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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 ...

Tuesday, January 24, 2012

More of the weird social justice that Obamacare has given us

See this article from Cato. By reclassifying the status of one hospital in Massachusetts, a number of hospitals in that state by some bizarre bureaucratic mechanism receive more Medicare payment from the Federal Government while that amount is made up for by cuts to the rest of hospitals in the country.This is a big blob of social justice right in your face.

Redistribution of funds based on arbitrary government bureaucratic decisions seems to be a recurrent feature of Obamacare,one poster child for which was the early on exceptions of certain companies from some of the provisions of the law. "The secretary shall determine" theme plays over and over.

The core of laws such a Obama care is that the devilish details are placed in the hands of executive branch entities who can then dish out favors as they see fit and the factions (Madison's quaint term for special interest groups) that can gain or loose from those decisions busy themselves with efforts to bring about some decree of regulatory capture or just simple payoffs.

The crap of "crony capitalism" get wrongfully blamed on capitalism while in reality the rent seeking ( the quaint term economists use for privilege seeking ) is a phenomenon that has become gargantuan because of the progressive mindset's endless quest to give more and more power to the government and to focus that power and control into ever increasing aspects of people's lives. No, I have not forgotten big government conservative's hypocritical initiatives to do about the same,albeit with a different rhetorical cover. More power to the government and thereby more efforts to harness that power for one's focused individual interest paid for by everyone else. But isn't Obamacare furthering social justice?

Sunday, January 22, 2012

CBO give results (largely negative) on several buzz word medicare demonstration projects

Buzz words abound in the wonky sector of health care, a domain in which many commentators comment more than they actually do health care.

Here is a CMO report on 10 demonstrations projects which sought to test the operational results
of several buzz word projects.

Dr. Robert Centor gives a brief summary of some of the finding on his blog.See here.

In the Disease Management programs,the costs seemed to exceed the benefits.In three out of four "Value based payment" program there was little or no savings.This is similar to comments I made almost 5 years ago regarding a radomized trial that show no value for a particular disease management program.

Dr Centor said:

Boys and girls, this stuff is much more complex than these demonstration projects can address. Physicians really do their best out there.

You bet it is more complex.

"The curious task of economics is to demonstrate to men how little they really know about what they imagine they can design." FA Hayek.The Fatal Conceit.

Russ Roberts writing in his blog, Cafe Hayek said in regard to some or other government program

"So many things the government does are attempts to circumvent the bad things caused by something else they already do."

It seems to be there are a lot of buzz word filled initiatives that are, at least in part, efforts to try and undo the mess made by CMS price controls on physicians fees and the primary care destroying RBRVS .

Tuesday, January 17, 2012

Is the American College of Physician's new Ethical Manual an ethical game changer

Dr. Michael Kirsch, author of the blog, MD Whistleblower, thinks so; see here for his view.

Here is a money quote from his commentary: He begins with a quotation from the ACP Ethics Manual;

Physicians have a responsibility to practice effective and efficient health care and to use health care resources responsibly.

This is an ethical game changer. According to the updated ethics manual, physicians should consider preserving health care resources for the population at large, which may conflict with our patient’s interest. Now, we are told that we are ethically obligated not only to advocate for our own patient, but also for hundreds of millions of other patients. If this becomes standard operating procedure, how will it impact the doctor-patient relationship? Will patients, who are increasingly skeptical of the medical profession, trust us? Will they suspect that we are restraining their care to serve the greater good?

The camel's nose (along with other anatomical parts) that sneaked under the medical ethical framework tent was the publication of a physician's" Charter" (aka New Professionalism) which in a gigantic non sequitur gratuitously asserted that social justice was now a major element in what they said what was medical professionalism, stopping just short of explicitly saying it was part of ethics.However, it was not clear what the separation between professionalism and ethics really was. Now the ACP makes that final move equating social justice with preserving health care resources for everyone and somehow balancing that against the individual patient's interest as an ethical responsibility. Has the concept of fiduciary duty to the patient really been shoved down the memory hole?

This is an ethical game changer but sometimes the ACP spokespeople seem to write and speak about both the charter and the ethics manual as if nothing has really changed. For example, I offer the following quote from recent comments from the president of the ACP, Dr. Virginia L. Hood in her message printed in the ACP Internist of January 2012.

She refers to the 2002 publication of a "physician charter to confront the health care challenges of a new millennium ". She continues " As well as restating (my bolding) the principles of 'primacy of patient welfare,patient autonomy, and social justice' ,it outlined a set of professional responsibilities..."

The charter did not restate social justice;it gratuitously inserted it and certainly never explained how striving for social justice enabled physicians to confront the new challenges. Now Dr. Hood writes about it as if social justice had always been a key element of medical ethics. It may be a useful rhetorical tool to just assume away a controversial issue but it should be clear that social justice based on a utilitarian calculus to allocate health care " resources" was when the charter was published and continues to be a source of considerable controversy in the medical community.

In a 1988 Annals of Internal Medicine Article,Hall and Berenson made- what appeared to many of us who were raised medically with the "old" medical professionalism of fiduciary duty to the patients- a startling proposal:

"We propose that devotion to the best interest of each individual be replaced with an ethic of the best interest of the group for which the physician is personally responsible."

Dr. Edmund Pelligrino writing in 1995 asked in the ethics of a profession could be changed at will.

Judging on the basis of the New Professionalism and the statements in the recent ACP Ethics Manual, it seems like it has.

DrRich of the blog "The Covert Rationing blog also believes it is a game changer.Further he offers his view as to what the real import of the new ethics is in this passage:

And here is the real import of the updated Ethics Manual. It aims to assuage the guilty conscience of physicians who follow handed-down guidelines to the letter, even against their better medical judgment, instead of tailoring the application of those guidelines to the benefit of their individual patients'

Exactly. It is an 180 degree switch from the antiquated ,fuddy duddy "fiduciary duty" silliness of a by gone era.

The ethical physician of today (again quoting DrRich) is "to follow the best evidence , in particular the best evidence on cost-effectiveness" and

" it is now the ethical obligation for doctors to follow expert produced guidelines" ( see here for DrRich's full commentary).

It is of some interest (or irony) that the introductory section of the 6th edition of the American College of Physicians Ethics Manual was written by an attorney, Lois Synder and there was no mention of a physician's fiduciary duty to his patient .

I do have trouble reconciling the words of the manual-particularly those quoted above-with these comments regarding the new manual from Dr. Hood as quoted in the 1/11/2012 Modern Medicine, on line:

“We have to consider cost as one of the factors when we make medical decisions, because that’s in the best interest of our patients,” Virginia Hood, MBBS, MPH, FACP, an internist and nephrologist and president of the ACP, tells eConsult. “It shouldn’t ever be an overriding part of a decision, but physicians need to take it into consideration.”

She continues:We have been advocating for efficient care since 1984, but it’s been given a slightly greater emphasis because the costs of care are so much higher,”,

So what is it- a slightly greater emphasis on cost or a real ethical game changer in which the fiduciary duty of the physician to the patient is not mentioned. Dr Hood's words quoted above seem reassuring but the black letter words as written in the ethics manual seem to pit the needs of the individual against the nebulous and ambiguously defined common good. In "box no.4 which addresses "Patients First and stewardship of resources" it says in part there is a responsibility to provide "parsimonious care that utilizes the most efficient means" [for diagnosis and treatment] . That sounds to me to be more than a slightly greater emphasis.

Also seemingly contrary to the representation that the new ethics manual really does not represent a major shift are several comments found in the editorial by Dr. Ezekiel Emanuel.(3 January 2012,Annals Internal Medicine,volume 156.number 1.pg 56)

Emanuel says :"Here is a professional society unafraid of advocating the principle of cost-effectiveness." Here aren't we talking about stuff like amount of dollars per life year saved?

He continues :These positions on efficiency, parsimony and cost effectiveness constitute an important shift,if not in ethics , then in emphasis." and

"It goes well beyond the usual banalities to take brave stand on current issues".

Monday, January 16, 2012

Price controls have worked so well in medical care, let's do some more

Doing some more is exactly what the Administration is doing here with its case by case decision regarding how medical insurers do their business. Of course, this level of central plannng on a mico level is part of the disaster unfolding as we see Obamacare play out. See here for the newspaper account of the Secretary of HHS ordering an insurance company to rescind its rate increase.

Arnold Kling,a MIT trained economist,is fond of saying that economists do not hold back the good stuff when they teach economics. Rather they reveal the important stuff in econ 101. In econ 101 the effects of price controls are clearly spelled out.Price controls in the form of price ceiling create several things:
2.reduction in quality of goods or services provided
3.Search costs including wasteful lines
4.loss gains from trade
5.allocations of economic resources.

Here is what George Mason University economist, Don Boudreaux, has to say about the HHS actions in his typical trenchant style.

As millions of more people will have insurance cards,and think they now have access to medical care, consider how much worse the shortage of primary care ( think Medicare price controls) will be and how much longer and more wasteful and frustrating the lines in emergency rooms will be.

Addendum: See here for the blog entry by John Goodman entitled "How Doctors are Trapped" for a detailed discussion of some of the particular ways that the CMS physician fee price controls are destructive and demoralizing to physicians and patients .

Friday, January 13, 2012

Fans of crony capitalism should love Obamacare

Writing in Forbes, Warren Meyers offered this eye catching title, " Crony Capitalism?Blame the Progressives."

Here is how it works as explained by Meyers in his posting in Forbes. See here for article.

Capitalism is simply the free exchange of individuals based on their self interest. There is no room for government subsides,bailouts or any of the other myriad forms of government interventions into the economy that favors one entity or groups over others. Whenever government has the power to dole out favors folks will seek those favors. They will seek out those privileges. The bigger the goverment, the more power to dole out favors, the more favor seeking and the more the targeted few benefit at the expense of the rest.

This privilege seeking activity in the jargon of the economist is called "rent seeking". Progressives as a group favor more goverment power to do all those things that they think wise leaders and technocrats can do much better than the people could do for themselves.Of course, Progressives share the blame with other big government politicians whether they be called big government conservatives or moderates or whatever.

Enter Obamacare as the poster child for what George Will has called the tendency of congress to pass intentions rather than statutes. What we get is legislation that outline an aspiration or a dream or a nice thought and then hands over the details which actually define the actions to various governmental appointees and agencies,who then become the target for possible regulatory capture or at the least effective lobbying efforts the results of which can be described as crony capitalism.

Here is an excellent essay on the nature of crony capitalism versus "Market capitalism" and how Obamacare is a poster child for the former.How does the furtherance of crony capitalism mesh with the alleged social justice that Obamacare was said to represent?

Thursday, January 12, 2012

American Psychiatric Association "Slapps" down web site critical of DSM5

Dr. Bernard Carroll,former head of psychiatry at Duke,writing on the blog Health Care Renewal ,writes about an interesting conflict between the APA and a former editor of DSM. See here.

Dr. Allen Francis who edited DSM4 has been highly critical of the DSM process and particularly of the yet to be released DSM5.He expresses concern that psychiatry is being practiced less by psychiatrists and more by primary care physicians, who are busy and often not very well trained in managing psychiatric problems and at times strongly influenced by marketing .

His criticism includes the charge that with the publication of DSM5, not yet released, there will be more patients diagnosed with DMS defined mental conditions as new diagnoses are being added and the criteria for others have been broadened. His comments regarding his view of the problems with DSM were appearing on at least one web site.

Now the APA,who owns DSM and profits from its publication and use, has sent out a cease and desist threat to the website previously known as "dsm5watch" Their argument was that the website to which he contributed a contained the letters DSM and that was a copyright infringement. The new name for the website is "dxrevisionwatch.wordpress.com"

The explanation for the strange spelling of "slap" in this post's headline is that the APA actions might be described by some as a "Strategic Lawsuit Against Public Participation". In this case only a threat.

See here for more comments by Dr. Francis and here for a reply by the APA to some of the criticism it has received lately.

Friday, January 06, 2012

More on the New Professionalism (medical) and what it is really about

The New Medical Professionalism has been a topic of concern to me for some time and I have tried to express my objections to what it represents on more than one occasion. See here.

But what I believe to be the definitive critique and explanation of what that document is all about has been published on the blog The Covert Rationing Blog by DrRich. See here.

Everyone should read it and share it with a colleague .Here is one quote:

To summarize, by the turn of the millennium doctors were being coerced to withhold healthcare from their patients at the bedside, and thus to violate their time-honored primary professional directive. The intent of the 2002 Charter on medical professionalism was to repair the problem (i.e., to cure the “frustration”), not by confronting the forces of evil doing the coercion, but rather, by simply changing medical ethics to make bedside rationing OK. And that’s just what the document did, though only after careful re-editing to make this radical change to medical ethics sound as benign as possible.

By explicitly endorsing the 2002 Charter on medical professionalism, the Sixth Edition of the ACP Ethics Manual thereby endorses healthcare rationing at the bedside – but it does so quietly, at arm’s length, so as not to stir up unwanted passions.

DrRich's topic for this essay is actually the New Ethics Manuel authored by the ACP and comments on the New Professionalism are offered in that context. Read his blog to learn about what Dr. Ezekiel Emanuel found particularly praise worthy regarding the new ethics.

Thursday, January 05, 2012

Bryan Caplan tears apart Jonathan Gruber's graphic novel on health care reform

Jonathan Gruber is a major player in the health care wonk games and has recently written a graphic novel ( aka comic book) on health care" reform", an area in which he has written and worked extensively. See here for GMU economist Bryan Caplan's detailed shredding of that work.

I have blogged before on the paper by a MIT economist see here which "startled" the health care wonk world with the data driven observation that when folks have access to a government financed health care programs ( ie. Medicare) the demand for health care services increases about that which occurred when folks paid for those services with their own money.

On that issue Caplan says the following:

Gruber explains the basic facts about health care costs: they're rising, and government picks up much of the tab. But he almost totally neglects the connection between the two. Medicare and Medicaid vastly increase demand for health care. There's no denying it. Imagine how much more affordable health care would be if these programs had never been adopted - or if they were abolished.

Let's see if I get it.People tend to spend other people's money with less prudence that when spending their own. I think Milton Freeman might have made that point.

Tuesday, January 03, 2012

In the Accountable Care Organizations (ACOs) to whom is the physician accountable?

Hint: It is not the patient, at least not in the structure or intent of the ACOs. See here for Paul Hsieh 's discussion of this issue.

Dr.Hsieh succinctly nails it here:

... under ObamaCare, your doctor will be increasingly pressured into sacrificing your individual medical interests for a nebulous “social justice.”


He references some key quotes from physicians and physician organizations who favor and have been lobbying for the substitution of the pursuit of an elastic and nebulous collective good for the long standing fiduciary duty of the physician to the patients.

A now-famous article in the 1998 Annals of Internal Medicine recommended that “devotion to the best medical interests of each individual patient be replaced with an ethic of devotion to the best medical interests of the group...” The American College of Physicians ethics charter now states that physicians should balance traditional principles of patient welfare and patient autonomy with “social justice” to achieve “a just distribution of finite resources.” A 2011 New England Journal of Medicine article urged abandoning “the primacy of patient welfare” in favor of “collectively caring for a defined population within a fixed annual budget.”

Read the entire piece. It is excellent. Dr.Hsieh has been working tirelessly to support the concept of freedom and individual rights particularly in regard to the individual rights of doctors and the practice of medicine. Read more from him here.