The Charter ( Medical Professionalism in the New Millennium.A Physician's Charter) did not deal with just the important relationship of ...
Monday, December 12, 2011
Consider the recent action of the Centers for Medicare and Medicaid (CMS) in regard to the imposition of pre-payment audits of certain procedures ( cardiac,joint replacements,spinal fusions)but only in certain states. See here.
This means that for these procedures hospitals will not be paid until government auditors review patient records and confirm that the procedure was "appropriate". How will that determination be made? What criteria will be applied to conclude that something was appropriate. Why does this only apply to NY,Texas,Florida,Michigan ,Ohio,North Carolina,Missouri and Pennsylvania? Uniform enforcement ? Clear Rules? According to CMS, some of the states have a high number of error or fraud cases while others just have a high volume of the procedures.
Rule of law fans have had little to cheer about since Obamacare was passed. The Secretary of HHS has issued exceptions to certain provisions of the law only to certain firms.See here for more on the waivers.
Dr.Wes has commented on the CMS plan suggesting that CMS may not actually have the expertise and organizational skills to render decisions in anything approaching a timely manner or to employ a rational evidence based decision making process. See here.
The blog "Secondhand Smoke" offered a commentary on Obamacare and its assault on the rule of law.
Richard Epstein has commented on Obamacare and Rule of Law. See Here.
Ambiguity in laws and regulations coupled with discretionary implementation are the friends of politicians and bureaucrats and lobbyists and the enemies of the rest of us.
Monday, December 05, 2011
Read the entire commentary but here is a flavor:
Hayek :"the legislative body will be reduced to choosing the persons who are to have practically absolute power."
Remember IPAB? See here to refresh memory of the power that this board of presidential appointees will have.
What could possibly go wrong with the IPAB? For those who seem to believe that government officials typically act in some nebulous "public interest"- nothing. For those who cynically think that people tend to respond to incentives and act in their own interests and believe that "regulatory capture" is real-a lot.
Obamacare is the prototypical progressive legislation.The progressive mindset is what Hayek talked about with his notion of the "fatal conceit".This is the belief that government will and should make the world better by social and economic planning and not by letting people free to coordinate their private plans.
Saturday, November 12, 2011
I blogged about this general topic several years ago.See here.
The term "Heterogeneity of treatment effects" (HET) is the translation into the jargon of the statistician of the basic fact that everyone does not respond the same to a particular treatment. Can the patient in the doctor's office be assumed to have the average response to a given treatment reported in a medical journal article? In a given group treated with a certain medication some subjects will fare better than average along some parameter of interest while others respond not at all and some in either group may have adverse effects,some serious some minor.You cannot expect every patient receiving a given treatment to do well let alone better than average which only occurs in the statistically impossible world of the children highlighted by Garrison Keillor.
RL Kravitz,N Duran and J Braslow authored the classic article on the issue of HET. See here for full text of the article which should be part of every medical student's education.
Dr. Michel Accad in his Blog Alert and Oriented discusses a recent paper that offers suggestions for ways to tame the problem of HET. The suggestions are aimed as those who carry out the clinical trials . See here for Accad's discussion entitled "Dealing with variable risk" and see here for a link to the full text of the article by Kent et al that he references.
Friday, November 04, 2011
A dual premise criticism of the retainer practice model is that is damages the furtherence of social justice as it applies to health care and that physicians have a ethical obligation to act to further social justice. Social justice is a usefully elastic concept and reasonable people may differ as to what it means in a given situation . It is also a key arrow in the quiver of those who favor a progressive and re-distributional agenda. It was inserted into the area of medical ethics by the New Professionalism by a small group of energetic and prolific medical "thought leaders" whose views may or may not be representative of the group whose thoughts they were leading.Nevertheless , many professional organizations accepted the package deal giving at least lip service to the notion and in my opinion without fulling vetted the concept or thinking through the consequences.To convince many medical professional organizations that to be "professional" a physician had to work for social justice was a very significant propaganda accomplishment.
Huddle and Centor cut to the chase with this:
..we should not assume that the pursuit of social justice is an integral aspect of physician identity,despite numerous assertions to that effect.We contend that social justice is a civic virtue that makes its claims upon physician as citizens.If we are obligated to further health care access for every member of society,we have that obligation as members of society,not as physicians.Promoting nonprofessional virtues or ethical imperatives is not the province of professional ethics.
Yes and amen. The authors of the New Professionalism did simplify assert that medical professionalism should include the obligation of the physician to strive for social justice.
Three years ago I wrote about the issue of social justice and retainer practice and framing the debate.See here. Once the nose of social justice was in the ethics tent we could expect that it would be used to rhetorically justify a given agenda or criticize opposition to it.It seems that some critics of retainer medicine are proposing banning the practice as they allege it decreases access to health care and is socially unjust. Well, a little coercion and restriction of individual freedom in name of social justice is occasionally necessary.
Previously I have suggested that the new professionalism project was a way,and increasingly it seems a successful way to high jack medical ethics for a social agenda.See here.
Monday, October 24, 2011
Dr. Rich at The Covert Rationing Blog gives us his excellent analysis of the the panel's recommendations and the data they emphasized as well as the data they underplayed.Here is a quote from that commentary that explains why what the panel at the Task Force says really matters.
Obamacare, which is now the law of the land, makes the USPSTF the final arbiter of which preventive services are to be covered by private insurers (Section 2713), by Medicare (Section 4105), and by Medicaid (Section 4106). Only those that have achieved a grade of A or B by the USPSTF will be covered. And if you believe you will be able to purchase for yourself PSA screening (or any other medical service which Obamacare has decided not to cover) you have not been paying attention. Perhaps you can do so today (if you’re not on Medicare or Medicaid), but probably not for long.
So CMS (Medicare and Medicaid ) will not pay for the tests.How long will it take private insurers to follow suit?The question remains can you pay for the test yourself.It is not clear that you cannot but I share Dr.Rick's concern that prohibiting private choices paid for with private money for health care issue may become illegal.
Cato has recently published their report on economic freedom. Freedom fans will not be pleased with the falling economic freedom indicators in the U.S. noted in their report. Health care freedom is incompatible with the vision that medical progressives have for the U.S.,namely that medical care is too important to be left in the control of individual physicians and individual patients. From the perspective of the progressives, Obamacare is a great step forward and has been heralded by certain medical organizations as promoting social justice while loss of individual freedom to make one's health care choices seems to be part of the price of that "justice".
Friday, October 21, 2011
Guidelines,the worse aspects of EMRs,time pressures and the metrics by which hospitalists are too often graded are some of the factors that make it more difficult than it used to be to ask "what else could the diagnosis be".
Tuesday, October 18, 2011
See here for the economist Alex Tabarrok's commentary on this fraud that contributed to the passage of Obamacare. Now, the Secretary of HHS has admitted the plan can't work and will be dropped,but even later breaking news is that the White House hints maybe not yet.
Friday, October 14, 2011
They relate certain changes in language related to health care to the movement to industrialize and standardize health care. These changes include the word "consumer" or "customer" for "patient" and lumping doctors,nurses,PAs,and NPs together under the designation of "health care provider".
The relationship and interaction between physician and patient fades out and is minimized by referring to the generic "health care", as if is in the words of the authors " fundamentally a prepacked commodity on a shelf that is "provided" to the "consumer".
What happens to considerations about the physician-patient relationship when you speak about providers and consumers.
Thomas Szasz wrote brilliantly about the power of language.
"The struggle for definition is veritably the struggle for life itself. In the typical Western two men fight desperately for the possession of a gun that has been thrown to the ground: whoever reaches the weapon first shoots and lives; his adversary is shot and dies. In ordinary life, the struggle is not for guns but for words; whoever first defines the situation is the victor; his adversary, the victim. For example, in the family, husband and wife, mother and child do not get along; who defines whom as troublesome or mentally sick?...[the one] who first seizes the word imposes reality on the other; [the one] who defines thus dominates and lives; and [the one] who is defined is subjugated and may be killed."In short, define or be defined. There was a time not long ago when physicians in many ways defined their role.Their role was to act as a fiduciary to their patients to follow Hippocrates's game plan namely,to do no harm and act in the interest of their patient.Now their role is being redefined as in part acting as stewards of resources.Yes, it has been members of the medical profession,largely a small group of internists, who have helped considerably in this effort to redefined medical ethics and have been able to implant those views in the medical school and post graduate curriculum. While I would not impugn the motives and sincerity of those physicians who have promoted that view and value system,I cannot resist applying the venerable Mafia Rule. Follow the money.Who gains from transforming physicians into health care providers and tasking them with saving money for the health care collective?
Their commentary closes with:
"We believe doctors and nurses,and others engaged in care should eschew the use of such terms (consumer,health care provider) that demean patients and professional alike and dangerous neglect the essence of medicine."
Monday, October 10, 2011
Hubris is defined as excessive pride or self confidence.From Wikipedia we read that the word implies an overestimation of one's own competence and capabilities particularly as exhibited by someone in a position of power. In Greek tragedy it leads to nemesis, or the end result of harm or ruin. However,in the context of public health expert advice and edicts, it seems to be the beneficiaries of the edits that run into harm's way and not the expert.
Several thinkers have issued warnings to those who would take portions of the scientific wisdom of the day and go forward with hypertrophied self confidence and idealistic certitude to make the world (or their little sector of interest) better.
Boris Pasternak said; " What is laid down, ordered, factual is never enough to embrace the whole truth.Life always spills over the rip of every cup." The medical elite in the public health sector who would tell everyone how to eat, or treat all folks with a given medical condition think "Well, not my cup" and charge ahead as if the concept of unintended consequences had never been formulated and that individual variation , personal circumstances and values would not have to be contended with and progress in medical knowledge would be frozen in time so as to not make necessary changes in their determinations.
Morton Hadler ( J.O.M.,Vol 31, pg 823,1989) spoke of various categories of truth including the distinction between scientific truth and clinical truth,the latter informed in part by the former and is determined by the joint efforts of the physician and the patient.
Karl Popper said "We know a great deal but our ignorance is sobering and boundless.All things are insecure and in a state of flux."
Ian Stewart and Jack Cohen in their book "Figments of Reality" spoke of "what science offers is not facts but understanding, not answers but contingency plans"
Those type comments could be considered life advice to the newly minted practitioners of various discipline, and in particular, in this commentary to medical doctors.
The type of hubris often seen in novices is typically what I am calling the more benign form and is often cured by experience and seeing highly regarding paradigms and treatment plans replaced by others often 180 degrees from the discarded notion.This is what I call Type 1 hubris. It is an unwarranted and persistent belief in the correctness and permanence of contemporary consensus views.It is a failure to realize they are working with concepts that are often more contingency plans than permanent solutions.This type of hubris often dissipates as the practitioner gains more experience and sees the various ways disease patterns play out and how patient's disease scripts differ from the text book. Aristotle spoke of phronesis or practical wisdom which is the result of combining the lessons of experience with empirical knowledge (episteme) and technical knowledge (teche).
However, there is a second type of hubris, a more dangerous form, logically named Type 2. Type 2 includes the over blown pride and hypertrophied confidence in one's beliefs and idealistic certitude as is found Type 1 but in addition includes the internalized imperative to to bring about widespread practice (s) consistent with their version of current medical wisdom or truth. Starkly put" I'm know what should be done,everyone should do it " and when someone with Type 2 hubris is in a position of power ",let's make them do it".
The five part series of articles published in JAMA in 1994 by David Eddy is , in my opinion,a candidate for the most hubristic series ever published in a major medical journal.Reference is "Rationing Resources while Improving Quality", Eddy, DM, JAMA,1994:272,817-824)
Eddy's answer to the problem of how to save resources while improving quality was to employ the utilitarian maxim/imperative strategy to do the greatest good for the greatest number or make the herd healthier along some metric even though some cows might be worse off.The herd here was a medical collective such as a HMO.This also applies to the ACOs put into play by Obamacare to the extent those entities based as they are on an Underware Gnome type plan will survive .
Dr. Don Berwick speaks of the need for "leaders with ideas" and the need to replace the physician-patient "dyad" with a group outcome oriented decision process authored by the wise leaders with ideas. ( You have to worry when someone talks about "dyads"). Those views conform with the Progressive Medical Axiom of " medicine is too complex and too important to be be left in the hands of the individual physicians and patients."
For most physicians, the Type 1 hubris wears off or withers away after the realities of a few years of clinical experience bump up against the overly simplistic concepts of the novice. Type 2 is what we need to worry about and to fear those leaders in positions of authority (or advisers to those in power) who never caught on to the Hayekian notion of "how little men know about what they imagine they can design..." But no matter, being a public health expert or a medical planner means you have never say you are sorry.
With Obamacare and IPAB's unprecedented powers as well as CMS's control over Medicare,there are great opportunities for leaders with ideas and the requisite amount of hubris to do unprecedented damage to the practice of medicine.
Minor syntactic,spelling and punctuation change made 8/18/14.
Friday, September 30, 2011
There is evidence that in the early hours after a marathon or an Ironman type triathlon there sometimes are elevations of troponin in the range seen in myocardial infarctions.There are also reports of echocardiographic changes that could be described as cardiac "fatigue". The changes are those of altered relaxation characteristics and a decreased contractility all of which, along with the elevated troponins returned to normal in 48 hours.There is the hope that all of this is just analogous to the sore leg muscles and raised total CK values that remit in a few days and is of as little consequence but there may be more to it that that.There is at least one report of some of the more subtle echo changes persist at least for one month after a race.
One post marathon study suggested that the above mentioned abnormalities were less marked in the better conditioned runners and another paper found the alterations more likely in first time runners versus more seasoned veteran marathoners. See here for my earlier blog entry discussing some of the issues involved in assessing the harm or absence thereof in marathoners.It should be noted that not all runners show the echo changes and there is a suggestion that the type of ACE gene pattern may play a role in that.
Well,all of the above really address the issue of over use damage that certainly is at least acute and some worry may lead to long lasting permanent cardiac damage, i.e. myocardial fibrosis or an endurance exercise induced cardiomyopathy.
Now for something completely different. There is a report suggesting that many years of marathon running may increase (not a typo) the risk of coronary artery disease at least as possibly indicated by increased coronary artery calcification.This seems counter intuitive as conventional wisdom tells us that exercise may decrease the risk of coronary disease but could this be an instance of " too much of a good thing".See here for that study.
Drs Robert and Jonathan Schwartz reported on a CTA (Coronary Computed Angiogram) study that involved 25 runners who had been running in the 26.2 mile races for 25 years or more and had completed 25 or more marathons.They found a statistically significant increase in calcified coronary plaques and an increase in non-calcified plaques that did not reach the level of statistical significance as compared with 25 controls.
Thursday, September 22, 2011
Here is in in a nutshell. The government gives a 527 million dollar loan guarantee to a solar panel manufacturing company whose business plan worked out badly and the company went broke.Now the employees have applied for a government funded jobs retraining program to cost another 14 million dollars.
On the one hand we have the government tossing away half a billion dollars on a company who was not viable in the market and on the other we have the government raiding and closing down ( hopefully only temporarily) a company on the basis on vague foreign laws.See here for DrRick's take on the Gibson Guitar Company raid by the Fish and Wildlife police and how that exemplifies the principle of Regulatory Speed Trap.
And speaking of regulations,it makes one feel warm and fuzzy and very secure to know that hundreds ( thousands ?) of government technocrats are working on the details that will give ambiguous and flexible operational meaning to the hundreds of pages of Obamacare. Yes, the very same government that gave us Solargate and raids a viable US company for using the wrong kind of wood is busy at work finishing the details that will shape health care for the country.What could go wrong with that??
Monday, September 19, 2011
A central theme of the second half of the book is described by Sowell in this way: (my bolding)
Even within democratic nations,the locus of decision making has drifted way from the individual,the family and voluntary associations of various thoughts and toward government.And within government, it has moved away from elected officials subject to voter feedback,and toward more insulated governmental institutions, such as bureaucracies and the appointed judiciary.
The ACA (Obamacare) represents a major shift in the locus of decision making regarding medical care. One could consider Obamacare the poster child for that concept. Of course, the locus has already been shifted to a major decree away from the the individual physician and individual patient ( the "dyad" in Don Berwick's quirky terminology ) by the hegemony of third party payers and the virtual single-payer status of government finance health care administered through CMS (Medicare and Medicaid).
A major theme of the first half of his book is the following. One should analyze the decision making processes of institutions in terms of the incentives faced,the constraints in place and the likely outcomes and whether the decision makers are immune from or influenced by feedback mechanisms .Do not look at the "hoped for results" or the mission statements but rather at the mechanics of the decision making process.
Consider those mechanics in the context of ACA and how the myriad details which will make the lofty goals operational will be determined. Various governmental agencies and panels will deliberate and churn out the pages of rules and regulations that physicians and patients will have to live with. For the most part these rules makers will be immune from meaningful feedback but they will will not be immune to lobbying efforts by various special interest groups during the rule making process.
Consider the mechanics of the Independent Payment Advisory Board ( IPAB) and how decisions will be made by its fifteen member presidential appointed panel and how lobbyists for various special interests will target this group and likely their efforts will be proportional to the power that IPAB has been given.
Addendum: Minor stylistic changes made 9/25/14
Thursday, August 18, 2011
The dilemma he describes is the following;
"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"
Fuchs tell the readers if all the physicians in a given health care collective practice (as in HMOs and now Accountable care Organizations) 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.
I believe 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 some may be harmed.
In his closing paragraph, Fuchs tells us that when a physician works in a health care collective in which there is a fixed annual budget the physician resolves the dilemma by favoring the cost effective option. This according to Fuchs become "appropriate". ( Why does Fuchs use quotes marks?) So,the cost effective choice is the appropriate choice and also the ethical one. It is ethical in the moral calculus of Kant "because if all physicians act the same way,all patients benefit" .
The basis of Kant's ethical precepts was the categorical imperative which is:
"Act only according to that maxim whereby you can,at the same time, will that it should become a universal law."
In other words, a person acts morally when he acts as if that conduct were establishing a universal law governing others in a similar situation.
I find it interesting and puzzling that Fuchs uses a Kantian based ethical argument to support cost effectiveness based decisions in health care as cost effectiveness analysis is typically justified using a consequentialist type argument. Philosophical support for the notion of resource allocation based on the best bang for the buck is supplied by this outcome based school of ethics.
Kantian ethics, on the other hand, is duty or rule based ,an approach called deontological in the literature of ethics.Kant believed that the individual should be considered an end in himself not as a means to an end. In the medical collective the individual's interests are subjugated to the aggregated good of the group;the individual functioning as a means to achieve the greater good of the collective whether or not a particular member of the collective enjoys the benefit.
In the moral conflict between the physician's fiduciary duty to do what is right for the individual patient and the imperative to serve the best interests ( by what ever aggregate parameter that is being used) of the group as a whole, would not Kantian rule-duty based ethics support the rule of do what is best for your patient and patient is a singular noun. If Fuchs is suggesting that cost effectiveness analysis should be determinative in medical decisions and that it is justified by Kantian ethics, I suppose the "rule" would be always do what is cost effective.Never mind that pesky notion of a person being considered an end in himself and not as a means.
Monday, August 08, 2011
Dr. Ezekiel J. Emanuel blames much of the problem of the 2001 Medicare Prescription Improvement and Modernization Act.
Here is a quote from Emanuel's opinion piece in the August 6,2011 NYT Sunday Review:
The act had an unintended consequence. In the first two or three years after a cancer drug goes generic, its price can drop by as much as 90 percent as manufacturers compete for market share. But if a shortage develops, the drug’s price should be able to increase again to attract more manufacturers. Because the 2003 act effectively limits drug price increases, it prevents this from happening. The low profit margins mean that manufacturers face a hard choice: lose money producing a lifesaving drug or switch limited production capacity to a more lucrative drug.
The economist Arnold Kling is fond of saying that they teach all the important stuff in Econ 101 not saving any big secrets for more advance study.I'm fairly sure Econ 101 explains the effects of wage and price controls and that incentives matter.
Sunday, August 07, 2011
Here, George Mason Economist,Don Boudreaux, tells a satirical tale about a medical analogue to Keynesian aggregate demand.
No, the fictional gross body health is not exactly what I argue about with the guideline-P4P thrust in clinical medicine but Boudreaux's commentary is worth reading.
Monday, August 01, 2011
This link from a news story on the discovery briefly discusses her findings and the mind boggling claim that this finding will change thinking about health care spending. Yeah, it is that old
"demand curves slope downward" thing again. Note: this is not breaking news as her report and news items on it date back to 2007 but I have fallen way behind on my health wonk literature reading.
Here is a quote from the news report:
Already, Finkelstein's analysis is shaking up views across the political spectrum. "This is pathbreaking work," says Joseph R. Antos, a health economist at the conservative American Enterprise Institute. Adds the more liberal MIT economist Jonathan Gruber: "This really changes the whole landscape in the way we think about health economics."
Wow! The economist ( Gruber) who advised in regard to Romney-care and Obamacare seemingly was unaware that people tend to buy more of something when it costs less.
Wow again, path-breaking work.Apparently no one heard or remembered what Milton Friedman had said about the ways people can spend.See here for that concept in Dr.Friedman's own words.The key point here is that when you spend someone else's money on yourself , you are not very careful about how much you spend.
Dr. Finkelstein work supports the notion that health care costs have increased in no small measure because millions of older American have Medicare insurance and they realize that they can get medical services much cheaper than otherwise when they show their card to various health care providers. The fact that some health care wonks thought her findings will change the way people will think about health care policy seems to mean that until now some health care experts believed that demand curves slope upward. Some admirers of Milton Friedman are celebrating the 99th anniversary of his birth. See here. Maybe health care economists might browse through some of his work.Perhaps an econometric demonstration of the absence of a free lunch might be forthcoming.
Addendum: 11/12/14 Minor changes made re style , spelling and one factual error in regard to Dr. Accad's first name.
Thursday, July 28, 2011
The term Commanding Heights was used by Lenin in a 1922 speech in which he refers to the dominate industries in Russia at the time indicating that they would be target of the central control of the communists. He gave up trying to control everything so he decided to control the key industries.These included heavy manufacturing,mining,electric generation and transportation.
Kling and Schult contend that those industries are now largely not controlled by the state in the United States and in western countries generally and while these sectors are important they present data showing they are no longer the major growth sectors in our economy.They argue convincingly that education and health care are the growth sectors in the United States.
History has made it clear that markets work. Market economies lead to prosperity,economic growth and innovation while central planning results in dismal and often tragic failures. Lenin promised to do what capitalism did plus eliminating waste, recessions, and inequality:what was produced was mass starvation and mass murder.
However, the authors warn markets advocates against premature celebration. Their thesis is that in the U.S., both in education and medical care, the new commanding heights, governmental controls are prevalent and growing and if the U.S. is to continues to grow and prosper, we need innovation in these areas? How much innovation occurs in government controlled economic sector?
Many (most?) discussions of the medical economy emphasize the overall
cost" of medical care and its growth ( it is a growth sector) and that it is a bad thing. Two comments are appropriate: 1) often overall costs are conflated with government costs ( i.e. Medicare and Medicaid) with overall costs 2) Costs are only one side of the accounting, one person's costs are another's income stream.
Controlling the amount of money that the government spends on health care or farm subsidies or foreign wars is one thing and is well within legitimate government activity, attempting to limit private spending on healthcare or cosmetics or anything other legal activity is quite something else.So with GDP not snapping back to previous more healthy levels do we really want to decrease activity in one of the two major economic growth centers?
Wednesday, July 20, 2011
Economists are fond of saying "demand curves slope downward" which is their jargony way of saying that people buy more when the prices is lower and less when it is higher. Milton Friedman has been quoted as saying that economics is simple- just remember there is no free lunch and demand curves slope downward.
Economists ,for some obscure reason possibly found deep in the history of their discipline, place the dependent variables on the X-axis and the independent variable on the Y-axis. This is just the reverse of the practice of physicists and engineers and most other people who like to draw graphs. So they place price on the Y axis and quantity demanded on the X axis and thus the demand curves slope downward because folks buy more when the price is cheaper.
Medicare patients "buy" more health care because of the way Medicare works they get a really good deal on the price that CMS allows to be charged. It gets better, Medicare generally pay 80% of a significantly lower "allowed price" and many seniors have supplemental insurance which further amplifies the illusion of a free lunch.So,of course,Medicare users utilize more services and the reason is not that fee-for-service doesn't work. Blaming fee-for-service is the current battle cry on many in Congress and many of the organizations who allegedly represent the practicing physicians.
Some would conflate fee-for-service with free markets in medicine but there has been no free market in medical care for many years now (except for a few markets such as lasik surgery and some plastic surgery and much of alternative medicine) and the Medicare system is characterized by price controls and the demand side characterized by folks buying services with someone else's money,both of which are the products of central planning. What could possibly go wrong with that circumstance?
The list of problems in medical practice are not due to fee-for-service but rather what happens in a nominal fee-for-service setting when there are price controls namely shortages,long waiting lines,poor quality and various other forms of rationing by other than prices.As is often the case, the results of central planning are blamed on that heartless,run-away greed all the way down, free market.And as is also often the case the solution is more central planning,which is what Obama care is all about.
Thursday, July 14, 2011
Particularly interesting were comments of someone who has been there and done things in the setting of a very important and powerful governmental appointed post.
Bruce Vladecks, the former head of CMS under Bill Clinton, had this to say :
"In the short term, it might theoretically work," he said. But the history with other independent regulatory agencies, like the Interstate Commerce Commission and the Civil Aeronautics Board is that over time "the regulated industries tend to capture them; and they tend to do more to protect the regulated industries than they do to protect consumers."
Considering the legislative hurdles that Obamacare put in place for Congress to over ride the edicts of IPAB, capturing IPAB would be prize well worth capturing.
Monday, July 11, 2011
Several commentators ( including spokesmen for the ACP and the AMA ) claimed that Obamacare furthered social justice. So could that be the moral justification for Obamcare?
In regard to social justice Thomas Sowell said the following:
Their passionate arguments for particular results tend to obscure or distract attention from the question of the social processes by which these hoped-for results are to be pursued.
Goodman,in this most recent cited commentary, and in numerous others posting on his blog gives great detail of the various social process set in motion by Obamacare and the numerous apparently unintended consequences
In short, the various elements of this outlandish long bill do just about anything other than the putative hoped-for results which is "affordable , accessible health care for all" and instead offer a mind boggling array of counterproductive results and bizarre inequities and the frightening promise that many more such dystopian outcomes will arise from the hundreds ( more likely thousands) of pages yet to be written by agencies created by Obamacare and the incredible discretionary powers given to the Secretary of HHS.
Perhaps,spokesmen for the medical organizations who champion (yes, they still support it in spite of the increasing evidence that the bill is a very bad idea) can offer a moral justification .
Sunday, July 10, 2011
They are not super randomized trials as the prefix "meta" might imply but should rightly reside significantly under RCTs in the hierarchy of clinical research methods.
Since the views expressed conform nicely with my biases I was drawn to this commentary by Dr Wes.
Friday, July 08, 2011
He praises Congress for their willingness to "abstain from meddling in matters they are poorly equipped to handle." He seems to be aware of Public Choice theory (he has a PhD in Economics from Harvard) when he talks about the temptation of Congress to spend money for political ends but seems to have missed the point when he apparently assumes that the IPAB panelists would be immune to lobbying efforts.Clearly, he believes it is a good and desirable thing for Congress to delegate its powers to agencies and other bodies- a view somewhat in opposition to how James Madison thought things would work out.
This is in stark contrast with the friend of the court brief that the Pacific Legal Foundation has filed to challenge the constitutionality of the creation of IPAB. See here for their comments on IPAB and a reference link to their brief challenging IPAB.
Aarons likens the creation of IPAB to the creation of the Federal Reserve which was to be an entity not subject to congressional control.
This may not be the best analogy with the increasing efforts of Congress (and not just Ron Paul ) to at least exert some surveillance of what the Fed does.
Monday, July 04, 2011
Warren Meyer,a libertarian entrepreneur and prolific writer, who writes the blog as well as being a contributor to Forbes list three principles more important than the right to vote. Here is the first one he discusses:
"The Rule of Law. For about 99% of human history, political power has been exercised at the unchecked capricious whim of a few individuals. The great innovation of western countries like the US, and before it England and the Netherlands, has been to subjugate the power of government officials to the rule of law. Criminal justice, adjudication of disputes, contracts, etc. all operate based on a set of laws known to all in advance and applying equally to all."
Meyer then points out the obvious contempt for the rule of law with the exemptions to certain provisions of the health care law .
Sunday, July 03, 2011
See here for one of the latest revelations about how basically unfair various aspects of the bill turn out to to be. As the AP article explains two families with same income would pay significantly different health insurance premiums to the exchange based on what type of income they receive.This problem seems to be tied to the definition of income used in the statute.
But it gets even worse, more folks become eligible for Medicaid based on the law's wording.
Medicare's top number-cruncher is warning that up to 3 million middle-class people in households that get at least part of their income from Social Security could suddenly become eligible for nearly free coverage through Medicaid, the federal-state safety net program for the poor. Chief Actuary Richard Fosters says that situation "just doesn't make sense."
Here,Orszag worries that high tech advances will worsen the gap between the rich and poor in longevity. The various (endless?) parameters that can be used to illustrate the fact that the rich and the poor are different is many ways provide much source of professed worry and endless calls to action from the progressives.
His move to Goldman Sacs should do much to insure that he will be at the top of that gap so that any "solution" to this problem must involve raising up the poor and not lowering the rich although his commentary seemed to offer no practical solution to this worrisome gap .
We will never run out of gaps.Market economics is the engine of prosperity and also the engine of inequality according to Milton Friedman.
There is a body of literature and discourse which emphasizes the notion that inequality is a major problem in the western world, as least in the U.S., and the inequality per se is bad and harmful and therefore there should be continuing policy efforts to shrink the gaps. Here is a well reasoned counterargument to that notion.
Wednesday, June 22, 2011
A recent commentary by one of favorite bloggers,Dr. Robert Centor, spoke favorably about IPAB, one of many,many provisions of ACA.See here.I made a brief reply to his entry. I recalled this earlier blog entry and if Dr.Centor's comment stirs up much furor I want to add this earlier blog post to the kerfuffle.Originally published 6/22/11 and now submitted with little editing.
I had been sketching out some comments about what I was going to call "Platonic Medicine" referring to the "leaders with ideas" who will lead the way to transform medicine based on the underlying premise that "medicine is too complex and important to be left to the individual physician and the individual patient" and therefore it should be controlled and directed by the wise medical elite who will determine the collective utility of a given approach and its value.I have commented before about Don Berwick's advocacy of that view.
However, someone had written something in that regard better than I could.See here.
Hat tip to the Pacific Legal Foundation who filed a friend-of-the-court brief to challenge the constitutionality of IPAB on the grounds of violation of the non-delegation doctrine and for the above mentioned link which alerted me to Jost's frightening comments.
It turns out that an outspoken advocate and supporter of Obamacare,law professor, Timothy Jost has already praised that legislative act in part because of what the IPAB will provide. He said:
A board of “Platonic Guardians” to govern the health care system or some aspects of it. The cost of health care is spinning dangerously out of control…. [O]ur traditional political institutions—Congress and the executive administrative agencies—are too driven by special interest politics and too limited in their expertise and vision to control costs. Enter the Platonic guardians…an impartial, independent board of experts who could make evidence-based policy determinations based purely on the basis of effectiveness and perhaps efficiency.
Incredibly Jost is asserting that this board will be immune to the influence of special interests and will make decisions rationally and in a proper evidence based manner.From what planet will these board member be chosen? Philosopher kings in charge,what could go wrong with that?
The PLF commentary pointed out that a Platonic government was definitely not what the founding fathers had in mind and Jefferson and associates were not big fans of Plato.
In the commentary that I was considering I thought perhaps calling the panel members Platonic Guardians would earn me the accusation of being overly dramatic and hyperbolic, but now we see an IPAB advocate using the same characterization and believing that to be a very good thing.
Dictating the coverage to control the cost for Medicare and Medicaid may not be enough for the medical Platonic elite as is illustrated by this quote from Dr. Robert Berenson:
"we ought to consider setting all payer-rates for providers." He continues "but the country's antigovernment mood renders such a discussion unlikely,at least for now".
I wonder who the "we" is that Berenson references.
Finally, another chilling quote from Mr. Jost:
"In the long run, Congress may not be able to cap Medicare expenditures without addressing private expenditures as well. If the IPAB opens the door to rate setting for all payers,it may well be the most revolutionary innovation of the ACA".
Yeah, it just might be.
Tuesday, June 21, 2011
Go here to read a detailed analysis by John Goodman of what factors are at work in the ongoing shortage of over 200 hundred medications. It turns out that at least a contributing factor to the shortage is price controls which are part of a 1992 Federal 340B drug rebate program to certain medical facilities.
Another, perhaps more important governmental factor is at work in the form of the the output controls put in place by the FDA which limits the production of product by drug companies and diminishes their ability to quickly react to market conditions with increased production.
No, price controls are not the entire explanation but government price controls and other regulatory actions impeding market process are playing a role. The situation is more complicated that the two factors mentioned above and some of the other contributing factors are discussed here. But,as the various shortages play out, I'll be it won't be long until we hear that the free market has failed again and more governmental controls are necessary to protect the public.
Friday, June 17, 2011
This study from the Women's Health Study generated some robust, relative risk numbers.I am not talking about the puny 1.2-1.4 relative risks (RRs) we often see in the typical data dredging articles and certainty not the ridiculous RR of 1.01 (not a typo) that was the alleged increased risk of death from vitamin E use.See here for that silliness.
Here are the age adjusted incidence numbers for symptomatic PAD
0.12 never smoked
0.34 former smoker
0.45 smoked less than 15 cigarettes per day
1.63 smoked greater than 15 cigarettes per day
You are not likely to see RRs greater 10 from the typical data dredge and the WHS data also demonstrated a dose-response effect.
So, how large should a RR be before one worries about it or seriously believes we may have a causal relationship?
Sackett ,of McMaster EBM fame, asked one of the giants of epidemiology that question. Sir Richard Doll said that if the RR were 20 or greater that would be almost sufficient to indicate causality.Sackett was not quite that cautious and indicated that a RR of greater than 3 was "convincing".
Some courts use a RR greater than 2 to reach the threshold of "more likely than not".This is the current level of proof in most tort cases.
Michale Thun, who at the time was vice-president of epidemiology and Surveillance at the American Cancer Society, said:
With epidemiology you can tell a little thing from a big thing.What's very hard to do it to tell a little thing from nothing at all.
With cigarettes and PAD, we have big thing and we will not likely see battling statisticians debating the data. However, we did see that when Nissen's NEJM article claimed a RR of 1.43 for of Avandia and heart disease and we will likely get to see another again with the current breaking news of a RR around 1.4 with Actos and bladder cancer.
Tuesday, June 14, 2011
Now what could possibly be wrong with that?
James Madison had some thoughts about that.He was concerned about what he referred to as "factions' which today would be thought of as special interest groups.Special interest groups have developed a potent skill set to influence government bodies to focus benefits on themselves while the cost are diffused.
In general, the founding fathers of the country has some thoughts about what could be wrong with that sort of entity.They tried to design a government not so that wise leaders could do great good but rather one that would limit the damage done by fools,thugs and would be despots who might(most assuredly would) find their way to influential posts in government.
Their wisdom seemed brushed aside as the view of a benevolent and wise government assumed the default position as it was persistently promoted by a cadre of progressive minded academia intellectuals and high school civics texts which visualized a government that would wisely recognize problems,devise safe and effective solutions and then without special favors execute remedial plans marvelously bereft of significant unintended consequences.
Fortunately, James Buchanan and Gordon Tullock resurrected Madisonian wisdom, enlarged upon it and explicated the theory of public choice which basically asserts that government officials and bureaucrats display the same characteristics as other humans, namely a proclivity to look after their own self interest. They definitely had some thoughts about what could possibly go wrong with something like IPAB.
The economist, George Stigler,who did much to develop the concept of regulatory capture might have some to say about what could go wrong with the IPAB.Governmental agencies and organizations can be subject to the influence of the very groups that they are nominally created to regulate and control .
Mafia dons and wise guys alike know the explanatory value of the "follow the money" and could explain simply what could go wrong with the IPAB.
Big Pharma had supported the passage of ACA but it is hard to believe that their support would have been forthcoming had they realized what IPAB would be.They certainly recognize the danger now.
The American College of Physicians (ACP) also supported Obamacare but now express opposition to the IPAB section "as written".Although (unfortunately in my view) they do not recommend repeal of IPAB but instead want certain changes that would make the entity acceptable.See here for ACP's position which objects to the exemption of hospitals and hospices from IPAB's edicts until 2019,the absence of primary care physicians on the panel,the lack of a mechanisms for significant congressional oversight and for preserving quality while decreasing costs.
So, much can go very,very wrong with IPAB but it gets even worse. Go here to read a recent commentary by George Will which discusses the chilling thought that the IPAB may not be stoppable. It may well be " entrenched".
Entrenchment refers to one legislative body passing a law that contains provisions that prohibit later legislatures from repealing the law.
Can a legislative body really pass a law that contains a wording to prohibit further changes in that law?Is the IMAB really an immutable entity?
Eric Posner discusses it here and, as best I can translate it from the legal dialect academic lawyers speak into everyday English is that the Supreme Court has decided that they cannot allow that but as with anything that might be litigated there are at least as many sides to the issue as there are interests who can loose or gain from a decision and Supreme Courts sometimes change its mind.
It is hard to find a better summation that the one penned by Mr. Will in his above cited recent column:
"The essence of progressivism, and of the administrative state that is progressivism’s project, is this doctrine: Modern society is too complex for popular sovereignty, so government of, by and for supposedly disinterested experts must not perish from the earth. "
And the corollary for progressive medicine is that "medical care is too important and complex to be left to the individual physician and the individual patient."
minor editorial changes and typo correction changes made 8/17/14.
more corrections made 11/29/14
Sunday, June 12, 2011
Professor Greg Mankiw has written with alarm about what a progressive think tank has proposed regarding the IPAB. See here for his commentary but I believe there is more to worry about than a proposal in regard to the IPAB. Mankiw references a proposal by the Liberal Center for American Progress to allow the IPAB to control the expenditures of private health insurance plans not just those expenditures regarding Medicare and Medicaid.
From what I understand the IPAB already has been given that power by Obamacare.
Dr.Richard Fogoros writing in his blog The Covert Rationing Blog explains how the IPAB was created and what it is authorized to do beginning in 2014. His reading of the statute indicates that this presidential appointed panel already has the legislative authority to limit expenditures by private health insurance companies. His analysis also describes how difficult it will be for Congress to over ride the panel's edicts. See here for his comments.
Thursday, June 02, 2011
Dr. Cooper sums it up this way:
"Medicare beneficiaries who received more medical care had better outcomes, even when they are sicker. MORE was MORE."
Isn't this what common sense would suggest?
Tuesday, May 31, 2011
Public health experts enjoy a decision making advantage over the medical doctor who has to often take aggregate data-such as randomized clinical trials but often less reliable data) and then attempt to apply that to the individual patients sitting in his office.All the public health expert has to do is to look at the aggregate data and base recommendations on that while the practicing physician realizes that lying under the summary statistics are individual patients some of whom may will benefit from the proposed treatment while others are unaffected and still others are harmed. Life in the dealing with real patient trenches is more complicated ,nuanced and reality based than in the offices of the academic public health experts who can base their conclusions and recommendation on the utilitarian imperative .
DrRich talks about public health experts " displaying every ounce of the overblown self-confidence traditionally enjoyed by the expert class operating within our Progressive
The public health experts share the following view with " leaders with ideas " who vie for the position of architect in the redoing of American health care :
The basic tenet of what I call the medical progressive is that:
health care is too important (and too complicated) to be left to the individual physician and her patient.
"..to demonstrate to men how little they really know about what they imagine they can design.
This F.A.Hayek's quote was directed to the central planners who believed they could control an economy from a governmental perch and did not need the knowledge derived from competition of a price driven market.The problem of knowing what and how much everyone should and should not eat is of a different sort but Hayek's words can function as a much needed counterpoint to their hubris .
Wednesday, May 25, 2011
It is amazing how often sound bites from that study are quoted not only by the main stream media but also recited as gospel by medical researchers often in the boiler plate introductions to what otherwise would legitimately pass for a scientific publication.
How many times have we been told that something must be done about the U.S. health care system because although the U.S. spends 16 % of its GDP on health care it ranks 37th (out 191 countries) in something the WHO staffers called "overall performance".
Dr. Atlas said the the WHO publication " ranked countries according to their alignment with a specific political and economic ideal-socialized medicine-and then claimed it was an objective measure of "quality" ".
Quality,which is always a usefully ambiguous concept, was in the view of the report's authors the degree to which a country had distributed wealth and centralized administration of health care.
Atlas explains that 62.5 % of the overall performance index created by the report to rank countries was an assessment of one particular concept of equality and not about health care outcomes at all.
Quoting Dr. Atlas :
In fact, World Health Report 2000 was an intellectual fraud of historic consequence—a profoundly deceptive document that is only marginally a measure of health-care performance at all.
Read Dr. Atlas's commentary for more details of the methods used by the WHO staffers to achieve this propaganda masterpiece. I expect politicians and policy wonks with a particular agenda to quote the WHO's factoids but it is embarrassing to see medical researchers use the bogus material from the report as fillers and appropriately politically correct genuflexions to the notion of social justice in their publications.
Sunday, May 22, 2011
The case he discusses and the subsequent decision of the Supreme Court can fairly be described as mind-boggling , the dictionary definition of which is "intellectually or emotionally overwhelming".
In regard to the case,Bennis versus Michigan,Boudreaux and his co-author, A.C. Pritchard, said in part the following:
[the Supreme Court's decision] allows government to impose huge costs on people never charged with criminal wrongdoing"
Those of us who,probably against all reason,still think that the Supreme Court will overturn Obamacare find little hope that the supremes will do the right thing after one reads their decision in this case.
A slightly positive note is this was a five to four decision by the court and one of the dissents was penned by Justice Kennedy who is generally thought to be the possible swing vote when the health care bill gets to the court. Maybe he will do the right thing again.
Monday, May 16, 2011
Some Democratic Senators and several spokesmen for medical organizations risked shoulder injury so exuberant were their efforts at self congratulation when the bill was signed into law.To be able to discern what the results would be in a bill so long, dense and ambiguous regarding details would require analytic ability not yet achieved by any creature who evolved on this earth.In fact, the details of the bill had not yet been written as the particulars were in numerous instances delegated to government entities for rule making some of which were yet to be formed.
Down the road there will be a situation in which this justice will be quite visible.That will play out in the emergency rooms across the country. The rich and the poor alike, those with insurance cards and those without will wait together as increasingly overworked and overstressed ER docs ( and their physician extenders) try and cope with the infusion of 30 plus million more insurance card holders into the health care system. Everyone waiting together to be screened by the NP or PA or as things evoke a NP assistant will give a lovely portrait of the wisdom of the central plan for [almost] everyone having nominal access to medical care but operationally finding little of it.
Social justice typically means redistribution and accordingly to CMS czar Dr. Donald Berwick good medicine must mean redistribution . Easier access to health care will be redistributed and diluted so that everyone gets to wait and wait and everyone's quality of care goes south.
For those of us who hope that having a retainer doc will help, and I think it will, here is a sobering thought and something else to worry about. With more vertical integration of medical care and the latest acclaimed saviors of medicine (the ACOs) becoming prevalent and perhaps dominant, will independent retainer docs even be allowed to admit and treat patients in a hospital or will her patients also end up in the increasingly long lines in the ERAs and the retainer physician unable do anything about it.Is there really anyway to escape from the clutches of Obamacare? Will it all be up to Justice Kennedy? Will it even be possible (i.e. legal) for someone to purchase health care outside of the centrally planned system? If you have not worried about that issue before I suggest you visit this and other commentaries by DrRich.
Here is a commentary from NPR on what ER docs think will happen when millions ( about 34 million) of new folks get an insurance card to show the clerk in the ER. Let us see-increased demand and no significant increase in supply combined with the already in place price controls in Medicare just might mean shortages , long lines, and decreased quality of care.You think.
Thursday, April 28, 2011
Not only are we treated to looking behind the curtains but there is an organized effort to opt out of the RUC influence. See here for information about the "Replace the RUC" effort.
Dr Poses raises several of the unanswered questions regarding the RUC. The one that interested me for some time is this. Why was there and is there so little outcry about the central governmental management of physician's fees, i.e. price controls.? (If there is anything Keynesians and non-Keynesians agree on it is that price controls lead to shortages and decreased quality) Could part of it be that the AMA whose brainchild we are talking about kept the whole process obscure and largely behind the scenes?
Tuesday, April 26, 2011
Friday, April 22, 2011
A few context setting comments are in order. First, it is well established that statins are clearly beneficial in secondary prevention of coronary disease. In patients with proven coronary artery disease few would disagree with statin use.Its efficacy and safety have been demonstrated in several of the well known so-called landmark statin trials.
Second, the argument is strong for the conclusion that statin use in primary prevention results in a decrease in cardiovascular (CV) deaths. The authors of the Archives article make their position clear in that regard when they say in their comments sections "the benefits of statins in CV deaths are unequivocal based on primary prevention data from the CTT meta-analysis." The Cholesterol Treatment Trialist Collaboration or CTT was published in Lancet in 2005 ( see here ) .
So, the issue that Ray and his fellow authors addressed was not do statins reduce CV mortality in primary prevention but do statins reduce all cause mortality and their data analysis lead to the conclusion it does not.
Ray analyzed data from 11 randomized clinical trials of patients with what they considered to be high risk for coronary artery disease ( 244,000 patient years). Big numbers for patient years tends to give credence to findings but the key thing here is that in these trials the follow-up period was only 4-5 years as is typical of clinical trials. In patients with increased CV risk -as opposed to patients with proven CAD-the ratio of CV deaths to total deaths is relatively low particularly in a 4-5 year time frame. So that it is not surprising that all cause mortality may not be decreased, which is what Ray demonstrated.
Both the editorialist in the Archives and a subsequent commentator in a Update section in the April 5, 2011
Annals of Internal Medicine seem to conflate failure to show decrease in all cause mortality in a short observation period with overall lack of benefit. Ray and co-authors do not deny benefits in terms of decrease in C-V mortality.
Thursday, April 21, 2011
See more about the Medicare Advantage ploy from Black Ribbon Project blog here. Also I commented on this egregious political play before.
Another alleged cost saving proposal included in Obamacare was the Community Living Assistance and Support Act (CLASS).
Early on, opponents of the health care bill insisted that its provisions were not fiscally sound and were placed in the bill to give the illusion that Obamacare would cost less than the magic one trillion dollar price tag. The plan was to front load the plan with premiums without any benefit payments for a number of years. It was advertised as a mechanism to decrease the federal deficit by 86 billion over a ten year period. Now even with the deck as rigged as it was it will not work . The Secretary of HHS has admitted that.
More and more elements of the Obamacare monster bill seem to be either unraveling completely or postponed until after the 2012 election.
Monday, April 18, 2011
For a while those who read or skimmed medical literature were treated to an array of articles that claimed numerous effects of the statins that were not just further evidence of the pleotrophic effects of statins but were really just short of miraculous. I wrote about some of those claims here. Most of those claims did not pan out. Another claim,that of the statins causing an epidemic of heart failure made by Dr. Peter Langsjoen ( see here),does not appear verified by the BMJ article.
Tuesday, April 05, 2011
It seemed to take a long time for someone to challenge this rule but someone finally did and the federal judge presiding over the case has now rejected the case with an appeal pending. Here is a link to the decision by the US District Court Judge Rosemary M. Collyer.
Her convoluted and self-contradictory reasoning (see here) concluded that this entitlement ( to Part A) is mandatory .To some the notion of a "mandatory entitlement" may seem Orwellian but at least the judge did offer some interesting comments in her written opinion that suggests lawyers even when they become judges might retain a sense of irony.
For example Judge Collyer said in her conclusion:
Plaintiffs are trapped in a government program intended for their benefit. They disagree and wish to escape. The Court can find no loophole...
In her introduction she stated:
Medicare costs are skyrocketing and may bankrupt us all; nonetheless, participation in Medicare Part A (for hospital insurance) is statutorily mandated for retirees who are 65 years old or older and are receiving Social Security Retirement (so-called ‘old age’) benefits. Whether Congress intended this result in 1965 or whether it is good fiscal and public policy in 2011 cannot gainsay the language of the statute and the regulations
It seems to me she might have well said, the program is ridiculous but that is the law -get over it.
DrRich takes up this case (see here) in his blog and considers this case in the broader context of his lingering (or growing) concern about the possibility that down the road seniors and others may face a health care system which prohibits the patient from purchasing any health care not approved by the central authorities. See here for his earlier commentaries on the efforts to limit individual prerogatives in obtaining medical care. I share his concern.