Should the symbol of Massachusetts Health Plan be the canary or the dead parrot?

An argument can be made for either candidate.

The canary,as in the canary in the coal mine, served as a early warning system for respirable hazards in the mines, and the experiment in Massachusetts in mandated health insurance can serve to demonstrate what might happen if the Mass. plan goes national as may occur with plans now being written in Congress. So far we have seen costs significantly higher than the plan's advocates claimed,significantly decreased access to care and most recently efforts underway to control costs cost by radically overhauling payment systems for medical care. The latest is a capitation plan which would turn the (at least) public portion of Mass-care into a big HMO with features that make regular managed care look like your overly generous uncle.

Economist Arnold Kling comments on the events in Massachusetts and the first comment in reply to his entry explains why capitation did not work when tried in the 1990s. Sandy Swarc at Junkfood Science has this detailed review of how badly capitation worked out and the implications and effects that a capitation system has on medical ethics.I have written before about the destructive effects of a HMO-capitation system on the physician-patient relationship and the attempts to redo medical ethical principles to be "better suited" for the statistical morality of group outcome data and payments directives based on them in which the physician is directed to care for the group's outcome and not be mired in the outdated belief in the primacy of the fiduciary duty to the individual patient.

The dead parrot also might be considered a mascot or symbol because of analogy to a classic Monty Python routine seen here. In this sketch the customer is complaining that the parrot he recently purchased is dead while the store clerk steadfastly maintains that the bird is sleeping or resting. The opponents of the Mass-care point to the rising costs and decreasing access to care as a failure while the advocates deny the bird is dead and scramble to devise more fixes to salvage a spiraling failure with more government controls and less patient choice and opportunity for physicians to use their judgment and care for their patients.

Can we really save the economy by spending more?

The Director of the CBO believes we can't at least not in the context of the spending involved in the health care bill. The administration's purposed health care re-do seems to go like this. Since the country will ultimately go broke if we continue top spend more and more on health care cost must be contained. This is expressed in the jaunty jargon of health care policy wonks as "bending the health care cost curve". To bend this curve the administration is recommending that we spend more on health care by making sure that all (well almost all) of everyone in the county have health care insurance. So how will this keep the country from going bankrupt?

Simple we will rely on the magic three: comparative effectiveness research (cer),prevention and use of electronic medical record (EMR) systems. Actually that appeard to be the gist of the original taking points points more recently there are varous tax increase proposals being formulated. Combining providing care for almost all with these three ( plus some as yet undecided upon package of increased taxes) will bring about a "budget neutral " economic miracle.Everyone (almost) will have health care and it won't cost anymore and the quality will be better and by not relentlessly increasing health care cost we will save the country from bankruptcy. QED.

Douglas Elmendorf, Director of the Congressional Budget Office testified before Congress and reminded everyone that the notion of there-is-no-such-thing-as-a free-lunch may still apply. He said in part:

".. bills crafted by House leaders and the Senate health committee do not propose "the sort of fundamental changes" necessary to rein in the skyrocketing cost of government health programs, particularly Medicare. On the contrary, Elmendorf said, the measures would pile on an expensive new program to cover the uninsured. (Quote is taken from this Washington Post article and the bolding is mine.)

New physician payment Rules for CMS,different slicing of a shrinking pie

New physician payment rules from CMS have been proposed, can be found here and will likely go into effect January 2010. The Obama administration has found money to increase the pay of primary care doctors a bit ( about 6-8%) by taking it away from other doctors. Radiologists and cardiologists will be paid less. DrRich comments on the understandable reaction of the cardiology leadership here. In the coming months we may get to see how effective the lobbying efforts of organized cardiology will be in their damage control.

Sandy Szwarz in this entry from her blog Junkfood Science sees more in this proposal that the simple pay-this-doctor-less-to-pay- this- doctor-more. She speaks of the vision of things to come. I quote from her posting:

The core of the new CMS proposals (described in section 1413-P33) was a new method for determining fees for services based on their costs (called “resource-based practice expenses”) and their relative value, as determined by a survey called the Physician Practice Information Survey (PPIS). This survey compiled the returned questionnaires from 3,656 physician and professional groups and had been conducted in 2007-8 by The Lewin Group, the contractor for the American Medical Association and the government.

It does not go unnoticed that the Lewin Group is part of Ingenix which is part of United Health Group.See here for some details of the flawed data used by Ingenix and some of the legal actions against them. It is not clear if the Lewin Group derived data used to determine the new pay scales are also flawed.

I recommend that everyone read the rest of her essay to get a flavor of the type of changes and emphasis we can expect in Medicare as the "reform" plays out.Look for emphasis on "lifestyle medicine"as a key element in the prevention part of purported ways to save money.

As suggested by Ms. Szwarz the plan is basically to cut funds to providers and hospitals and institute a covering of "quality" measures so the claim can be made-see we spent less and quality improved.Look, when we pay the bills , we get to say what quality is.

The change (aka "reform") of health care that is promoted by the administration promises to increase coverage and decrease costs while increasing quality by the magic of the triple whammy consisting of electronic medical records, comparative effectiveness research and prevention. It is instructive to look at what comparative effectiveness research has to say about the extensive efforts that have been made to prevent coronary artery disease by attacking multiple risk factors. This is what the Cochrane Group has to say about that.

In many countries, there is enthusiasm for "Healthy Heart Programmes" that use counseling and educational methods to encourage people to reduce their risks for developing heart disease. These risk factors include high cholesterol, excessive salt intake, high blood pressure, excess weight, a high-fat diet, smoking, diabetes, and a sedentary lifestyle. This updated review of all relevant studies found that the approach of trying to reduce more than one risk factor - multiple risk factor intervention - advocated by these Programmes do result in small reductions in blood pressure, cholesterol, salt intake, weight loss, etc. Contrary to expectations, these lifestyle changes had little or no impact on the risk of heart attack or death. Possible explanations for this are that the small risk factor changes are not maintained long-term or are not real but caused by some of the studies being poorly conducted. This review is based on the findings from 39 trials conducted in several countries over the course of three decades. Its authors discourage more research on the topic: "Our methods of attempting behaviour change in the general population are very limited. Different approaches to behaviour change are needed and should be tested empirically before being widely promoted. For example, the availability of foods and better access to recreational and sporting facilities may have a greater impact on dietary and exercise patterns respectively, than health professional advice."

As primary care physicians' practices have changed in large part due to the tightening of the reimbursement screws one of the effects has been the increased use of ER by the primary care doctors' patients ( in off hours and weekends) and/or those folks who cannot find a primary care doc to begin with. With this change one would think the increasing importance of the role of the ER docs should be evident to all including the policy wonks at CMS. Apparently they do not as their new pay schedule gives these figures for the ER physician and the chiropractor:EM docs are valued at $ 38.36 per hour versus chiropractors valued $65.33 a hour.

Is fee for service really the culprit for health care costs?

Fee for service is said to be a major cause of the high health care costs that we are told must be brought under control to save the economy.Dr. Donald J. Boudreaux,Chair of the Economics Department at George Mason University, argues that is not correct.Rather a major cause is the fact that much of medical care is paid for with someone else's money. Go here to read his entire commentary.

Comment writer asks retired doc about single payer

This post is a reply to a comment made on one of my earlier postings that inquired about the single payer option for U.S.health care or at least what were my thoughts.

I believe the major issue is whether the single payer system that we may eventually end up with allows a parallel system of private care as is the case in Great Britain or if government forbids people to spend their own (or insurance) money for services not provided by the single payer government plan, as is the case in Canada. In the later arrangement the patient's life and health is literally in the hands of the government and without the private option there is no practical appeal to the edicts of the bureaucracy that control the expenditures of the single payer system. Of course, in Canada not infrequently folks go south for health care that is denied or so delayed that it is for practical purposes denied. Also, recently there is an interesting and encouraging move to some elements of private care becoming available in Canada (see here). As the U.S. seemingly is moving to more government involvement in health care, there seem to be a directionally opposite move in Canada where they have had years to see how well or badly their hyper-egalitarian health care system works in the real world.

We have had Medicare since 1965 and it is not going away.The best we can hope for after the re-working of the medical care system comes to pass is for the people to be able to purchase health care denied by the government system without having to travel overseas. ( Maybe the private care movement in Canada will be mature enough by then so we can go there for care.)

An interesting twist on this general topic is the suggestion made in a WSJ October 2008 editorial to "allow"seniors to opt out of Medicare entirely, not just Part B.See here for a discussion of how that might be good for some and harming none, something economists seem to refer to as Pareto Optimal.Currently if someone wants to opt out of Part A he will loose Social security benefits.

I did not realize that until recently.Here is the rule in the words of the government:

"Individuals entitled to monthly benefits which confer eligibility for HI ( hospital insurance,Part A of Medicare) may not waive HI entitlement. The only way to avoid HI entitlement is through withdrawal of the monthly benefit application. Withdrawal requires repayments of all RSDI and HI benefit payments."
h/t to Junkfood Science)

This was not the way the Medicare law was written. You have to wonder what prompted the SS administration to add on this rule. Why would they object to someone opting out of Part A? It would only be a saving for Social Security.

The terms one tier and two tier are sometimes used to distinguish between the systems exemplified by the British and the Canadian systems. One Tier would be Canada and two tier would be Great Britain. In this article in the Archives of Internal Medicine there is a discussion about the ethics of the two systems. Interestingly, one of the authors who supported a two tier system from a practical and ethical point of view is Dr. Ezekiel Emanuel who is the brother of Rohm Emanuel.I hope Rohm will give some thought to his brother's views.

National Demonstration Project for Medical homes-some early observations and concerns

Medscape has a republished a report from the National Demonstration Project regarding the Medical Home concept that appeared in the Annals of Family Medicine in June 2009. See here. The full name for Medical Homes in this context is "Patient-centered Medical Home" or PCMH.The authors examined how the transition of a number of traditional family practices to the PCMH model was working out.

There is much to discuss in regard to the report in particular how difficult a transition is from "regular" practice to the medical home type practice can be but my attention become focused on this paragraph.Bolding is mine.

"Transformation to the PCMH Requires Personal Transformation of Physicians

Transformation to a PCMH requires not only implementing new, sophisticated office systems, but also adopting substantially different approaches to patient care. Such a fundamental shift nearly always challenges doctors to reexamine their identity as a physician. For example, transformation involves a move from physician-centered care to a team approach in which care is shared among other adequately prepared office staff.^[25] To function in this team-based environment, physicians need facilitative leadership skills instead of the more common authoritarian ones. A PCMH requires expanding the clinical focus from 1 patient at a time to a proactive, population-based approach, especially for chronic care and preventive services.^[26,27] In addition, physician-patient relationships need to shift toward a style of working in relationship-centered partnerships to achieve patients' goals rather than merely adhering to clinical guidelines.^[28-30]"

The report is hardly a glowing endorsement of the program at least from the view point of a physician considering taking that road. Not only does the report indicate the costs are greater than anticipated,the transitions take longer than anticipated and the entire process is difficult but the physician may have reexamine his identity as a physician. Does this involve pushing into the background the long standing venerable duty of the doctor to the individual patient? "A PCMH requires expanding the clinical focus from 1 patient at a time to a proactive, population-based approach.."

Does this mean that the physician's strong fiduciary duty to the patient may have to be balanced with more concern for the collective.Trust in the physician commitment to the welfare of the individual patient has been the durable glue of the doctor-patient relationship. One wonders how group meetings and a "population based" approach will collide with the duty-to-the-patient ethic that most practicing physician were inoculated with in the medical training.(I realize that inculcation process has weakened more than a little bit in recent years but still is a strong element in the physician sense of professional identity.)

I wonder if NPs who lead medical homes will have to have that same identity metamorphosis.Earlier I blogged about new Medical Homes funded by a House bill that will allow NPs to independently lead these homes. The American College of Physicians has endorsed this bill, a move that both DrRich and I have critically blogged about.See here and here.

The review indicates that three years is not long enough to transform to this type practice and that the current funding and reimbursements may not be adequate. I find it hard to understand why any internist or family practice doctor ( this study involved family practice physicians) would willingly enter into this experiment considering it to be a more than 3 years process and it having significant likelihood of financial insolvency and may involve taking part in workshops to help you retool your ethical compass so it points to the new correct position in the context of the New Professionalism.

Everyone go read Dr. Wes's Open Letter to patients

Go here.His satire elegantly captures so much of what is happening and is threatening to happen.Those of you who still get up everyday and practice medicine should consider handing it out to your patients.

Ignoring history-doomed to repeat it ?

President Obama recently spoke to the American Medical Association and offered in part some reassurances that the public choice option would not lead to a single payer and his Secretary of HHS assured NPR listeners that their plan is not a Trojan horse with a single payer lurking inside.Various administration spokesmen have promised a plan that will increase coverage, save money and improve quality of care.

Sometimes insight may be gained by sitting back and reflecting on some recent (1965) past history.Here is food for thought from the Medicare bill.

I quote from section 1801:

"Nothing in this tittle shall be construed to authorize any federal official or employee to exercise any supervision or control over the practice of medicine..."

So how has that worked out?

American College Physicians (ACP) endorses house bill that allows NP lead Medical Homes

Note this is a republication of an earlier version with a new headline and some introductory remarks..As pointed out by Bob Doherty in a comment to my earlier posting ( I am not sure that comment will survive this editing but that reflects my lack of mastery with blogger rather than an intent to silence his criticism) that the earlier headline was "demonstrably wrong". It said " The American college of Physicians endorses independent NP practices." To avoid misleading anyone I should have said what the current headline says namely that ACP has endorsed a house bill that does allow NP lead medical home practices.The ACP does not endorse NP lead practices in general only in the context of what is outlined in the house bill, ie in the context of the medical home practices.. Although my earlier headline is arguably technically accurate, it could be misleading and I hope my correction will satisfy Mr. Doherty's concerns. Judging from comments on Bob Doherty's blog I am not the only internist who has serious concerns about the issue of ACP going along with this element of the House bill and the ACP's support for what they do support is bad enough without me implying they are endorsing something worse. So here is the rest of the posting without any changes.

The American College of Physicians is endorsing a bill before the house that would enable NPs to practice independently in the context of the ACP sponsored "Medical Home". Further they seemingly welcome the opportunity to take part in a contest using certain quality measures to see who is the better provider.The bill,HR2350,can be read in all of vagueness and details yet to worked out here.

Go here to read what the ACP's man in Washington, Bob Doherty, has to say about how real practicing internists should enthusiastically get on board and strive to follow the appropriate quality driven guidelines to prove to the world that an internist provides better medical care that a RN with an extra two years Master degree that qualifies him as a NP.

Doherty says that the leaders of the ACP are endorsing this proposal because they are so pleased with the other elements of the bill, which include more training slots for general internists and some very modest increases in reimbursements from CMS and it furthers promotion of their highly touted Medical Home proposal. With these and other elements in the bill they are willing to endorse it even though the NP provision "goes past" what they had previously supported.

Doherty argues that if internists really were confident in their superior training they would welcome the opportunity to show they are better than folks with significantly less medical training. They should relish the opportunity to play a game even those it will likely be with rules that not disclosed (those devils in the details will be worked out later) and are likely to be written by folks who may well have an agenda which would be well served by either a victory for NPs or even a tie, which would also be a victory for the NPs . Go to the proposed bill and see if you can find what will be the rules of the comparison game between doctors and nurses.They are to be worked out later. So we should agree to a contest with rules to be worked out later?

Go here to read from the virtual pen of DrRich of the situation facing the general internist and his views of this "capitulation" of the ACP in his commentary that laments the now official nature of the death of the general internists even if the bill is not passed. (With the current state of the Republican party left toothless since the last election just about any democratic sponsored bill will be passed.) By virtue of their current stand the ACP has already stipulated that NPs are for practical purposes equivalent to internists.HR 2350 may set up more general internal medicine training programs but as DrRich points out what medical students with any modicum of cognitive function left would choose to enter a field of medicine that its professional organization has publicly stated that its members are equivalent to other health care providers with much less training. What does that about what the ACP thinks of an internist training and worth? What good will the Medical Home be to internists or the ACP when its Medical Home becomes a NP run organization?

The assertion that internists will prevail in a head to head who-gives -the- best- care contest seems to me to be naive or hypocritical. Does anyone really believe that such a comparison would be based on anything other than the usual "quality" measurements of compliance with easy to account guidelines and/or coarse grained outcomes too crude to show a difference in the short run.

If you think that it is not possible for this development be spun as a good news-bad news story read the second related commentary by DrRich. Go here for that. He suggests that this ACP capitulation could be taken as a opportunity for internists to get out of this "primary care" farce and become retainer docs leaving what primary care has become to a few internists who may just want to run the clock out and the NPs and whatever level of provider that the NP lead practices may devolve into.

This type of internist he and I trained to be may find professional satisfaction in a retainer practice ( at least before medical "reform" deems that to be illegal) or by becoming a hospitalist . The primary care environment that the internist turned officist now faces is-for many of us-not worth doing.

For those who worry about government managed CER,MedPAC may be your real worry.

From the WSJ we read about the entity that may be the group that really will pull the budget strings for Medicare and have major influence on what the third party payers pay ( if there are any left after medical care reform kick in).MedPac is not a well known word. What is it anyway? Here is what it is in their own words from their website.


The Medicare Payment Advisory Commission (MedPAC) is an independent Congressional agency established by the Balanced Budget Act of 1997 (P.L. 105-33) to advise the U.S. Congress on issues affecting the Medicare program. The Commission's statutory mandate is quite broad: In addition to advising the Congress on payments to private health plans participating in Medicare and providers in Medicare's traditional fee-for-service program, MedPAC is also tasked with analyzing access to care, quality of care, and other issues affecting Medicare.

By the way, the strange sequence of capital and lower case letters in MedPAC is necessary because MEDPAC is something else entirely.It is the PAC of the Minnesota Medical Society.

Here are the current players in MedPAC. They are appointed by the director of the GAO who is the Comptroller General, who is appointed by the president subject to congressional approval.

So far, their pronouncements have been advisory but a recently proposed bill will elevate their expressed wisdom to fiat. The commission will become a government agency whose decisions regarding Medicare payments will largely be determinative.(Congress will have to work out exactly how determinative it will be, i.e. how difficult it will be for Congress to over ride their decisions).

This is being heralded by some as a way to take politics out of governmental medical payment decisions. Let's see how that won't be political. The members are appointed by a presidential appointee. Their decisions will determine how billions of dollars will be spent. Explain to me how all of the major players (drug companies,hospitals,medical equipment manufacturers, physician associations) will not do all they can to influence both the choice of those who will populate the agency and their decisions. Lobbying is not directed to just elected members of Congress. Explain to me again how investing that much power in an agency will not be the one of the best opportunities for regulatory capture ever.

The term "regulatory capture" is of fairly recent origin, but the concept is not new. Here is what President Woodrow Wilson said in 1913.

"If the government is to tell big business men how to run their business, then don't you see that big business men have to get closer to the government even than they are now? Don't you see that they must capture the government, in order not to be restrained too much by it? Must capture the government? They have already captured it."

Must reading for all internists-DrRichs' take on the bill purported to save internal medicine

DrRich's blog entries typically are insightful and entertaining. This one goes way beyond his usual very high standards.Go here to read his reply to Bob Doherty's recent blog entry," Do internists have confidence in their own training when compared to NPs?"

DrRich writes about the death of internal medicine now being official.I sadly have to agree with him about the ACP supported bill before Congress which he discusses in the context of the current state of primary care in general and internists in particular.

CMS's "never events"-so much for reason and let the unintended consequences begin

Aggravated DocSurg offers cogent comments about the seeming lack of logic or common sense in their program of denying payments for so called "never -events". In particular he discusses deep vein thrombosis (DVT). In the recent issue of the NEJM we find an excellent commentary about an even more absurd requirement of this new set of CMS rules,this one involving falls in the hospital.

For those who advocate a "Medicare for all" approach for the United States, I suggest they read what Medicare itself says about the inclusion of falls in their never-events policy.Here is a sample as quoted from the NEJM commentary which explains clearly that CMS is making a requirement for some things that cannot be done.

"There is no evidence that hospital falls "can be consistently and effectively prevented through the application of evidence-based guidelines." The authors of the CMS rule acknowledge this fact. In the final rule, as recorded in the Federal Register on August 22, 2007, they note that "although we have not identified specific prevention guidelines for the conditions . . . we believe these types of injuries and trauma should not occur in the hospital and we look forward to working with CDC and the public in identifying research that has or will occur that will assist hospitals in following the appropriate steps to prevent these conditions from occurring after admission." Although clinical trial results suggest that certain strategies may reduce the risk of falling in community settings, fall prevention in the hospital has been much less studied. What little evidence is available is not encouraging. A recent systematic review suggested that, at best, about 20% of hospital falls can be prevented.¹ Moreover, no intervention has yet been shown to reduce the risk of serious injury, the outcome of clinical relevance."

If one follows all the best evidence driven rules and suggestions for how to prevent DVTs, DVTs will still occur. Under the best circumstances of the very best randomized clinical trials which involve meticulous attention to detail , and applications of the very best preventive measures, DVTs still occur. The incidence is not zero. Furthermore, in regard to falls , CMS recognizes as indicated in the quote above that there are no evidence based guidelines but hospitals and physicians have to obtain a zero incidence rate anyway.We don't know how you will do it but you have to do it.

I have been impressed by Thomas Sowell's approach to try and understand some of the actions of governmental agencies that appear to lack in common sense, or appear to be irrational or just plain silly. He says look at the incentives and constraints they face and the feedback or lack thereof to which they are subject. Here, however, it is difficult to understand how anyone (even a committee) could devise and publish for all to see something that is absurd. OK I 'll try and think about their incentives etc. If their aim was to save money and to dress up their work orders in the current jargon of safety and quality, maybe their plan makes sense to them, but for the rest of the world -not so much . If you make rules that are apparently subject to no appeal,your rules don't have to make sense.

Does ultra sound help decisions regarding length of anticoagulation for DVT

The answer provided in a recent issue of the Annals of Internal Medicine suggests use of U/S to help determine how long to continue anticoagulation in cases of DVT is a qualified yes. See here for abstract,full article requires subscription.

Why qualified? As is often the case the exclusion criteria for entry into a clinical trial limits the applicability. In this instance, patients were excluded if they have prior DVTs,"continuing risk factors or thrombophilic factors ( except for factor V Leiden)."

Previously I wrote about some evidence that an elevated d-dimer may be worthwhile used as indicator of the need for continuing anticoagulation. There appears to be some plausible pathophysiological rationale for both tests.( I remember when internists like to talk about pathophysiology rather than guidelines,quality indicators and coding techniques.)

Annals Internal Medicine commentary laments imminent death of internal medicine

Dr. David D. Nerenbert writing in the May 19,2009 issue of the Annals of Internal Medicine offers his analysis of why internal medicine is dying;"the progressive devaluation of individualized clinical judgment". See here for abstract.Subscription is required for full text.

In the past,he continues, "careful thought was thought to be our forte".He correctly observes that a physician cannot do justice to the complex,complicated patients with multiple medical problem in fifteen minutes. There is no time for careful thought and still stay in practice, at least not if you play the Medicare and third party player game. Can you do it all in fifteen minutes?Of course, you can't.Why are we even trying? How did the hour we used to spend for new patients and perhaps 30 minutes for return visits morph into the now prototypical 10 to 15 minute farce?" Because we can't afford to spend the time any more because the per visit charges are too low and we are trying to mitigate the economic loss by increasing volume.

Is it really all about money? Is the root cause simply the imposition of price controls by Medicare and the third party payers generally following suit. The practice pattern of internists in the 70s and early 80s of spending time with patients in the office AND caring for patients in the hospitals was made possible by the income level internists enjoyed in that era. Not only did the practice patterns depend on a reasonable level of income but the practice environment-bereft as it was of mandates and insurance company driven requirements-was one in which there was a strong sense of professional identity and satisfaction and prestige among other physicians,patients and others in the health care endeavor. And then the price controls from Medicare came on the scene around 1991 and gradually everything changed.See here for my earlier attempt at summarizing the events that marked the beginning of the end of the internist as we once knew him.

Is the rise of NPs and PAs and the birth and development of hospitalists based on the same economic causes? The consequences of price controls are well known and include: shortages, poor quality and black markets or rationing by favoritism. We have all of that except black markets (unless retainer practices are ultimately outlawed and then we will see the full spectrum of the effects of wage controls)

A small single digit increase in Medicare payments, federal funds to increase the number of internists trained, or a plan to help with medical student loans will not fix the internist's plight. More residency slots are not the answer when the current slots do not fill now.Those who choice a retainer practice may be able to sidestep the problem on an individual basis.Hospitalists can salvage one aspect of the practice on the internists of the 80's but some worry they can do so only at the pleasure of the hospitals and there is no guarantee of that in the future.

The origin of the internists dilemma is government imposed price controls and tweaking the prices a bit and increasing the role of government in medical care will not fix the systemic problem. Mandating health insurance for everyone will not fix the problem of too few primary care doctors; it will make it worse. Again, I point to Massachusetts as the canary in the mine shaft. See here for recent update in waiting times. Dr.Nerenberts's suggestion of a pilot program with internists being on government salary to take care of Medicare patients is again to purpose a governmental solution to a government caused problem, and I think few internists, as upset as they are with the way things are now,would sign up for a salaried government job.

Cogent commentary about the Dartmouth Atlas conclusions by a senior medical educator and troublesome observations by Atul Gawande

The Obama administration is promoting the idea that we can finance a wide and expensive variety of government programs-including better quality health care for everyone- by getting the waste out of medical care. The factual (alleged) basis for this claim to some degree comes from a widely quoted ecological study, the Dartmouth Atlas. The publications from this project apparently has had significant influence on policy recommendations.

This study divided the nation into five Medicare quintiles and then compared money spent with several outcomes.When the region's selected outcomes did not improve as expenses increased they concluded that the difference in expenditures was "wasted" money. Other conclusions are possible and from what I read may make more sense although no one speculation based on aggregate data should stand unchallenged. One such conclusion is that differences in poverty level and in total medical expenditure offer a better explanation ( see below) that the notion that for some basically unexplained reason physicians in some regions just are prone to waste money by doing too much in terms of health care services.

I suppose the suggestion is that greedy and/or misinformed physicians tend to congregate in certain parts of the country.There is at least some anecdotal evidence that that certain cities may in fact have significantly higher medical expenditures due to variations in medical practices at least some of which may be profit driven.

A recent article in the New Yorker by the prolific Dr.Atul Gawande seems to argue the case that McAllen Texas is such a city. The article is worth reading and I found it very troublesome as Gawande relates stories (mostly heresay) of physicians requesting kickbacks for hospital admission and thinly disguised kickbacks from nursing homes. How widespread are the practices narrated by Gawande and to what extent overall health care expenditures are impacted are questions that remain unanswered as does the question why would that be regional.

Go here to read analysis from a former medical school dean, and longtime physician,Dr. Richard (Buz) Cooper, who obviously has spent much time and effort in studying this problem. He argues that Medicare spending is not an accurate proxy for total medical care expenditure and that in states with more total medical spending medical care is better, a conclusion 180 degrees from the Dartmouth conjectures.

I continue to be impressed by how often aggregate data can be used to reach conclusions and policy advice that is conjectural and at times agenda driven. The Dartmouth project may be one .Another is the recent NEJM article on hospital readmission rates of Medicare patients, a topic for a future blog.In both instances the numbers are real but the underlying factors are difficult to tease out and may be refractory to statistical techniques designed to eliminate confounding.Data gathering and statistical analysis have become cheap and widely available ,what to do with the data requires reasoning and that is as scarce as ever.

Dr. RW (see here) has recently commented on the illogical and overreaching conclusions of the Dartmouth folks.

The Dartmouth Atlas project is funded by three large insurance companies or their foundations ( Aetna,United Health care and Well Point) with the other two contributors being The Robert Wood Johnson Foundation and The California Health Group Foundation.

To claim that results may be influenced by their source of funding risks accusations of indulging in a version of an ad hominem argument. Still you have to wonder if large insurance companies would continue funding for a long standing project that published results that did not further their business interests or if they would spend much money in supporting research such as that discussed by Dr.Cooper.If you run a medical insurance company you have to like a study that claims to demonstrate widespread wasted medical spending. It is of interest that here waste is defined by a third party observer not by either the providers nor the recipients of the services. Having said that, the results are either valid or not (or we just can't tell) independent of who financed the project.

I remember learning that ecological studies might at best serve as hypothesis generating activities not as generating answers so definite and certain that they could form the basis for sweeping health care changes.

I continue to be very suspicious about conclusions from studies based on aggregate data.Serious and thoughtful and non-biased commentators are able to offer opposite stories to "explain" the data. However, Dr. Gawande's observations about practices and hospitals in several cities with significantly different practice patterns and levels of medical cost (and profits) and perhaps quality of care make me wonder if the Dartmouth conclusions might be not quite as unjustified that I want to believe as that conclusion painfully bumps up against my philosophical priors and epistemological biases. At least I am less inclined to dismiss them out of hand even though there must be more to the story than marked regional variations in greed.

addendum; Minor spelling,grammar and syntax changes were made on 8/28/14.

The IOM speaks: mandatory nap time for house staff

The very name Institute of Medicine for reasons that have eluded me seems to mean to many a venerable assortment of very wise people who unlike the rest of the human race are able to act without personal bias or agenda and do what it right or as the myth goes act in the public interest. Their latest unfunded quasi-mandate is to mandate nap time for residents and for the ACGME to monitor the program,which I guess means make sure everyone gets their naps.

Thanks goodness, for a change, some one has the gumption, to at least, question the consequences of this IOM's pronouncement. This article in the NEJM dared to ask the questions:what would the cost be and what is the evidence that the suggestions would achieve their stated goals. The answers: It would cost a lot and the evidence of beneficial outcome is lacking.

The IOM which has been around since 1970 is a non-governmental organization that was chartered as part of the US National Academies of Science.

More and More data is ganging up on Proton pump inhibitors

The story of PPIs apparently interfering with the beneficial effect of Plavix is widely distributed and read. Now we see data (see here for abstract) that links spontaneous bacterial peritonitis (SBP) in advanced cirrhosis with PPI use. This was a case control study with an OR of 4.3,so I cannot make my typical whinny remark about the appropriate level of concern with relative risks of less than 2.

PPIs seem to be the mirror image of statins which have an increasing number of studies indicating a new benefit.With regard to PPIs, we may have to worry more and more about bad effects including: pneumonia ( see here for a rather unconvincing study), fractures ( see here), heart attacks ( see here for a good review of the Plavix-PPIs issue by Dr. Richard Fogoros) and now SBP. I would not be surprised if H2 blocker sales may have an uptick.

Electronic Medical Records, tool to save health care costs or windfall for the tool makers

One of the package of health care "reforms" that will increase quality, provide care for all and save money is the widespread implementation of electronic medical records (EMR). The other major elements are comparative effectiveness research and preventive medicine.

Here is one economist's take on one aspect of the EMR issue.As much as
"change" was heralded as a major characteristic of the new administration it appears that some things change very little.Lobbyists still stalk the halls of government and sometimes score big.

Whether the massive savings alleged by the proponents of the health care reform will accrue from EMRs or not will have to be seen in time. We do not have to wait to see how certain purveyors of these systems will make out. See here for a Washington Post article on the efforts,some of which have been years in the making, to cash in on the federal outlay of

See a detailed discussion of this special interest issue as well as concerns about the safety of this rush to implementation of EMR by one expert on this subject at Health Care Renewal.

Is the latest medical world cahoots insurance companies and academia

The Last Psychiatrist (TLP). suggests that an unholy alliance between medical insurance companies and medical academia is well underway.See here.

He discusses an article from medical academia that apparently concludes that the much hated by physicians "prior authorization" for medication is really a good thing. Good for whom? TLP suggests that the drug promoted is as likely as not neither the cheapest nor the best but rather the one for which a deal has been struck between the drug manufacturer and the insurers and or the medication management company. They don't need any stinking comparative effectiveness research.

The poster child for the new insurance company-medical academia alliance is found at Harvard where is found the "only medical school department cosponsored by a health plan". The plan is the Harvard Pilgrim Health Care and the department's name is The department of Ambulatory and Preventive Care.

Here is one paragraph from TLP:

"If you want to see what the next ten years in medicine look like, stop looking at Astra Zeneca. The next unholy alliance is between academic medicine and insurers/providers. The placebo controlled trials on the treatment of bipolar will no longer be controlled by Abott (Depakote off patent 2008), but by United Healthcare."

Next we will have to not allow medical students to have pens and mugs with insurance company logos.

More on the three magic elements of reforming health care.

To reform" health care" (and to fix the nation's economy) we are told we must have electronic medical records, government funded and managed comparative effectiveness research and more prevention.

In regard to the first I strongly recommend that you go here and read about just how much trouble there has been so far with the security of computerized medical information and why does anyone really believe that problem will just go away. Go here to see a good summary of other non-security related serious issues with the EMR proposed panacea.

In regard to the second I strongly recommend that you go here to learn the real reason that Dr.Rich favors government funded and managed comparative effectiveness research which he designates as "CER" as opposed to the generic term of cer. Dr Fogoros makes the argument that all cer may be biased so it is not the case that he favors CER because it will be not biased.Read his entry to see where his argument goes. I suspect more that a few advocates of CER will not be pleased.

Of course, even if we have much more cer with the addition of the CER to the data base, it will be all for nothing unless the medical profession gets on board and acts according to the published comparative effectiveness research. The grand guru daddy of the hospitalists. Dr. Bob Wachter suggests for those who won't go along they should be". dragged" along. Wonder who will be doing the dragging. In the new world of CER,will there be the draggers and the dragees? You betcha.Dr. Wachter in his dragging proposal is less concerned than is the new AMA president regarding the risk of malpractice suits if adherence to the CER directed guidance leads to the withholding of certain procedures that arguably lead to bad patient outcomes.

All in all it may be a good time to be a retired doc but as for being a patient, not so much.

Will Protecting people from second hand smoke decrease heart attacks?

Well, the early relatively small studies gave the public health rule makers some empirical justification for claiming success, further study suggest the opposite.Here is a blog posting suggesting a couple of reasons why that could be.The blog's author is Milton Friedman's son David who was trained as a physicist but writes about economics and has gained some fame for Friedman 's Law.

I'll bet we will soon be seeing papers that conclude that the attack rate of heart attacks is significantly down since the implementation of various local laws outlawing trans fat.

Whistle blowing is always risky,In Great Britain's NHS even worse,nurse looses a lot

See here for what happened to a nurse in England who dared to help let the public know how bad things were at one NHS service about which I have commented before in regard to the issue of how very wrong things can go when quality performance targets dominate the scene.

Two of my favorite medical bloggers seem to disagree regarding CER

When I read a recent blog posting by DB,who postings inspired me to start to blog and with whom I rarely disagree, I was sharpening up my blogging tools to respectfully offer a view counter to his, but as is often the case DrRW beat me to the draw (See here).

Those who oppose or at least have serious doubts about government- run CER are likely not against comparing the effectiveness of various medical treatments ( i.e.. not against CER) but are very skeptical of the ability of a government agency to regularly turn out results that will be free of bias and may also reject the thesis that all drug company sponsored research is biased.

Research can be spun one way or the other-there are so many ways to stack the deck and cook the books that lurk beneath behind the pages of a research project.To believe that a government agency is a) without an agenda and b) incapable of making such an agenda-generated bias operational requires much more faith in the integrity of the government that I summon and seems to ignore what we have learned about how governmental entity really operate versus the high school civics views that describes things in terms of purported aims rather than in real results. A leisurely half hour or so with a discussion of Public Choice theory might disabuse many of the vision of government as a hybrid between Santa Claus and superman.

Dr. RW's final paragraph deserves much consideration:

No one that I know of is objecting to more unbiased data. But CER is not inherently unbiased. Moreover, it is inherently susceptible to design flaws for reasons I pointed out here, with several examples. Bias has more to do with who’s sponsoring the research than the type of research. There’s no reason to think that the government would introduce less bias. In fact, the government policy makers who are pushing CER are explicitly very biased. If you don’t believe me just read the Congressional Budget Office paper which was pushing for CER, which I cited here.

Still more thoughts on problems with EMRs and who or what is responsible for the patient

Here is a link to a discussion of more problems with electronic medical records (EMRs) that ties in with the issue of individual versus group responsibility.

The particular case involved a patient at an academic medical center in which

It took three days for the patient's care team to realize that the results entered into his EMR were for a biopsy they did not order of a lesion he did not have. Before the error was recognized, it had caused the patient "tremendous pain and mental anguish."

The author, John Goodman, continues with a theme I have ranted about before, (see here) the increasing lack of individual responsibility for patient care and the replacement with "team care" and computers systems are, of course,increasingly part of the team.

At bottom, the error got as far as it did because of the "medical team" approach - no single person was responsible for this patient's care. Each person relied on the (erroneous) electronic medical record for his view of the whole.

We seem to be replacing personal physician responsibility with "systems".

With so much rhetoric these days about instilling professionalism in medical students and house officers how can individual responsibility be given such short shrift? In 2003 the ACGME eliminated the following statement from their pronouncements:

Physicians must recognize their obligation is not discharged at any given time or any given day.

No, that is not a typo -they eliminated what used to be considered a fundamental principle of the doctor-patient relationship,that the physician is responsible for his patient

I believe that it is not coincidental that the same ACGME in their 2003 general core competencies statement mentions "systems" or "system" seven times but saw no reason to include the statement quoted above. The authors of the competencies are more concerned with team play, group dynamics,system this and system that, and conserving society's resources and fostering social justice than in inculcating in medical trainees a sense of individual responsibility for their individual patients, which is what I thought it was all about.

Earth Day -some cogent counterpoints to the standard green koolaid

The first thing I remember about Earth day were reports of some cases of histoplasmosis in a group of well meaning well-meaners who breathed in a bunch of fungal spores when they set out to clean up their little portions of the earth.

Dr. Don Boudreaux,chairman of the economics department at George Mason University, submits this essay on what he is grateful for on earth day. He sums up his thoughts in this closing paragraph:

I am, in short, thankful for private-property markets that are the main driving force behind these (and many other) anti-pollutants -- a force so powerful that we today enjoy the incredible luxury of being able to worry, should we so choose, about very distant and very speculative forms of environmental problems such as species loss and global warming.

Dr. Mark Perry,economics professor at University of Michigan,wrote this editorial explaining what has driven the cleaning and greening of things since the 1970s birth of Earth Day. (hint it was not Al Gore). He ends his essay with this answer to what has made the earth greener.

.. capitalism has. Through wealth generated by the free market, we have enough resources to move beyond the subsistence economies that damage the environment, enough disposable income to fund clean-up programs, enough wealth to scrub and polish industry.

Only in advanced economies can the technology needed to recycle hazardous waste or to replace dirty coal-fired power plants with cleaner gas or nuclear plants be developed. That technology cannot be produced in centrally planned economies where the profit motive is squelched and lives are marshalled by the state.

There's nothing wrong with setting aside a day to honor the Earth. In fairness, though, it should be complemented by Capitalism Day. It's important that the world be reminded of what has driven the environmental improvements since Earth Day began in 1970.

Health Insurance does not equal health care

Worth reading is this commentary by internist Dr. Marc Siegel who cautions that "health insurance does not equal health care".Neither is the promise of a government of universal coverage equal to the actual delivery or ready availability of health care.

Medicare (which some may remember as the government program that promised not to interfere with the physician-patient relationship) has so limited the payment to physicians (particularly primary care physicians) that the promise for medical care for the elderly increasingly is becoming unfulfilled as more and more primary care docs opt out or at least refuse to see new medicare payments. This is government care for just one segment of the population.In Canada the unfulfilled promises can affect everyone or at least those who cannot go south and pay for their care.

A recent Texas Medicare Association survey indicated that only 38% of primary care doctors are accepting new Medicare patients and the situation is worse with Medicaid patients.

Problems finding a physician in Massachusetts affects everyone since they instituted the brilliant plan of getting medical insurance for all by simply passing a law that mandated it.This is the same plan that is now asking for a federal bailout.See here for how that is working out.

There are many interpretations for the cryptic lyrics of the song "Hotel California" which says in part

"...relax, said the night man, We are programmed to receive. You can checkout any time you like, But you can never leave! "

My interpretation is that the hotel provides the trappings or appearance of a service but not the real service. What does your national health service card mean if you have to wait so long for the care that it might not matter or if the shortage of docs gets to the point where little care is available.

In Canada health care is a right,wait ,no it isn't?

In Canada, there is universal health care with a single payer and for the most part no opting of the system.Their supreme court ruled that patient rights were been violated because their access to health care was in some instances so delayed that it was no care at all.

Now consider the case of an orthopedic surgeon, Dr. Brian Day who is involved in legal proceedings with the provincial health care entity in British Columbia for accepting payment from a private citizen for medical care. See here for some details and here for details of Dr. Day's lawsuit which seeks to overturn the law in BC that bans private medical care. In this matter the government is arguing that the supreme court ruling does not apply because health care is not a right after all.

Wait,I thought the government of Canada provided medical care for all because of the belief that medical care was a right but now it isn't.

More concerns about Government mandated and financed electronic medical records

To reform medical care we are told that we need three things; 1)electronic medical records (EMR), 2)comparative effectiveness research (done by the federal government)(CER) and 3)more efforts at prevention . From these elements we can derive care for all,better quality care and great cost savings.(Why does this remind me of "cheap,fast and good-pick any two"?)

Concerns about the government mandated EMR have been recently expressed regarding the following issues:
1.The Legacy issue
2.The error problem
3.The monopoly problem.

While Dr. Michael O'Connor of the blog The Ether Way eloquently writes (see here) about a more fundamental problem with the EMR, namely that it is,at least in part, a cut-and-paste tool of the administrators and the regulators and not so much of the physicians caring for the patients and as such serves the ends of the first two groups much better than those of the physicians and patients and that physician sometimes resort to "shadow charts" as a work-around to the constraints of the EMR.

Dr. Wes offers this posting about the" Legacy problem" with EMR. This is easily related to by anyone who remembers floppy discs ( remember the kind that were really floppy) and how your current computer does not even have slot for those now. Some may have experienced how various drivers did not work when their new PC was driven by Vista and they were not supported by this new improved Microsoft product.Read the trajectory of frustration ,wasted time and money that is explained in detail on Dr.Wes's entry. As computer systems evoke, incompatibilities arise with older system still in use which can lead to increased costs or partial or complete abandonment of the system.

Another serious matter is discussed in detail on Junkfood Science.See here. The main point is that electronic records can be erroneous (errors creep in from various often unrecognized sources) and those errors can be lethal and good luck getting those changed or even finding out what they say.For a detailed description of just some of what can and does go wrong with electronic medical records, go here for an alarming essay by Dr. S. Silverstein (AKA MednformaticsMD) who has tirelessly been educating the readers of Health Care Renewal about the many problems with medical IT.

Still another issue is raised by a commentary in NEJM about which there is a WSJ article ( see here).Since the stimulus bill gives the government power to define and approve which programs and systems will be used there is the power to create a medical high tech monopoly leaving innovation and corrective improvements out in the cold.

Dr. O'Conner's critique of the EMR should be read in its entirety but here is one good quote.

Many EMRs read like Madlibs(for those of you old enough to remember what they are), because they are in fact cut-and-pasted snippets of data from other parts of the EMR, put in place to fulfill some billing documentation requirement or some regulatory imperative. Free text annotation is often discouraged, and frequently impossible to juxtapose next to the appropriate snippet of information in the chart. Some systems make it very difficult to generate any kind of free form documentation, and consequently critical events in the course of a hospitalization are never documented. In most or all hospitals, practitioners have developed a shadow chart that incorporates all of the critical information that practitioners need to know to care for a patient. The existence of these shadow charts has been driven by the hijacking of the medical record for billing and regulatory purposes. The creation of these charts represents additional effort for everyone who directly participates in the care of patients. That such busy people are willing to do this is striking. Little you want to know is in the chart; everything you need to know is in the shadow chart.

I'll admit I had not heard about shadow charts since I have been away from clinical care for a while. Perhaps a reader can inform how widespread this is.

We are told that to reform medical care, billions will be spent to ensure EMRs will cover
everyone's medical records and we can watch as the quality of care is monitored from "this perch" which may well consist of coarse grain and often erroneous data extracted from various EMRs (including the notoriously inaccurate coding information) often excluding the important nuances of the real medical world.

Comparative effectiveness research-more warnings

Those, including several medical bloggers, who seem to have placed more than a little faith in the notion of a government funded and run comparative effectiveness research program (CER) should read the following sobering posting from Health Care Renewal.

The commentary in part expresses concerns about the following recent comments from Governor Sebelius from her congressional hearing for head of HHS.

“The goal,” Sebelius said, “is to provide every American with a safe, secure electronic health record by 2014." The nominee also endorsed efforts to use data gleaned from electronic medical records to conduct “comparative effectiveness research" (the authors bolding)(CER) to provide information on the relative strengths and weaknesses of alternative medical interventions to health providers and consumers.”

The author of the Health Care renewal entry is properly alarmed that use of the often garbage type data from EMR have a high likelihood of generating detailed printouts of elaborately presented ( replete with very low p values) results that could be misleading at best and more likely harmful. To expect such " highly uncontrolled" data bases to meaningfully determine if treatment X is better than treatment Y raises unrealistic expectations to a new level.

It seems to me that some pro government CER advocates make two mistakes in their advocacy of the government funded CER.

First, they maintain that we have no or at best very little comparative effectiveness data at all now so the government must provide it. Dr RW in this posting proves that is not the case. A recent example of non-government funded CER is the SYNTAX trial.

Secondly, they conflate the desire to have really good data on what works with the assumption that such will be the product from a government funded CER. Yes,it would be very nice if there were someway to have realms of great CER without bias and without spin but should we really trust a government agency who would somehow be populated by selfless, brilliant, dedicated public servants who would bring no biases to the table and who somehow will be immune to the outside influences that seemed to have plagued every governmental agency ever created and that the output from analysis would not be put to the purpose of limiting government payment for such treatment that they found inferior.
Limiting payment for medical services deemed inferior by data dredging exercises is not what we need to improve medical quality but may well be what government sponsored CER will bring.

Medical Home will not be enough, we need the Medical Village

I written before about my skepticism regarding the Medical Home concept.It has been suggested that the home does not go far enough and that a "village "concept should be explored and possibly adopted. Here is one doc's version of how that village concept would be applied to one aspect of medical care. Thanks to Dr. Hal Dall's blog for insightful comments and satire.

Statins (or at least one of them) seems to just get better and better

Just as we thought there could not possibly be any more purported benefits of the statin drugs we are treated to still another reason to get on the bandwagon- prevention of venous clots.

At least that is what we are told by more breaking news from the latest paradigm shifting, landmark study, the JUPITER trial. We now learn that in this large , randomized trial of persons whose LDL were less than 130 and their CRP were greater than 2,that there was a 43 % decrease in the incidence of venous thrombotic disease in the rosuvastatin (20 mg) group. See here for the entire article from the NEJM.

Previously I had blogged about the reported benefits of pre-operative statins in terms of fewer deaths,fewer strokes and a lower incidence of atrial fibrillation.

What the heck could increased variation in red blood cell size have to do with heart disease or mortality?

This article from the Archives of Internal Medicine seems to link a measure of variability in red blood cell (rbc) size with all cause mortality. As the article explains, previously there had several studies that suggested a link between heart disease and RBC size variability as judged by measurement of the RDW by automated blood cell analyzers. (See here for one article linking elevated RDW and adverse clinical outcomes in patients with heart disease). The Archive article examined a large data base for evidence of a similar correlation with all cause mortality and seemed to find one that reached statistical significance.

The RDW is the red cell distribution width which is the standard deviation of red cell width divided by the mean cell width and normally is around 10-15 %. Remember we used to talk about anisocytosis. It may have some limited utility in differentiating iron deficiency anemia from thalassemia with the RDW increased in the former reflecting the fact that in iron deficiency there are two populations of red cells and in thalassemia there is a more homogeneous population of relatively small rbcs. In my experience, it is a by product of automatic blood cell analyzers that most docs ignore, including a couple of hematologist associates I asked about it.

The study authors also wondered how/why RDW seems to correlate with all cause mortality.They investigated the relationship between C reactive protein (CRP) and RDW postulating that somehow inflammation was involved but that did not seem to be the case.

How long will it take for the JUPITER data be dredged to see if statins ( at least rosuvastatin) can lower the RDW?

Is the Massachusett Universal coverage plan the canary in the mine?

See this article from WSJ online to gather facts about how poorly things are working out in the grand universal health care program for Massachusetts.

Three years into the program (which has been labeled the Bay State bait and switch) the costs have increased far beyond the projections that were part of the program's promises. The budget projection for 2010 is 880 million which is a 42% increase from the 2006 number. (other projections go even higher, see below). They have increased fines for those who can afford insurance but choose to not sign up, also increasing are premiums and penalties for business. A panel has been set up to look at options. It is never good news that a panel has been set to "find solutions". Limiting care is one,limiting profits for insurers is another after premiums and penalties have increased to a point were public outcry becomes too loud.

Proponents had promised universal coverage with lower costs.

Go here for many more details of how badly things have gone as outlined on the Blog Junkfood Science.Here is an except:

By February of this year (2008), the state was asking the Federal government to bail it out ( my bold) and cover half of the program’s costs from 2009 through 2011. According to the Boston Globe, the program will cost taxpayers $1.95 billion this year and is expected to cost $1.35 billion annually by June 2011 — figures that “far outstrip the original plans.” Massachusetts medical authorities, in efforts to keep the program solvent, had approved changes in December to cut payments to doctors and hospitals, reduce choices and benefits for patients, and possibly increase how much patients have to pay.

The WSJ article closes with:

The real lesson of Massachusetts is that reform proponents won't tell Americans the truth about what "universal" coverage really means: Runaway costs followed by price controls and bureaucratic rationing.

At least citizens of Massachusetts have a safety value, something that might not be readily available if the Mass. plan goes national.

We are promised universal health care that will magically be less expensive because of the promised savings of "investments" in medical IT, comparative effectiveness research and preventive medicine.The plan seems to be spend more on health care so we can save more.What could go wrong with that?

NHS's hospital from hell showcases performance measures

The British NHS is investigating how things could go so very wrong at one of their hospitals,the Stafford hospital. See here for the newspaper report that puts at least part of the blame on a situation where mindless adhering to quality targets may have caused deaths.

See also here for the story that has this quote:

...So what the government decided to do instead was make hospitals compete on things that mostly weren't related to clinical outcomes; things that could be easily measured, such as the four-hour wait in A&E. If you talk to clinicians, they'll say this has nothing to do with outcomes and doesn't improve the care that patients receive. You can find ways to fiddle the numbers to tick that box, and you can put resources in to try to meet the targets.

At a time when the incredibly bad care that is documented in the two above cited newspapers article was taking place the hospital was getting pretty good grades on its various performance measures.

One such target was "get the patients out of (A&E ) accident and emergency) to the wards in 4 hours.".If you thought there were problems with the U.S. "4-hour pneumonia rule"....

I have blogged before on Goodhart's law which says:

"Once a measure is made a target for the purpose of conducting policy it will loose the information content that would qualify it to play such a role".

While the mindlessness of treating to the quality measure is part of the problem at this NHS hospital there is much more wrong than that .See here for Health Care BS's take on the matter.