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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 ...

Wednesday, December 26, 2012

More and more physicians work for corporations-what could possibly go wrong?

Dr Roy Poses tells us that plenty can go wrong and has already and will only get worse. See here for his latest commentary  of things going wrong when physicians' salaries are dependent on hospitals and other corporations for their livelihood who in turn exists to maximize profits and "quality care" is just a marketing phrase.

This detailed article from the NYT provides more chilling documentation of what can happen and,is happening, as corporate entities practice medicine and physicians become more and more under the control of the corporations' suits.

When there is a conflict between the corporation's bottom line and the individual patient's well being one could only hope that the physician's ethical compass would point in the direction of the patient benefit.However, with the new medical ethics , one could argue that the good of the collective ( the HMO or ACO or hospital  or whatever) may well trump the welfare of the individual .

 That was not the case with the "old ethic" in which the good of the collective was not mentioned and the physician was considered the fiduciary of the patient.Try and find the word fiduciary in the New Professionalism or in the latest edition of the ethics manual of the American College of Physicians.

When the physician and the corporation have the same interest  (corporate bottom line) and the former act in the interests of the latter the published desire of Berwick and Brennan to do away with the [physician - patient ] dyad as a decision making unit will be fulfilled. See here for my earlier comments on the following quote from Berwick's Book entitled New Rules.

"Today, this isolated relationship[ he is speaking of the physician patient relationship] is no longer tenable or possible… Traditional medical ethics, based on the doctor-patient dyad must be reformulated to fit the new mold of the delivery of health care...Regulation must evolve. Regulating for improved medical care involves designing appropriate rules with authority...Health care is being rationalized through critical pathways and guidelines. The
primary function of regulation in health care, especially as it affects the quality of medical care, is to constrain decentralized individualized decision making.

In the 17 years since the publication of New Rules,considerable progress has been made in their desired reformulation of ethics and how medicine is practiced and one can surmise that the authors are appropriately gratified. Those of us who hoped that in our hour of medical need we would be attended by physicians who acted in their fiduciary duty to us and not in accordance with a reformulated ethical framework are a bit less sanguine.

Friday, December 21, 2012

More revolving door antics with Obamacare

I have commented before about the happy feet of Elizabeth Fowler and her travels in and out of government and in and out of the industries materially affected by the branch of government in which she "served".See here for earlier commentary.

Now a similar tale can be told in regard to a major player in the governmental regulation of the health  insurance industry.Steve Larsen's resume is similar to Dr. Fowler. As outlined here he worked with an insurance company and then played a key role in HHS  dealing with insurance regulation as regards ACA and now back to insurance, this with a subsidiary of a company who was the beneficiary of a large HHS contract while Larsen was employed by HHS.

Larsen left his position as head of HHS's Center for Consumer Information and Insurance Oversight shortly before SOCTUS ruled Obamacare was constitutional and is now an executive VP with the UHG subsidiary Optum. Mr. Larsen also played a role in one of favorite examples of the social justice brought about by Obamacare,the granting of exemptions to friends of the administration. See here.

Tuesday, December 18, 2012

Expose of how big pharma worked on the sausage of Obamacare's social justice

See here for a fascinating, detailed account of the behind the scenes activities in the creation of one part of the Affordable Care Act.

Details of the cahoot activities were gleaned from numerous E-mails studied by the House Energy and Commerce committee.

After an agreement was reached between PhRMA (the lobby group for big pharma) and the white house they donated 150 million for an ad campaign and another 70 million for two front groups to advocate for passage of the bill. Big Pharma was able to block efforts to allow re-importation of medications and to enable CMS to negotiate drug prices for medicare part D.

The WSJ on line article linked above includes this paragraph.

At least PhRMA deserves backhanded credit for the competence of its political operatives—unlike, say, the American Medical Association. A thread running through the emails is a hapless AMA lobbyist importuning Ms. DeParle and Mr. Messina for face-to-face meetings to discuss reforming the Medicare physician payment formula. The AMA supported ObamaCare in return for this "doc fix," which it never got.

 If the lobbyists for AMA were hapless, what can you say about the lobbyists for the medical device manufacturing sector? See here for an article indicating that now even liberal Democratic senators seem to belatedly realize that the tax on that sector will cause the loss of jobs .

Perhaps the Obamacare sausage maker who should be singled out for special recognition is Elizabeth Fowler who some (including Max Baucus who should know) have said is the real author of ACA. Another important aspect of the cahooting,crony capitalism,baptist and the bootlegger world of legislation is the revolving door aspect. See here for how flagrant that process can be with a detailed chronology of Dr. Fowler's resume.Here are comments in that regard by Glenn Greenwald,by whom very little gets by:

  Ms. Fowler “will receive ample rewards from that same industry as she peddles her influence in government and exploits her experience with its inner workings to work on that industry’s behalf, all of which has been made perfectly legal by the same insular, Versailles-like Washington culture that so lavishly benefits from all of this.”

h/t Dr. G.Keith Smith for reference to House Committee's report

Sunday, December 16, 2012

Affordable Care Act as a monumental Baptist and Bootlegger morality tale

 "We are pattern-seeking,story-telling animals".

From chapter 1 , Macroeconomic Patterns and Stories, Edward E. Leamer

In a 1983 article in the journal Regulation, the economist Bruce Yandle introduced the concept of the Baptist and the Bootlegger (B+B). It refers to the situation in which a given legislation or regulatory action is supported by some group on high moral grounds as in denouncing the evils of alcohol.Support also comes another group who stand to get economic gain from that legislation such as bootleggers would if alcohol sales were banned. The Mafia rule of "follow the money" is useful in seeking out who might be the bootleggers in a given situation.See here for some classic examples of the B+B pattern including the acid rain story and the tale of  spotted owl.

After I became aware of the B+B pattern I seem to see it in many places, even in the Affordable Care Act.So here is the story.

I can see the medical progressives as the Baptists. Medical progressives believe (many of them sincerely) that health care or medical care is too complex,complicated and important to be left to the individual patient and his physician.Rather it should be determined by the elite who using a utilitarian ethic with the tools of cost effectiveness research will be able to find practices that will benefit society as a whole.But control is not the what the medical progressives explicitly argue for in their advocacy but rather it is the furtherance of the social justice that will be fulfilled as millions will now have access to health care and health care inequality will be greatly diminished. No, not  all physicians who  supported ACA  fall into that category.There are many sincere physicians who believe the statute is the way to obtain health care for  millions who are now under served and who are not part of the progressive medical elite but typically it is not their voice we hear from the pulpit.

I can see a coalition of bootleggers at work in the formulation of the many pages of dense, self referential legal prose that comprises ACA. The Mafia rule works well here.

Who would gain from millions of new clients with health care insurance?

Easy answers. The hospitals would gain simply as there would be many more  clients to be able to seek out and pay for their services. Similarly the big health insurance companies would welcome millions of more clients who are forced to pay for their product.Big Pharma would be in the position of more customers who could buy their products with other people's money. Information technology companies would relish the legislation to force or nudge physicians to buy and maintain computers systems.

But there is more.While the Baptists were singing hymns of praise for social justice,equality,elimination of waste, and the millions of uninsured Americans,the bootleggers and their lobbyists were busy working with the movers and deciders on the hill (eg. Max Baucus and his adviser, Elizabeth " revolving door" Fowler) to work out the important details. Big Pharma was able to get restrictions on the re importation of generic drugs,big hospital was able to be exempted from the actions of IPAB until 2020 and big health insurance was able to keep the public option from being included in the statute.

 Of course, metaphors and other figures of speech only can go so far,the reality flows over the cup.What about the medical professional organizations such as AMA, ACP, AAFP, etc.Many of these talked the talk of the preachers.Yet some had something to gain. The AMA  gathers more cash flow from its monopoly on coding than from the decreasing number of members' dues and coding will only increase as more patients are seen by physicians.Why did ACP and AAFP and others advocate for passage of Obamacare? Did they have anything to gain or were they merely dedicated preachers? Maybe the metaphor does not allow for much moral ambiguity.

The preacher who is pure in heart and sincere in belief gains only the satisfaction of doing the right thing.Preachers rarely have part time jobs as bootleggers or renounce the cloth and become a full time dealer in illegal sales of a prohibited substance. 

Folks with MD degrees who advocate for universal health care and alterations in medical ethics favorable to third party payers who either before or after that advocacy hold executive positions in major health insurance companies might gain more than self satisfaction. Maybe some people can really do well by doing good and that would be true in this instance if in fact passage of ACA is considered a good thing. Sometimes it is hard to tell the Baptists from the Bootleggers .

Thursday, December 13, 2012

More social justice bubbles up from the magic Obamacare fountain

There is so much social justice being dispensed from ACA that I can't really keep up. Here is one more instance,one that is imminent, ( Jan 1, 2013) the capping of health saving accounts at $ 2,500 down from 5,000 see here for Forbes article.

Twenty per cent of workers have HSAs.Meanwhile premiums rise on health insurance. So ACA forces folks to spend more on their health insurance and "nudging" them to spend less at their own discretion.

While this latest wrinkle is only a relatively small cog in the mammoth ACA legislation the progressive medical elite can savor it as it is one more move to limit the individual's choice in medical care which is the operational arm of their dominant theme which is "medical care is too important and complicated to be left to individual patient and his physician."