gave neither the IRS nor the president any authority to delay the imposition of the Patient Protection and Affordable Care Act’s employer mandate. In the section of the law creating that mandate, Congress included several provisions indicating the mandate will take effect in 2014. In case those provisions were not clear enough, Section 4980H further clarifies:
(d) EFFECTIVE DATE.—The amendments made by this section shall apply to months beginning after December 31, 2013.It is hard to see how the will of the people’s elected representatives – including President Obama, who signed that effective date into law – could have been expressed more clearly, or how it could be clearer that the IRS has no legitimate power to delay the mandate."
Read all of Cannon's essay in which he lists some of the various ways that the current administration has behaved like "rulers" exercising powers not delegated by the statute to protect Obamacare's image and to lessen any negative impact it may have on their supporters (think unions) and on elections (think Medicare advantage and the 2014 mid term congressional and fallout from the disruption of the employer mandate.)
So both houses of congress pass a law,with great fanfare the President signs the law and then SCOTUS declares most the law is constitutional. And now an administrative agency simply ignores the letter and intent of the law and postpones a portion of it even though it has no statutory authority to do so. Will Madisonian checks and balances kick it to play and somehow order the IRS to obey the law? I think not- most of the times legality or fear of judicial action does not impede the current trend of ruling by rulers.More and more no one complains and the courts are not called upon. The barking dogs in the blog world and the non Main Stream Media bark away (along with the occasional legislator) and the ruler caravan moves on.
Addendum: 7/5/2013 It just gets more and more unclear as more analyses are offered. See here for a detailed discussion about the issue of what exactly is being postponed.Does the administration really have the authority to do whatever they think they did?Does anyone have legal standing to bring legal action to force the administration of a statute? And even if the courts found for the plaintiff ( if one could be found) could the court really force the executive to do anything? I'll bet that James Madison thought his checks and balances and "sufficient virtue" of the American people would have worked out better.
Addendum: 7/8/2013. More delays in Obamacare. In this posting from the Washington Post we learn that some elements of Obamacare will be on the "honor system", at least for a while.Somehow I have a problem thinking about the IRS overseeing a honor system arrangement.
Tuesday, June 18, 2013
"The fundamental problem with state and employer-based programs"..[in regared to health care]
The title comes from the following paragraph written by Nobel prize winning economist Vernon Smith in his 2008 book entitled "Rationality in Economics" which is found on page 96:
"The fundamental problem with state and employment-based programs to solve the problem of extending medical care to all risk classes is as follows:
A (the physician,hospital,or other medical service supplier) recommends to B (the patient) what he or she should buy from A and C (the insurance company or government) reimburses A for the services. This is an incentive nightmare and it explains why the price of medical services persistently rises faster than almost all other economic products and services..."
Smith then comments that educational services are analogous and continues "These are examples in which consumer sovereignty is compromised by lack of direct experience and knowledge, and the supplier who harbors an inherent conflict of interest, is considered best capable of deciding what the consumer should buy."
If Smith analysis is on target what can we expect fromthe massive crony capitalism health care bill Obamacare? Many more folks are eligible for Medicaid (depending on what various states do) and will get health care paid for by government money also known as someone else's money and possibly more will be covered by employers health insurance which is typically spent by employees in the belief that they are spending someone else's money. So the incentive nightmare of Smith's ABCs made even worse.
The incentive issue is what Milton Freedman talks about when he talked about the various way people can spend money.
"The fundamental problem with state and employment-based programs to solve the problem of extending medical care to all risk classes is as follows:
A (the physician,hospital,or other medical service supplier) recommends to B (the patient) what he or she should buy from A and C (the insurance company or government) reimburses A for the services. This is an incentive nightmare and it explains why the price of medical services persistently rises faster than almost all other economic products and services..."
Smith then comments that educational services are analogous and continues "These are examples in which consumer sovereignty is compromised by lack of direct experience and knowledge, and the supplier who harbors an inherent conflict of interest, is considered best capable of deciding what the consumer should buy."
If Smith analysis is on target what can we expect from
The incentive issue is what Milton Freedman talks about when he talked about the various way people can spend money.
Friday, May 24, 2013
Will Obamacare's success depend of the kindness and goodwill of strangers (young , healthy ones)?
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.
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.
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.
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