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Is the new professionalism and ACP's new ethics really just about following guidelines?

The Charter ( Medical Professionalism in the New Millennium.A Physician's Charter) did not deal with just the important relationship of ...

Thursday, July 31, 2008

Still more possible benefits from statins-the list goes on and on

Dementia prevention and statins are again in the news with this study. Previous studies offered contradictory data , some showing an benefit in risk reduction in the development of dementia from statin use while others did not.

The current study is a bit more robust than some of the previous ones as patients were followed over time and periodic tests of cognitive ability were performed and the statins users scored higher.

Another study (a meta-analysis-and thanks to Dr. RW for that reference) offered evidence that post operative onset of atrial fibrillation can be reduced by statins. I guess we could use something new now after those unpleasant, unintended consequences noted from giving almost everyone beta-blockers pre op.

I have marveled before about how many good things can be attributed to statins all of which make me feel good about taking one of them even though my LDL wasn't all that high anyway.

I have written before about the contradictory results regarding statins and risk of colon cancer and commented that another case-control study will not settle that issue (for that matter,any issue) but that is exactly what the NEJM published in the face of previously published dueling case controls studies addressing that issue.

The story of dementia and statins is still being written but maybe in the meanwhile we can keep exercising in the hope that it will keep our hippocampi big and healthy and our frontal lobes relatively free of white matter bright spots.Anyway it would be nice to think so.

Wednesday, July 23, 2008

The really, really dark side of P4P (maybe the only side)

Comments by an Hawaii physician,called to our attention by the prolific Sandy Suracz, should do more than raise a few eyebrows.I have characterized P4P as, among other things,bribing physicians for doing their job. It seems to be worse than that.There may be instances of docs being bribed to use certain medications.

Now we seem to have more reason to believe that some health plans are being bribed by drug companies to prescribe certain medications and then the health plans bribing and coercing the physicians in the plan to prescribe those medication under the feel-good facade of
quality care and guidelines.

Dr.Catey Shanahan from Hawaii is the whistle blower in this instance describing what went on in the plan for which she works and alleged comments from a management person in another plan where she interviewed for a position. Details can be found here in her letter to the editor of a newspaper. The guidelines that Dr.Shanahan found questionable involved the dictum that all type 2 diabetics should be treated with a statin medication to drive the LDL below some magic number.I hope the usual fate of whistle-blowers does not await Dr. Shanahan.

One can argue about the validity of the conclusion that all such patients be treated to that target with that class of medication and can question the robustness of the data that suggest that such treatment is both safe and efficacious, let alone effective. ( I'll admit I have/had firmly bought into that line of thinking but am rethinking that now) However, there is no argument, as far as any reasonable or even conceivable interpretation of medical ethics, about bribing physicians to prescribe certain medications. DrRich sent me (and everyone who reads his blog and book) the message that medical ethics and pride are in a downward spiral and if medical ethics is in a crisis, trust is next to fall.

Three years ago my brother-in-law received a prescription for simvastatin ( not the generic) because of his slightly elevated LDL. He was of the belief-without any specific supporting data- that the doctor was getting some type of "kick back" for using that medication. In my naivete,I told him in no uncertain terms that that sort of thing just does not happen.The conversation would have to be a bit different now.

This same general issue attracted a bit of attention when the "EPO" stories broke and the question of rebates for physicians and health care plans came to light at that time.I wrote about that here.

Fortunately the shattering of the trust in doctors which such activities will bring about will be mitigated by knowledge that no longer will pharma firms hand out the mind altering pens and mugs decorated by the names of medications. That should restore trust in physicians.

Sunday, July 20, 2008

More deserved criticism of P4P

I welcome attacks on the dangerous and muddled headed concept and practice of P4P. There is so much wrong with it that I hardly know where to begin. A good place to begin is this most recent entry by Dr.Roy Poses of Health Care Renewal. He summarizes most of the problems with pay for performance in this posting. To his excellent essay I would only add never forget Goodhart's Rule, which tell us that once a measurement becomes a target or a goal it is no longer a valid measure or more accurately phrased

Once a measure is made a target for the purpose of conducting policy, it will loose the information content that would qualify it to play such a role.

Dr. Robert Centor in his blog sends us to an extremely well written article in JAMA. You need a subscription but he gives us at least a hint of the flavor of that satire here.Ridicule sometimes is a sharper sword than thoughtful critiques.

I am afraid that in spite of biting satire and the elucidation of valid arguments against P4P, too many of our fellow physicians continue to collaborate with this travesty that can only serve to further accelerate the downward spiral to the ethics and pride of the medical profession.

Critics of the gate-keeper version of managed care were often told that the train had already left the station and now critics of P4P are being told that as well. The gate-keeper train ultimately derailed and I believe docs should let the P4P express train leave without them being aboard.

Friday, July 18, 2008

More things too important for individuals to manage for themselves

I have ranted before about those who think and want everyone to think that medical care is far too important to be left to uninformed, selfish egotistical decisions that physicians and patients are likely to make when they meet secretly in the former's office away from the watchful eyes of third party payers and conspire to spend some one else's money.The last thing a rationing unit would want to happen is to allow the unfettered actions of doctors and patients to prevail. DrRich's writings have made that point with great literary skill.

That activity makes sense if you consider the "pay with other people's money principle" but groups other than third party payers also share in similar movements and I am less sure of their motives. Case in point are the activities of several local public health units in moving to monitor the blood sugar levels - as surrogated for by the Hemoglobin A1C levels-of citizens without their consent.They would have us believe that the public health imperative is so strong that diabetes treatment cannot be left to willy-nilly, half hearted efforts of individual physicians and their patients.

We are seeing more and more of that same type of thinking in regard to "managing" the food intake and other activities of children. There are major efforts out there by groups who believe that what a child eats and what activities they do are too important to be left to the uniformed,almost-negligence proclivities of parents.After all it is those parents who are to blame for the current ever growing epidemic of fat kids.

Great Britain and Canada seem to be a bit ahead of the U.S. in this nanny-state nutritional impetus but we are closing fast.Sandy Szwarc in her July 15,2008 entry give us this instance of how far it is going in one region of England where parents may not be "allowed" to send lunches to school with their children.

Hayek writes of the "Fatal Conceit" of those who not only believe they know what is best for everyone but also see fit to take measures to insure that their wisdom becomes operational even it means the power of the state will enforce it.

Tuesday, July 08, 2008

WSJ editorial carries foward theme of Medicare as a harbinger of what a single payer would be like

Recently, I wrote that if you wonder what a single payer for medical care in this country would be like, all you need to study is how Medicare is working now. This same idea is expressed in this editorial from the Wall Street Journal. If you want to look at a real life example in the U.S. of what you may have learned in your Economics 101 class about price controls, all you need to study in how Medicare works.

WSJ says this:

The fight over doctor fees [the current annual dance over cuts in Medicare physician payments] is merely an appetizer for such a system, where competing interest groups would clash for their share of the spending pie. Highly politicized Medicare-like price controls on providers and services would spread to every health decision. The result would be rationing and declines in quality of care.

The writer explains:

As a virtual monopoly, Medicare uses a complex formula to set reimbursement rates for thousands of services. In short, it controls prices. That's why doctors are supposed to eat a pay cut, even though everyone knows this would prompt more doctors to stop seeing Medicare patients. But price fixing is the way that an open-ended entitlement like Medicare – which gobbled up $432 billion in 2007 – tries to control spending.

Thomas Sowell said that ignoring basic economic ideas is about as realistic as ignoring gravity in this essay on price controls. Medicare is all about price controls and rationing.

Monday, July 07, 2008

Pediatric organization issues proactive recommendations re use of stains in children

Several years ago, Dr. Antonio Gotto, noted lipid researcher, jokingly suggested putting statins in the drinking water. While we are not quite there yet, we are closer to that facetious goal with the latest recommendations from the American Academy of Pediatrics. Go here to read their paper.

I found their recommendations more than a bit surprising in light of the following: 1) an apparent reversal from their earlier pronouncements, 2) the lack of evidence presented in their paper addressing the issues of long term safety and long term efficacy regarding decrease in clinical coronary artery disease events. The emphasis on surrogate measurements on which they had to rely given the paucity of long term outcome data is in contrast to the bad press surrogate measurements have recently received in diabetes drug trials.

So what group of children should be considered for prescription drug therapy.Here is what the AAP said:

  1. For patients 8 years and older with an LDL concentration of ≥190 mg/dL (or ≥160 mg/dL with a family history of early heart disease or ≥2 additional risk factors present or ≥130 mg/dL if diabetes mellitus is present), pharmacologic intervention should be considered. The initial goal is to lower LDL concentration to <160> 110 mg/dL may be warranted when there is a strong family history of CVD, especially with other risk factors including obesity, diabetes mellitus, the metabolic syndrome, and other higher-risk situations.
After you read the Pediatric association's argument for their position go here and read what is ,in my opinion, a much more reasoned and scholarly assessment of this general issue by the prolific Sandy Szwarc.(Thanks to Dr. Wes for that reference).

How will a government single payer work?Go to the Happy Hospitalist to see how it did/does work for Medicare

Everyone who is a physician or is training to be one,everyone who is a patient or who might someday be one (that really is almost everyone) needs to go now and read and re-read one of the latest essays by the Happy Hospitalist. Physicians to whom the education of physicians is entrusted should either copy that post and hand it out or send all of their students to the the link on the web .Would anyone like to wager that it will not find its way into any publication from a major medical organization?

Physicians who are so fed up with what medical practice has become and are so desperate that they are now recommending a single payer should read his article and see if their views about a single payer will change.

Happy explains what the CMS system is. If he is right,and I believe him to be right, the ship will sink in a few years and there will be not enough primary care docs to care for those folks who will need their services. Of course, many have prophesied that as well but the professional organizations such as ACP who also forecast disaster have not offered a viable solution, in my opinion.

The die was cast in 1989 with the passage of the Omnibus Budget Reconciliation Act. Wage controls were enacted for Medicare services, something that was promised to not ever happen when the Medicare bill was passed. With price controls one can expect shortages, increased demand , poor service and even black markets. All of the expected consequences did not occur overnight, but most (I don't think there is much of a black market yet) are very evident now and are getting worse.

The system that HH expertly explains so far has damaged the primary care physicians most but one can see effects moving up the doctor food chain. We are seeing ob-gyns offering botox and selling vitamins and are told there it is easier to get a vascular surgery fellowship than a dermatology residency. We read that a nurse anesthetist (CRNA) is averaging higher incomes than an internist or family doc or peds doc. Orthopedists are using PAs to do some of the non-procedural stuff (e.g. actually talking to patients) so their time can be spent with the higher paying activities like sawing and sewing.When you read how the system works much makes more sense: why we suddenly can't get by without hospitalists while 20 years ago there were no such entities, why the old medical ethics of putting the patient first had to be replaced by social justice concerns and a utilitarian viewpoint.It is the covert rationing so cogently explained by DrRich.

We all should know what wage and price controls do but the CMS system is worse than that. It is structured so that it will self destruct. Go to HH's post to see how that works.It is a death spiral of ever increasing volume and decreasing payment per unit of service that is crushing primary care and those docs who do the procedures will survive only a little longer.

He references his proposed solution in his blog. I don't know if his cure is the right medicine or not but he sure has done everyone a great service by explicating the pathophysiology of the problem.