A subset of pneumonia patients -those considered at risk of having a multi-drug bacterial etiology-did worse if their physician complied with ATS-IDSA guidelines according to a recent study. See here for reference to the article that was published on Lancet online.
I have blogged before about the dangerous tendency of guidelines tendency to cause unintended consequences and talked about the idiotic four hour pneumonia rule, one unintended consequence of which was the treatment of non-pneumonia patients for pneumonia within the four hour deadline.Well at least the treatment was started within 4 hours.
My longest screed about guidelines can be found here.
Guidelines can be considered part of the mind that says " medicine is too important and too complicated to be left to the individual physician and individual patient." This dangerous mind set was made explicit and championed by the former header of CMS, Dr. Don Berwick who said :
"Today, this isolated relationship [ed. the individual doctor-patient ] 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.” (My bolding).
Yeah,that pesky decentralized decision making just gets in the wise of wise centralized decision making which history tells us worked out really well in the 20th century.
The best quality or guidelines rules are supported to varying degrees by randomized clinical trials but even here one should proceed slowly because the well known efficacy-effectiveness gap tolerates simplistic approaches poorly. RCTs are often small and have multiple exclusion rules and fail to capture the perplexing diversity of relevant pathophysiological variables (known and unknown) that coexist in complex, hospitalized patients. It is in the sickest patients that rules formulated by committees based on what-ever data or personal bias that the most harm can be done and in whom individual variation overwhelm premature generalizations and an eager rush to mandate treatment rules.No, all guideline writers do not always intend that their wisdom should be mandatory ( but some do) and write disclaimers at the end of the articles to that effect, but guidelines have a way of morphing from suggestions to dicta and rules the ignoring of which may have financial or other consequences for the rouge doctor.
The mandatory and quasi mandatory nature of guidelines or quality indicators as wielded by the CMS mandarins and other institutional elites become even more dangerous with the spreading use of the "disruptive physician" doctrine. Not only must you go by the rules you can't complain about them without incurring the wrath of the hospital's disruptive physician committee.This doctrine is a brilliant control mechanism.If you challenge the disruptive physician concept you are by definition disruptive.
Thursday, March 29, 2012
Monday, March 26, 2012
Cardiac stress test before endurance exercise might just make sense
The party line (I mean the consensus of reasoned expert opinion by panels of highly educated people) has been there should not be stress tests before a person begins training for or entering a marathon because of some combination of the following reasons: low incidence of cardiac events in endurance races and shorter fun runs,large numbers of false positives noted on treadmill stress testings,and the dominant theory that the major cause of cardiac events precipitated by exercise is acute plaque rupture rather than fixed coronary artery stenosis.
An extensive assessment of cardiac events during long distance runs might change the thinking in that regard.
JH Kim et al reached that conclusion following their analysis of cardiac arrests associated with marathon and half marathon races in the US from 2000 to 2010.See here for ref.
The authors' data including races involving 10.9 millions runners and 51 men had cardiac arrests. Hypertrophic cardiomyopathy and atherosclerotic coronary disease were the two most common causes.
The authors said:
"The absence of coronary plaque rupture in these persons was surprising because prior data and expert consensus documents have suggested that exercise induced acute coronary syndrome result from atherosclerotic plaque disruption and coronary thrombosis.
Their findings suggested that rather than plaque rupture that there was an imbalance between oxygen supply limited by stenotic coronary arteries and oxygen demand greatly increased by the exercise.
So exercise testing would be useful to the extent that the exercise related events were due to fixed obstruction. Of course both mechanisms could be present alone or in combination in various people. A resting ekg should be helpful in alerting to the possibility of hypertrophic cardiomyopathy. But, of course, there is that new directive by the progressive medical elite for parsimonious care to take under consideration.
An extensive assessment of cardiac events during long distance runs might change the thinking in that regard.
JH Kim et al reached that conclusion following their analysis of cardiac arrests associated with marathon and half marathon races in the US from 2000 to 2010.See here for ref.
The authors' data including races involving 10.9 millions runners and 51 men had cardiac arrests. Hypertrophic cardiomyopathy and atherosclerotic coronary disease were the two most common causes.
The authors said:
"The absence of coronary plaque rupture in these persons was surprising because prior data and expert consensus documents have suggested that exercise induced acute coronary syndrome result from atherosclerotic plaque disruption and coronary thrombosis.
Their findings suggested that rather than plaque rupture that there was an imbalance between oxygen supply limited by stenotic coronary arteries and oxygen demand greatly increased by the exercise.
So exercise testing would be useful to the extent that the exercise related events were due to fixed obstruction. Of course both mechanisms could be present alone or in combination in various people. A resting ekg should be helpful in alerting to the possibility of hypertrophic cardiomyopathy. But, of course, there is that new directive by the progressive medical elite for parsimonious care to take under consideration.
Thursday, March 22, 2012
More spending leading to better care seems true in Canada also
Recently I blogged about data indicating that sometimes more (money spent ) is better (better outcomes in health care) as well as in most everything else even though you sometimes hear just the opposite from devotees who misinterpret and over interpret the Dartmouth Atlas data.
Now we have this JAMA article from Canada that suggests that outcomes for heart failure,hip fracture and some other conditions are better when more money in spent.
Now we have this JAMA article from Canada that suggests that outcomes for heart failure,hip fracture and some other conditions are better when more money in spent.
Monday, March 19, 2012
Guess what - Obamacare will cost more than one trillion over ten years
The hype leading up to the passage of Obama care included claims that the bill would protect the country from bankruptcy,bend the health care cost curve and boost health care quality. Now the projection for 10 years of Obamacare is for 1.76 trillion and by the time we can get a even finer tuned projection it will likely be twice what it was claimed to be. See here for the projection of OBM.
I guess the social justice will cost a little more as we watch 34 million new health care card carrying folks scramble for the shrinking number of primary care doctors who will see Medicaid and Medicare patients.
The one trillion dollar number seemed to play an important role in the push and pull going on before the health care bill was passed.The cost of the plan had to be less than one trillion and getting the projected cost to be less than one trillion apparently played a significant role in the bill finally being passed.However, the cost estimates were rigged and only three years later are we getting more realistic projections showing how much flim- flam was involved.
I guess the social justice will cost a little more as we watch 34 million new health care card carrying folks scramble for the shrinking number of primary care doctors who will see Medicaid and Medicare patients.
The one trillion dollar number seemed to play an important role in the push and pull going on before the health care bill was passed.The cost of the plan had to be less than one trillion and getting the projected cost to be less than one trillion apparently played a significant role in the bill finally being passed.However, the cost estimates were rigged and only three years later are we getting more realistic projections showing how much flim- flam was involved.
Friday, March 16, 2012
Sometimes spending more on health care brings better outcomes -duh
The widely quoted data from the Dartmouth Atlas has been almost as widely misunderstood to mean "more is less". How something so counter-intuitive and contrary to much everyday experience could get so much argumentative traction is a testament to a cognitive weakness that even Dr. Kahneman failed to document and explain in his book Thinking Fast and Slow. Maybe he does, it is simply gullibility or buying into data that confirm your priors.
Dr. Ashish K Jha sets the record straighter .See here.
Here is part of what he had to say.
“The Dartmouth Atlas shows that among communities, there are large variations in health care costs and large variations in quality, and some with high costs also have low quality. This convinces a lot of people that there can be a free lunch—that if we can get spending down in high-costs communities like McAllen, Texas, to levels seen in Minnesota, where spending is low and quality is high, we can save money and improve outcomes. But how you implement this in policy is hard, and often policy makers misunderstand what to do."
Dr, Jha's study is certainty not the first to counter some of the over-blown nonsense about the relationship to spending and outcomes in health issue. Here is an earlier on post dealing in part with some of the enlightening work of Dr. Richard Cooper in that regard. Also here is a thoughtful discussion of Cooper's work by one of my favorite economists, Arnold Kling.
The Atlas used coarse grained data, regional variations in cost and outcome, but was used to make much more fine grained conclusions by those who hyped the study .Individual hospital or (God forbid) individual patient data were not analyzed yet policy recommendations were applied to the more fine grained entities.
Dr. Ashish K Jha sets the record straighter .See here.
Here is part of what he had to say.
“The Dartmouth Atlas shows that among communities, there are large variations in health care costs and large variations in quality, and some with high costs also have low quality. This convinces a lot of people that there can be a free lunch—that if we can get spending down in high-costs communities like McAllen, Texas, to levels seen in Minnesota, where spending is low and quality is high, we can save money and improve outcomes. But how you implement this in policy is hard, and often policy makers misunderstand what to do."
Dr, Jha's study is certainty not the first to counter some of the over-blown nonsense about the relationship to spending and outcomes in health issue. Here is an earlier on post dealing in part with some of the enlightening work of Dr. Richard Cooper in that regard. Also here is a thoughtful discussion of Cooper's work by one of my favorite economists, Arnold Kling.
The Atlas used coarse grained data, regional variations in cost and outcome, but was used to make much more fine grained conclusions by those who hyped the study .Individual hospital or (God forbid) individual patient data were not analyzed yet policy recommendations were applied to the more fine grained entities.
Monday, March 12, 2012
Colon cancer screening - not for 75 years olds?
The headline references one of the latest recommendations from the American College of Physicians (ACP).Seven members of the Clinical Guidelines Committee of the American College of Physicians have "determined" that consistent with the principle of cost conscious,high value care that "clinicians should not screen adults aged greater than equal to 75 years or those with substantial co-morbid conditions ..with a life expectancy of less than 10 years ."
The reference is "Screening for Colorectal cancer: A Guidance statement from the American College of Physicians. Annals of Internal Medicine 2012:156;378-386.
This is in contrast to the less rigid recommendation of the USPSTF which said:
USPSTF recommends against routine screening for colorectal cancer in adults 76 to 85 years of age. There may be considerations that support cancer screening in an individual patients.
Kudos to the USPSTF for allowing something that might at least pass for " patient centered care" to actually be centered on the patient and her concerns and her particular set of facts and to have those considered by her and her physician rather than having the option of colonoscopy categorically excluded by a general rule based on age. Further, the opposite of kudos to the ACP committee for their recommendation for not doing so.
ACP quotes a study in the Archives of Internal Medicine that "suggests that colonoscopy is overused in elderly patients including repeated screening at less than 10-years intervals and routine screening of patients older than 80 years."
The referenced article( see here for abstract) was an analysis of a large sample of Medicare patients who received colonoscopy exams for screening and around 45% received an second exam in less than 10 years. This is evidence than a number of patients received exams sooner than the 10 years recommendation for repeat exam so in that limited sense there was "overuse". The logical leap from that article to the recommendations of no screening past age 75 is unsupported by evidence or articulated reasoning expressed in the Annals article.
Why not age 73 or 76 or 80 or 65?
The age choice appears arbitrary and the absence of an articulated waiver based on individual circumstances is surprising and you have to wonder what evidence was used to reach their conclusion.You have to wonder because the article seemed bereft of any supporting evidence.
The print boiler plate disclaimer at the end of the article says:
"Clinical guidance statements are "guides" only and may not apply to all patients and all clinical situations.Thus,they are not intended to override clinicians' judgment."
But what will be remembered and quoted will be the 75 years cut point.
Page 385 of the Annals article has a table with the left hand column having a heading of "high-value,cost conscious care" across from the age related cutoff and their general screening recommendations.The implication is that the age recommendation is consistent with this "principle" of high-value,cost conscious care.
However,invoking the new magic words "High-value,cost-conscious care" (HVCCC) does not substitute for offering an analysis of the data regarding the outcomes of colonoscopy in older patients,e.g. complications, positive findings and ( here is something radical) how did the patients value the procedure.
I cannot help but worry that whatever righteous and rational reasoning and good intentions lead to the notion of HVCCC , it will become like the term "patient centered care" meaning whatever the authors of articles chose to have it mean. There are certain tactical advantages to have an elastic, ambiguous concept . I am preparing some comments on the notion of "value" as it is being applied to medical issues,particularly in regard to the difference between the use of the term by certain business consultant gurus and its questionable transfer to medical care and the standard
definition of value as explained in introductory economics texts.
The reference is "Screening for Colorectal cancer: A Guidance statement from the American College of Physicians. Annals of Internal Medicine 2012:156;378-386.
This is in contrast to the less rigid recommendation of the USPSTF which said:
USPSTF recommends against routine screening for colorectal cancer in adults 76 to 85 years of age. There may be considerations that support cancer screening in an individual patients.
Kudos to the USPSTF for allowing something that might at least pass for " patient centered care" to actually be centered on the patient and her concerns and her particular set of facts and to have those considered by her and her physician rather than having the option of colonoscopy categorically excluded by a general rule based on age. Further, the opposite of kudos to the ACP committee for their recommendation for not doing so.
ACP quotes a study in the Archives of Internal Medicine that "suggests that colonoscopy is overused in elderly patients including repeated screening at less than 10-years intervals and routine screening of patients older than 80 years."
The referenced article( see here for abstract) was an analysis of a large sample of Medicare patients who received colonoscopy exams for screening and around 45% received an second exam in less than 10 years. This is evidence than a number of patients received exams sooner than the 10 years recommendation for repeat exam so in that limited sense there was "overuse". The logical leap from that article to the recommendations of no screening past age 75 is unsupported by evidence or articulated reasoning expressed in the Annals article.
Why not age 73 or 76 or 80 or 65?
The age choice appears arbitrary and the absence of an articulated waiver based on individual circumstances is surprising and you have to wonder what evidence was used to reach their conclusion.You have to wonder because the article seemed bereft of any supporting evidence.
The print boiler plate disclaimer at the end of the article says:
"Clinical guidance statements are "guides" only and may not apply to all patients and all clinical situations.Thus,they are not intended to override clinicians' judgment."
But what will be remembered and quoted will be the 75 years cut point.
Page 385 of the Annals article has a table with the left hand column having a heading of "high-value,cost conscious care" across from the age related cutoff and their general screening recommendations.The implication is that the age recommendation is consistent with this "principle" of high-value,cost conscious care.
However,invoking the new magic words "High-value,cost-conscious care" (HVCCC) does not substitute for offering an analysis of the data regarding the outcomes of colonoscopy in older patients,e.g. complications, positive findings and ( here is something radical) how did the patients value the procedure.
I cannot help but worry that whatever righteous and rational reasoning and good intentions lead to the notion of HVCCC , it will become like the term "patient centered care" meaning whatever the authors of articles chose to have it mean. There are certain tactical advantages to have an elastic, ambiguous concept . I am preparing some comments on the notion of "value" as it is being applied to medical issues,particularly in regard to the difference between the use of the term by certain business consultant gurus and its questionable transfer to medical care and the standard
definition of value as explained in introductory economics texts.
Sunday, March 04, 2012
Department of HHS makes economic breakthrough: declares there IS a free lunch after all
Nobel prize winning economist,Milton Friedman, is quoted as saying that economics could be summed up with two principles. 1) There is no such thing as a free lunch and 2)demand curves slope downward or ( in non econo-speak) people buy more when the price is lower and less when prices are higher.
Dr Friedman did not live long enough to see that his first principle overturned.
When the dictum of the HHS Department ordering employers to provide medical insurance that included paying for birth control pills hit a snag when the Catholic Church hierarchy raised a loud and righteous ruckus as it impacted Catholic hospitals and schools, necessity once again became the mother of invention.
The Secretary of HHS , in a move alleged to be compromise, declared that: no, the employer would not have to pay but rather the insurance company would. (see here).When challenged with the argument that the insurance company would simply increase the premiums,the Secretary replied;no, the insurance company would not be allowed to do so. Further, that order would actually save the insurance company money because the savings from medical costs not incurred because of the decrease in the number of pregnancies pregnancies would be greater than the cost of the pills. So, not only are the birth control pill free but provide a saving to the insurance company.So it is even better than a free lunch. The insurance companies should be happy to be forced to save money.
But this previously unrecognized saving ( which for some strange reason insurers never recognized on their own) is only the beginning. If taking statins and blood pressure pills decrease the risk of heart attack, should not insurance companies be giving those medications to policy holders as well. After all, generic pills are cheap enough and treating a heart attack is a big ticket item. The opportunities along these lines seem endless.Once insurance companies grasp this principle their profits will soar and they will begin to "give away" a lot of stuff even without government coercion.
Some would argue that these dicta from the Department of HHS make any contract that existed between the insurer and the insured a farce since for hundreds of years a contract based on force or coercion rather than mutual agreement of the parties was considered not valid.(See here for the comments from the Institute for Justice arguing that is exactly what the individual mandate does.) Those naysayers just cannot see the big picture which is that a new economic principle has been discovered- namely there can be a free lunch if the government says so.
Now HHS needs to get to work on the abrogation of Friedman's second principle; the demand curve thing.Recently an MIT economist re-discovered that principle in regard to medical costs and Medicare.She found that there was an increase in the quantity of care demanded once older folks had the Medicare card which made their health care cheaper. See here for my earlier post explaining the data and analysis employed by the economist to "discover" that people like to spend other people's money.
Might not the huge increase in the number of folks who will be given an insurance card ( or forced to buy one) pose a real problem as there is no concomitant increase in the number of physicians to provide that care.One solution would be for HHS to determine that people do not demand more services and goods when they are cheaper which would solve the problem of a physician shortage.
Getting those silly economic misconceptions out the way should really make Obamacare work more smoothly and all of the social justice embedded in the 2000 pages of the statute can emerge.
Dr Friedman did not live long enough to see that his first principle overturned.
When the dictum of the HHS Department ordering employers to provide medical insurance that included paying for birth control pills hit a snag when the Catholic Church hierarchy raised a loud and righteous ruckus as it impacted Catholic hospitals and schools, necessity once again became the mother of invention.
The Secretary of HHS , in a move alleged to be compromise, declared that: no, the employer would not have to pay but rather the insurance company would. (see here).When challenged with the argument that the insurance company would simply increase the premiums,the Secretary replied;no, the insurance company would not be allowed to do so. Further, that order would actually save the insurance company money because the savings from medical costs not incurred because of the decrease in the number of pregnancies pregnancies would be greater than the cost of the pills. So, not only are the birth control pill free but provide a saving to the insurance company.So it is even better than a free lunch. The insurance companies should be happy to be forced to save money.
But this previously unrecognized saving ( which for some strange reason insurers never recognized on their own) is only the beginning. If taking statins and blood pressure pills decrease the risk of heart attack, should not insurance companies be giving those medications to policy holders as well. After all, generic pills are cheap enough and treating a heart attack is a big ticket item. The opportunities along these lines seem endless.Once insurance companies grasp this principle their profits will soar and they will begin to "give away" a lot of stuff even without government coercion.
Some would argue that these dicta from the Department of HHS make any contract that existed between the insurer and the insured a farce since for hundreds of years a contract based on force or coercion rather than mutual agreement of the parties was considered not valid.(See here for the comments from the Institute for Justice arguing that is exactly what the individual mandate does.) Those naysayers just cannot see the big picture which is that a new economic principle has been discovered- namely there can be a free lunch if the government says so.
Now HHS needs to get to work on the abrogation of Friedman's second principle; the demand curve thing.Recently an MIT economist re-discovered that principle in regard to medical costs and Medicare.She found that there was an increase in the quantity of care demanded once older folks had the Medicare card which made their health care cheaper. See here for my earlier post explaining the data and analysis employed by the economist to "discover" that people like to spend other people's money.
Might not the huge increase in the number of folks who will be given an insurance card ( or forced to buy one) pose a real problem as there is no concomitant increase in the number of physicians to provide that care.One solution would be for HHS to determine that people do not demand more services and goods when they are cheaper which would solve the problem of a physician shortage.
Getting those silly economic misconceptions out the way should really make Obamacare work more smoothly and all of the social justice embedded in the 2000 pages of the statute can emerge.
Friday, February 17, 2012
Remember how HMOs gave physicians more autonomy,ACOs will be even better
Remember how HMOs made patients happier,doctors more satisfied with their work and also brought about better care while bending the cost curve downwards. Well, we are told that ACOs will do that only even better.
Dr. Ezekiel J. Emanuel , in this commentary, in JAMA assures physicians who might have foolishly worried that joining an ACO would lead to some loss of autonomy. He and his co-author argue that actually ACOs offer the opportunity for more ( not a typo ) autonomy.
So how does working with (for?) a large vertically integrated organization which by definition will have a large bureaucracy lead to autonomy?
Here is quote from Emanual's article that suggests one way.
More relevant to physicians' autonomy, the ACA initiates payment reforms that will give physicians greater financial flexibility to redesign care delivery, and to provide services that may not have been reimbursed before. For example, traditional fee-for-service payment mechanisms do not reimburse for efforts to enhance medication compliance or to oversee the results of wireless physiological monitoring in patients' homes.
and more
Another provision of the ACA that offers physicians more liberty to pursue patients' best interests is the move toward accountable care organizations (ACOs), which are combinations of physician groups, hospitals, and other providers that will coordinate care for patients.6 The proposed ACO regulations require physician leadership and empower physicians to determine the information systems and infrastructure necessary for coordinating care. The freedom to redesign care occurs along a spectrum depending on how the ACO is paid.
Does anyone who has worked with the administration of a large hospital or an insurance company really think that the typical ( or atypical ) physician is going to "determine" much of anything."Freedom to redesign" ? More like freedom to follow the rules and guidelines of the organization or seek employment elsewhere.
Some of us may have been fooled or seduced or coerced by the HMOs , fool me twice...
Surveys have indicated a number of physicians will leave practice early because of Obamacare.I guess the prospect of greater autonomy is just too frightening.
Dr. Ezekiel J. Emanuel , in this commentary, in JAMA assures physicians who might have foolishly worried that joining an ACO would lead to some loss of autonomy. He and his co-author argue that actually ACOs offer the opportunity for more ( not a typo ) autonomy.
So how does working with (for?) a large vertically integrated organization which by definition will have a large bureaucracy lead to autonomy?
Here is quote from Emanual's article that suggests one way.
More relevant to physicians' autonomy, the ACA initiates payment reforms that will give physicians greater financial flexibility to redesign care delivery, and to provide services that may not have been reimbursed before. For example, traditional fee-for-service payment mechanisms do not reimburse for efforts to enhance medication compliance or to oversee the results of wireless physiological monitoring in patients' homes.
and more
Another provision of the ACA that offers physicians more liberty to pursue patients' best interests is the move toward accountable care organizations (ACOs), which are combinations of physician groups, hospitals, and other providers that will coordinate care for patients.6 The proposed ACO regulations require physician leadership and empower physicians to determine the information systems and infrastructure necessary for coordinating care. The freedom to redesign care occurs along a spectrum depending on how the ACO is paid.
Does anyone who has worked with the administration of a large hospital or an insurance company really think that the typical ( or atypical ) physician is going to "determine" much of anything."Freedom to redesign" ? More like freedom to follow the rules and guidelines of the organization or seek employment elsewhere.
Some of us may have been fooled or seduced or coerced by the HMOs , fool me twice...
Surveys have indicated a number of physicians will leave practice early because of Obamacare.I guess the prospect of greater autonomy is just too frightening.
Monday, February 13, 2012
Another comment on the "controversy" over HHS dicta regarding reproductive services
A minor political storm emerged over the ruling of the Department of HHS regarding the mandatory inclusion of certain reproductive services in health insurance. Obamacare has made the HHS Secretary the final arbiter of many things in health care including what health insurance plans must cover so this is likely the first of many such mini-storms.
Much of the ensuring public discussion has veered off on tangents which while being perhaps of interest and worthy of discourse per se miss the main point here.
Now to the main issue here .
Those in control of health insurance, which since Obamacare was passed is the HHS Department who answers to the President and is seeming beyond any appellate measure, are not really concerned with the arguments over the particulars of their latest dictum which is only one of very many to come .They do not care so long as those who disagree concede the legitimacy of the power of the central government to make those dictates in the first place.
In fact they may relish the furor over the details of this particular ruling as long the anger is not focused on the legitimacy of the governments authority in this regard. At least they relish it as long as the political fall out seem minor and controllable although it is not clear that is either at this juncture.
Much, if not most, of the outcry have focused on a "battle" between the administration and the Catholic church, or on an alleged great unfulfilled need of women to have access to birth control which they say should not be left to the caprice of employers .Folks who make that latter argument seems clueless as to the obvious caprice of the HHS decisions.
So the major issue is should the government have that power to decide what we must pay for in our health insurance . However, frighteningly, it may get worse that that. This idea is expressed in the following quote from Dr. Richard Fogoros's blog The Covert Rationing Blog .
DrRich has pointed out many times that the real battle we will face as Obamacare is being rolled out is the battle over whether American citizens will retain individual freedom sufficient to be permitted to spend their own money on their own healthcare. Indeed, DrRich has written a series of posts that spells all this out in painful detail. If you need to know why limiting individual prerogatives is so critically important to Progressives, and why Obamacare must be the vehicle for establishing these limitations, simply read the first post in that series.
I see it this way; Once we loose the battle over whether the government has the legitimate power and authority to dictate what health care must contain,it is a short jog down the road for a government with that power to determine what health care may not consist of even if paid for by the patient herself. Could that happen? It happened in Canada. Must it happen? It did not happen in Great Britain?
I hope DrRich's and my fears are wasted and individual freedom will persist in this regard. However, when I see some of the reaction to the latest Obamacare dictum and people are talking about things like whether the Catholic Church ought to modernize its archaic views or the sudden mysterious shortage of birth control methods which must be alleviated by the government while there is so little commentary on the fundamental issue (should the government have that power in the first place),my worry titer goes back up.
Much of the ensuring public discussion has veered off on tangents which while being perhaps of interest and worthy of discourse per se miss the main point here.
Now to the main issue here .
Those in control of health insurance, which since Obamacare was passed is the HHS Department who answers to the President and is seeming beyond any appellate measure, are not really concerned with the arguments over the particulars of their latest dictum which is only one of very many to come .They do not care so long as those who disagree concede the legitimacy of the power of the central government to make those dictates in the first place.
In fact they may relish the furor over the details of this particular ruling as long the anger is not focused on the legitimacy of the governments authority in this regard. At least they relish it as long as the political fall out seem minor and controllable although it is not clear that is either at this juncture.
Much, if not most, of the outcry have focused on a "battle" between the administration and the Catholic church, or on an alleged great unfulfilled need of women to have access to birth control which they say should not be left to the caprice of employers .Folks who make that latter argument seems clueless as to the obvious caprice of the HHS decisions.
So the major issue is should the government have that power to decide what we must pay for in our health insurance . However, frighteningly, it may get worse that that. This idea is expressed in the following quote from Dr. Richard Fogoros's blog The Covert Rationing Blog .
DrRich has pointed out many times that the real battle we will face as Obamacare is being rolled out is the battle over whether American citizens will retain individual freedom sufficient to be permitted to spend their own money on their own healthcare. Indeed, DrRich has written a series of posts that spells all this out in painful detail. If you need to know why limiting individual prerogatives is so critically important to Progressives, and why Obamacare must be the vehicle for establishing these limitations, simply read the first post in that series.
I see it this way; Once we loose the battle over whether the government has the legitimate power and authority to dictate what health care must contain,it is a short jog down the road for a government with that power to determine what health care may not consist of even if paid for by the patient herself. Could that happen? It happened in Canada. Must it happen? It did not happen in Great Britain?
I hope DrRich's and my fears are wasted and individual freedom will persist in this regard. However, when I see some of the reaction to the latest Obamacare dictum and people are talking about things like whether the Catholic Church ought to modernize its archaic views or the sudden mysterious shortage of birth control methods which must be alleviated by the government while there is so little commentary on the fundamental issue (should the government have that power in the first place),my worry titer goes back up.
Friday, February 03, 2012
Obamacare: "anger and division are inevitable consequences of the Law"
The title is a quote from Michael Cannon of Cato.See his commentary .
His current comments are in regard to the latest decree from the HHS Secretary regarding the mandate for the details of the health insurance that Obamacare mandates with the threat of a fine for non compliance. This time the Catholic Church is the focus of attention with the insistence that that organization will, in fact, have to provide insurance that covers among other things,certain reproductive services including birth control pills.
When the government, this time a single high ranking government presidential appointee, decides what you shall have and shall not have in your health insurance, there is bound to be anger and division as Cannon said.
Some folks with a more progressive mind set may be pleased that the enlightened HHS secretary will force a program so that women can afford contraception,but the government control knife cuts more ways. I quote Cannon again
The same apparatus that can force Americans to subsidize elective abortions can also be used to ban private abortion coverage once the other team wins. The rancor will only grow.
Thomas J. Sargent said the following in his address to graduates at UC Berkeley in May 2007.
"Other people have more information about their abilities,their efforts and their preferences that you do."
I suppose even progressive planners would admit that but with a "Yes,but". Yes but we know better what is best for other people.
Of course, with the power of HHS mandates and the reach of IPAB,the apparatus of government health care control system can force certain things and ban others regardless of the wishes and the particular circumstances of the "other people".
The social justice bestowed on us rolls on. It just gets better and better.
His current comments are in regard to the latest decree from the HHS Secretary regarding the mandate for the details of the health insurance that Obamacare mandates with the threat of a fine for non compliance. This time the Catholic Church is the focus of attention with the insistence that that organization will, in fact, have to provide insurance that covers among other things,certain reproductive services including birth control pills.
When the government, this time a single high ranking government presidential appointee, decides what you shall have and shall not have in your health insurance, there is bound to be anger and division as Cannon said.
Some folks with a more progressive mind set may be pleased that the enlightened HHS secretary will force a program so that women can afford contraception,but the government control knife cuts more ways. I quote Cannon again
The same apparatus that can force Americans to subsidize elective abortions can also be used to ban private abortion coverage once the other team wins. The rancor will only grow.
Thomas J. Sargent said the following in his address to graduates at UC Berkeley in May 2007.
"Other people have more information about their abilities,their efforts and their preferences that you do."
I suppose even progressive planners would admit that but with a "Yes,but". Yes but we know better what is best for other people.
Of course, with the power of HHS mandates and the reach of IPAB,the apparatus of government health care control system can force certain things and ban others regardless of the wishes and the particular circumstances of the "other people".
The social justice bestowed on us rolls on. It just gets better and better.
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?
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 .
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".
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:
1.Shortages
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 .
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:
1.Shortages
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?
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.
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:
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.
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.”
Exactly
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.
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.”
Exactly
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.
Monday, December 12, 2011
In health care we don't need no stinking rule of law
The concept of rule of law at a minimal means clarity of laws and regulations and uniform enforcement.
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.
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.
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