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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, January 22, 2014

So how's that health care insurance for "nearly everyone" working out for you?

Advocates of Obamacare in defense  of it in spite of all the flaws and the ever increasingly list of unintended and intended- but not advertized- consequences ( eg tax payer subsidies for insurance companies  that might loose money on the exchanges) typically fall back on the twin refrains of "health care will be available for nearly everyone" and social justice is being promoted.

Of course, those folks are conflating health care with having insurance but ignoring that for a moment it looks more and more unlikely that the nearly everyone )(usually estimated to be about 30 million) will  actually get the insurance cards . So far  fewer of the uninsured are actually shining up on the exchanges.McKinsey did a study and their analysis indicates that the vast majority of those who are signing up were already insured and only about 11% were moving from the uninsured group to the insured group. See here for some details of that study. If McKinsey's analysis is even close to be correct the 30 million claim will not likely be reached.

As far the social justice argument let me repeat that Rawls defended inequality if it benefited the most disadvantaged in society but while some of that is happening with Obamacare , a significant number are forced into paying more for insurance and often buying benefits which they can never use.

So the plan seemed to be that the young, healthy would sign  up in sufficient numbers to fund the scheme  and the uninsured would rush to the website and sign up since getting those 30 million insured was the purported reason for the legislation in the first place. So far it seems that neither of those things are actually happening in sufficient numbers to   prevent the so called death spiral.More aspects of the Obamacronycare law come to light, one of the most recent  one being the news that HHS is writing or rewriting the details of subsides to bail insurance companies to make them even more generous.

And this quote from Coyote Blog which comments on the fact that many people who are now getting subsidies had insurance before:

"So, we know that 80% of the people are getting subsidized on the exchanges, and now we know that 70-90% of those previously had a unsubsidized policy beforehand.   This means that what the exchanges are doing is NOT insuring the uninsured, but converting people previously responsible for their own health care into government dependents.  The more cynical out there will argue that was the whole point in the first place."

And for  what party will folks dependent on the government likely  vote?

Monday, January 20, 2014

Can widely accepted guidelines be dangerous?

Projections assuming the wide acceptance of peri operative beta blocker guidelines in Europe suggests the answer is a frightening yes..See here for details of what seems to be a candidate for  the mother of all iatrogenic disasters. The authors of that referenced article suggest deaths may be in the hundreds of thousands.Extrapolations are fraught with great mis -estimates but even with assumptions of much less adherence to the guidelines there have to be a large number of patients that died or experienced non fatal strokes in a terribly misguided effort to save lives. Hubris of the medical planners and the danger of excessive faith in the truth producing power of meta analysis and the dangers of guidelines enforcement  are among the windmills at which I  repeatedly joist. 

I shamelessly quote a slightly re-edited comments which I made in 2007 following the disappointing results of the POISE trial that cast an unfavorable light on the use of peri operative beta blockers in non cardiac surgery which demonstrated an increased risk of stroke in the treatment arm of the trial.

"quality measures  often drive care and influence the way physicians care for their patients. If a physician should exert great care in deciding what to do for an individual patient it would seem a greater level of concern and contemplation should be expended in writing "rules" that will influence the care of many patients.

I do not mean to imply that physicians who author quality rules take their responsibility lightly but events such as the beta-blocker saga should perhaps make us insist on a very high standard of proof of efficacy and safety be shown before we presume to tell others physician what they should do particularly when those rules are "enforced" by economic carrots or sticks. Further if an intervention is to prevent something, i.e to decrease the risk of a bad outcome, the level of certainty should be higher than in the circumstance when the physician is treating a certain medical condition.  I increasingly wonder if those sweeping recommendations should be based to a large degree on meta analyses. In a seriously ill, patient you often have to act, even to use treatments that lack super solid proof of efficacy; when you are in the prevention mode, you had better have a much greater level of certainty.

The individual physicians not only have a fiduciary duty to do what it right for the patient but they are held to a legal duty. At least physicians were taught that duty before the days of the New Professionalism as promoted by the ACP with their new ethic and the ABIM Foundation and the Robert Wood Johnson Foundation.See how often you find the word "fiduciary" in the new ethics or the New Professionalism.

The individual physician deals with the stroke patient and has to answer to him and the family, and perhaps to the family's attorney while the quality rule writers have to answer to whom. Apparently no one. Being a  public health expert or a guideline author seems to confer immunity for having to say you are sorry.  The individual physician strives to do what is the right thing for his patient and hopes that what he does is right, the quality rule makers seem presume to know what is good for everyone. Obviously, they frequently do not. Oh well, you can't make an omelet unless...

When guidelines were operationally what they claim to be now suggestions,their benefit and their potential harm was limited. Enter the ever increasing hegemony of the third party payers (government or private insurers ) which  has morphed guidelines into requirements with greatly increased power to do good or harm but with seeming impunity.

(edited on 4/24/24 to correct several spelling and grammar issues)

Wednesday, January 08, 2014

Are cuts in Medicare (mainly Medicare Advantage) more of the magical social justice of Obamacare?

As this Forbes article by Scott Gottlieb explains,Medicare Advantage programs are in the cross hairs of the Obama administration as ACA continues to roll out benefits for some and just roll over others.

Obamacare is partly funded by cuts to Medicare Advantage,a program popular among low income seniors,particularly those who may not be able to afford the medicare supplements plans.More of these plan members are being shifted to Medicaid, a health care delivery "system" generally perceived as something less than typical care that one obtains under Medicare. If social justice means redistributing stuff around so that the most disadvantaged are benefited. you have to wonder how diminishing the health care for one group of lower income folks to enable another group of low income folks to have insurance cards( not health care but cards) is any type of justice at all. Cuts to Medicare Advanatage had been postponed so that they kick in after the 2012 election, will they be postponed again with the administration's eye on the 2014 elections?

Quoting Dr. Gottlieb:

"The net effect of all of these cuts is already expected to shrink the program. The Obama Administration is disproportionately shifting these cuts onto so-called Medicare “special needs” plans. These are Medicare Advantage plans that are specifically designed to enroll patients with certain serious and costly chronic illnesses like diabetes and heart disease. Many of these patients are low income, and dually eligible for both Medicare and Medicaid. "

 We are seeing more strange social justice in the situation in which the program at least nominally designed to help the most sick of those in Medicare Advantage will be cut the most (that is unless the administration decides to post pone it again in the run up to the next elections).

John Goodman also covers this issue here.

"About one of 20 seniors on Advantage had to switch plans because their old coverage was cancelled, but the damage has been particularly acute in a category called special needs plans, or SNPs. More than 1.5 million people were covered by about 500 of these plans in 2013, but the consultants at Avalere Health report that 13% were wiped out."

Being old and sick and poor is becoming more dangerous for some to help pay for insurance cards for some others who may also be sick and poor.   

Friday, January 03, 2014

As 2014 sees Obamacare ramp up,another tip of the crony hat to its "architect" is in order

Of course no one person wrote the bill,it took a small village of cronies to put it together being as careful as they could to make sure that the health insurers were among  the beneficiaries as well as a few other crony beneficiaries.

A health care "reform" bill was constructed that forced large numbers of the uninsured to buy health insurance and included safeguards ( particularly Section 1341 and section 1342) for the insurance industry to minimize losses should the overall strategy ( to get 40% of the newly enrolled to be young and healthy) not work out as projected.

The statute was crafted by the senate finance committee lead by Max Baucus. According to Baucus much credit should be given to one of his staffers,Liz Fowler. Quoting Mr. Baucus;

"“I wish to single out one person, and that one person is sitting next to me. Her name is Liz Fowler. Liz Fowler is my chief health counsel. Liz Fowler has put my health care team together. Liz Fowler worked for me many years ago, left for the private sector, and then came back when she realized she could be there at the creation of health care reform because she wanted that to be, in a certain sense, her profession lifetime goal."

From 2001 to 2005 Ms.Fowler was Baucus's top health care adviser.She left in 2006 to become Vice President of the nation's largest health care insurer  (Well Point) and returned to play a major role in crafting Obamacare in 2008.That's right, an executive at the nation's largest health care insurer helped write the bill that forced folks to purchase the product that company sold. But it gets even better. She was then hired by the Obama administration to help implement the bill and subsequently left to become a vice president at a pharmaceutical company about which Glen Greenwald ( see here) said the following:

"The pharmaceutical giant that just hired Fowler actively supported the passage of Obamacare through its membership in the Pharmaceutical Researchers and Manufacturers of America (PhRMA) lobby. Indeed, PhRMA was one of the most aggressive supporters - and most lavish beneficiaries - of the health care bill drafted by Fowler. Mother Jones' James Ridgeway proclaimed "Big Pharma" the "big winner" in the health care bill. And now, 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."

Also of interest is she is now also a member of the Institute of Medicine.See here. The IOM is touted as being a disinterested organization of health care experts who will recommend what is right for the health of the nation and its citizens and whose members are not driven by any special interests.

Of course, none of this is a state secret.Many have written about it including Bil Moyers,Mother Jones, the Huffington Post to name a few.

And yet what do we hear from the physician's organizations, particularly the AMA and the American college of Physicians? Why do not they speak out denouncing this massive pork barrel project.? I cannot accept ignorance or naivete as credible explanations.these organizations have their people in Washington who know what is going on.Surely AMA and ACP do not sponsor, condone or take part in crony capitalism.

Even the Daily Kos,which is very pro Democratic Party,says in headlines " Thank you Max Baucus and Liz Fowler for turning the AHC into a Rube Goldberg machine".. (see here.) while ACP continues its defense of the legislation.

Even recently one of their blogs defended  Obamacare as providing affordable insurance coverage to "nearly  all Americans" and of course, furthering  social justice. Apparently " nearly all" means all but 31 million, not counting those who recently lost their insurance.  Social justice typically means redistribution to benefit the most disadvantaged.Yes, some of that occurs with AHC as some folks do gain an insurance card (but not necessarily medical care)but it is hard not to realize how much redistribution might occur from the taxpayers to the insurance companies and Big Pharma. These increasingly lame defenses of Obamacare is getting embarrassing.