Medical decision making moves to Washington

Every time I re-read a section of Thomas Sowell's Knowledge and Decisions I am more impressed with how brilliant it is,how filled with insights and how well written .

A central theme of the second half of the book is described by Sowell in this way: (my bolding)

Even within democratic nations,the locus of decision making has drifted way from the individual,the family and voluntary associations of various thoughts and toward government.And within government, it has moved away from elected officials subject to voter feedback,and toward more insulated governmental institutions, such as bureaucracies and the appointed judiciary.

The ACA (Obamacare) represents a major shift in the locus of decision making regarding medical care. One could consider Obamacare the poster child for that concept. Of course, the locus has already been shifted to a major decree away from the the individual physician and individual patient ( the "dyad" in Don Berwick's quirky terminology ) by the hegemony of third party payers and the virtual single-payer status of government finance health care administered through CMS (Medicare and Medicaid).


A major theme of the first half of his book is the following. One should analyze the decision making processes of institutions in terms of the incentives faced,the constraints in place and the likely outcomes and  whether the decision makers are immune from  or influenced  by  feedback mechanisms .Do not look at the "hoped for results" or the mission statements but rather at the mechanics of the decision making process.

Consider those mechanics in the context of ACA and how the myriad details which will make the lofty goals operational will be determined. Various governmental agencies and panels will deliberate and churn out the pages of rules and regulations that physicians and patients will have to live with. For the most part these rules makers will be immune from meaningful feedback but they will will not be immune to lobbying efforts by various special interest groups during the rule making process.

Consider the mechanics of the Independent Payment Advisory Board ( IPAB) and how decisions will be made by its fifteen member presidential appointed panel and how lobbyists for various special interests will target this group and likely their efforts will be proportional to the power that IPAB has been given.

Addendum: Minor stylistic changes made 9/25/14

Victor Fuchs solves the "doctor's dilemma"-appropriate care is cost effective and ethical too

Victor R. Fuchs,Economics Professor Emeritus at Stanford, wrote a Perspective commentary in the August 18,2011 Issue of the New England Journal of Medicine entitled: The Doctor's Dilemma-What is "Appropriate" Care ?

The dilemma he describes is the following;

"How can a commitment to cost-effective care ( as physicians have been "committed" to that since the Physician charter and the New Professionalism) be reconciled with a fundamental principle of primacy of patient welfare"


Fuchs tell the readers if all the physicians in a given health care collective practice (as in HMOs and now Accountable care Organizations) cost effective medicine the resources saved can be used for the benefit of the defined population which includes the patients of the physician who seemingly may face a conflict. So, if all the physicians act in the same way all patients benefit.

I believe Fuchs conflates the good of group as indicated by some aggregate number with the good of each individual in a particular situation in which a particular individual may not enjoy the benefit and may actually be harmed. In fact cost effectiveness analysis involves aggregate data. With any outcome in a group some may benefit some may be harmed.

In his closing paragraph, Fuchs tells us that when a physician works in a health care collective in which there is a fixed annual budget the physician resolves the dilemma by favoring the cost effective option. This according to Fuchs become "appropriate". ( Why does Fuchs use quotes marks?) So,the cost effective choice is the appropriate choice and also the ethical one. It is ethical in the moral calculus of Kant "because if all physicians act the same way,all patients benefit" .

The basis of Kant's ethical precepts was the categorical imperative which is:

"Act only according to that maxim whereby you can,at the same time, will that it should become a universal law."

In other words, a person acts morally when he acts as if that conduct were establishing a universal law governing others in a similar situation.


I find it interesting and puzzling that Fuchs uses a Kantian based ethical argument to support cost effectiveness based decisions in health care as cost effectiveness analysis is typically justified using a consequentialist type argument. Philosophical support for the notion of resource allocation based on the best bang for the buck is supplied by this outcome based school of ethics.

Kantian ethics, on the other hand, is duty or rule based ,an approach called deontological in the literature of ethics.Kant believed that the individual should be considered an end in himself not as a means to an end. In the medical collective the individual's interests are subjugated to the aggregated good of the group;the individual functioning as a means to achieve the greater good of the collective whether or not a particular member of the collective enjoys the benefit.

In the moral conflict between the physician's fiduciary duty to do what is right for the individual patient and the imperative to serve the best interests ( by what ever aggregate parameter that is being used) of the group as a whole, would not Kantian rule-duty based ethics support the rule of do what is best for your patient and patient is a singular noun. If Fuchs is suggesting that cost effectiveness analysis should be determinative in medical decisions and that it is justified by Kantian ethics, I suppose the "rule" would be always do what is cost effective.Never mind that pesky notion of a person being considered an end in himself and not as a means.

Once again price control in medicine results in shortages,this time cancer drugs

There has been and continues to be shortages in some of the older well proven cancer drugs. See here for an explanation of what is happening there.

Dr. Ezekiel J. Emanuel blames much of the problem of the 2001 Medicare Prescription Improvement and Modernization Act.

Here is a quote from Emanuel's opinion piece in the August 6,2011 NYT Sunday Review:

The act had an unintended consequence. In the first two or three years after a cancer drug goes generic, its price can drop by as much as 90 percent as manufacturers compete for market share. But if a shortage develops, the drug’s price should be able to increase again to attract more manufacturers. Because the 2003 act effectively limits drug price increases, it prevents this from happening. The low profit margins mean that manufacturers face a hard choice: lose money producing a lifesaving drug or switch limited production capacity to a more lucrative drug.

The economist Arnold Kling is fond of saying that they teach all the important stuff in Econ 101 not saving any big secrets for more advance study.I'm fairly sure Econ 101 explains the effects of wage and price controls and that incentives matter.

Aggregate Healthiness, Gross Body Health,Keynesian Medicine

I have ranted and sometime more reflectively argued quietly against the morality of the aggregate as it applies to medical practice. Rules,pay for performance (now re branded as value based purchasing) rely on the statistical aggregates and often overly simplified guidelines. I know, aggregates can be useful in a number of contexts but the individual patient ( what other kind of patient is there?) may have her interest devoured by obsession with rules based on the statistical abstractions.

Here, George Mason Economist,Don Boudreaux, tells a satirical tale about a medical analogue to Keynesian aggregate demand.

No, the fictional gross body health is not exactly what I argue about with the guideline-P4P thrust in clinical medicine but Boudreaux's commentary is worth reading.

MIT Prof discovers people like to spend other people's money

Amy Finkelstein,a PhD economist from MIT,has "discovered" that people when given a card that lets them buy something cheaper than they could otherwise buy more stuff. Thanks Dr. Michel  Accad at the blog, Alert and Oriented,for calling this discovery to my attention.

This link from a news story on the discovery briefly discusses her findings and the mind boggling claim that this finding will change thinking about health care spending. Yeah, it is that old
"demand curves slope downward" thing again. Note: this is not breaking news as her report and news items on it date back to 2007 but I have fallen way behind on my health wonk literature reading.

Here is a quote from the news report:

Already, Finkelstein's analysis is shaking up views across the political spectrum. "This is pathbreaking work," says Joseph R. Antos, a health economist at the conservative American Enterprise Institute. Adds the more liberal MIT economist Jonathan Gruber: "This really changes the whole landscape in the way we think about health economics." 

Wow! The economist ( Gruber)  who advised in regard to Romney-care and Obamacare seemingly was unaware that people tend to buy more of something when it costs less.

Wow again,  path-breaking work.Apparently no one heard or remembered what Milton Friedman had said about the ways people can spend.See here for that concept in Dr.Friedman's own words.The key point here is that when you spend someone else's money on yourself , you are not very careful about how much you spend.

Dr. Finkelstein work supports the notion that health care costs have increased in no small measure because millions of older American have Medicare insurance and they realize that they can get medical services much cheaper than otherwise when they show their card to various health care providers. The fact that some health care wonks thought her findings will change the way people will think about health care policy seems to mean that until now some health care experts believed that demand curves slope upward. Some admirers of Milton Friedman are celebrating the 99th anniversary of his birth. See here. Maybe health care economists might browse through some of his work.Perhaps an econometric demonstration of the absence of a free lunch might be forthcoming.


Addendum: 11/12/14 Minor changes  made re style , spelling  and one factual error in regard to Dr. Accad's first name.

Health Care and Education-the new "commanding heights -"Kling and Schult

An interesting and insightful commentary by Arnold Kling and Mick Schult is found in the Summer issue of "National Affairs" and is entitled "The New Commanding Heights".The title is a play on the title of the book by Daniel Yergin and Joseph Stanislaw "entitled "The Commanding Heights:The battle for the world economy". See here for the Kling essay.

The term Commanding Heights was used by Lenin in a 1922 speech in which he refers to the dominate industries in Russia at the time indicating that they would be target of the central control of the communists. He gave up trying to control everything so he decided to control the key industries.These included heavy manufacturing,mining,electric generation and transportation.

Kling and Schult contend that those industries are now largely not controlled by the state in the United States and in western countries generally and while these sectors are important they present data showing they are no longer the major growth sectors in our economy.They argue convincingly that education and health care are the growth sectors in the United States.

History has made it clear that markets work. Market economies lead to prosperity,economic growth and innovation while central planning results in dismal and often tragic failures. Lenin promised to do what capitalism did plus eliminating waste, recessions, and inequality:what was produced was mass starvation and mass murder.

However, the authors warn markets advocates against premature celebration. Their thesis is that in the U.S., both in education and medical care, the new commanding heights, governmental controls are prevalent and growing and if the U.S. is to continues to grow and prosper, we need innovation in these areas? How much innovation occurs in government controlled economic sector?

Many (most?) discussions of the medical economy emphasize the overall
cost" of medical care and its growth ( it is a growth sector) and that it is a bad thing. Two comments are appropriate: 1) often overall costs are conflated with government costs ( i.e. Medicare and Medicaid) with overall costs 2) Costs are only one side of the accounting, one person's costs are another's income stream.

Controlling the amount of money that the government spends on health care or farm subsidies or foreign wars is one thing and is well within legitimate government activity, attempting to limit private spending on healthcare or cosmetics or anything other legal activity is quite something else.So with GDP not snapping back to previous more healthy levels do we really want to decrease activity in one of the two major economic growth centers?

Surprise-economic principles apply to old folks and Medicare costs

See here for a report on some data gathering that should be filed under the heading of "very bloody obvious". The link is to the 7/16/2011 blog entry from Dr. Mark J.Perry which tells us 1)Medicare utilization is about 50% higher than private health insurance utilization and 2) why Medicare patients see their doctor so (too?) much. Hint:it has something to do with spending someone's else money and the law of demand.

Economists are fond of saying "demand curves slope downward" which is their jargony way of saying that people buy more when the prices is lower and less when it is higher. Milton Friedman has been quoted as saying that economics is simple- just remember there is no free lunch and demand curves slope downward.

Economists ,for some obscure reason possibly found deep in the history of their discipline, place the dependent variables on the X-axis and the independent variable on the Y-axis. This is just the reverse of the practice of physicists and engineers and most other people who like to draw graphs. So they place price on the Y axis and quantity demanded on the X axis and thus the demand curves slope downward because folks buy more when the price is cheaper.

Medicare patients "buy" more health care because of the way Medicare works they get a really good deal on the price that CMS allows to be charged. It gets better, Medicare generally pay 80% of a significantly lower "allowed price" and many seniors have supplemental insurance which further amplifies the illusion of a free lunch.So,of course,Medicare users utilize more services and the reason is not that fee-for-service doesn't work. Blaming fee-for-service is the current battle cry on many in Congress and many of the organizations who allegedly represent the practicing physicians.

Some would conflate fee-for-service with free markets in medicine but there has been no free market in medical care for many years now (except for a few markets such as lasik surgery and some plastic surgery and much of alternative medicine) and the Medicare system is characterized by price controls and the demand side characterized by folks buying services with someone else's money,both of which are the products of central planning. What could possibly go wrong with that circumstance?

The list of problems in medical practice are not due to fee-for-service but rather what happens in a nominal fee-for-service setting when there are price controls namely shortages,long waiting lines,poor quality and various other forms of rationing by other than prices.As is often the case, the results of central planning are blamed on that heartless,run-away greed all the way down, free market.And as is also often the case the solution is more central planning,which is what Obama care is all about.

More on IPAB and the risk of regulatory capture

See here for a recent report on views of the IPAB.

Particularly interesting were comments of someone who has been there and done things in the setting of a very important and powerful governmental appointed post.

Bruce Vladecks, the former head of CMS under Bill Clinton, had this to say :

"In the short term, it might theoretically work," he said. But the history with other independent regulatory agencies, like the Interstate Commerce Commission and the Civil Aeronautics Board is that over time "the regulated industries tend to capture them; and they tend to do more to protect the regulated industries than they do to protect consumers."


Considering the legislative hurdles that Obamacare put in place for Congress to over ride the edicts of IPAB, capturing IPAB would be prize well worth capturing.

What is the moral case for Obamacare?

Is there one at all?This commentary by the economist John Goodman argues there is none. After Dr.Goodman made his case he invited readers to offer such a moral justification.I could find none in the forty reply to his article.

Several commentators ( including spokesmen for the ACP and the AMA ) claimed that Obamacare furthered social justice. So could that be the moral justification for Obamcare?

In regard to social justice Thomas Sowell said the following:

Their passionate arguments for particular results tend to obscure or distract attention from the question of the social processes by which these hoped-for results are to be pursued.


Goodman,in this most recent cited commentary, and in numerous others posting on his blog gives great detail of the various social process set in motion by Obamacare and the numerous apparently unintended consequences

In short, the various elements of this outlandish long bill do just about anything other than the putative hoped-for results which is "affordable , accessible health care for all" and instead offer a mind boggling array of counterproductive results and bizarre inequities and the frightening promise that many more such dystopian outcomes will arise from the hundreds ( more likely thousands) of pages yet to be written by agencies created by Obamacare and the incredible discretionary powers given to the Secretary of HHS.

Perhaps,spokesmen for the medical organizations who champion (yes, they still support it in spite of the increasing evidence that the bill is a very bad idea) can offer a moral justification .

Meta-analyses-money well spent?

I have blogged more than once ( see here and here )about meta-analyses (MA) and quoted Steve Goodman MD PhD more than once when he said that MAs are just observational studies in which the observed elements are studies. I would add and we just don't know what went on behind the curtain.

They are not super randomized trials as the prefix "meta" might imply but should rightly reside significantly under RCTs in the hierarchy of clinical research methods.

Since the views expressed conform nicely with my biases I was drawn to this commentary by Dr Wes.

"Wise Legislators " pass ACA with IPAB,their "good deed"

Henry J.Aaron,of the Brookings Institute, has written three commentaries in the Perspective section of the NEJM in the last year. He seems to be their go-to guy for IPAB issues.Here is a link to his latest.

He praises Congress for their willingness to "abstain from meddling in matters they are poorly equipped to handle." He seems to be aware of Public Choice theory (he has a PhD in Economics from Harvard) when he talks about the temptation of Congress to spend money for political ends but seems to have missed the point when he apparently assumes that the IPAB panelists would be immune to lobbying efforts.Clearly, he believes it is a good and desirable thing for Congress to delegate its powers to agencies and other bodies- a view somewhat in opposition to how James Madison thought things would work out.

This is in stark contrast with the friend of the court brief that the Pacific Legal Foundation has filed to challenge the constitutionality of the creation of IPAB. See here for their comments on IPAB and a reference link to their brief challenging IPAB.

Aarons likens the creation of IPAB to the creation of the Federal Reserve which was to be an entity not subject to congressional control.

This may not be the best analogy with the increasing efforts of Congress (and not just Ron Paul ) to at least exert some surveillance of what the Fed does.

July 4th, all about the right to vote or much more than that?

This commentary from the Coyote Blog is good fourth of July reading.

Warren Meyer,a libertarian entrepreneur and prolific writer, who writes the blog as well as being a contributor to Forbes list three principles more important than the right to vote. Here is the first one he discusses:


"The Rule of Law. For about 99% of human history, political power has been exercised at the unchecked capricious whim of a few individuals. The great innovation of western countries like the US, and before it England and the Netherlands, has been to subjugate the power of government officials to the rule of law. Criminal justice, adjudication of disputes, contracts, etc. all operate based on a set of laws known to all in advance and applying equally to all."

Meyer then points out the obvious contempt for the rule of law with the exemptions to certain provisions of the health care law .

More of the "social justice" fallout from ACA

As more and more inequities and unintended consequences of Obamacare are revealed as we learn more and more about the bill,we can see that the social justice Obamacare advocates (you know who you are )boasted about following its passage is a very strange type of justice.

See here for one of the latest revelations about how basically unfair various aspects of the bill turn out to to be. As the AP article explains two families with same income would pay significantly different health insurance premiums to the exchange based on what type of income they receive.This problem seems to be tied to the definition of income used in the statute.

But it gets even worse, more folks become eligible for Medicaid based on the law's wording.

Medicare's top number-cruncher is warning that up to 3 million middle-class people in households that get at least part of their income from Social Security could suddenly become eligible for nearly free coverage through Medicaid, the federal-state safety net program for the poor. Chief Actuary Richard Fosters says that situation "just doesn't make sense."

The progressive mind set worries about inequality just about everywhere

See here for David Henderson's remarks about a commentary from former white house adviser and Director of OMB and now VP of global banking at Goldman Sachs.Peter Orszag.

Here,Orszag worries that high tech advances will worsen the gap between the rich and poor in longevity. The various (endless?) parameters that can be used to illustrate the fact that the rich and the poor are different is many ways provide much source of professed worry and endless calls to action from the progressives.

His move to Goldman Sacs should do much to insure that he will be at the top of that gap so that any "solution" to this problem must involve raising up the poor and not lowering the rich although his commentary seemed to offer no practical solution to this worrisome gap .

We will never run out of gaps.Market economics is the engine of prosperity and also the engine of inequality according to Milton Friedman.

There is a body of literature and discourse which emphasizes the notion that inequality is a major problem in the western world, as least in the U.S., and the inequality per se is bad and harmful and therefore there should be continuing policy efforts to shrink the gaps. Here is a well reasoned counterargument to that notion.

Platonic Medicine and the ACA with its IPAB

 A recent commentary by one of favorite bloggers,Dr. Robert Centor, spoke favorably about IPAB, one of many,many provisions of ACA.See here.I made a brief reply to his entry. I recalled this earlier blog entry and if Dr.Centor's comment stirs up much furor  I want to add this earlier blog post to the kerfuffle.Originally published  6/22/11 and now submitted with little editing.

I had been sketching out some comments about what I was going to call "Platonic Medicine" referring to the "leaders with ideas" who will lead the way to transform medicine based on the underlying premise that "medicine is too complex and important to be left to the individual physician and the individual patient" and therefore it should be controlled and directed by the wise medical elite who will determine the collective utility of a given approach and its value.I have commented before about Don Berwick's advocacy of that view.

However, someone had written something in that regard better than I could.See here.

Hat tip to the Pacific Legal Foundation who filed a friend-of-the-court brief to challenge the constitutionality of IPAB on the grounds of violation of the non-delegation doctrine and for the above mentioned link which alerted  me to Jost's frightening comments.

It turns out that an outspoken advocate and supporter of Obamacare,law professor, Timothy Jost has already praised that legislative act in part because of what the IPAB will provide. He said:

A board of “Platonic Guardians” to govern the health care system or some aspects of it. The cost of health care is spinning dangerously out of control…. [O]ur traditional political institutions—Congress and the executive administrative agencies—are too driven by special interest politics and too limited in their expertise and vision to control costs. Enter the Platonic guardians…an impartial, independent board of experts who could make evidence-based policy determinations based purely on the basis of effectiveness and perhaps efficiency.

Incredibly Jost is asserting that this board will be immune to the influence of special interests and will make decisions rationally and in a proper evidence based manner.From what planet will these board member be chosen? Philosopher kings in charge,what could go wrong with that?

The PLF commentary pointed out that a Platonic government was definitely not what the founding fathers had in mind and Jefferson and associates were not big fans of Plato.

In the commentary that I was considering I thought perhaps calling the panel members Platonic Guardians would earn me the accusation of being overly dramatic and hyperbolic, but now we see an IPAB advocate using the same characterization and believing that to be a very good thing.

Dictating the coverage to control the cost for Medicare and Medicaid may not be enough for the medical Platonic elite as is illustrated by this quote from Dr. Robert Berenson:

"we ought to consider setting all payer-rates for providers." He continues "but the country's antigovernment mood renders such a discussion unlikely,at least for now".

I wonder who the "we" is that Berenson references.

Finally, another chilling quote from Mr. Jost:

"In the long run, Congress may not be able to cap Medicare expenditures without addressing private expenditures as well. If the IPAB opens the door to rate setting for all payers,it may well be the most revolutionary innovation of the ACA".

Yeah, it just might be.

Why is there a shortage of certain drugs?

When faced with a shortage in some good or services a good first guess as to what might be going on is to see if there are price controls at work?

Go here to read a detailed analysis by John Goodman of what factors are at work in the ongoing shortage of over 200 hundred medications. It turns out that at least a contributing factor to the shortage is price controls which are part of a 1992 Federal 340B drug rebate program to certain medical facilities.

Another, perhaps more important governmental factor is at work in the form of the the output controls put in place by the FDA which limits the production of product by drug companies and diminishes their ability to quickly react to market conditions with increased production.

No, price controls are not the entire explanation but government price controls and other regulatory actions impeding market process are playing a role. The situation is more complicated that the two factors mentioned above and some of the other contributing factors are discussed here. But,as the various shortages play out, I'll be it won't be long until we hear that the free market has failed again and more governmental controls are necessary to protect the public.

Peripheral arterial disease (PAD) and smoking, now there is a real relative risk

While I thought there was little doubt remaining about the relationship between cigarette smoking and PAD, a recent study published in the Annals of Internal Medicine (see here for abstract) provided more convincing data, this time in women. Yes, cigarettes are bad for women's peripheral arteries as well.

This study from the Women's Health Study generated some robust, relative risk numbers.I am not talking about the puny 1.2-1.4 relative risks (RRs) we often see in the typical data dredging articles and certainty not the ridiculous RR of 1.01 (not a typo) that was the alleged increased risk of death from vitamin E use.See here for that silliness.

Here are the age adjusted incidence numbers for symptomatic PAD

0.12 never smoked
0.34 former smoker
0.45 smoked less than 15 cigarettes per day
1.63 smoked greater than 15 cigarettes per day

1.63/0.12 =13.6

You are not likely to see RRs greater 10 from the typical data dredge and the WHS data also demonstrated a dose-response effect.

So, how large should a RR be before one worries about it or seriously believes we may have a causal relationship?

Sackett ,of McMaster EBM fame, asked one of the giants of epidemiology that question. Sir Richard Doll said that if the RR were 20 or greater that would be almost sufficient to indicate causality.Sackett was not quite that cautious and indicated that a RR of greater than 3 was "convincing".

Some courts use a RR greater than 2 to reach the threshold of "more likely than not".This is the current level of proof in most tort cases.

Michale Thun, who at the time was vice-president of epidemiology and Surveillance at the American Cancer Society, said:

With epidemiology you can tell a little thing from a big thing.What's very hard to do it to tell a little thing from nothing at all.

With cigarettes and PAD, we have big thing and we will not likely see battling statisticians debating the data. However, we did see that when Nissen's NEJM article claimed a RR of 1.43 for of Avandia and heart disease and we will likely get to see another again with the current breaking news of a RR around 1.4 with Actos and bladder cancer.

Independent Payment Advisory Board (IPAB)-what could go wrong with that?

The IPAB which was inserted into Obamacare at the last minute without anything approaching proper legislative review and contemplation establishes a 15 member panel appointed by the President which will beginning in 2014 ( if a cost limit trigger is met) have unprecedented power to control medical spending in the country with almost no significant or likely effective congressional oversight.

Now what could possibly be wrong with that?

James Madison had some thoughts about that.He was concerned about what he referred to as "factions' which today would be thought of as special interest groups.Special interest groups have developed a potent skill set to influence government bodies to focus benefits on themselves while the cost are diffused.

In general, the founding fathers of the country has some thoughts about what could be wrong with that sort of entity.They tried to design a government not so that wise leaders could do great good but rather one that would limit the damage done by fools,thugs and would be despots who might(most assuredly would) find their way to influential posts in government.

Their wisdom seemed brushed aside as the view of a benevolent and wise government assumed the default position as it was persistently promoted by a cadre of progressive minded academia intellectuals and high school civics texts which visualized a government that would wisely recognize problems,devise safe and effective solutions and then without special favors execute remedial plans marvelously bereft of significant unintended consequences.

Fortunately, James Buchanan and Gordon Tullock resurrected Madisonian wisdom, enlarged upon it and explicated the theory of public choice which basically asserts that government officials and bureaucrats display the same characteristics as other humans, namely a proclivity to look after their own self interest. They definitely had some thoughts about what could possibly go wrong with something like  IPAB.

The economist, George Stigler,who did much to develop the concept of regulatory capture might have some to say about what could go wrong with the IPAB.Governmental agencies and organizations can be subject to the influence of the very groups that they are  nominally created to regulate and control .

Mafia dons and wise guys alike know the explanatory value of the "follow the money" and could explain simply what could go wrong with the IPAB.

Big Pharma had supported the passage of ACA but it is hard to believe that their support would have been forthcoming had they realized what IPAB would be.They certainly recognize the danger now.

The American College of Physicians (ACP) also supported Obamacare but now express opposition to the IPAB section "as written".Although (unfortunately in my view) they do not recommend repeal of IPAB but instead want certain changes that would make the entity acceptable.See here for ACP's position which objects to the exemption of hospitals and hospices from IPAB's edicts until 2019,the absence of primary care physicians on the panel,the lack of a mechanisms for significant congressional oversight and for preserving quality while decreasing costs.

So, much can go very,very wrong with IPAB but it gets even worse. Go here to read a recent commentary by George Will which discusses the chilling thought that the IPAB may not be stoppable. It may well be " entrenched".

Entrenchment refers to one legislative body passing a law that contains provisions that prohibit later legislatures from repealing the law.

Can a legislative body really pass a law that contains a wording to prohibit further changes in that law?Is the IMAB really an immutable entity?

Eric Posner discusses it here and, as best I can translate it from the legal dialect academic lawyers speak into everyday English is that the Supreme Court has decided that they cannot allow that but as with anything that might be litigated there are at least as many sides to the issue as there are interests who can loose or gain from a decision and Supreme Courts sometimes change its mind.

It is hard to find a better summation that the one penned by Mr. Will in his above cited recent column:

"The essence of progressivism, and of the administrative state that is progressivism’s project, is this doctrine: Modern society is too complex for popular sovereignty, so government of, by and for supposedly disinterested experts must not perish from the earth. "

And the corollary for progressive medicine is that "medical care is too important and complex to be left to the individual physician and the individual patient."

minor editorial changes and typo correction changes made 8/17/14.
more corrections made 11/29/14

Harvard economist expresses concern over plans for IPAB

When a main-stream, Harvard economist expresses concern about a entity created by the enormous health care bill (ACA,Obamacare) known as the IPAB, it should evoke more wide spread concern about the wide reaching aspects of the legislation.

Professor Greg Mankiw has written with alarm about what a progressive think tank has proposed regarding the IPAB. See here for his commentary but I believe there is more to worry about than a proposal in regard to the IPAB. Mankiw references a proposal by the Liberal Center for American Progress to allow the IPAB to control the expenditures of private health insurance plans not just those expenditures regarding Medicare and Medicaid.

From what I understand the IPAB already has been given that power by Obamacare.

Dr.Richard Fogoros writing in his blog The Covert Rationing Blog explains how the IPAB was created and what it is authorized to do beginning in 2014. His reading of the statute indicates that this presidential appointed panel already has the legislative authority to limit expenditures by private health insurance companies. His analysis also describes how difficult it will be for Congress to over ride the panel's edicts. See here for his comments.

Remember the notion that "more [medical care] is less " and harmful as well -Guess what

Dr. Buz Cooper sticks a dagger in the heart of the non-sense that claims more medical care is harmful and less care is better. See here for his take on the latest study from the Dartmouth group which seems to contradict the mantra they have been selling to the gullible and to the progressive planners for years.

Dr. Cooper sums it up this way:

"Medicare beneficiaries who received more medical care had better outcomes, even when they are sicker. MORE was MORE."

Isn't this what common sense would suggest?

Being a (public health) expert means never having to say you are sorry

One of the continuing pleasures of following and sometimes participating in the world of medical blogging is the enjoyment of watching some bloggers who regularly hit things out of the park. I am thinking particularly about DrRich (aka Dr Richard Fogoros of the blog " the covert rationing blog") and his recent commentary about public health efforts that go wrong,sometimes badly so,and how the experts cram their previous advice down the memory hole and go on with their latest recommendations . See here for his latest and then here for an earlier spot-on critique of our public health brothers and their follies .

Public health experts enjoy a decision making advantage over the medical doctor who has to often take aggregate data-such as randomized clinical trials but often less reliable data) and then attempt to apply that to the individual patients sitting in his office.All the public health expert has to do is to look at the aggregate data and base recommendations on that while the practicing physician realizes that lying under the summary statistics are individual patients some of whom may will benefit from the proposed treatment while others are unaffected and still others are harmed. Life in the dealing with real patient trenches is more complicated ,nuanced and reality based than in the offices of the academic public health experts who can base their conclusions and recommendation on the utilitarian imperative .

DrRich talks about public health experts " displaying every ounce of the overblown self-confidence traditionally enjoyed by the expert class operating within our Progressive
institutions "

The public health experts share the following view with " leaders with ideas " who vie for the position of architect in the redoing of American health care :

The basic tenet of what I call the medical progressive is that:

health care is too important (and too complicated) to be left to the individual physician and her patient.

"..to demonstrate to men how little they really know about what they imagine they can design.

This F.A.Hayek's quote was directed to the central planners who believed they could control an economy from a governmental perch and did not need the knowledge derived from competition of a price driven market.The problem of knowing what and how much everyone should and should not eat is of a different sort but Hayek's words can function as a much needed counterpoint to their hubris .

Is WHO's "World Health report 2000" the worst study ever?

After reading the commentary (see here )by Dr. Scott W. Atlas I would give that publication my vote as the worst or darn close to it. Dr. Atlas is a Senior Fellow at the Hoover Institution and is chief of neuroradiology at the Stanford University Medical Center and has a long list of scientific publications to his credit.

It is amazing how often sound bites from that study are quoted not only by the main stream media but also recited as gospel by medical researchers often in the boiler plate introductions to what otherwise would legitimately pass for a scientific publication.

How many times have we been told that something must be done about the U.S. health care system because although the U.S. spends 16 % of its GDP on health care it ranks 37th (out 191 countries) in something the WHO staffers called "overall performance".

Dr. Atlas said the the WHO publication " ranked countries according to their alignment with a specific political and economic ideal-socialized medicine-and then claimed it was an objective measure of "quality" ".

Quality,which is always a usefully ambiguous concept, was in the view of the report's authors the degree to which a country had distributed wealth and centralized administration of health care.

Atlas explains that 62.5 % of the overall performance index created by the report to rank countries was an assessment of one particular concept of equality and not about health care outcomes at all.

Quoting Dr. Atlas :

In fact, World Health Report 2000 was an intellectual fraud of historic consequence—a profoundly deceptive document that is only marginally a measure of health-care performance at all.

Read Dr. Atlas's commentary for more details of the methods used by the WHO staffers to achieve this propaganda masterpiece. I expect politicians and policy wonks with a particular agenda to quote the WHO's factoids but it is embarrassing to see medical researchers use the bogus material from the report as fillers and appropriately politically correct genuflexions to the notion of social justice in their publications.

Can this really happen in the U.S.?

This commentary is fairly far afield from the areas of my usual writing but the facts are so egregious and frightening that I had to say something. The topic is civil forfeiture. I defer to the excellent commentary on this subject by one of my favorite writers,Dr. Donald Boudreaux who is trained in economics and the law having a PhD in the former and is teaching at George Mason University.See here.

The case he discusses and the subsequent decision of the Supreme Court can fairly be described as mind-boggling , the dictionary definition of which is "intellectually or emotionally overwhelming".

In regard to the case,Bennis versus Michigan,Boudreaux and his co-author, A.C. Pritchard, said in part the following:

[the Supreme Court's decision] allows government to impose huge costs on people never charged with criminal wrongdoing"

Those of us who,probably against all reason,still think that the Supreme Court will overturn Obamacare find little hope that the supremes will do the right thing after one reads their decision in this case.

A slightly positive note is this was a five to four decision by the court and one of the dissents was penned by Justice Kennedy who is generally thought to be the possible swing vote when the health care bill gets to the court. Maybe he will do the right thing again.

Will the over crowded ERs generated by Obama care reflect social justice

As the facts continue to flow out of various analyses of Obamacare and we learn that it will not keep the nation from "going bankrupt"and (shockingly) it will actually cost money and that various elements of it have to be postponed or exemptions for certain provisions have to manufactured to avoid voter push back in 20122, advocates are running out of justifications and may have to fall back on their claim of furtherance of social justice.

Some Democratic Senators and several spokesmen for medical organizations risked shoulder injury so exuberant were their efforts at self congratulation when the bill was signed into law.To be able to discern what the results would be in a bill so long, dense and ambiguous regarding details would require analytic ability not yet achieved by any creature who evolved on this earth.In fact, the details of the bill had not yet been written as the particulars were in numerous instances delegated to government entities for rule making some of which were yet to be formed.

Down the road there will be a situation in which this justice will be quite visible.That will play out in the emergency rooms across the country. The rich and the poor alike, those with insurance cards and those without will wait together as increasingly overworked and overstressed ER docs ( and their physician extenders) try and cope with the infusion of 30 plus million more insurance card holders into the health care system. Everyone waiting together to be screened by the NP or PA or as things evoke a NP assistant will give a lovely portrait of the wisdom of the central plan for [almost] everyone having nominal access to medical care but operationally finding little of it.

Social justice typically means redistribution and accordingly to CMS czar Dr. Donald Berwick good medicine must mean redistribution . Easier access to health care will be redistributed and diluted so that everyone gets to wait and wait and everyone's quality of care goes south.

For those of us who hope that having a retainer doc will help, and I think it will, here is a sobering thought and something else to worry about. With more vertical integration of medical care and the latest acclaimed saviors of medicine (the ACOs) becoming prevalent and perhaps dominant, will independent retainer docs even be allowed to admit and treat patients in a hospital or will her patients also end up in the increasingly long lines in the ERAs and the retainer physician unable do anything about it.Is there really anyway to escape from the clutches of Obamacare? Will it all be up to Justice Kennedy? Will it even be possible (i.e. legal) for someone to purchase health care outside of the centrally planned system? If you have not worried about that issue before I suggest you visit this and other commentaries by DrRich.

Here is a commentary from NPR on what ER docs think will happen when millions ( about 34 million) of new folks get an insurance card to show the clerk in the ER. Let us see-increased demand and no significant increase in supply combined with the already in place price controls in Medicare just might mean shortages , long lines, and decreased quality of care.You think.

The semi-secret RUC is getting less and less secret

The RUC (more formerly known as the AMA/Specialty Relative Value Update Committee) up until recently has been an obscure creature of the AMA about which little was known and even less was written about. Thanks to a number of physicians,including Dr. Roy Poses, more and more information of the composition of that group is being revealed. See here for Dr. Poses's latest revelations about the current members of the RUC and and some of their relationships which might represent conflicts of interest.

Not only are we treated to looking behind the curtains but there is an organized effort to opt out of the RUC influence. See here for information about the "Replace the RUC" effort.

Dr Poses raises several of the unanswered questions regarding the RUC. The one that interested me for some time is this. Why was there and is there so little outcry about the central governmental management of physician's fees, i.e. price controls.? (If there is anything Keynesians and non-Keynesians agree on it is that price controls lead to shortages and decreased quality) Could part of it be that the AMA whose brainchild we are talking about kept the whole process obscure and largely behind the scenes?

How bad is the Supreme's denial for expedited review of Obamacare?

According to David Catron the news is really bad for those of us who still hold out some hope that Obbamacare will be stopped by the Supreme Court. Here is his commentary in the American Spectator. While the issue(s) crawl though the courts, the "leaders with ideas" are cranking out rules and regulations for the statute's implementation.

Meta-analysis fails to show all-cause mortality benefits to statins in primary prevention

A 2010 meta-analysis by Dr. KK Ray et al ( see here for full text) in the Archives of Internal Medicine stirred a bit of interest and commentary as it failed to show an all-cause mortality benefit from statin use in the setting of primary prevention in patients with elevated risk factors for coronary artery disease.

A few context setting comments are in order. First, it is well established that statins are clearly beneficial in secondary prevention of coronary disease. In patients with proven coronary artery disease few would disagree with statin use.Its efficacy and safety have been demonstrated in several of the well known so-called landmark statin trials.

Second, the argument is strong for the conclusion that statin use in primary prevention results in a decrease in cardiovascular (CV) deaths. The authors of the Archives article make their position clear in that regard when they say in their comments sections "the benefits of statins in CV deaths are unequivocal based on primary prevention data from the CTT meta-analysis." The Cholesterol Treatment Trialist Collaboration or CTT was published in Lancet in 2005 ( see here ) .

So, the issue that Ray and his fellow authors addressed was not do statins reduce CV mortality in primary prevention but do statins reduce all cause mortality and their data analysis lead to the conclusion it does not.

Ray analyzed data from 11 randomized clinical trials of patients with what they considered to be high risk for coronary artery disease ( 244,000 patient years). Big numbers for patient years tends to give credence to findings but the key thing here is that in these trials the follow-up period was only 4-5 years as is typical of clinical trials. In patients with increased CV risk -as opposed to patients with proven CAD-the ratio of CV deaths to total deaths is relatively low particularly in a 4-5 year time frame. So that it is not surprising that all cause mortality may not be decreased, which is what Ray demonstrated.

Both the editorialist in the Archives and a subsequent commentator in a Update section in the April 5, 2011
Annals of Internal Medicine seem to conflate failure to show decrease in all cause mortality in a short observation period with overall lack of benefit. Ray and co-authors do not deny benefits in terms of decrease in C-V mortality.
.

Major cuts in Medicare Advantage postponed until after election

Remember how we were told that if ACA ( Obamacare) were not passed the country would "go broke". Obamacare would reduce the deficit. One of the cost saving mechanisms contained in the bill was a major reduction in Medicare costs including significant reductions in Medicare Advantage (MA).This was supposed to bolster the long term solvency of the entire Medicare program. Now the Obama administration has decided to postpone saving the country from going broke until after the election and actually spend a little more money of the MA program.Why? To avoid a voter push back from looming cuts in Medicare Advantage seems the obvious answer . AARP can't be happy with that. See here for more on AARP.

See more about the Medicare Advantage ploy from Black Ribbon Project blog here. Also I commented on this egregious political play before.

Another alleged cost saving proposal included in Obamacare was the Community Living Assistance and Support Act (CLASS).

Early on, opponents of the health care bill insisted that its provisions were not fiscally sound and were placed in the bill to give the illusion that Obamacare would cost less than the magic one trillion dollar price tag. The plan was to front load the plan with premiums without any benefit payments for a number of years. It was advertised as a mechanism to decrease the federal deficit by 86 billion over a ten year period. Now even with the deck as rigged as it was it will not work . The Secretary of HHS has admitted that.

More and more elements of the Obamacare monster bill seem to be either unraveling completely or postponed until after the 2012 election.

Still more data on adverse and beneficial effects of statins

Here is a recent article in the BMJ detailing the absence of numerous adverse effects of the statin class of drugs and the occurrence on a few beneficial effects. The article mentions cataract as a complication of statin therpay , an adverse effect that was of concern in very early animal work by Merck but about which I had stopped worrying until the BMJ article. In fact, there was this study from 2010 which claimed the opposite, i.e . a decrease in the risk of cataracts from statin use and this 2003 fairly large case-control article that found no effect in regard to cataract.


For a while those who read or skimmed medical literature were treated to an array of articles that claimed numerous effects of the statins that were not just further evidence of the pleotrophic effects of statins but were really just short of miraculous. I wrote about some of those claims here. Most of those claims did not pan out. Another claim,that of the statins causing an epidemic of heart failure made by Dr. Peter Langsjoen ( see here),does not appear verified by the BMJ article.

Federal Judge" Entitlements" are mandatory-people are trapped [in Medicare]

Regulations put into place during the administration of Bill Clinton prohibited folks from opting out of Medicare part A unless they agreed to forgo their social security payments ( and pay back whatever SS funds they had received).

It seemed to take a long time for someone to challenge this rule but someone finally did and the federal judge presiding over the case has now rejected the case with an appeal pending. Here is a link to the decision by the US District Court Judge Rosemary M. Collyer.


Her convoluted and self-contradictory reasoning (see here) concluded that this entitlement ( to Part A) is mandatory .To some the notion of a "mandatory entitlement" may seem Orwellian but at least the judge did offer some interesting comments in her written opinion that suggests lawyers even when they become judges might retain a sense of irony.

For example Judge Collyer said in her conclusion:

Plaintiffs are trapped in a government program intended for their benefit. They disagree and wish to escape. The Court can find no loophole...

In her introduction she stated:

Medicare costs are skyrocketing and may bankrupt us all; nonetheless, participation in Medicare Part A (for hospital insurance) is statutorily mandated for retirees who are 65 years old or older and are receiving Social Security Retirement (so-called ‘old age’) benefits. Whether Congress intended this result in 1965 or whether it is good fiscal and public policy in 2011 cannot gainsay the language of the statute and the regulations

It seems to me she might have well said, the program is ridiculous but that is the law -get over it.

DrRich takes up this case (see here) in his blog and considers this case in the broader context of his lingering (or growing) concern about the possibility that down the road seniors and others may face a health care system which prohibits the patient from purchasing any health care not approved by the central authorities. See here for his earlier commentaries on the efforts to limit individual prerogatives in obtaining medical care. I share his concern.

Follow the money rule suggests reason for AARP support of Obmacare

The venerable follow the money rule continues to have explanatory power. This time, apply it to AARP's support for the health care overhaul-reconfiguration bill and presto we have a plausible explanation for AARP support for the bill . Simply put, AARP makes a hefty brokerage fee for selling Medicare supplemental policies and Obamacare dealt a blow to the Medicare Advantage programs so that it is likely many senors will migrate from MA plans to traditional Medicare and will likely purchase a supplemental policy the sale of which is a major income stream for AARP.

See here for details about how much money AARP might make as a result of changes brought about by the health care bill that they vigorously supported.

Meanwhile surveys suggest that most seniors believe Obamacare will diminish access to care for them (that they are the Peters robbed to pay Paul) and more entities are receiving waivers from some of the provisions of Obamacare. Things just get better and better.

Earth Day again-time to look at the satellite view of Korea

Rather than encouraging school kids to guilt their parents into turning off the lights for a while to "celebrate" earth day ,my suggestion is for school teachers to assign an essay to their charges. The topic-why is North Korea dark and South Korea lighted as illustrated in this iconic image.

An alternative topic might be what would our lives be without electricity.

Here is an earlier earth day commentary offered as a counterpoint to the usual sanctimonious
earth day platitudes and indoctrination of youth with the secular religion of naive environmentalism with its rituals of turning off lights and mindless recycling.

Finally, here is an essay from the economist Steven E. Landsburg from his book "The Armchair Economist" in which he makes the distinction between the religion of environmentalism and the science of ecology and makes clear my choice of "mindless" to modify "recycling", putting forward the notion that recycling per se is not a moral issue and therefore always right (or wrong) but each case is an empirical one.

Still another argument against P4P

I have based my opposition to P4P in medicine on several lines of argument. These included :

1) It is unethical (see here for the comments of Drs. Edmund Blum and Faith Fitzgerald)

2 ) it often is a disingenuous method to control costs with feigning a desire to improve care

3)Goodhart's Law (see here).

Now the prolific Dr. Doug Perednia offers another reason to oppose P4P. Read about it here ( this is part 2, read Part 1 also). He offers a brief and very instructive introduction to a field of study known as Self-determination Theory (SDT) and relates that to the P4P issue.

SDT is based upon the idea that there are many things that people do not for the promise of external reward, but because of some sort of intrinsic, human desire for autonomy, competence and relatedness.

Including in that category of things people do not necessarily because of carrots and sticks is the practice of medicine.

The theoretical and empirical case against P4P has grown so strong that the only reason physicians and their organizations put up with it must be they just want to go along to get along.

HHS gets more efficient , now giving an entire state an exemption from Obamacare

The task of giving exemptions to aspects of Obamacare company by company might have proved to be to time consuming for the Department of Health and Human services so they are issuing state by state. See here.

The state of Maine was given a waiver,good for three years,exempting health care insurers from the requirement that they spend at least 80% of premium fees on actual patient care. In Maine, at least for a while, 65% will suffice.

Earlier Maine's secretary of insurance has expressed concern that one company,Healthmarkets,Inc, would drop coverage for policyholders and leave the state.See here for some background on that company .

Class Act a fraud? Secretary HHS claims she will "reform" it

Financially unsound is the most generous way one can describe the part of Obamacare known as the CLASS Act ( The Community Living Assistance and Supports Act). see here.

Even the secretary of HHS admits to problems with this section of ACA but her answer is that she will use her discretionary powers to " reform it". What ever happened to the rule of law? A law is passed and if there are problems with it and an administrative arm of the executive branch will alter the law to fix it.It will be fixed by a politically appointed administrator who serves at the pleasure of the president.

Secretary Sebelius,at a congressional hearing, said that those provisions were "totally unsustainable" meaning it would not pay for itself and would require taxpayer money to make it fiscally viable.

Early on, opponents of ACA insisted that the provisions were not fiscally sound and were placed in the bill to give the illusion that Obamacare would cost less than the magic one trillion dollar price tag. The plan was to front load the plan with premiums without any benefit payments for a number of years. It was advertised as a mechanism to decrease the federal deficit by 86 billion over a ten year period. Now even the administration admits it will do no such thing.

Either the authors of the CLASS Act were aware of the lack of sustainability but proceeded on in a wink-wink-nod-nod manner or they did not know what they were doing. Ms. Sebelius testified that they (the folks at HHS) realized right way that was the case. Did the folks at HHS have no input to the crafting of the legislation?

One of the ways Obamacare was to "save money" was to cut Medicare Advantage but now..

But now HHS announces that , at least for the short term- that is until the 2012 elections, payments will increase for Medicare Advantage Programs. See here.

It was a decrease in the Medicare Advantage Payments ,along with cuts to hospitals and other providers, that was to provide about half of the funding for the expanded insurance coverage to low income folks. It was projected that some 137 billion would be saved from cuts to Medicare Advantage programs. The alleged savings was touted to also extend the solvency of the Medicare Part A Trust fund.

The actions of HHS in this regard is typical of what George Will references as the "administrative state" which the United States have (has?) morphed into. In the "administrative state", Congress passes "sentiments" not laws, and delegates to the administrative tentacles of the Executive Branch the authorship and administration of the various rules that make the Congressional sentiments operational.See here for Will's comments.

Woodrow Wilson envisioned a government that would be run by experts who would be unencumbered by the messy give and take of politicians who would stray from what was right and good for the people by the actions of various interest groups and their own selfish urges. Somehow the only PhD to occupy the White House did not realize that the experts of the various agencies might themselves posses human characteristics that steer them to act for political reasons. It is hard to consider the recent actions of HHS other than being politically motivated.

So how did that P4P thing work out in Great Britain?

If you want to know the answer to that headline question, go here to Dr. Doug Perednia masterful analysis of a large study of how P4p worked out in Britain's NHS. The bottom line was that P4P had no useful effect at all.None.

If the so-called thought leaders and powers that be in such organizations as AMA and ACP and others supported ( continue to support?) P4P because of a belief that patient care would improve they should now take a strong stand against such programs. P4P does not work.

Implicit in P4P program is the concept of target goals. Goodhart's Law stands the test of time and logic. When a measure ( as in a purported measure of "quality") becomes a target it looses its value as a measure.

Is lying for the greater good part of the New Medical Ethics

Dr. Paul Hsieh discusses the antics of alleged physicians in the current Wisconsin kerfuffle writing notes falsifying an illness to excuse absence from work while the recipients attended the rally.See here.

He suggests that this dishonest behavior ties in nicely with the New Medical Ethics as promulgated by the American college of Physicians in which the notion of Social Justice is elevated to a prominent position.

Well, one way or another someone is lying. If those claiming to be physicians are really not, they are obviously lying and if they are physicians they are lying about the purported sick time.

Dr. Scott Silverstein, writing on the blog "Health Care Renewal" discusses the sick-note incident in terms of the slippery-slope situation that arises when there is "physician dishonesty-on-an-agenda " which he describes as the face of postmodern medicine.

Overhauling America's Health Care - a must read book

Go here to read a lucid review of an excellent book by Dr. Douglas Perednia.Then go to Amazon to buy the book.It is entitled "Overhauling America's Healthcare Machine."

Dr. Perednia provides a brilliant and detailed description of what is wrong with the current system/non system and then offers his proposal to remedy the mess, a proposal very similar to that offered by Dr. Richard Fogoros in his book, "Fixing American Healthcare".

Wait- why read about plans to overhaul American healthcare, don't we already have a solution in the form of ACA? If you want to read a brief explanation of why ACA is not the answer, go and read Dr. John Goodman's latest comments on the incredible absurdity that Congress put together.

AND congratulation to DrRich At Covert Rationing Blog for his Weblog award for the category of Health Policy and Ethics.

Limited "coarse grain" data suggest following certain pneumonia guidelines can be bad for survival

While that headline sounds like a typo that is what a recent article in Lancet seemed to show.Further we are not talking about all pneumonia guidelines,as , for example the guidelines for the treatment of community acquired pneumonia (CAP) actually work out rather well. The focus in the above headlined article was on the ATS and IDSA guidelines for the treatment of hospital acquired pneumonia (HAP).

When I read about that finding my first thought was to look more closely at the guidelines and importantly what was the evidence underlying the recommendation. As has happened more than once, Dr.RW saved me the trouble. See here.

Dr RW's analysis suggests that the evidentiary basis of the recommendation of the IDSA and does not belong on the top of the classical,mythical evidence based medicine (EBM) evidence hierarchy in which randomized clinical trials and meta-analyses perch at the top.

My take on this article is that we might be cautious in accepting the findings on face value. After all this was a retrospective observational study replete with all the potential biases this type study might possess. This is what I call coarse grain data without the fine grain detail that might be provided by detailed patient level analysis. For example, the authors speculated that perhaps the side effect of the double gram negative antibiotic combination may have contributed to the increased mortality in the group treated in accord with the guidelines. Maybe so, but more detailed analysis might provide support or refute that speculation.

Runner has seizure at near the end of Houston Marathon

On an unusually warm and humid day in Houston ( Jan. 30,2010) the Houston marathon was held.According to this local TV report,a female runner had an apparent seizure near the finish line.She was treated on the scene , experienced two cardiac arrests and was successfully resuscitated,intubated and transported to a hospital.Further details are not available.

One of the first things that comes to mind is exercised associated hyponatremia (EAH).

EAH has attracted much attention in recent years. Dr. Tim Noakes,from Cape Town ,South Africa, attributes the apparent increase incidence of the condition to overemphasis of encouraging runners to drink liquids past the point of reasonable and safe short term replacement needs. Subsequently more physiologically reasonable recommendations regarding drinking during longer races have been issued. The New York Marathon's fluid replacement advice was 8 ounces every 20 minutes. The International Marathon Medical Directors Association (IMMA) recommended 400-800 ml per hour. Too often in the past the advice seemed to be drink as much as possible.This advice seemingly lead to some slower runners ingesting so much liquid that they actually gained weight during the event.

Acute EAH has been associated with cerebral edema and non-cardiac pulmonary edema. With acute lowering of the serum sodium and less than instant re-equilibration of cerebral intracellular solutes, water moves into brain cells. If untreated in severe forms, cerebral herniation can occur with brainstem compression. Judicious amounts of three percent saline I.V. has become the consensus treatment.

Here is an earlier blog entry on putative mechanisms in EAH.

An elite runner collapsed and died early on in the marathon trials in New York and at least early reports indicated no specific cause was determined. Exercise associated hyponatremia was not a likely cause in this case.See here for comments regarding causes of sudden death in athletes.

Marathons in hot weather can be a disaster ( the Houston weather was merely warm and humid) which is how some reporters described the ill fated 2007 Chicago Marathon. See here.

New Guidelines for treatment of carotid artery stenosis

The full text of the new guidelines for treatment of vertebral and carotid stenosis can be found here.

The guidelines apparently were a joint effort of the cardiologists and practically everybody else who had interest in the diagnosis,medical or surgical or catheter treatment of vascular construction to the brain.

The paper is gives a wealth of information and references and could easily take up many hours of study. Here is one snippet-

It is reasonable to prefer endarterectomy (CEA) over stenting in asymptomatic patients with greater than 70% stenosis.The panel had grade A evidence for that recommendation.

Although they do not recommend screening for carotid obstruction in asymptomatic patients, many folks will be getting ultrasound exams of their necks,abdomens and doppler exams for vascular disease of the lower extremities as roaming, proprietary groups are frequenting churches and other sites.So when your patient for whom you did not recommended screening shows up with a report suggesting significant blockage you have a good resource to consult.

"High-value"health care achieves buzz word status-An ACP Committee defines "rationing"

In the 1 Feb 2011 issue of the Annals of Internal Medicine in the Clinical Guideline section, ACP's Clinical Guideline Committee authored an article entitled :

High-Value, Cost Conscious Health Care: Concepts for Clinicians to Evaluate the Benefits,Harms,, and Costs of Medical Intervention". see here for full text.

Dr. Douglass K. Owens, author of numerous cost effectiveness studies, was the lead author.

The article begins with expression of the customary alarm about increasing health care costs and the need for cost control, an effort the authors believe should focus on the value of the health care interventions.

Their operational definition of value is " an assessment of the benefit of an intervention relative to expenditures".Value is determined by balancing benefit and costs.

This is consistent with Harvard Business School professor, M.E. Porter's definition which is:
Value =outcome/cost.

Simple enough we just figure out the benefits and the cost and ...but the devil is in the details as always.

The Annals authors then make what they believe to be critical distinction -the distinction between cost and value. A high cost item may or may not provide high value and low cost may have little benefit , therefore that intervention is of low value. So what we want is high-value health care.

(As best I can tell,the busswordification of" high-value health care" can be attributed at least in part to the efforts of Porter and Dr. Elizabeth Teisberg, although I don't wish to slight Dr. Don Berwick and physicians at the ACP.Whatever it origins and vectors of spread, medical authors and policy wonks talk about it now as if everyone knows what it is.)


The authors then redefine rationing (or in the authors words " more appropriately" define) to mean "restricting the use of effective, high-value care". So that if an intervention that is "determined" to be low value is restricted that would not be by the new definition considered rationing. This should provide comfort to those who worry about the rationing of health care. eliminating an intervention that is determined (By whom?) to be of low value is not rationing at all. One can see what power this puts in the hands of those determining what is high and low value.

The authors then discuss the importance of considering the downstream costs and benefits of an intervention.For example, one has to factor in the cost of maintaining a ICD not just the initial cost of assessment and placement of the device.

If a treatment is both better and cheaper than an alternative there is no problem in deciding between the two. More complexity emerges when an alternative provides more benefits but also costs more.

In this situation we are told we need comparative effectiveness analysis which is basically cost benefit analysis (CAB) that compares the various alternative interventions. Conceding this point, at least for the sake of argument, one now asks who will make that analysis

Owens et al provide the answer:

...we recommend assessing their value [competing interventions] to patients and society by using cost effectiveness analysis. Such analysis require specialized expertise and training,are often expensive, and thus are typically performed by investigators.

Note this type of assessment cannot be done by just anybody, only those with specialized expertise and note what they claim to provide-assessment of value not only to patients but to society.

Realizing that some may find that level of hubris unsettling, the real money quote of the article is :

"The choice of a cost effectiveness threshold is itself a value judgment and depends on several factors, including who the decision maker is.

That is the heart of the matter, after all of the gathering of various costs and developing estimates of the quality adjusted life years (QALY) and the aggregation of costs and aggregation of estimated benefits and using various analytic tools ( e.g. cost-effectiveness ratios), someone or some committee has to make a value judgment. Is the benefit worth the cost or not? At the end, it is a human value judgment- not the solving of some equation. Then the question is who will decide.


In the same issue of the Annals of Internal Medicine there is an Editorial by Michael Gusmano and Daniel Callahan of the Hasting Center offering cautionary counterpoints.

They emphasize Owen and co-authors' admission that effectiveness evidence is lacking and our ability to assess quality of life is inadequate. If the evidence is lacking and our ability to assess quality of life is inadequate even investigators with expertise and special training might be challenged. Gusmano and Callahan continue:



Perhaps the biggest problem with cost-utility analysis in that the expenditures on health care cannot be compared with other societal needs..the failure to consider opportunity costs may eliminate existing,but un-assessed health care technologies and services that are a better value than the "cost effective" technology included in these assessments.

More on the concept expressed by Goodhart's law

Calling it "teaching to the test" or ...

John Goodman asks the question "Does measuring quality actually decrease quality?". See here for his recent blog entry.

Charles Goodhart, a British economist put it this way in 1975:

Any observed statistical regularity will tend to collapse once pressure is placed upon it for control purposes

In other words, a measurement when used as a target looses its value as a measure.

This basic notion was expressed about the same time by a sociologist, Donald Campbell, who said :

"The more any quantitative social indicator is used for social decision-making, the more subject it will be to corruption pressures and the more apt it will be to distort and corrupt the social processes it is intended to monitor."

A poster child for this phenomenon in the context of quality measures in medicine is the absurd 4-hour pneumonia rule.I have blogged about that before.

When the incentive for ED staff was to get the antibiotics to pneumonia patients within 4 hours, because that was established as a quality measure, distortion and corruption emerged in the form of giving less prompt attention to non-pneumonia suspects and treating folks who really didn't have pneumonia with antibiotics.

From Goodman's post:

Quality measures also degrade quality by distorting behavior.

Dr. Douglas Perednia had a great discussion of this topic here.