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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 ...

Friday, August 27, 2010

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

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

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

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

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

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

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

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

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

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

Wednesday, August 25, 2010

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

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

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

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

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

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

Tuesday, August 17, 2010

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Monday, August 09, 2010

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

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

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

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

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

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

Monday, August 02, 2010

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

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

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

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

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

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

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

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

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

Wachter continues saying:

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

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

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

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

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

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