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

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

Thursday, March 28, 2013

Here is a shocker- Bogus "commission" recommends abolition of physician fee for service

Fee for service has increasingly become the bogus reason for  all of what is wrong with health care in the U.S. Now a  group of self designated experts deliberated and concluded what they all likely believed at the onset namely that we must eliminate fee for service (ffs) in medical care.Reference here is to the  "National Commission on Physician Payment Reform". See here for the report.

One could get a idea regarding their likely recommendations by considering some who are on the commission.  Here are some of the participants:

Dr. Troyen Brennan who wrote with Dr. Don Berwick about replacing the physician patient dyad in their 1996 book,  "New Rules" was formerly a VP at Aetna and now an executive VP at CVS Caremark. Here is a quote from Drs.Berwick and Brennan from that book:

“Today, this isolated 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.”

 Guess how the author of that paragraph would feel about fee for service for physicians.

Dr. Judy Bigby is Secretary of HHS for Massachusetts.

Dr. Lisa Lotts is a VP at Well Point.

 Somehow the image of a commission of  prominent foxes gathering to make recommendations regarding hen house security comes to mind.

One thing most of the fee for service critics propose is that physicians become part of Accountable Care Organizations (ACOs) and therefore they will be compensated for "quality and not volume of care". Does anyone really believe that physician employees of a ACO will not have volume requirement?

Dr John Goodman in this blog commentary says it better than I can in regard to fee for service and ACOs.

"There is absolutely no support for the notion that ACOs will do anything ― anything ― to reduce costs or improve quality (see this recent NCPA blog, “Question: Why Did Anyone Ever Believe in ACOs?”). It is nothing more than a wish dressed up with high-falutin’ language (sustainable, cost-effective, high-quality, interoperable, coordinated, etc.) In fact, virtually all of the evidence indicates just the opposite ― that the elements of ACOs (disease management, pay-for-performance and so on) are useless or worse."

And here is the money quote:

" ... the problem in health care is not fee-for-service, but third-party payment. Almost everything we do during the course of a day is done on a fee-for-service basis and none of it results in high inflation or poor quality. Quite the opposite. The only difference in health care is that someone else is paying the bill, so there is no constraint on the consumer or the provider of services."

Exactly-health care is largely paid for with some one else's money and those some one elses are doing all they can to limit that spending and increase their bottom lines and demonizing ffs and promoting the new bigger and better HMO ( now renamed as ASOs) seems to be their current tactic.

Sadly, the major medical professional organizations are complicit in this push into the ACOs which cannot possibly fix the health care problems but can put many more nails in the coffin of the fiduciary duty of the physician to the patients. How much individual patient advocacy are you going to see in a large organization in which the physician are the employees?  To what extent  will physicians trained in the era in which the world medical view is that physicians are  stewards of society's resources and that their actions should be controlled by utilitarian based cost effectiveness analysis and directives  be dedicated advocates for their patients?

Tuesday, March 19, 2013

"physicians as stewards of society's medical resources" is not just bogus but is a dangerous concept

The "physician as a steward" idea is implicit in Medical Professionalism as defined and promoted by a number of physicians who I label medical progressives and notably by the ABIM Foundation. In their own words they are advocates for " a just and cost effective distribution of finite resources." See here for source of quote.

 I argue that the physician-steward is a bogus and dangerous concept.
To consider physicians as stewards is to consider the medical care resources as a collective entity.
This is to say that  Individually possessed  resources or assets should be considered as part of a collective pool owned by everyone and that all have an equal right to some share of the pool.That is the core concept implicit in the physician as a steward phrase.

In regard to a private property system the rights of the owner in general terms are clear. He has the right to use his property,exclude others from use of the property and dispose of the property through sale,gift or inheritance.

 In contrast , the rights are in a common ownership system are vague and indeterminate. It is  not clear how one can be said to "own" something if no one in principle is excluded from making a claim .

 Once the common ownership idea is accepted it then seems to make sense to talk about allocating resources and to consider some one or some group or groups as the appropriate allocators. With common ownership it simply would not work for all of society to willy-nilly feed on the medical commons as soon the resources would be depleted Rather there needs to be a rational plan so that just and cost effective distribution can take place.

The first thing wrong with considering  medical resources as collectively owned is that they are not collectively owned in any real ,literal or legal sense in a free or even semi free society. U.S.medical resources are not like a grassy field in which all of the town folks sheep can come to graze.

While a grassy field for the villager's sheep to graze can be defined by a specific surveyor description, the "medical commons" is a extremely large,always changing, amorphous array,the elements of which defy enumeration. Various entities own various elements of this array-society owns none even though various government entities own some but the government is not society.It is an amorphous abstraction.

The skills,and knowledge of thousands of physicians and others involved in health care are aggregated and then allocate. Further, to speak of allocation means some one or some elite group will do the allocating not individual physician patient units.You know the "dyads" that Drs.Berwick and Brennan wanted to eliminate as the decision making unit in matters of health care.(See here for what Berwick and Brennan has to say about that.)

The dangerous element of the concept is that when medical decisions are made on the basis of cost effectiveness as judged by some third party the individual is at risk of being harmed in the name of some aggregate benefit allegedly exceeding the aggregated cost. It is the utilitarian enterprise -the greatest good for the greatest number. there will be winners and losers and as long as the "utility" of the winners exceeds the utility lost by the losers we have a cost effective outcome. As since society as a whole is better off  it must be fair by definition. Never mind that individuals may be sacrificed to some abstract aggregate benefit .

 This utilitarian approach is not just opposed by libertarians but the egalitarian thinker, John Rawls says of utilitarianism that individual rights may be breached in its effort to bring about the happiness or utility of the greatest number and objects to utilitarian decisions because it ignores the separateness and distinctness of individuals.

The ABIM foundation and committees of the ACP both  are  promoting cost effectiveness analysis. Note this is not comparative effectiveness analysis but recommending the technique to determine  for example if two treatments are both effective that the one with a more favorable cost effective ratio be used.

The idea that medical data analysis technocrats  should be the allocators or at least advisers to the actual allocators is what one would expect from the medical progressives whose major tenet appears to be that medical decisions and too complex to be made by the individual physician patient dyads and is also a  died-and- gone- to- heaven moment for the third party payers who could not be more pleased that is the medical profession itself ( or certain elements of it) who are advocating cost effectiveness .

Social justice was the Trojan horse on which cost effectiveness allocation of finite resources and guideline adherence rode. Operationally it seems that to the ABIM Foundation social justice is mainly all about fair and cost effective allocation of resources. In that scheme there will be two tiers of physicians.

There will be the highly trained cost effectiveness analysts who will determine what is just and cost effective and the worker bee physicians who by adhering to the allocators' guidelines will be promoting social justice in their stewardship role. 

Monday, March 11, 2013

Social Justice quote for the day from F.A. Hayek

Since the medical progressive leadership has at least nominally enshrined the pursuit of social justice as a ethical requirement for all physicians I think it is appropriate to at least look at what various prominent philosophers have had to say about the concept of social justice. Such a look is justified if for no other reason that the various polemics promoting a social justice imperative for physicians were bereft of any consideration  of the impressive body of thought which rejects social justice  as a meaningful concept.

FA Hayek's writings are  prominence in that regard .The following quote is from his lengthy treatise "Law,Legislation and Liberty" Volume 2,The Mirage of Social Justice"

"[I]n...a system in which each is allowed to use his knowledge for his own purposes the concept of `social justice' is necessarily empty and meaningless, because in it nobody's will can determine the relative incomes of the different people, or prevent that they be partly dependent on accident. `Social justice' can be given a meaning only in a directed or `command' economy (such as an army) in which the individuals are ordered what to do; and any particular conception of `social justice' could be realized only in such a centrally directed system...In a free society in which the position of the different individuals and groups is not the result of anybody's design--or could, within such a society, be altered in accordance with a generally applicable principle--the differences in reward simply cannot meaningfully be described as just or unjust." (pp. 69-70)

One Sociology text book version of what the concept of social justice  typically involves is the following:

  • Historical inequities insofar as they affect current injustices should be corrected until the actual inequities no longer exist or have been perceptively "negated".
  • The redistribution of wealth, power and status for the individual, community and societal good.
  • It is government's (or those who hold significant power) responsibility to ensure a basic quality of life for all its citizens.
Those precepts while standard fare in the social democracies of Europe could not be more different than the notion of justice expressed in the U.S. constitution and in the thoughts of John Locke.

 Why the views of classical liberalism should be excluded from medical ethics without discussion and the standard welfare state progressive's notion of social justice be included is by no mean clear nor was a cogent argument for that presented in either the New Professionalism on the new ACP ethics.

Friday, March 08, 2013

Is medical practice moving from "What can I do for you" to "What can't I do for you"?

In a society in which individuals are more or less free to interact with one another and seek each other's services and goods the following phrase is routine; "What can I do for you?" or "how can I help you?"
I have said that  said many times to a patient at the beginning of an office visit.

It seems to me that that phrase captures  an important aspect of the mind set of the clinician as she relates to her patients. What can I do for you, how can I help you, what are you concerned about all speak to the role of the physician in her fiduciary duty to the patient.

Why is it that clinicians seems to be concerned with what they can do for patients and so often health policy wonks emphasize  how we as physicians  can limit what patients receive? To talk of the need  to limit resource use is to assume that a vaguely defined or undefined  too much is being done for patients which translates further to a third party ( either a third party payer or a third party self appointed expert) deciding that the individual decisions of doctors and patients about clinical management issues results in "overuse" of resources.There is a body of thought that maintains physicians are not only obligated to serve the best interests of their individual patient but somehow they are ethically obligated to be the stewards of  resources that somehow in other than a metaphorical sense are owned by society.

 Overuse seems to lie in the eye of the third party payer. Could it be that many in the health policy arena and many of the self appointed thought leaders of major medical professional organizations  believe that patient treatment is too important to leave to the myopic lens of doctor and patient and that their selfish interests are no basis for appropriate medical decisions and that the experts' enduring wisdom should over ride the archaic physician patient dyad.Perhaps first advice and "education" would be enough to disabuse the practicing physician and her relentlessly self centered patient from doing too much. However if discussions about cost savings did not prevail more carrots and sticks might be required.

Of course "what can I do for you" is not an boundless,open ended agreement to do all and everything a patient may request. If a patient concerned about difficulty with word finding and misplacing his car keys possibly indicating early dementia you might reasonably refuse to comply with his request for a referral for a brain biopsy.  The physician can give informed and reasoned advice about how to proceed taking into account the views and wishes and concerns of the individual patient.

The new initiative lead by the ABIM Foundation (does anyone else wonder why a organization ostensibly tasked to test the competence of internists needs a foundation ) labelled Choosing Wisely appears to be a list of  "thou shall not s"- sort of a hundred commandments. OK, they are currently phrased not as absolutes but are presented as the much softer and gentler opportunities to have a discussion with your patient not as rules not to be broken.Suggestions first, guidelines later and then perhaps extra payment for compliant socially conscious stewards of society's resources namely the physicians (make that health care professionals) and reduced payment for the recalcitrant and selfish.

Of course some tests and treatments are ordered and carried out in instances in which no patient benefit is obtained and in some cases harm may  done  but for numerous medical professional organizations to proclaim that  numerous tests and procedures should  not be done ( however gently this is currently presented) seems to me to be efforts to change to mind set from the traditional what can I do for you to what I can not allow you to have.

I have seen few comments ( see here for one) in anyway critical of the specific recommendation of the Choosing Wisely campaign but there should be thoughtful analysis of each of them before there is any widespread acceptance.Remember evidence based medicine. What is the evidence behind for example no pap tests before age 21.Are there randomized clinical trials ? Is it based on expert opinion? Are we told about potential conflicts of   interests of the authors of the recommendations? Are there published systematic reviews or cost effectiveness analysis for each of the recommendations or for any?

Any of the numerous ( current count is 130 but stay tuned) recommendations  made by various medical professional organization may well pass the tests of coherence and correspondence with valid evidence but you have to be skeptical  of some many recommendations appearing seemingly so quickly and their manner of presentation appears more authority based or expert based than evidence based.

No one is in favor of tests and procedures that are of no benefit and/or are harmful.No one is against Mom and apple pie or in favor of the nation going broke from run away medical costs, but to rush to publish 100 plus prohibitions under the banner  of preventing  harm or waste may end up itself doing much more harm than good and even costing more if each specific recommendation is not based on sound evidence based analysis.  Making recommendations that might affect the health and lives of thousands of people is serious and heady business and time after time we have seen well meaning medical recommendations turn out to be very bad advice ( remember HRT for just about all post menopausal women and then for none and then again for some). Doctor,were you wrong then or are you wrong now?

 American Board of Internal Medicine President Christine Cassel, MD, said such rules of thumb  (those suggested by various medical professional organizations regarding certain tests and procedures) seek to change the mindset of physicians and patients alike that "more is better," which can lead to wasteful spending and sometimes harm to the patient.

"What you're talking about is a culture change," Dr. Cassel told Medscape Medical News in a recent published interview. Let's hope the hoped for  cultural change does not include discarding the fiduciary role.Yet I believe it is significant that neither the New Medical Professionalism nor the New medical ethics of the ACP talks about the fiduciary responsibility of the  physician to the patient.I believe that de-
 emphasizing the fiduciary role of the physician and claiming a role of resource steward for physicians is
conceptually dangerous and to the extent it is incorporated into day to day medical thinking destructive to the traditional physician patient relationship doling damage to both physicians and patients.

For each of the recommendations published by the Choosing Wisely campaign  physicians and their patients need to know what is the nature of the evidence? For some probably the evidence is strong and convincing for others maybe not so much.Let's not replace "more is better" with" less is better" because neither is a universal all encompassing decision rule and clinical decisions should not be based on  empty catch phrases such as "less is more" and the vacuous  "the right treatment for the right patient at the right time".