do you need a physician to order your blood tests?

There are a number of folks who want to eliminate at least one aspect of  gate-keeper role of the physician  or at least allow people  to order blood tests without getting a physician's order.

To name a few: Dr Eric Topol,Elizabeth Homes,and apparently the governor of Arizona.

Elizabeth Holmes is founder and CEO of a company named Theranos,which has developed a technology to enable a very large number of blood tests to be done from a few drops of blood,less than the tube drawn on a standard veni- puncture.

In April 2015 , the governor of Arizona signed a statute "allowing" clinical labs to perform blood tests without a physician's health care provider's order.

Laboratory Corporation of American has recently announced that they will perform lab tests on folks without requiring a doctor's order. See here for article.

According to the Bloomberg article linked above some twenty states already allow blood tests to be done without a physician's order.However according to this chart more states than that allow what is call "direct access testing". (This table is from a website called Longevity Testing.Com and I cannot attest to its accuracy as there are no links to supporting data.)

LabCorp and Quest and other large commercial labs have seen decrease in fees from CMS cuts and also from fewer referrals from independent physician's office as more doctors move to large groups or are being bought out by hospitals,who have their own labs. So they obviously welcome more direct assess customers.

In some instances a person's copay for a visit to a doctor to get a hall pass for a blood test may be more than the fee for service going the direct access route plus you do not have to wait in the doc;s office to see him and then wait for his office to send you your results.Of course,this assumes that the quality and resource conservation guidelines that he is "encouraged"   to follow will "allow" you to have the test.As you know the American College of Physicians and the American Board of Internal Medicine have declared that physicians are the "stewards" of the allegedly collectively owned national medical resources

Direct access testing fits in nicely with Dr. Topol's latest book The Patient will see you now in which he argues that smart phone based technology will go a long way to the democratization of medicine and the continuing stamping out of the lingering paternalism that was a regular feature of medicine for centuries.

Bad news for pediatricians-good news for ABMS and the hegemony of the progressive medical elite

See this blog posting regarding the unfortunate situation regarding board certification for pediatricians and how, at least so far, the  monopoly of ABMS is preserved.

If possible the MOC situation regarding peds is even worse that that regarding internists and their board, the ABIM.

One major insurer has refused to recognize certification from anything other than a ABMS recognized board.

Quoting Dr. Med Edison in her blog:

 " After months of speculation about insurer acceptance of anything other than ABMS certification, Blue Cross Blue Shield of Michigan is on record refusing certification through the National Board of Physicians and Surgeons. To my knowledge, they are the first to do so.
This is actually a big deal for pediatricians in Michigan. For our internist friends, the ABIM has slowed down implementation of MOC. But the American Board of Pediatrics refuses to listen to pediatricians, and instead instructs insurers to “check” our certificates yearly."

From the narrative related by Dr. Edison the folks at ABIM seem like avuncular colleagues compared to the even more hard nosed folks at the pediatrics board.

It may be too early to say  but it looks like we might see another situation in which the dogs bark and the caravan moves on. If other insurance companies refuse to accept NBPAS certification the viability  of that organization is in doubt.

Who elected the ACP as the"conscience" of medicine?

In a embarrassing display of  self congratulatory praise , in this  commentary Bob Doherty ,senior vice president of the American College of Physicians office of government affairs and public policy, makes the assertion that internists and particularly  the ACP are the "conscience of medicine".

How does he support that claim? First, he cites the advocacy that ACP has provided for universal health care and for other causes..He also quotes from a commentary from Lancet which declared that internists and ACP were the conscience of medicine.Further, he makes the claim that the ACP has always put the patient first even if some aspect of their advocacy might not be in the best interests of internists,while other professional organizations lobby in Washington  for their parochial interests. In his view apparently ACP (or at least its leadership) knows what it is best for the public good and selflessly strives to achieve those goals.

Conscience can be defined as the complex of ethical and moral principles that controls or inhibits the actions or thoughts of an individual or an inner sense impelling one toward right action.

Does Mr. Doherty believe that the ACP has acted in some way or ways that distinguish it from other medical professional groups  in regard to this alleged role as medicine's conscience?

What about pediatricians and their professional organization,the American Academy of Pediatricians, (AAP). If advocacy in regard to certain positions for various social issues is one criterion for being medicine's conscience,one could argue that the AAP has "out-advocated" ACP or at least earned a tie.Maybe ACP and AAP could be the co-conscience of medicine.

For example AAP has taken stands on measures to decrease firearms deaths,supported the Affordable Care Act,increased funding for the Children's health Insurance Program (CHIP) to name a few of their efforts.Since its founding  AAP has  advocated for the "health of all children", so ACP has no monopoly in putting "the patient first" and to claim that it is only internists that put patients first is without foundation and seems more like self serving rhetoric .

The American Psychiatric Association says its mission is in part to promote the highest quality care for individuals. That sounds like they put patients first too. The APA is more modest , however, in that their claim is that APA is the "voice and conscience of modern psychiatry".So maybe ACP should soften its claim and say they are the "conscience of medicine except for psychiatric issues".

In light of the most recent Newsweek revelation regarding executive pay and booking keeping practices and other alleged improprieties  at ABIM in regard to its maintenance of certification program (MOC), perhaps ACP could flex its conscience muscles and actually make a comment about ABIM's behavior.

It might also be in order to make a statement regarding ACP's educational products sold to internists that are promoted  as helpful for ABIM recertification.There are  numbers of internists out there who, rightly or wrongly,suspect there has been a very cozy and cahoots relationship between ABIM and ACP and their foundations with a revolving door type situation regarding the leadership ranks of those not for profit organizations . Surely, the voice of the conscience of  medicine should have something to say about that.

 Does advocacy for certain solutions to perceived social ills or problems constitute evidence for someone or something acting out of conscience?  It might but would it not be more correct to characterize ACP's advocacy for certain solutions as simply expressing views consistent with mainstream progressive thought which is in  some if not most  instances  contrary to mainstream conservative or libertarian thinking.While it may be possible that a majority of internists (I am not aware of a head count) consider themselves progressive, there are doubtlessly many libertarian and conservative internists who find ACP's views on a number of topics not an expression of their conscience.

Can a regular exercise program improve cardiac function in asymptomatic diastolic dysfunction with and without heart failure?

 Well ,at least one recent research paper answered that question in the affirmative.

 Dr. Nole and colleagues  (see below for reference) did a detailed study on the effects of endurance and resistance exercise on a small group of patients, some of who only had diastolic dysfunction (DD) and others who in addition had heart failure (HF) with preserved ejection fraction.

 For purposes of the study normal diastolic function was defined as having: the following echocardiographic findings 1) E/A greater than one,2)E/e prime less than  10 and 3) preserved E/A greater than one during the valsalva maneuver.The E/A ratio is the ratio of early diastolic filling of the ventricle to the late filling (aka atrial kick).The E/e prime ratio is the ratio of velocity of early diastolic filling to the movement of the mitral value annulus as determined by tissue Doppler  and is thought to be a reasonable estimate of the pulmonary capillary pressure,but not under all conditions including Left bundle branch block.

 See here for the full text article.

Basically the exercise program which was mainly endurance training with some resistance exercise which was added later in the program lead to improvement in symptoms in those who were symptomatic and in indices of diastolic function as determined by cardiac echos.

Other studies have also demonstrated that exercise training can improve diastolic function.I have commented before about the effects of long time endurance exercise and the possible mitigation of age related diastolic dysfunction.

 The other site of improvement in exercise capacity resulting from an exercise program is improvement in the A-V 02 difference and several studies have indicated that it is that aspect of physiology that improves in HF patients who benefit from endurance exercise.This is the first paper I have seen that suggests that the heart  benefits as well.


.WNolte K., Schwarz S., Gelbrich G., Mensching S., Siegmund F., Wachter R., Hasenfuss G., Düngen H.-D., Herrmann-Lingen C., Halle M., Pieske B., and Edelmann F. (2014) Effects of long-term endurance and resistance training on diastolic function, exercise capacity, and quality of life in asymptomatic diastolic dysfunction vs. heart failure with preserved ejection fraction, ESC Heart Failure, 1, pages 59–74, doi: 10.1002/ehf2.12007




 

Summertime running in the south, quicker glygogen depletion and possible value of ice slurries

You don't have to be an exercise physiologists to know you cannot run as fast or as long in the summer.

One of the reasons long training runs don't work out as well is  glycogen depletion occurring sooner in hot weather. .This seems to be a fairly well demonstrated physiological fact.See here. Of course, volume depletion is a more dominant limiting factor.

 First, a brief taste of stylized "glycogenology". The classical 70 kilogram person of physiology textbook lore carries around about 100 grams of glycogen in the liver and about 500 grams in muscles.Liver glycogen can be broken down and released into the blood as glucose while muscle glycogen can only be directly used locally to fuel muscle action,getting ATP to the myosin heads.

After a 24 hour fast some 50-60% of liver glycogen is depleted to supply glucose for resting metabolic activities. Indirectly, muscle glycogen can function as a blood sugar source by producing lactate which can be transported to the liver and converted back to glucose (Cori Cycle).Glycogen depletion is a major factor in endurance exercise adventures and this can be mitigated a bit by glycogen loading,ingesting carbohydrates during the event,repleting liver glycogen before the event and by lots of training which hopefully shifts the fuel mix somewhat to fat utilization delaying the time of glycogen depletion.When that occurs you slow down appreciably as muscles fuled mainly by free fatty acids cannot contract as rapidly. 

 So, maybe if you can keep cooler you can delay glycogen depletion.

One thing  you can do to keep cooler seems to be to drink ice slurries.

I quote from an article in the Scandinavian Journal of Medicine and Science in Sports By authors Tan and Lee from the National University of Singapore.See here for abstract.

"The ingestion of ice slurry during exercise is a practical and an effective strategy that greatest the greatest heat sink because of the additional energy required to effect a phase change from solid ice to liquid water.A smaller volume of ice slurrry ( as compared with that of cold drinks is required to achieve similar reductions in body core temperature and improvements in endurance performance."

An earlier paper by J Dugas compared running times in the heat ingesting slurries with cold water and found his subjects could run further before exhaustion with the slurry. See here.

A similar study from Australia   by Siegel and co authors also showed a increase in running duration ( about 20%) in the heat when cold water ingestion was compared with ingestion of ice slurry.See here.

The ice slurry function as a Heat Sink, a concept well known to folks who fiddle around inside computers.The small ice particles have a high surface area to volume ratio which facilitates heat transfer.

If you like snow cones you might give it a try on a hot summer days. I find the  slurries refreshing and fun to eat whether my endurance is enhanced on not. 

The U.S. medical care boondoggle depends on hookwinking the physicians

The terms hoodwink and boondoggle are so appropriate. My comments here were inspired in large measure by Dr Michel Accad's Jan 2009 insightful  blog entry from which I quote:

'... beyond ignoring the obvious tension between the individual and the group,hoodwinking physicians into practicing "population medicine" is of course the essential  means to confuse practitioners into thoughtlessly carrying out sweeping intervention whose primary benefit is the profit of third parties."

 to this I add :  and the profit-not necessarily in monetary terms-of the academics whose writings give a scholarly veneer to this monumental hoodwinking enterprise.

See here for Dr. Accad's entire essay,

In this regard several terms and concepts are important:  population medicine, physicians as stewards of finite resources,cost  effectiveness research and  high value care. The key idea is to establish the notion that medical resources is a collectively owned resource and all are entitled to it by virtue of their existence. From this follows that the  utility of the aggregate matters and not that of the individual and that  some one has to manage this collectively owned resource and the elite medical progressives are the self nominated candidates for that job.

The medical  progressive's claim  to being egalitarian advocates of social justice is contradicted by their advocacy for a utilitarian approach to the allocation of these finite resources. Utilitarianism is not a subset of egalitarianism.A leading egalitarian, John Rawls accurately characterizes utilitarianism as being inattentive to the separateness of individuals and treating people merely as means for the achievement of some aggregate or social end. The medical progressives claim to promote social justice in the abstract but operationally sponsor utilitarian calculus in which some individuals may suffer to further  some alleged statistical benefit to the collective. The progressives play the social justice card frequently in their polemics profiting from this polymorphic notion's lack of generally agreed upon specificity - the term social justice is loose , vague and indeterminate.

The medical progressives causally dismiss the notion of rationing by their unilateral re-definition  which excludes the limiting of "low value" care from their universe  of rationing. Rationing according to this formulation means only limiting high value care and they presume they will be the arbiters of what value is high and what value is low. 


Another linguistic trap is to speak of a given medical expenditure as a "cost to the system" rather than an exchange.  So when someone goes to the ER with chest pain or severe headache that is considered to be a cost to the system or even more ridiculously a drain of resources rather than providing a service for a fee and the transfer of funds as part of various exchanges that are part of the ER medical encounters.

 When someone goes to a car repair shop to replace a radiator or visits a barber for a haircut why do we not speak of draining the car care industry's resources or depleting the finite hair care resources?It is because to a large degree we are paying for the medical care with someone else's money It is the third party payers and their academic facilitators that have accomplished a monumental hoodwinking of the public and most of the medical profession by distorting the language of medical care and shifted the emphasis from a long standing  oath based imperative to care for the patient to one of limiting care the effect of which is to benefit the third party payers

 The language of medicine has been transformed into the language of medical collectivism and the third party payers owe a large debt to the efforts of the collectivists in medical academia and to some of those individuals in influential leadership positions of certain professional medical associations.

In support of the claim that many physicians have been hoodwinked is the amazing amount of support  from professionals medical organizations for the passage of the so-called "doc-fix" or MACRA which mainly replaced one centrally planned system of price controls with another such system , one that placed even more control of medical care in the hands of federal planners and administrators and some "thought leaders" who have arisen from the leadership of various national medical organizations with important input from the lobbyists from the "Bigs" (big pharma,big hospital, big insurance,etc)


In closing I quote Dr. Accad again with this masterful summary:

" But beyond ignoring the obvious tension between the individual and the group, hoodwinking physicians into practicing “population medicine” is of course the essential means to confuse practitioners into thoughtlessly carrying out sweeping interventions whose primary benefit is the profit of third parties.  Only clever sophistry can claim to reconcile the needs of patients with the profit margin of insurance companies, the bottom line of hospital administrators, the end-of-the-month income of practitioners, the annual reports of employers, the promises of legislators, the zeal of government regulators, the self-importance of academics, the confused intentions of voters, and the pocketbooks of taxpayers.  The term “society” simply conceals the myriad of interest groups that partake in the boondoggle we call the health care system."

endurance exercise and the right ventricle-some thoughts

The issue of the effect(s) of endurance exercise on the right ventricle bothers me from time to time and I have blogged about it before.(see here)

A number of studies have shown that endurance exercise, marathons,triathlons, etc,  may result in transient changes in right ventricular function  (increased volume , decreased ejection fraction), while such changes in the left ventricle are typically not the case although some transient changes have been documented..But an important question is- do repeated episodes of prolonged exercise lead to some deleterious changes in the right  ventricle  which could include a predisposition to ventricular tachycardia or worse.Is there an exercise induced clinical picture of ARVD in someone who does not have the recognized genetic profile for ARVD?(see below).After thinking about it again and reading more about it,I think maybe but it does not seem to happen very often.

J. Ector and co workers studied right ventricular  (RV) function  in a group of  22 endurance athletes who had experienced episodes  of ventricular arrhythmias and concluded "Endurance athletes with arrhythmias have a high prevalence of right ventricular structural and/or arrhythmic involvement." ,the implication being the repeated endurance events predisposed to the rhythm problems (Eur Heart J. 2007, Feb 28 (3),345-53)

LaGerche studied 39 endurance athletes, see here, immediately after an endurance event,and one week later with echocardiography and Magnetic resonance Imaging. with gadolinium. Transient RV function changes noted immediately after  the event resolved by one week but 5/39 demonstrated  late deposition of gadolinium (delayed gadolenium enhancement or DGE) in the interventricular septum.The authors seemed to assume that the MR findings were fibrotic lesions and were causally related  to multiple bouts of endurance exercise but the actual cause of the late deposition of gadolinium has not been determined but it is true that  in some contexts ( maybe most) the histologic basis of the delayed gadolenium uptake is fibrosis.

Arrhymogenic right ventricular dysplasia (ARVD)-also called Arrhymogenic right ventricular cardiomyopathy) is an inherited condition primarily involving the right ventricle with replacement of cardiac muscle with fibrous tissue and fat, leading to decreased  right ventricular function and predisposition to arrhythmias including ventricular tachycardia and ventricular fibrillation.. Typically it is inherited as an autosomal dominant and involves several mutations in the genes that code for the desomsomal adhesive proteins which function to help bind muscle cells together.

ARVC is much more common in Italy and naturally there is more awareness in Italy and more more published research. The most common cause of sudden cardiac  death in the young in Italy is ARVC accounting for 22% of deaths versus 7 % from hypertrophic cardiomyopathy (HCM) in contrast to  HCM being the most common congenital problem found in sudden deaths in young athletes in the United states.See here for details of the long standing cardiac screening program in Italy.

While it seem reasonable to conjecture that a person with one of the ARVD gene patterns might hasten the clinical manifestations of ARVD by endurance exercise , is it possible/likely that a person could bring about an  ARVD-like clinical picture by repeated endurance training and endurance events in the absence of the Italian or other recognized  genetic patterns ?

Earlier work in 2009  by Breuckmann et al ( see here ) also demonstrated some marathoners with delayed gadolenium enhancement (DGE) but in a different distribution that seen in LaGerche's subjects. Of 102 marathon runners age 50-72 who had run at least five marathons in the preceding 3 years,12 showed a DGE .Of those, 5 had a "coronary artery disease" pattern along the distribution of the left anterior descending coronary artery while 7 showed a "predominantly midmyocardial patchy pattern".Could these midmyocardial patches of presumed fibrosis be the earliest lesions of a endurance athlete's cardiomyopathy, which to my knowledge, except for arguably ARVC , has not been reported. Have autopsies been done on Tarahumara runners?

Standard maximal heart rate prediction formula may result in an underestimate

For stress tests purposes ( regular treadmill and nuclear exercise imaging) physicians  typically use the formula : Maximal heart rate =220-age.

Another formula is the Tanaka formula; Maximal heart rate =209-.7age

More recently based on a Norwegian study by Nes  and co workers the following formula is suggested :

Maximal heart rate= 211-.64 with an error term of +/- 10.8. See here for reference.

For the three formulas applied to a 75 year old we get maximal heart rate predictions of
145,156 and 163 . (Standard,Tanaka,Nes)

Frequently stress tests are terminated at when the patient reaches 85% of the predicted max heart rate.
For the three formula we get :

123
132
138.

The validity of a stress tests depends in part on having the patient exercise to a high enough level to induce some degree of stress into the stress tests and use of 220-age formula would seem to make  false negative tests more likely.This is not breaking news, Tanaka said as much in his 2001 article in the American College of Cardiology Journal  but still some  stress test facilities still use the 220 formula . See here.

Do we neeed to worry about the right ventricle in endurance exercise?

Is the right ventricle the Achilles heel of endurance exercise? I wrote briefly about this subject in 2007 .

In that regard there is more data now about which to fret.  A 2011 article by researchers in Australia and Belgium  gives reason to believe that endurance exercise affects the left and right ventricles differently and possibly  not in a good way .Could endurance exercise induce chronic changes in the structure of the right ventricle such that it is vulnerable to ventricular arrhythmias, similar to those related to an inherited cardiomyopathy (arrhythmogenic right ventricular cardiomyopathy).  See here. ARVC is very uncommon in the US but more commonly seen in Europe particularly in Italy where it is said to be the most common cause of sudden cardiac death in young athletes.

 The authors studied 40 well trained endurance athletes before an event , immediately afterwards and 6-11 days later.Echocardiograms were done at all three times and cardiac MRs were done at baseline. 

 Immediately post race, right ventricular ejection fraction was reduced  and RV volume was increased while comparable   changes were not present in the left ventricle. RV function did recover by one week except for an echo derived index  called "global strain".(In echo lingo strain means deformation which can be determined by tissue Doppler techniques)

Five of the 39 athletes demonstrated delayed gadolinium enhancement (DGE) in the ventricular septum. These changes believed to represent fibrosis were more common in the athletes who had  been competitive endurance athletes longer  and the authors suggested that the areas of  fibrosis noted on the gadolinium scan were in the area of the septum which bulges into the left ventricle as a result of the tissue deformation noted  in the right ventricle.


As the authors stated, the long-term clinical significance warrants further study.Will there be re-modelling of the RV in such a way as to predispose to ventricular arrhythmias?

Another publication by some of the same authors  had previously examined the prevalence of gene mutations in athletes with complex ventricular arrhythmias. Specifically they looked for desmosomal gene mutations of the type typical of ARVC ( Arrhythmogenic  Right Ventricular Cardiomyopathy). Desmosomes are complexes of protein that function to facilitate cell to cell adhesion. In 20 of the 47 cases no desmosome gene mutations was identified.A suggestion was made that prolonged endurance exercise could bring about remodeling of the right ventricle which would predispose to ventricular arrhythmias  even in some athletes who do not have the recognized desmosomal gene mutation..I wrote in more detail about this study here.

The right ventricular issue may well be worth worrying a bit about but the small but consistently  increased incidence of atrial fibrillation in long term exercisers has a more robust data base in its support. 

Is the doc-fix bill worse than SGR?

Here is what Dr. Scott Gottlieb has to say in his Forbes column on 3/19/15:

"The current Medicare reforms being put before Congress ( he was writing before the bill was passed) are better than the existing scheme, the so-called sustainable growth rate or SGR. But the new measures sill envisions Medicare actuaries and  at the center of a price setting process. Now they will also have the authority to mandate clinical practice standards. That this woeful development stands as an improvement to the status quo is a measure of how much our current approach has corroded so many aspects of medical care."

That is I believe the worse and most important part of MACRA. The folks at Medicare will mandate clinical practice standards that it turn will drive physicians compensation.Some well intentioned physicians working within various medical societies sincerely believe they can inject rationality into those yet to be written standards.Those well intentioned few are up against the lobbying powers of the various crony capitalists,the bureaucratic inertia of the administrative state, and the bully pulpit power of a subset of the leadership of professional organizations who either sincerely or cynically advocate for the purportedly calculable  good of the collective over the individual patient.

Yes, of course it is good that physicians no longer have the threat of a 21% immediate reduction in fees and to receive a slight increase (less than the rate of inflation) but after you look past that the slight and temporary  gains made now will seem like a Pyrrhic victory and I believe that Dr. Gottlieb may have been overly optimistic in his comments.

One of the reasons allegedly for the widespread support of MACRA was  that the impending 21% cut would force many physicians to opt out of Medicare. I submit that once the Merit Based Incentive Payment System (MIPS) is implemented and understood by practicing physicians it will be likely that even more physicians will leave Medicare.

Will well meaning  physicians somehow find the time,money and energy to fix the heretofore inadequate or harmful quality measures replacing them with better ones?  Will the CMS quality "metrics" some how escape  the inescapable  reach of Goodhart's law?  A measure of something looses its value as a measure when it become a target. With quality measures as will be defined by CMS and resource utilization embedded into MICRA  more and more medical decisions will be made in Washington and physicians will be less and less able to act as the fiduciary agents of their patients with trust in physicians and reliance on evidence based medicine fading away.

For a detailed and frightening analysis of what MACRA contains please read this commentary by Dr. Arvind Cavale. See here.

There is so much to fret about that is explained by Dr. Cavale  not the least of which is the move to have your physician share the insurance risk with the insurance company. Have a nice day.

The Doc Fix, prayers of the progressive medical elite have been answered and then some

In regards to the passage of the doc fix bill (known now by the acronym MACRA) John Goodwin said it well: " it locks in Obamacare's vision of the relationship between physicians and the state." ... Now, doctors and patients will have to get used to a new reality where the federal government and beltway lobbyists’ priorities are more deeply embedded in physicians’ offices than ever."

Further the exact details and degree of the embedding will not be made known  until  phase three of new payments system. Remember we have to pass the bill to see what is in it?

The changes made in physicians payments are in three phases and from the years 2015 -2020 there will be a 0.5% increase in physician CMS fees and from 2020 -2026 the increase will be zero.

Phase 1 is the "lull-docs-to-sleep" phase in which all physicians will "enjoy"  increases in the payment schedule  (that do not keep pace with inflation) and for a while not worry about the always impending threat of a SGR imposed fee cut. This is the deal that is too- good- to -pass-up phase which typically  occurs in the early stages of a scam.This phase runs from 2015 to 2019.Docs who are part of an APM )(see below) will receive an extra 5%.

Phase 2 is what I call the the devil is in the details phase.Physicians will be reimbursed based on a formula that takes into account  four buzz word filled metrics.The categories of metrics are 1)quality 2)resource utilization 3)meaningful use of electronic health record. 4) clinical practice improvements. This phase runs from 2019 through 2025 and the overarching   buzz word  is MIPS (Merit based incentive payment system).
 CMS will play the major role is setting physician payment.Note the meaningful use requirement will likely have more teeth and there is reason to believe that the much reviled MOC has received more statutory authority,although there are conflicting claims as to whether MOC is explicitly in Doc Fix or if it was already part of ACA or not in either.The National Quality Forum (NQF) is contracted by CMS for three years to provide advice and make suggestions regarding quality issues.It should not go unnoticed that the CEO of the NQF is the same Christine Cassel who was CEO of ABIM during the time that MOC was implemented and the Choosing Wisely Campaign was launched.

Whoever the rule makers will be will be targeted by lobbyists stake holders to try and mold the rules to suit their particular concern.

Phase 3 is the everyone-work- for- the-man final phase  in which physician pay will be dictated by their involvement in a "alternative payment model", examples of which would be an ACO or a medical home or some sort of scheme involving large vertically integrated health behemoths.This phase begins in 2026.

Medical decisions will be shifted even more than they are  now to Washington and the wishes of Don Berwick and Troyen Brennan that they expressed in their book  New Rules are much closer to being realized. I quote from their writing:

"Today, this isolated relationship[ he is speaking of the physician patient relationship] is no longer tenable or possible… Traditional medical ethics, based on the doctor-patient dyad must be reformulated to fit the new mold of the delivery of health care...Regulation must evolve. Regulating for improved medical care involves designing appropriate rules with authority...Health care is being rationalized through critical pathways and guidelines."


The Doc Fix also moves forward the recommendation of Dr. Robert Berenson that he and a co-author made in a 1998 Annals of Internal Medicine Article ( p 395-402):


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

MACRA will go a long way to achieving that proposal.

After 18 years and randomized trials with 25,000 men ,the relationship between 5 ARs and prostate cancer is still ??

This commentary from JAMA give a good summary of where we are with 5 ARs ( Five alpha reductase inhibitors) and prostate cancers.Large randomized clinical trials (PCPT trial and the REDUCE trial have been done with  finasteride (Proscar) and dutasteride (Avodart).

My take is that  the 5 ARs seem to reduce the risk of developing low grade prostate cancer but may increase the risk of higher grade prostate cancer. However, a reasonable argument can be made that the 5 ARs do not in fact increase the risk of high grade cancer but just make the cancers more easily detectable but we probably will never know because is is unlikely that many further studies will be done and  I doubt further analysis of existing data will be convincing.

One can also argue that a 5 AR driven decrease in the occurrence of low grade prostate cancer may not translate into fewer prostate cancer deaths. Most every diagnostic or therapeutic  decision involves a tradeoff, but here exactly what the tradeoff here is remains unclear.The drugs clearly decrease prostate size but in regard to prostate cancer there is much lingering doubt.

As hard as answers are to come by in preventive medicine issues ( think the changing panorama of suggestions for healthy diets and aspirin use, glucose control in diabetics, etc), it is astounding that the population medicine folks think that they can discern what preventive measures "should" be done and would be willing to recommend  that some should have to forgo treatment  so some in the future would be the beneficiary of some greater aggregate good. See here for Dr. Harold Sox's plan for just that policy.Hubris-city.

 I used to spend considerable time giving preventive medicine advice in the context of a corporate wellness program. As I think back on what I said then ( with more certainty that the data warranted ) I have more than a few doubts now about what I said then. The only thing I am more sure about now is that for the most part regular exercise is a good thing. I am much less sure about the advice I gave about aspirin and statins for primary coronary disease prevention and for PSA screening and screening for bone density. It may well be that randomized clinical trials are the best we can do in terms of discerning medical management plans but it not uncommon to finalize RCTs  and still the answer(s) remain undetermined as is the case of the reductase inhibitors.

The old plaintiff lawyer meme of "Doctor, were you wrong then or are  you wrong now" continues to hit home, particularly in the enterprise of preventive medicine.

The medical progressive's fear-that someone,somewhere is deciding with his physician's input what his health care should be

H.L. Mencken defined Puritanism as that haunting fear that someone,somewhere may be happy.

The Medical Progressive Elite's haunting fear is that someone,somewhere is making their own medical decisions with input from their private physician.This fear is shared by the third party payers. In recent years,there appears to be considerable progress in alleviating their fear.

The last thing that the third party payers and the medical progressive elite want is that medical decisions be made  a physician- patient "dyad".This situation is ripe for a classic Baptists and Bootleggers scenario,the medical elite sincerely believing that medicine is too complex and expensive to be left to the judgment of patients with advice from their physicians and the third party payers striving to decrease the cost of doing business and increasing profits share holder value.

This medicine-is-too important-to-be left-patients-and-their- physicians view  is made crystal clear in the following quote from the book,"New Rules"  written by Drs. Don Berwick and Troyen Brennan:

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


Dr.Berwick went on the be the  head of CMS for a while and Dr. Brennan went on to be the chief medical office of Aetna insurance company and then CVS Caremark.Sometimes the line between the Baptists and the Bootleggers gets a bit blurry.

Destroying the physician patient dyad or relationship  has been a strategic goal of the progressive elite for years and a major initiative to that end was the 2002 publication "Medical Professionalism in the New Millennium:A physician charter".That was a joint effort by the ACP Foundation,the ABIM Foundation and the European Federation of Internal Medicine. The project chair was Troy Brennan and, in my opinion, importantly in terms of future funding and  promotion of the "charter" a member of the project was  Dr. Risa Lavizzo-Mourey of the Robert Wood Johnson Foundation.The RWJF has been a major source of funds for the ad campaign for the Professionalism project.  She has been the CEO and President of the RWJF since 2002. Dr. Harry Kimball ,president of ABIM from 1991 to 2003 was also a project participant.

The Professionalism 's theme is to downplay the fiduciary role of the physician to the patient and insert a nebulous co-duty of  the physician to be a steward of society's limited medical resources and to work for social justice. A particular political agenda was inserted into medical ethics. For physicians who wondered how that role was to be played out, later the ABIMF clarified  things by explaining that one could be a steward of the [collectively owned] medical resources  and social justice would be achieved by providing efficient health care.In one document the authors changed the nature of traditional medical ethics and  also rewrote the meaning of social justice which was now efficient care as opposed to the widely accepted meaning of social justice as redistribution.  In a bait and switch move they have redefined social justice as efficient health care attempting to aggregate the values that individuals might place on a treatment with some collective metric allegedly representing the greatest good to the greatest number.They then further simplified things for the practicing internists (actually all physicians) by gratuitously asserting that following guidelines would be the road to social justice.

Disappointingly, the AMA went along with this flim flam sophistry of the physicians as stewards of society's collectively owned medical resources.See here.

In the ACP-ABIM world no longer would the patient and the physician  be the primary determiners of a test or treatment value but value would be designated as high or low  primarily on a cost effectiveness calculus.Rather than treating each patient as an independent moral agent an aggregate utilitarian metric would be imposed  in which "high value care" is not in the eye of the patient but rather defined by a third party and expressed in  quality adjusted life years per dollar spent The only or at least determinate value is economic efficiency.

Of course, the medical professional elite is a subset of the larger progressive community whose operational credo is that most things are too complex and complicated  to be left to average people and if they will not listen to the delivered wisdom they should be compelled  while the progressive's polar star and major talking point is  to fight against inequality. The poster child for the stick approach has be the comments of Dr. Robert Benson Jr.,the emeritus president of ABIMF,writing on the blog of the ABIMF:

" CMS, which has the ultimate negotiating position in the form of reimbursement for Medicare services, could only accept negotiated bundled charges. It could also refuse payment for non-compliance with the Choosing Wisely recommendations."...ABIM could require candidates to achieve a perfect score on questions related to costs and redundant care as a requirement for admission to secure exams for initial certification or MOC." (This would seem to be a rather severe penalty for not complying with a "recommendation" which Benson thinks should be an edict.)

Consider how important the Choosing Wisely rules would be if  Benson's wishes were enacted.Consider how much of a target the Choosing Wisely decisions would be to various lobbying groups.Third party payers would relish such a situation.


If you want to know what the ABIM and its foundation are about, just read  the ABIMF blog.

The combination of mega hubris and libido domini spells trouble in health care as it does pretty much everywhere.


minor spelling and punctuation corrections made on 3/31/15 and 4/21/16

Newsweek article echos practicing internists concerns about the ABIM and the ABIMF

 Rising criticism about the American Board of Internal Medicine and its twin, the American Board of Internal Medicine Foundation is getting wider coverage.

The leadership at the ABIM-ABIMF cannot be happy with this recent article in Newsweek by Pulitzer :Prize winning investigator journalist, Kurt Eichenwald.

Most of the article highlighted the activities of the ABIM but he did say the following about the ABIM Foundation:


"And there is another organization called the ABIM Foundation that does...well, it’s not quite clear what it does. Its website reads like a lot of mumbo-jumbo. The Foundation conducts surveys on how “organizational leaders have advanced professionalism among practicing physicians.” And it is very proud of its “Choosing Wisely” program, an initiative “to help providers and patients engage in conversations to reduce overuse of tests and procedures,” with pamphlets, videos and other means."

As to the growing opposition to the actions of the ABIM and questions about what the ABIMF is all about , I wonder if Dr Benson,emeritus CEO of ABIMF  might wish the following comments had not been published on the AMIF's blog: I have added the bolding.


" CMS, which has the ultimate negotiating position in the form of reimbursement for Medicare services, could only accept negotiated bundled charges. It could also refuse payment for non-compliance with the Choosing Wisely recommendations."...ABIM could require candidates to achieve a perfect score on questions related to costs and redundant care as a requirement for admission to secure exams for initial certification or MOC."

Apparently , in Dr. Benson's eyes the Choosing Wisely pronouncements are ( or should be) more that a few talking points that physicians and patients can focus on as they discuss what might be "the right treatment for the right patient at the right time" .There should be requirements for Medicare payments and demonstration that a ABIM exam candidate has mastered them before they would even be "allowed" to take their "secure examination".  Comments such as these suggest more is going on at ABIMF than harmless mumbo-jumbo. It is worthy of that  other medical policy wonks are sending up trial balloons for proposals  giving Choosing Wisely regulatory teeth. See here.

The more light shined on the folks and activities at ABIM-ABIMF the less likely they will be able to preserve their phoney-baloney,self appointed positions. 


H/T Dr Wes

Addendum Walter Bond on his blog asks will the ABIM board members, present and the recent past,defend what they did or argue that they fought against all the bad stuff and blame as much as possible on Dr. Christine Cassel.See here

Defensive backs at greatest risk for serious head and neck injuries from football.

This article from AANS regarding traumatic brain injury (TBI) data from 2012 discusses sports related concussions and the more serious brain injuries and injuries to the cervical spine.

Defensive backs in American football are at the greatest risk for both fatal head injury and serous cervical spine injury. Quoting the report:

"The majority of catastrophic injuries occur while playing defensive football. In 2012, two players were on defense and one was in a weight lifting session. Since 1977, 228 players with permanent cervical cord injuries were on the defensive side of the ball and 55 were on the offensive side with 44 unknown. Defensive backs were involved with 34.6 percent of the permanent cervical cord injuries followed by member of the kick-off team at 9.2 percent and linebackers at 9.5 percent."

Spending even a small amount of time watching high school,college and professional football on TV makes it clear that the vast majority of high impact collisions occur in the defensive zone involving defensive backs and either runners or receivers and on kickoffs.Quarterbacks receive many hits with the helmets impacting the ground and have a significant risk of concussion but apparently have  lower risk of fatal injury or injury leading to permanent disability.Offensive linemen may receive more sub-concussive head blows over a game or a season and whatever the long term consequences of that may be but seem less likely to regularly  be involved in high impact collisions and therefore less at risk for serious brain or cervical spine injury

Don't let your babies grow up to be defensive backs

As the destroy fee for service movement ramps up just remember there is no perfect compensation mechanism

 The Obama administration is ramping  up the campaign against medical  fee for service and claiming they want to pay for quality not quantity of care. See. Dr.Paul Hsieh (of the blog We Stand Firm)  remarks about that issue here. It is really about cost control.

Quoting the economist, Arnold Kling:

"Keep in mind that there is no perfect system for compensating doctors. For example, if you pay them a fixed amount of money per patient, then their incentive is to see a lot of healthy patients and avoid the sick ones. If you pay them a fixed salary, their incentive is to work short hours. If you pay them for “quality care,” that means that a central bureaucracy, comparable to IPAB, has to define the meaning of quality."   

Of course it is all about incentives.

And remember Goodhart's Law- when a measure become a target it looses its value as a measure.Further many of the so-called quality targets do little to enhance patient care and some can be harmful,remembering the four hour pneumonia rule.

The various rent-seeking special interest groups  and certain members of the progressive medical elite have considerable control of the current narrative and we will hear more about the horrors of fee for service and nothing about the incentives physicians face in a capitated system or as employees of large vertically integrated health care conglomerate..

Are patients pawns on the chess board of population medicine?

They would seem to  be at least so it appears to be in the presentation of the "population medicine approach" of by Dr. Harold Sox,former editor of the Annals of Internal Medicine, former president of the American College of Physicians (ACP) and former chair of the U.S. Preventive Services Task Force, offered in the November 13 ,2014 issue of  the Journal of the American Medical Association (JAMA).

Here is my thumbnail summary of what Dr. Sox wrote in describing how the population medicine approach would work.The major important diseases would be identified as would methods for their prevention. With that knowledge in hand , then funds could be transferred across patients and disease processes so that the maximal overall health benefit could be achieved.In this process it might well be that sometimes funds would be diverted away from the testing and treatment of some so that the preventive measures could be funded and then  " in a few generations" the benefit would be fully realized.He is explicit regarding the fact that in the short run some people would be harmed although he does not seem to explain why it would be only the short run as would not new preventative measures always be formulated and have funds diverted to their execution.The population medicine advocates claim the approaching of each patient strictly as a individual is "obsolete" and  are promoting a statistical medicine that claims to be capable of provided the greatest health benefit to the greatest number.Practicing physicians know how difficult it can be to recommend what might be best for the individual patient,the "populationists" glibly claim to know what is best for everyone.

In chess, pawns or for that matter any piece, might be sacrificed in executing a strategy of placing the opponent 's king in checkmate. Is it the case that individuals might be sacrificed in executing a strategy of maximizing the health of the specified population as measured by some metric such as quality adjusted life years  (QALY) per dollar spent ? After careful study and  multiple re-reads of Dr. Sox's article my answer to the question posed in this commentary's title is yes.The patients are the pawns on the chess board of population medicine.

Maybe the health care supply curve slopes upwards and more ACA bait and switch

See here for a review of a recent NEJM article that supplied data indicating that the temporary increase in Medicaid fees which was part of ACA  may have increased access to medical care.So as Medicaid professional fees increase more services are supplied.

From Nov 2012 to July 2014,

" [t]he availability of primary care appointments in the Medicaid group increased by 7.7 percentage points, from 58.7% to 66.4%, between the two time periods. The states with the largest increases in availability tended to be those with the largest increases in reimbursements, with an estimated increase of 1.25 percentage points in availability per 10% increase in Medicaid reimbursements (P = 0.03). No such association was observed in the private-insurance group. During the same periods, waiting times to a scheduled new-patient appointment remained stable over time in the two study groups."

So now that the Medicaid fee increase has elapsed and fees will be cut should we not see a decrease in availability? The specter of more folks on Medicaid and fewer docs likely to see Medicaid patients is part of why this article talks about the great bait and switch of ACA.We see more of a distorted version of social justice emerging from Obamacare.

Is Maintenance of Certification (MOC) part of ACA and who put it there?

The short answer is :

Yes, MOC  has been implanted into the legislative structure of ACA and for many (most?) practicing physicians this is really breaking news and for those of us who oppose the ABIM's MOC program, may mean  bad news.

 Dr. Wes explicates how the Maintenance of Certification has been made part of Obamacare in his recent blog entry in which he questions the viability of an alternative "Board" to challenge and hopefully replace the ABIM's widely criticized MOC program.Does the letter of the law with its establishment of MOC in some aspects of Medicare preclude the replacement of ABIM's MOC with some less onerous process by a rival organization?  


"The Affordable Care Act (ACA) modified Sections 1848(k) and 1848(m) of the Social Security Act which defines how CMS pays physicians for their services.  Section (k) is the section that defines how a "Quality Reporting System" is to be set up (with subsection (4) requiring the "Use of Registry-based Reporting") and Section (m) defining physician incentive payments physicians might receive if quality reporting occurs properly. (Sadly, those CMS incentive payments do not cover the cost of participating in MOC for most of us.)

Section (k) was modified by the ACA to include the ABMS MOC program as a "physician registry."  The registry was "defined" as requiring all four parts of the MOC program created by the ABMS, including the much-maligned "practice improvement modules" that have been described by the physician community as overly time-consuming, irrelevant ...."


After re-reading of the relevant sections, it is not clear to me exactly what penalty a physician would incur by forgoing MOC. I welcome any input regarding that.

ABMS's MOC program is part of the law and what ever alternative organization set up to do some version of less onerous MOC is not part of the law and IMO the political clout of the rank and file real physicians is likely not up to the task of changing the law.


Dr. Wes, see here, raises interesting questions about possible collusion between principals in certain organizations  and CMS, those certain organizations being some of the ones which would  benefit financially  from the statutory establishment of MOC in ACA.

 Medical certification boards would obviously profit from the MOC process being quasi mandatory  or tied in in real ways to a physician's compensation.  Dr. Wes focuses on two physicians with ties to ABIM and ABIMF and CMS and the National Quality Forum which incidentally receives significant funding from CMS.

[An interesting aside is that a member of NQF's Board is Liz Fowler, currently a VP at Johnson and Johnson and someone who  played a major role in the drafting of ACA. See my earlier commentary entitled  "Who Wrote Obamacare and where is she now?") Ms. Fowler has been described , accurately in my opinion, as the poster girl for the revolving door in regard to government and major health care players.It seems that some of the prominent medical elite know how to open the doors as well.}

Quoting Dr. Wes:

"Troubling concerns of collusion of ABIM board members with the Center for Medicare and Medicaid Services (CMS) and the National Quality Forum (which receives the bulk of its revenues from grants supplied by CMS) exist. Christine Cassel, MD, who is the current President and CEO of the National Quality Forum, was President and CEO of the ABIM from 2003 to 2013 and ultimately responsible for the $2.3 million dollar luxury condominium purchase by the ABIM Foundation in December, 2007....."

Dr. Wes then chronicles the job history of the current ABIM CEO, Dr. Richard Baron who was associated with ABIM and then left to be a full time employee of CMS from 2011 -2013 and came home to his current ABIM's six figure salary.

Again quoting Dr. Wes:

"Which leads to the question: how much influence did the ABIM leadership have in establishing a continuous money stream for itself and its Foundation during the writing and mark-up of the Affordable Care Act? (see pages 247 and 844-845 of this large pdf). Clearly, there should be public record available to this effect and physicians should inspect this record before creating an alternate MOC pathway"

The fact that the term "professionalism" is found in ACA may be significant.. ABIMF has been promoting their particular version of professionalism for several years such promotion being the major stated goal of that organization. Unlike traditional medical  ethics the ABIMF professionalism embeds the obligation of social justice and an obligation for physicians  to act not only for the individual patient but for some collective,which operationally could be a given ACO or HMO. Has or will ACA make the ABIMF's sea change professionalism "the law of the land"?

Statutory language does not appear by a random process.Public choice theory tells us to look at who might profit from a given law or regulation and often you will find who was responsible for it.  Cui bono.

If you wondered what the American Board of Internal Medicine Foundation was all about...

I have asked more than once on this blog why does the American Board of Internal Medicine (ABIM) have a foundation ( the ABIMF).Why did one non-profit set up another one?

 Dr. Westby Fisher, writing  on his blog "Dr. Wes"  provides an eye-opening and in my opinion, shocking narrative about what is happening at the ABIM and ABIMF.This detailed expose about the ABIM and the ABIMF should be required reading not just for internists but for all physicians .

This entire article should be read and shared with colleagues.Here are some highlights and excepts as well as some of my comments.

The ABIM established the ABIMF  and  is its major source of funds. (I am aware the the Robert Wood Johnson Foundation gave the ABIMF 5 million dollars for its Choosing Wisely campaign, but most comes from ABIM)

The ABIM's source of funds is mainly from testing internists for certification and more  recently for maintenance  of certification (MOC) testing. It seems that if you subtract their operating expenses from their money flow from testing and certifying and re-certifying internists there is a lot left over to give to the ABIMF.

The principal activities  of the ABIMF are promotion of the new medical professionalism and   the Choosing Wisely Campaign while the ABIM is pushing its maintenance of certification (MOC) program.. Choosing Wisely  began as an apparently reasonable, mom and apple pie  program but may well be morphing into more than that or at the least a number of policy wonks ( and the former CEO of ABIMF) want it to be more controlling than the simple "conversation" between  physician and patient that is was originally purported to be.See here for a commentary about remarks made by the former CEO of the ABIMF ( Dr. John Benson) on the ABIMF 'blog  and by Dr. N, Mortin writing in the NEJM. Both speak of enforcement of the ABIM's edicts recommendations.

So, internists take tests for the which the costs and requirements continue to increase and the "profits" (at least cash in minus expenses) or a significant percentage of it is funneled to the ABIMF where it is spent on   promotion  of the seemingly ever expanding Choosing Wisely campaign as well as the medical  ethics game changing new professionalism.

Quoting Dr. Wes:'s introduction:

"Is it "medically professional" for a non-profit organization to use physician testing fees to "choose wisely" a $2.3 million luxury condominium complete with a chauffeur-driven BMW 7-series town car? In my view, obviously not. To most people such an action would conjure up images of hypocrisy, waste, and corruption.
Yet, after a review of public and tax records, it appears to me this is exactly what has happened."

Hypocrisy,waste and corruption are strong words.Dr. John Mandrola, writing on his blog "Dr. John M:" uses the words, hubris,overreach and tone deafness. in regard to the ABIM's MOC efforts.

I think  Drs. Fisher and Mandrola are if anything too restrained in their characterizations of the activities of ABIM and ABIMF.

The greater uproar and push-back from practicing internists is  directed at, understandably, the egregious and over reaching MOC program but I am afraid that the promotion of the new professionalism and the  linked political agenda may be even more dangerous to the practice of  medicine-all emanating from the ABIM-ABIMF conjoined twins.

Addendum: 1/26/15-Much deserved kudos to Dr. Wes ( AKA Dr.Wesby G Fisher,EP cardiologist) for pulling back the curtain revealing at least some the back stage activities of the ABIM-ABIMF.