A subset of pneumonia patients -those considered at risk of having a multi-drug bacterial etiology-did worse if their physician complied with ATS-IDSA guidelines according to a recent study. See here for reference to the article that was published on Lancet online.
I have blogged before about the dangerous tendency of guidelines tendency to cause unintended consequences and talked about the idiotic four hour pneumonia rule, one unintended consequence of which was the treatment of non-pneumonia patients for pneumonia within the four hour deadline.Well at least the treatment was started within 4 hours.
My longest screed about guidelines can be found here.
Guidelines can be considered part of the mind that says " medicine is too important and too complicated to be left to the individual physician and individual patient." This dangerous mind set was made explicit and championed by the former header of CMS, Dr. Don Berwick who said :
"Today, this isolated relationship [ed. the individual doctor-patient ] is no longer tenable or possible… Traditional medical ethics, based on the doctor-patient dyad must be reformulated to fit the new mold of the delivery of health care...Regulation must evolve. Regulating for improved medical care involves designing appropriate rules with authority...Health care is being rationalized through critical pathways and guidelines. The primary function of regulation in health care, especially as it affects the quality of medical care, is to constrain decentralized individualized decision making.” (My bolding).
Yeah,that pesky decentralized decision making just gets in the wise of wise centralized decision making which history tells us worked out really well in the 20th century.
The best quality or guidelines rules are supported to varying degrees by randomized clinical trials but even here one should proceed slowly because the well known efficacy-effectiveness gap tolerates simplistic approaches poorly. RCTs are often small and have multiple exclusion rules and fail to capture the perplexing diversity of relevant pathophysiological variables (known and unknown) that coexist in complex, hospitalized patients. It is in the sickest patients that rules formulated by committees based on what-ever data or personal bias that the most harm can be done and in whom individual variation overwhelm premature generalizations and an eager rush to mandate treatment rules.No, all guideline writers do not always intend that their wisdom should be mandatory ( but some do) and write disclaimers at the end of the articles to that effect, but guidelines have a way of morphing from suggestions to dicta and rules the ignoring of which may have financial or other consequences for the rouge doctor.
The mandatory and quasi mandatory nature of guidelines or quality indicators as wielded by the CMS mandarins and other institutional elites become even more dangerous with the spreading use of the "disruptive physician" doctrine. Not only must you go by the rules you can't complain about them without incurring the wrath of the hospital's disruptive physician committee.This doctrine is a brilliant control mechanism.If you challenge the disruptive physician concept you are by definition disruptive.
Thursday, March 29, 2012
Monday, March 26, 2012
Cardiac stress test before endurance exercise might just make sense
The party line (I mean the consensus of reasoned expert opinion by panels of highly educated people) has been there should not be stress tests before a person begins training for or entering a marathon because of some combination of the following reasons: low incidence of cardiac events in endurance races and shorter fun runs,large numbers of false positives noted on treadmill stress testings,and the dominant theory that the major cause of cardiac events precipitated by exercise is acute plaque rupture rather than fixed coronary artery stenosis.
An extensive assessment of cardiac events during long distance runs might change the thinking in that regard.
JH Kim et al reached that conclusion following their analysis of cardiac arrests associated with marathon and half marathon races in the US from 2000 to 2010.See here for ref.
The authors' data including races involving 10.9 millions runners and 51 men had cardiac arrests. Hypertrophic cardiomyopathy and atherosclerotic coronary disease were the two most common causes.
The authors said:
"The absence of coronary plaque rupture in these persons was surprising because prior data and expert consensus documents have suggested that exercise induced acute coronary syndrome result from atherosclerotic plaque disruption and coronary thrombosis.
Their findings suggested that rather than plaque rupture that there was an imbalance between oxygen supply limited by stenotic coronary arteries and oxygen demand greatly increased by the exercise.
So exercise testing would be useful to the extent that the exercise related events were due to fixed obstruction. Of course both mechanisms could be present alone or in combination in various people. A resting ekg should be helpful in alerting to the possibility of hypertrophic cardiomyopathy. But, of course, there is that new directive by the progressive medical elite for parsimonious care to take under consideration.
An extensive assessment of cardiac events during long distance runs might change the thinking in that regard.
JH Kim et al reached that conclusion following their analysis of cardiac arrests associated with marathon and half marathon races in the US from 2000 to 2010.See here for ref.
The authors' data including races involving 10.9 millions runners and 51 men had cardiac arrests. Hypertrophic cardiomyopathy and atherosclerotic coronary disease were the two most common causes.
The authors said:
"The absence of coronary plaque rupture in these persons was surprising because prior data and expert consensus documents have suggested that exercise induced acute coronary syndrome result from atherosclerotic plaque disruption and coronary thrombosis.
Their findings suggested that rather than plaque rupture that there was an imbalance between oxygen supply limited by stenotic coronary arteries and oxygen demand greatly increased by the exercise.
So exercise testing would be useful to the extent that the exercise related events were due to fixed obstruction. Of course both mechanisms could be present alone or in combination in various people. A resting ekg should be helpful in alerting to the possibility of hypertrophic cardiomyopathy. But, of course, there is that new directive by the progressive medical elite for parsimonious care to take under consideration.
Thursday, March 22, 2012
More spending leading to better care seems true in Canada also
Recently I blogged about data indicating that sometimes more (money spent ) is better (better outcomes in health care) as well as in most everything else even though you sometimes hear just the opposite from devotees who misinterpret and over interpret the Dartmouth Atlas data.
Now we have this JAMA article from Canada that suggests that outcomes for heart failure,hip fracture and some other conditions are better when more money in spent.
Now we have this JAMA article from Canada that suggests that outcomes for heart failure,hip fracture and some other conditions are better when more money in spent.
Monday, March 19, 2012
Guess what - Obamacare will cost more than one trillion over ten years
The hype leading up to the passage of Obama care included claims that the bill would protect the country from bankruptcy,bend the health care cost curve and boost health care quality. Now the projection for 10 years of Obamacare is for 1.76 trillion and by the time we can get a even finer tuned projection it will likely be twice what it was claimed to be. See here for the projection of OBM.
I guess the social justice will cost a little more as we watch 34 million new health care card carrying folks scramble for the shrinking number of primary care doctors who will see Medicaid and Medicare patients.
The one trillion dollar number seemed to play an important role in the push and pull going on before the health care bill was passed.The cost of the plan had to be less than one trillion and getting the projected cost to be less than one trillion apparently played a significant role in the bill finally being passed.However, the cost estimates were rigged and only three years later are we getting more realistic projections showing how much flim- flam was involved.
I guess the social justice will cost a little more as we watch 34 million new health care card carrying folks scramble for the shrinking number of primary care doctors who will see Medicaid and Medicare patients.
The one trillion dollar number seemed to play an important role in the push and pull going on before the health care bill was passed.The cost of the plan had to be less than one trillion and getting the projected cost to be less than one trillion apparently played a significant role in the bill finally being passed.However, the cost estimates were rigged and only three years later are we getting more realistic projections showing how much flim- flam was involved.
Friday, March 16, 2012
Sometimes spending more on health care brings better outcomes -duh
The widely quoted data from the Dartmouth Atlas has been almost as widely misunderstood to mean "more is less". How something so counter-intuitive and contrary to much everyday experience could get so much argumentative traction is a testament to a cognitive weakness that even Dr. Kahneman failed to document and explain in his book Thinking Fast and Slow. Maybe he does, it is simply gullibility or buying into data that confirm your priors.
Dr. Ashish K Jha sets the record straighter .See here.
Here is part of what he had to say.
“The Dartmouth Atlas shows that among communities, there are large variations in health care costs and large variations in quality, and some with high costs also have low quality. This convinces a lot of people that there can be a free lunch—that if we can get spending down in high-costs communities like McAllen, Texas, to levels seen in Minnesota, where spending is low and quality is high, we can save money and improve outcomes. But how you implement this in policy is hard, and often policy makers misunderstand what to do."
Dr, Jha's study is certainty not the first to counter some of the over-blown nonsense about the relationship to spending and outcomes in health issue. Here is an earlier on post dealing in part with some of the enlightening work of Dr. Richard Cooper in that regard. Also here is a thoughtful discussion of Cooper's work by one of my favorite economists, Arnold Kling.
The Atlas used coarse grained data, regional variations in cost and outcome, but was used to make much more fine grained conclusions by those who hyped the study .Individual hospital or (God forbid) individual patient data were not analyzed yet policy recommendations were applied to the more fine grained entities.
Dr. Ashish K Jha sets the record straighter .See here.
Here is part of what he had to say.
“The Dartmouth Atlas shows that among communities, there are large variations in health care costs and large variations in quality, and some with high costs also have low quality. This convinces a lot of people that there can be a free lunch—that if we can get spending down in high-costs communities like McAllen, Texas, to levels seen in Minnesota, where spending is low and quality is high, we can save money and improve outcomes. But how you implement this in policy is hard, and often policy makers misunderstand what to do."
Dr, Jha's study is certainty not the first to counter some of the over-blown nonsense about the relationship to spending and outcomes in health issue. Here is an earlier on post dealing in part with some of the enlightening work of Dr. Richard Cooper in that regard. Also here is a thoughtful discussion of Cooper's work by one of my favorite economists, Arnold Kling.
The Atlas used coarse grained data, regional variations in cost and outcome, but was used to make much more fine grained conclusions by those who hyped the study .Individual hospital or (God forbid) individual patient data were not analyzed yet policy recommendations were applied to the more fine grained entities.
Monday, March 12, 2012
Colon cancer screening - not for 75 years olds?
The headline references one of the latest recommendations from the American College of Physicians (ACP).Seven members of the Clinical Guidelines Committee of the American College of Physicians have "determined" that consistent with the principle of cost conscious,high value care that "clinicians should not screen adults aged greater than equal to 75 years or those with substantial co-morbid conditions ..with a life expectancy of less than 10 years ."
The reference is "Screening for Colorectal cancer: A Guidance statement from the American College of Physicians. Annals of Internal Medicine 2012:156;378-386.
This is in contrast to the less rigid recommendation of the USPSTF which said:
USPSTF recommends against routine screening for colorectal cancer in adults 76 to 85 years of age. There may be considerations that support cancer screening in an individual patients.
Kudos to the USPSTF for allowing something that might at least pass for " patient centered care" to actually be centered on the patient and her concerns and her particular set of facts and to have those considered by her and her physician rather than having the option of colonoscopy categorically excluded by a general rule based on age. Further, the opposite of kudos to the ACP committee for their recommendation for not doing so.
ACP quotes a study in the Archives of Internal Medicine that "suggests that colonoscopy is overused in elderly patients including repeated screening at less than 10-years intervals and routine screening of patients older than 80 years."
The referenced article( see here for abstract) was an analysis of a large sample of Medicare patients who received colonoscopy exams for screening and around 45% received an second exam in less than 10 years. This is evidence than a number of patients received exams sooner than the 10 years recommendation for repeat exam so in that limited sense there was "overuse". The logical leap from that article to the recommendations of no screening past age 75 is unsupported by evidence or articulated reasoning expressed in the Annals article.
Why not age 73 or 76 or 80 or 65?
The age choice appears arbitrary and the absence of an articulated waiver based on individual circumstances is surprising and you have to wonder what evidence was used to reach their conclusion.You have to wonder because the article seemed bereft of any supporting evidence.
The print boiler plate disclaimer at the end of the article says:
"Clinical guidance statements are "guides" only and may not apply to all patients and all clinical situations.Thus,they are not intended to override clinicians' judgment."
But what will be remembered and quoted will be the 75 years cut point.
Page 385 of the Annals article has a table with the left hand column having a heading of "high-value,cost conscious care" across from the age related cutoff and their general screening recommendations.The implication is that the age recommendation is consistent with this "principle" of high-value,cost conscious care.
However,invoking the new magic words "High-value,cost-conscious care" (HVCCC) does not substitute for offering an analysis of the data regarding the outcomes of colonoscopy in older patients,e.g. complications, positive findings and ( here is something radical) how did the patients value the procedure.
I cannot help but worry that whatever righteous and rational reasoning and good intentions lead to the notion of HVCCC , it will become like the term "patient centered care" meaning whatever the authors of articles chose to have it mean. There are certain tactical advantages to have an elastic, ambiguous concept . I am preparing some comments on the notion of "value" as it is being applied to medical issues,particularly in regard to the difference between the use of the term by certain business consultant gurus and its questionable transfer to medical care and the standard
definition of value as explained in introductory economics texts.
The reference is "Screening for Colorectal cancer: A Guidance statement from the American College of Physicians. Annals of Internal Medicine 2012:156;378-386.
This is in contrast to the less rigid recommendation of the USPSTF which said:
USPSTF recommends against routine screening for colorectal cancer in adults 76 to 85 years of age. There may be considerations that support cancer screening in an individual patients.
Kudos to the USPSTF for allowing something that might at least pass for " patient centered care" to actually be centered on the patient and her concerns and her particular set of facts and to have those considered by her and her physician rather than having the option of colonoscopy categorically excluded by a general rule based on age. Further, the opposite of kudos to the ACP committee for their recommendation for not doing so.
ACP quotes a study in the Archives of Internal Medicine that "suggests that colonoscopy is overused in elderly patients including repeated screening at less than 10-years intervals and routine screening of patients older than 80 years."
The referenced article( see here for abstract) was an analysis of a large sample of Medicare patients who received colonoscopy exams for screening and around 45% received an second exam in less than 10 years. This is evidence than a number of patients received exams sooner than the 10 years recommendation for repeat exam so in that limited sense there was "overuse". The logical leap from that article to the recommendations of no screening past age 75 is unsupported by evidence or articulated reasoning expressed in the Annals article.
Why not age 73 or 76 or 80 or 65?
The age choice appears arbitrary and the absence of an articulated waiver based on individual circumstances is surprising and you have to wonder what evidence was used to reach their conclusion.You have to wonder because the article seemed bereft of any supporting evidence.
The print boiler plate disclaimer at the end of the article says:
"Clinical guidance statements are "guides" only and may not apply to all patients and all clinical situations.Thus,they are not intended to override clinicians' judgment."
But what will be remembered and quoted will be the 75 years cut point.
Page 385 of the Annals article has a table with the left hand column having a heading of "high-value,cost conscious care" across from the age related cutoff and their general screening recommendations.The implication is that the age recommendation is consistent with this "principle" of high-value,cost conscious care.
However,invoking the new magic words "High-value,cost-conscious care" (HVCCC) does not substitute for offering an analysis of the data regarding the outcomes of colonoscopy in older patients,e.g. complications, positive findings and ( here is something radical) how did the patients value the procedure.
I cannot help but worry that whatever righteous and rational reasoning and good intentions lead to the notion of HVCCC , it will become like the term "patient centered care" meaning whatever the authors of articles chose to have it mean. There are certain tactical advantages to have an elastic, ambiguous concept . I am preparing some comments on the notion of "value" as it is being applied to medical issues,particularly in regard to the difference between the use of the term by certain business consultant gurus and its questionable transfer to medical care and the standard
definition of value as explained in introductory economics texts.
Sunday, March 04, 2012
Department of HHS makes economic breakthrough: declares there IS a free lunch after all
Nobel prize winning economist,Milton Friedman, is quoted as saying that economics could be summed up with two principles. 1) There is no such thing as a free lunch and 2)demand curves slope downward or ( in non econo-speak) people buy more when the price is lower and less when prices are higher.
Dr Friedman did not live long enough to see that his first principle overturned.
When the dictum of the HHS Department ordering employers to provide medical insurance that included paying for birth control pills hit a snag when the Catholic Church hierarchy raised a loud and righteous ruckus as it impacted Catholic hospitals and schools, necessity once again became the mother of invention.
The Secretary of HHS , in a move alleged to be compromise, declared that: no, the employer would not have to pay but rather the insurance company would. (see here).When challenged with the argument that the insurance company would simply increase the premiums,the Secretary replied;no, the insurance company would not be allowed to do so. Further, that order would actually save the insurance company money because the savings from medical costs not incurred because of the decrease in the number of pregnancies pregnancies would be greater than the cost of the pills. So, not only are the birth control pill free but provide a saving to the insurance company.So it is even better than a free lunch. The insurance companies should be happy to be forced to save money.
But this previously unrecognized saving ( which for some strange reason insurers never recognized on their own) is only the beginning. If taking statins and blood pressure pills decrease the risk of heart attack, should not insurance companies be giving those medications to policy holders as well. After all, generic pills are cheap enough and treating a heart attack is a big ticket item. The opportunities along these lines seem endless.Once insurance companies grasp this principle their profits will soar and they will begin to "give away" a lot of stuff even without government coercion.
Some would argue that these dicta from the Department of HHS make any contract that existed between the insurer and the insured a farce since for hundreds of years a contract based on force or coercion rather than mutual agreement of the parties was considered not valid.(See here for the comments from the Institute for Justice arguing that is exactly what the individual mandate does.) Those naysayers just cannot see the big picture which is that a new economic principle has been discovered- namely there can be a free lunch if the government says so.
Now HHS needs to get to work on the abrogation of Friedman's second principle; the demand curve thing.Recently an MIT economist re-discovered that principle in regard to medical costs and Medicare.She found that there was an increase in the quantity of care demanded once older folks had the Medicare card which made their health care cheaper. See here for my earlier post explaining the data and analysis employed by the economist to "discover" that people like to spend other people's money.
Might not the huge increase in the number of folks who will be given an insurance card ( or forced to buy one) pose a real problem as there is no concomitant increase in the number of physicians to provide that care.One solution would be for HHS to determine that people do not demand more services and goods when they are cheaper which would solve the problem of a physician shortage.
Getting those silly economic misconceptions out the way should really make Obamacare work more smoothly and all of the social justice embedded in the 2000 pages of the statute can emerge.
Dr Friedman did not live long enough to see that his first principle overturned.
When the dictum of the HHS Department ordering employers to provide medical insurance that included paying for birth control pills hit a snag when the Catholic Church hierarchy raised a loud and righteous ruckus as it impacted Catholic hospitals and schools, necessity once again became the mother of invention.
The Secretary of HHS , in a move alleged to be compromise, declared that: no, the employer would not have to pay but rather the insurance company would. (see here).When challenged with the argument that the insurance company would simply increase the premiums,the Secretary replied;no, the insurance company would not be allowed to do so. Further, that order would actually save the insurance company money because the savings from medical costs not incurred because of the decrease in the number of pregnancies pregnancies would be greater than the cost of the pills. So, not only are the birth control pill free but provide a saving to the insurance company.So it is even better than a free lunch. The insurance companies should be happy to be forced to save money.
But this previously unrecognized saving ( which for some strange reason insurers never recognized on their own) is only the beginning. If taking statins and blood pressure pills decrease the risk of heart attack, should not insurance companies be giving those medications to policy holders as well. After all, generic pills are cheap enough and treating a heart attack is a big ticket item. The opportunities along these lines seem endless.Once insurance companies grasp this principle their profits will soar and they will begin to "give away" a lot of stuff even without government coercion.
Some would argue that these dicta from the Department of HHS make any contract that existed between the insurer and the insured a farce since for hundreds of years a contract based on force or coercion rather than mutual agreement of the parties was considered not valid.(See here for the comments from the Institute for Justice arguing that is exactly what the individual mandate does.) Those naysayers just cannot see the big picture which is that a new economic principle has been discovered- namely there can be a free lunch if the government says so.
Now HHS needs to get to work on the abrogation of Friedman's second principle; the demand curve thing.Recently an MIT economist re-discovered that principle in regard to medical costs and Medicare.She found that there was an increase in the quantity of care demanded once older folks had the Medicare card which made their health care cheaper. See here for my earlier post explaining the data and analysis employed by the economist to "discover" that people like to spend other people's money.
Might not the huge increase in the number of folks who will be given an insurance card ( or forced to buy one) pose a real problem as there is no concomitant increase in the number of physicians to provide that care.One solution would be for HHS to determine that people do not demand more services and goods when they are cheaper which would solve the problem of a physician shortage.
Getting those silly economic misconceptions out the way should really make Obamacare work more smoothly and all of the social justice embedded in the 2000 pages of the statute can emerge.
Friday, February 17, 2012
Remember how HMOs gave physicians more autonomy,ACOs will be even better
Remember how HMOs made patients happier,doctors more satisfied with their work and also brought about better care while bending the cost curve downwards. Well, we are told that ACOs will do that only even better.
Dr. Ezekiel J. Emanuel , in this commentary, in JAMA assures physicians who might have foolishly worried that joining an ACO would lead to some loss of autonomy. He and his co-author argue that actually ACOs offer the opportunity for more ( not a typo ) autonomy.
So how does working with (for?) a large vertically integrated organization which by definition will have a large bureaucracy lead to autonomy?
Here is quote from Emanual's article that suggests one way.
More relevant to physicians' autonomy, the ACA initiates payment reforms that will give physicians greater financial flexibility to redesign care delivery, and to provide services that may not have been reimbursed before. For example, traditional fee-for-service payment mechanisms do not reimburse for efforts to enhance medication compliance or to oversee the results of wireless physiological monitoring in patients' homes.
and more
Another provision of the ACA that offers physicians more liberty to pursue patients' best interests is the move toward accountable care organizations (ACOs), which are combinations of physician groups, hospitals, and other providers that will coordinate care for patients.6 The proposed ACO regulations require physician leadership and empower physicians to determine the information systems and infrastructure necessary for coordinating care. The freedom to redesign care occurs along a spectrum depending on how the ACO is paid.
Does anyone who has worked with the administration of a large hospital or an insurance company really think that the typical ( or atypical ) physician is going to "determine" much of anything."Freedom to redesign" ? More like freedom to follow the rules and guidelines of the organization or seek employment elsewhere.
Some of us may have been fooled or seduced or coerced by the HMOs , fool me twice...
Surveys have indicated a number of physicians will leave practice early because of Obamacare.I guess the prospect of greater autonomy is just too frightening.
Dr. Ezekiel J. Emanuel , in this commentary, in JAMA assures physicians who might have foolishly worried that joining an ACO would lead to some loss of autonomy. He and his co-author argue that actually ACOs offer the opportunity for more ( not a typo ) autonomy.
So how does working with (for?) a large vertically integrated organization which by definition will have a large bureaucracy lead to autonomy?
Here is quote from Emanual's article that suggests one way.
More relevant to physicians' autonomy, the ACA initiates payment reforms that will give physicians greater financial flexibility to redesign care delivery, and to provide services that may not have been reimbursed before. For example, traditional fee-for-service payment mechanisms do not reimburse for efforts to enhance medication compliance or to oversee the results of wireless physiological monitoring in patients' homes.
and more
Another provision of the ACA that offers physicians more liberty to pursue patients' best interests is the move toward accountable care organizations (ACOs), which are combinations of physician groups, hospitals, and other providers that will coordinate care for patients.6 The proposed ACO regulations require physician leadership and empower physicians to determine the information systems and infrastructure necessary for coordinating care. The freedom to redesign care occurs along a spectrum depending on how the ACO is paid.
Does anyone who has worked with the administration of a large hospital or an insurance company really think that the typical ( or atypical ) physician is going to "determine" much of anything."Freedom to redesign" ? More like freedom to follow the rules and guidelines of the organization or seek employment elsewhere.
Some of us may have been fooled or seduced or coerced by the HMOs , fool me twice...
Surveys have indicated a number of physicians will leave practice early because of Obamacare.I guess the prospect of greater autonomy is just too frightening.
Monday, February 13, 2012
Another comment on the "controversy" over HHS dicta regarding reproductive services
A minor political storm emerged over the ruling of the Department of HHS regarding the mandatory inclusion of certain reproductive services in health insurance. Obamacare has made the HHS Secretary the final arbiter of many things in health care including what health insurance plans must cover so this is likely the first of many such mini-storms.
Much of the ensuring public discussion has veered off on tangents which while being perhaps of interest and worthy of discourse per se miss the main point here.
Now to the main issue here .
Those in control of health insurance, which since Obamacare was passed is the HHS Department who answers to the President and is seeming beyond any appellate measure, are not really concerned with the arguments over the particulars of their latest dictum which is only one of very many to come .They do not care so long as those who disagree concede the legitimacy of the power of the central government to make those dictates in the first place.
In fact they may relish the furor over the details of this particular ruling as long the anger is not focused on the legitimacy of the governments authority in this regard. At least they relish it as long as the political fall out seem minor and controllable although it is not clear that is either at this juncture.
Much, if not most, of the outcry have focused on a "battle" between the administration and the Catholic church, or on an alleged great unfulfilled need of women to have access to birth control which they say should not be left to the caprice of employers .Folks who make that latter argument seems clueless as to the obvious caprice of the HHS decisions.
So the major issue is should the government have that power to decide what we must pay for in our health insurance . However, frighteningly, it may get worse that that. This idea is expressed in the following quote from Dr. Richard Fogoros's blog The Covert Rationing Blog .
DrRich has pointed out many times that the real battle we will face as Obamacare is being rolled out is the battle over whether American citizens will retain individual freedom sufficient to be permitted to spend their own money on their own healthcare. Indeed, DrRich has written a series of posts that spells all this out in painful detail. If you need to know why limiting individual prerogatives is so critically important to Progressives, and why Obamacare must be the vehicle for establishing these limitations, simply read the first post in that series.
I see it this way; Once we loose the battle over whether the government has the legitimate power and authority to dictate what health care must contain,it is a short jog down the road for a government with that power to determine what health care may not consist of even if paid for by the patient herself. Could that happen? It happened in Canada. Must it happen? It did not happen in Great Britain?
I hope DrRich's and my fears are wasted and individual freedom will persist in this regard. However, when I see some of the reaction to the latest Obamacare dictum and people are talking about things like whether the Catholic Church ought to modernize its archaic views or the sudden mysterious shortage of birth control methods which must be alleviated by the government while there is so little commentary on the fundamental issue (should the government have that power in the first place),my worry titer goes back up.
Much of the ensuring public discussion has veered off on tangents which while being perhaps of interest and worthy of discourse per se miss the main point here.
Now to the main issue here .
Those in control of health insurance, which since Obamacare was passed is the HHS Department who answers to the President and is seeming beyond any appellate measure, are not really concerned with the arguments over the particulars of their latest dictum which is only one of very many to come .They do not care so long as those who disagree concede the legitimacy of the power of the central government to make those dictates in the first place.
In fact they may relish the furor over the details of this particular ruling as long the anger is not focused on the legitimacy of the governments authority in this regard. At least they relish it as long as the political fall out seem minor and controllable although it is not clear that is either at this juncture.
Much, if not most, of the outcry have focused on a "battle" between the administration and the Catholic church, or on an alleged great unfulfilled need of women to have access to birth control which they say should not be left to the caprice of employers .Folks who make that latter argument seems clueless as to the obvious caprice of the HHS decisions.
So the major issue is should the government have that power to decide what we must pay for in our health insurance . However, frighteningly, it may get worse that that. This idea is expressed in the following quote from Dr. Richard Fogoros's blog The Covert Rationing Blog .
DrRich has pointed out many times that the real battle we will face as Obamacare is being rolled out is the battle over whether American citizens will retain individual freedom sufficient to be permitted to spend their own money on their own healthcare. Indeed, DrRich has written a series of posts that spells all this out in painful detail. If you need to know why limiting individual prerogatives is so critically important to Progressives, and why Obamacare must be the vehicle for establishing these limitations, simply read the first post in that series.
I see it this way; Once we loose the battle over whether the government has the legitimate power and authority to dictate what health care must contain,it is a short jog down the road for a government with that power to determine what health care may not consist of even if paid for by the patient herself. Could that happen? It happened in Canada. Must it happen? It did not happen in Great Britain?
I hope DrRich's and my fears are wasted and individual freedom will persist in this regard. However, when I see some of the reaction to the latest Obamacare dictum and people are talking about things like whether the Catholic Church ought to modernize its archaic views or the sudden mysterious shortage of birth control methods which must be alleviated by the government while there is so little commentary on the fundamental issue (should the government have that power in the first place),my worry titer goes back up.
Friday, February 03, 2012
Obamacare: "anger and division are inevitable consequences of the Law"
The title is a quote from Michael Cannon of Cato.See his commentary .
His current comments are in regard to the latest decree from the HHS Secretary regarding the mandate for the details of the health insurance that Obamacare mandates with the threat of a fine for non compliance. This time the Catholic Church is the focus of attention with the insistence that that organization will, in fact, have to provide insurance that covers among other things,certain reproductive services including birth control pills.
When the government, this time a single high ranking government presidential appointee, decides what you shall have and shall not have in your health insurance, there is bound to be anger and division as Cannon said.
Some folks with a more progressive mind set may be pleased that the enlightened HHS secretary will force a program so that women can afford contraception,but the government control knife cuts more ways. I quote Cannon again
The same apparatus that can force Americans to subsidize elective abortions can also be used to ban private abortion coverage once the other team wins. The rancor will only grow.
Thomas J. Sargent said the following in his address to graduates at UC Berkeley in May 2007.
"Other people have more information about their abilities,their efforts and their preferences that you do."
I suppose even progressive planners would admit that but with a "Yes,but". Yes but we know better what is best for other people.
Of course, with the power of HHS mandates and the reach of IPAB,the apparatus of government health care control system can force certain things and ban others regardless of the wishes and the particular circumstances of the "other people".
The social justice bestowed on us rolls on. It just gets better and better.
His current comments are in regard to the latest decree from the HHS Secretary regarding the mandate for the details of the health insurance that Obamacare mandates with the threat of a fine for non compliance. This time the Catholic Church is the focus of attention with the insistence that that organization will, in fact, have to provide insurance that covers among other things,certain reproductive services including birth control pills.
When the government, this time a single high ranking government presidential appointee, decides what you shall have and shall not have in your health insurance, there is bound to be anger and division as Cannon said.
Some folks with a more progressive mind set may be pleased that the enlightened HHS secretary will force a program so that women can afford contraception,but the government control knife cuts more ways. I quote Cannon again
The same apparatus that can force Americans to subsidize elective abortions can also be used to ban private abortion coverage once the other team wins. The rancor will only grow.
Thomas J. Sargent said the following in his address to graduates at UC Berkeley in May 2007.
"Other people have more information about their abilities,their efforts and their preferences that you do."
I suppose even progressive planners would admit that but with a "Yes,but". Yes but we know better what is best for other people.
Of course, with the power of HHS mandates and the reach of IPAB,the apparatus of government health care control system can force certain things and ban others regardless of the wishes and the particular circumstances of the "other people".
The social justice bestowed on us rolls on. It just gets better and better.
Tuesday, January 24, 2012
More of the weird social justice that Obamacare has given us
See this article from Cato. By reclassifying the status of one hospital in Massachusetts, a number of hospitals in that state by some bizarre bureaucratic mechanism receive more Medicare payment from the Federal Government while that amount is made up for by cuts to the rest of hospitals in the country.This is a big blob of social justice right in your face.
Redistribution of funds based on arbitrary government bureaucratic decisions seems to be a recurrent feature of Obamacare,one poster child for which was the early on exceptions of certain companies from some of the provisions of the law. "The secretary shall determine" theme plays over and over.
The core of laws such a Obama care is that the devilish details are placed in the hands of executive branch entities who can then dish out favors as they see fit and the factions (Madison's quaint term for special interest groups) that can gain or loose from those decisions busy themselves with efforts to bring about some decree of regulatory capture or just simple payoffs.
The crap of "crony capitalism" get wrongfully blamed on capitalism while in reality the rent seeking ( the quaint term economists use for privilege seeking ) is a phenomenon that has become gargantuan because of the progressive mindset's endless quest to give more and more power to the government and to focus that power and control into ever increasing aspects of people's lives. No, I have not forgotten big government conservative's hypocritical initiatives to do about the same,albeit with a different rhetorical cover. More power to the government and thereby more efforts to harness that power for one's focused individual interest paid for by everyone else. But isn't Obamacare furthering social justice?
Redistribution of funds based on arbitrary government bureaucratic decisions seems to be a recurrent feature of Obamacare,one poster child for which was the early on exceptions of certain companies from some of the provisions of the law. "The secretary shall determine" theme plays over and over.
The core of laws such a Obama care is that the devilish details are placed in the hands of executive branch entities who can then dish out favors as they see fit and the factions (Madison's quaint term for special interest groups) that can gain or loose from those decisions busy themselves with efforts to bring about some decree of regulatory capture or just simple payoffs.
The crap of "crony capitalism" get wrongfully blamed on capitalism while in reality the rent seeking ( the quaint term economists use for privilege seeking ) is a phenomenon that has become gargantuan because of the progressive mindset's endless quest to give more and more power to the government and to focus that power and control into ever increasing aspects of people's lives. No, I have not forgotten big government conservative's hypocritical initiatives to do about the same,albeit with a different rhetorical cover. More power to the government and thereby more efforts to harness that power for one's focused individual interest paid for by everyone else. But isn't Obamacare furthering social justice?
Sunday, January 22, 2012
CBO give results (largely negative) on several buzz word medicare demonstration projects
Buzz words abound in the wonky sector of health care, a domain in which many commentators comment more than they actually do health care.
Here is a CMO report on 10 demonstrations projects which sought to test the operational results
of several buzz word projects.
Dr. Robert Centor gives a brief summary of some of the finding on his blog.See here.
In the Disease Management programs,the costs seemed to exceed the benefits.In three out of four "Value based payment" program there was little or no savings.This is similar to comments I made almost 5 years ago regarding a radomized trial that show no value for a particular disease management program.
Dr Centor said:
Boys and girls, this stuff is much more complex than these demonstration projects can address. Physicians really do their best out there.
You bet it is more complex.
"The curious task of economics is to demonstrate to men how little they really know about what they imagine they can design." FA Hayek.The Fatal Conceit.
Russ Roberts writing in his blog, Cafe Hayek said in regard to some or other government program
"So many things the government does are attempts to circumvent the bad things caused by something else they already do."
It seems to be there are a lot of buzz word filled initiatives that are, at least in part, efforts to try and undo the mess made by CMS price controls on physicians fees and the primary care destroying RBRVS .
Here is a CMO report on 10 demonstrations projects which sought to test the operational results
of several buzz word projects.
Dr. Robert Centor gives a brief summary of some of the finding on his blog.See here.
In the Disease Management programs,the costs seemed to exceed the benefits.In three out of four "Value based payment" program there was little or no savings.This is similar to comments I made almost 5 years ago regarding a radomized trial that show no value for a particular disease management program.
Dr Centor said:
Boys and girls, this stuff is much more complex than these demonstration projects can address. Physicians really do their best out there.
You bet it is more complex.
"The curious task of economics is to demonstrate to men how little they really know about what they imagine they can design." FA Hayek.The Fatal Conceit.
Russ Roberts writing in his blog, Cafe Hayek said in regard to some or other government program
"So many things the government does are attempts to circumvent the bad things caused by something else they already do."
It seems to be there are a lot of buzz word filled initiatives that are, at least in part, efforts to try and undo the mess made by CMS price controls on physicians fees and the primary care destroying RBRVS .
Tuesday, January 17, 2012
Is the American College of Physician's new Ethical Manual an ethical game changer
Dr. Michael Kirsch, author of the blog, MD Whistleblower, thinks so; see here for his view.
Here is a money quote from his commentary: He begins with a quotation from the ACP Ethics Manual;
Physicians have a responsibility to practice effective and efficient health care and to use health care resources responsibly.
This is an ethical game changer. According to the updated ethics manual, physicians should consider preserving health care resources for the population at large, which may conflict with our patient’s interest. Now, we are told that we are ethically obligated not only to advocate for our own patient, but also for hundreds of millions of other patients. If this becomes standard operating procedure, how will it impact the doctor-patient relationship? Will patients, who are increasingly skeptical of the medical profession, trust us? Will they suspect that we are restraining their care to serve the greater good?
The camel's nose (along with other anatomical parts) that sneaked under the medical ethical framework tent was the publication of a physician's" Charter" (aka New Professionalism) which in a gigantic non sequitur gratuitously asserted that social justice was now a major element in what they said what was medical professionalism, stopping just short of explicitly saying it was part of ethics.However, it was not clear what the separation between professionalism and ethics really was. Now the ACP makes that final move equating social justice with preserving health care resources for everyone and somehow balancing that against the individual patient's interest as an ethical responsibility. Has the concept of fiduciary duty to the patient really been shoved down the memory hole?
This is an ethical game changer but sometimes the ACP spokespeople seem to write and speak about both the charter and the ethics manual as if nothing has really changed. For example, I offer the following quote from recent comments from the president of the ACP, Dr. Virginia L. Hood in her message printed in the ACP Internist of January 2012.
She refers to the 2002 publication of a "physician charter to confront the health care challenges of a new millennium ". She continues " As well as restating (my bolding) the principles of 'primacy of patient welfare,patient autonomy, and social justice' ,it outlined a set of professional responsibilities..."
The charter did not restate social justice;it gratuitously inserted it and certainly never explained how striving for social justice enabled physicians to confront the new challenges. Now Dr. Hood writes about it as if social justice had always been a key element of medical ethics. It may be a useful rhetorical tool to just assume away a controversial issue but it should be clear that social justice based on a utilitarian calculus to allocate health care " resources" was when the charter was published and continues to be a source of considerable controversy in the medical community.
In a 1988 Annals of Internal Medicine Article,Hall and Berenson made- what appeared to many of us who were raised medically with the "old" medical professionalism of fiduciary duty to the patients- a startling proposal:
"We propose that devotion to the best interest of each individual be replaced with an ethic of the best interest of the group for which the physician is personally responsible."
Dr. Edmund Pelligrino writing in 1995 asked in the ethics of a profession could be changed at will.
Judging on the basis of the New Professionalism and the statements in the recent ACP Ethics Manual, it seems like it has.
DrRich of the blog "The Covert Rationing blog also believes it is a game changer.Further he offers his view as to what the real import of the new ethics is in this passage:
And here is the real import of the updated Ethics Manual. It aims to assuage the guilty conscience of physicians who follow handed-down guidelines to the letter, even against their better medical judgment, instead of tailoring the application of those guidelines to the benefit of their individual patients'
Exactly. It is an 180 degree switch from the antiquated ,fuddy duddy "fiduciary duty" silliness of a by gone era.
The ethical physician of today (again quoting DrRich) is "to follow the best evidence , in particular the best evidence on cost-effectiveness" and
" it is now the ethical obligation for doctors to follow expert produced guidelines" ( see here for DrRich's full commentary).
It is of some interest (or irony) that the introductory section of the 6th edition of the American College of Physicians Ethics Manual was written by an attorney, Lois Synder and there was no mention of a physician's fiduciary duty to his patient .
I do have trouble reconciling the words of the manual-particularly those quoted above-with these comments regarding the new manual from Dr. Hood as quoted in the 1/11/2012 Modern Medicine, on line:
“We have to consider cost as one of the factors when we make medical decisions, because that’s in the best interest of our patients,” Virginia Hood, MBBS, MPH, FACP, an internist and nephrologist and president of the ACP, tells eConsult. “It shouldn’t ever be an overriding part of a decision, but physicians need to take it into consideration.”
She continues:We have been advocating for efficient care since 1984, but it’s been given a slightly greater emphasis because the costs of care are so much higher,”,
So what is it- a slightly greater emphasis on cost or a real ethical game changer in which the fiduciary duty of the physician to the patient is not mentioned. Dr Hood's words quoted above seem reassuring but the black letter words as written in the ethics manual seem to pit the needs of the individual against the nebulous and ambiguously defined common good. In "box no.4 which addresses "Patients First and stewardship of resources" it says in part there is a responsibility to provide "parsimonious care that utilizes the most efficient means" [for diagnosis and treatment] . That sounds to me to be more than a slightly greater emphasis.
Also seemingly contrary to the representation that the new ethics manual really does not represent a major shift are several comments found in the editorial by Dr. Ezekiel Emanuel.(3 January 2012,Annals Internal Medicine,volume 156.number 1.pg 56)
Emanuel says :"Here is a professional society unafraid of advocating the principle of cost-effectiveness." Here aren't we talking about stuff like amount of dollars per life year saved?
He continues :These positions on efficiency, parsimony and cost effectiveness constitute an important shift,if not in ethics , then in emphasis." and
"It goes well beyond the usual banalities to take brave stand on current issues".
Here is a money quote from his commentary: He begins with a quotation from the ACP Ethics Manual;
Physicians have a responsibility to practice effective and efficient health care and to use health care resources responsibly.
This is an ethical game changer. According to the updated ethics manual, physicians should consider preserving health care resources for the population at large, which may conflict with our patient’s interest. Now, we are told that we are ethically obligated not only to advocate for our own patient, but also for hundreds of millions of other patients. If this becomes standard operating procedure, how will it impact the doctor-patient relationship? Will patients, who are increasingly skeptical of the medical profession, trust us? Will they suspect that we are restraining their care to serve the greater good?
The camel's nose (along with other anatomical parts) that sneaked under the medical ethical framework tent was the publication of a physician's" Charter" (aka New Professionalism) which in a gigantic non sequitur gratuitously asserted that social justice was now a major element in what they said what was medical professionalism, stopping just short of explicitly saying it was part of ethics.However, it was not clear what the separation between professionalism and ethics really was. Now the ACP makes that final move equating social justice with preserving health care resources for everyone and somehow balancing that against the individual patient's interest as an ethical responsibility. Has the concept of fiduciary duty to the patient really been shoved down the memory hole?
This is an ethical game changer but sometimes the ACP spokespeople seem to write and speak about both the charter and the ethics manual as if nothing has really changed. For example, I offer the following quote from recent comments from the president of the ACP, Dr. Virginia L. Hood in her message printed in the ACP Internist of January 2012.
She refers to the 2002 publication of a "physician charter to confront the health care challenges of a new millennium ". She continues " As well as restating (my bolding) the principles of 'primacy of patient welfare,patient autonomy, and social justice' ,it outlined a set of professional responsibilities..."
The charter did not restate social justice;it gratuitously inserted it and certainly never explained how striving for social justice enabled physicians to confront the new challenges. Now Dr. Hood writes about it as if social justice had always been a key element of medical ethics. It may be a useful rhetorical tool to just assume away a controversial issue but it should be clear that social justice based on a utilitarian calculus to allocate health care " resources" was when the charter was published and continues to be a source of considerable controversy in the medical community.
In a 1988 Annals of Internal Medicine Article,Hall and Berenson made- what appeared to many of us who were raised medically with the "old" medical professionalism of fiduciary duty to the patients- a startling proposal:
"We propose that devotion to the best interest of each individual be replaced with an ethic of the best interest of the group for which the physician is personally responsible."
Dr. Edmund Pelligrino writing in 1995 asked in the ethics of a profession could be changed at will.
Judging on the basis of the New Professionalism and the statements in the recent ACP Ethics Manual, it seems like it has.
DrRich of the blog "The Covert Rationing blog also believes it is a game changer.Further he offers his view as to what the real import of the new ethics is in this passage:
And here is the real import of the updated Ethics Manual. It aims to assuage the guilty conscience of physicians who follow handed-down guidelines to the letter, even against their better medical judgment, instead of tailoring the application of those guidelines to the benefit of their individual patients'
Exactly. It is an 180 degree switch from the antiquated ,fuddy duddy "fiduciary duty" silliness of a by gone era.
The ethical physician of today (again quoting DrRich) is "to follow the best evidence , in particular the best evidence on cost-effectiveness" and
" it is now the ethical obligation for doctors to follow expert produced guidelines" ( see here for DrRich's full commentary).
It is of some interest (or irony) that the introductory section of the 6th edition of the American College of Physicians Ethics Manual was written by an attorney, Lois Synder and there was no mention of a physician's fiduciary duty to his patient .
I do have trouble reconciling the words of the manual-particularly those quoted above-with these comments regarding the new manual from Dr. Hood as quoted in the 1/11/2012 Modern Medicine, on line:
“We have to consider cost as one of the factors when we make medical decisions, because that’s in the best interest of our patients,” Virginia Hood, MBBS, MPH, FACP, an internist and nephrologist and president of the ACP, tells eConsult. “It shouldn’t ever be an overriding part of a decision, but physicians need to take it into consideration.”
She continues:We have been advocating for efficient care since 1984, but it’s been given a slightly greater emphasis because the costs of care are so much higher,”,
So what is it- a slightly greater emphasis on cost or a real ethical game changer in which the fiduciary duty of the physician to the patient is not mentioned. Dr Hood's words quoted above seem reassuring but the black letter words as written in the ethics manual seem to pit the needs of the individual against the nebulous and ambiguously defined common good. In "box no.4 which addresses "Patients First and stewardship of resources" it says in part there is a responsibility to provide "parsimonious care that utilizes the most efficient means" [for diagnosis and treatment] . That sounds to me to be more than a slightly greater emphasis.
Also seemingly contrary to the representation that the new ethics manual really does not represent a major shift are several comments found in the editorial by Dr. Ezekiel Emanuel.(3 January 2012,Annals Internal Medicine,volume 156.number 1.pg 56)
Emanuel says :"Here is a professional society unafraid of advocating the principle of cost-effectiveness." Here aren't we talking about stuff like amount of dollars per life year saved?
He continues :These positions on efficiency, parsimony and cost effectiveness constitute an important shift,if not in ethics , then in emphasis." and
"It goes well beyond the usual banalities to take brave stand on current issues".
Monday, January 16, 2012
Price controls have worked so well in medical care, let's do some more
Doing some more is exactly what the Administration is doing here with its case by case decision regarding how medical insurers do their business. Of course, this level of central plannng on a mico level is part of the disaster unfolding as we see Obamacare play out. See here for the newspaper account of the Secretary of HHS ordering an insurance company to rescind its rate increase.
Arnold Kling,a MIT trained economist,is fond of saying that economists do not hold back the good stuff when they teach economics. Rather they reveal the important stuff in econ 101. In econ 101 the effects of price controls are clearly spelled out.Price controls in the form of price ceiling create several things:
1.Shortages
2.reduction in quality of goods or services provided
3.Search costs including wasteful lines
4.loss gains from trade
5.allocations of economic resources.
Here is what George Mason University economist, Don Boudreaux, has to say about the HHS actions in his typical trenchant style.
As millions of more people will have insurance cards,and think they now have access to medical care, consider how much worse the shortage of primary care ( think Medicare price controls) will be and how much longer and more wasteful and frustrating the lines in emergency rooms will be.
Addendum: See here for the blog entry by John Goodman entitled "How Doctors are Trapped" for a detailed discussion of some of the particular ways that the CMS physician fee price controls are destructive and demoralizing to physicians and patients .
Arnold Kling,a MIT trained economist,is fond of saying that economists do not hold back the good stuff when they teach economics. Rather they reveal the important stuff in econ 101. In econ 101 the effects of price controls are clearly spelled out.Price controls in the form of price ceiling create several things:
1.Shortages
2.reduction in quality of goods or services provided
3.Search costs including wasteful lines
4.loss gains from trade
5.allocations of economic resources.
Here is what George Mason University economist, Don Boudreaux, has to say about the HHS actions in his typical trenchant style.
As millions of more people will have insurance cards,and think they now have access to medical care, consider how much worse the shortage of primary care ( think Medicare price controls) will be and how much longer and more wasteful and frustrating the lines in emergency rooms will be.
Addendum: See here for the blog entry by John Goodman entitled "How Doctors are Trapped" for a detailed discussion of some of the particular ways that the CMS physician fee price controls are destructive and demoralizing to physicians and patients .
Friday, January 13, 2012
Fans of crony capitalism should love Obamacare
Writing in Forbes, Warren Meyers offered this eye catching title, " Crony Capitalism?Blame the Progressives."
Here is how it works as explained by Meyers in his posting in Forbes. See here for article.
Capitalism is simply the free exchange of individuals based on their self interest. There is no room for government subsides,bailouts or any of the other myriad forms of government interventions into the economy that favors one entity or groups over others. Whenever government has the power to dole out favors folks will seek those favors. They will seek out those privileges. The bigger the goverment, the more power to dole out favors, the more favor seeking and the more the targeted few benefit at the expense of the rest.
This privilege seeking activity in the jargon of the economist is called "rent seeking". Progressives as a group favor more goverment power to do all those things that they think wise leaders and technocrats can do much better than the people could do for themselves.Of course, Progressives share the blame with other big government politicians whether they be called big government conservatives or moderates or whatever.
Enter Obamacare as the poster child for what George Will has called the tendency of congress to pass intentions rather than statutes. What we get is legislation that outline an aspiration or a dream or a nice thought and then hands over the details which actually define the actions to various governmental appointees and agencies,who then become the target for possible regulatory capture or at the least effective lobbying efforts the results of which can be described as crony capitalism.
Here is an excellent essay on the nature of crony capitalism versus "Market capitalism" and how Obamacare is a poster child for the former.How does the furtherance of crony capitalism mesh with the alleged social justice that Obamacare was said to represent?
Here is how it works as explained by Meyers in his posting in Forbes. See here for article.
Capitalism is simply the free exchange of individuals based on their self interest. There is no room for government subsides,bailouts or any of the other myriad forms of government interventions into the economy that favors one entity or groups over others. Whenever government has the power to dole out favors folks will seek those favors. They will seek out those privileges. The bigger the goverment, the more power to dole out favors, the more favor seeking and the more the targeted few benefit at the expense of the rest.
This privilege seeking activity in the jargon of the economist is called "rent seeking". Progressives as a group favor more goverment power to do all those things that they think wise leaders and technocrats can do much better than the people could do for themselves.Of course, Progressives share the blame with other big government politicians whether they be called big government conservatives or moderates or whatever.
Enter Obamacare as the poster child for what George Will has called the tendency of congress to pass intentions rather than statutes. What we get is legislation that outline an aspiration or a dream or a nice thought and then hands over the details which actually define the actions to various governmental appointees and agencies,who then become the target for possible regulatory capture or at the least effective lobbying efforts the results of which can be described as crony capitalism.
Here is an excellent essay on the nature of crony capitalism versus "Market capitalism" and how Obamacare is a poster child for the former.How does the furtherance of crony capitalism mesh with the alleged social justice that Obamacare was said to represent?
Thursday, January 12, 2012
American Psychiatric Association "Slapps" down web site critical of DSM5
Dr. Bernard Carroll,former head of psychiatry at Duke,writing on the blog Health Care Renewal ,writes about an interesting conflict between the APA and a former editor of DSM. See here.
Dr. Allen Francis who edited DSM4 has been highly critical of the DSM process and particularly of the yet to be released DSM5.He expresses concern that psychiatry is being practiced less by psychiatrists and more by primary care physicians, who are busy and often not very well trained in managing psychiatric problems and at times strongly influenced by marketing .
His criticism includes the charge that with the publication of DSM5, not yet released, there will be more patients diagnosed with DMS defined mental conditions as new diagnoses are being added and the criteria for others have been broadened. His comments regarding his view of the problems with DSM were appearing on at least one web site.
Now the APA,who owns DSM and profits from its publication and use, has sent out a cease and desist threat to the website previously known as "dsm5watch" Their argument was that the website to which he contributed a contained the letters DSM and that was a copyright infringement. The new name for the website is "dxrevisionwatch.wordpress.com"
The explanation for the strange spelling of "slap" in this post's headline is that the APA actions might be described by some as a "Strategic Lawsuit Against Public Participation". In this case only a threat.
See here for more comments by Dr. Francis and here for a reply by the APA to some of the criticism it has received lately.
Dr. Allen Francis who edited DSM4 has been highly critical of the DSM process and particularly of the yet to be released DSM5.He expresses concern that psychiatry is being practiced less by psychiatrists and more by primary care physicians, who are busy and often not very well trained in managing psychiatric problems and at times strongly influenced by marketing .
His criticism includes the charge that with the publication of DSM5, not yet released, there will be more patients diagnosed with DMS defined mental conditions as new diagnoses are being added and the criteria for others have been broadened. His comments regarding his view of the problems with DSM were appearing on at least one web site.
Now the APA,who owns DSM and profits from its publication and use, has sent out a cease and desist threat to the website previously known as "dsm5watch" Their argument was that the website to which he contributed a contained the letters DSM and that was a copyright infringement. The new name for the website is "dxrevisionwatch.wordpress.com"
The explanation for the strange spelling of "slap" in this post's headline is that the APA actions might be described by some as a "Strategic Lawsuit Against Public Participation". In this case only a threat.
See here for more comments by Dr. Francis and here for a reply by the APA to some of the criticism it has received lately.
Friday, January 06, 2012
More on the New Professionalism (medical) and what it is really about
The New Medical Professionalism has been a topic of concern to me for some time and I have tried to express my objections to what it represents on more than one occasion. See here.
But what I believe to be the definitive critique and explanation of what that document is all about has been published on the blog The Covert Rationing Blog by DrRich. See here.
Everyone should read it and share it with a colleague .Here is one quote:
But what I believe to be the definitive critique and explanation of what that document is all about has been published on the blog The Covert Rationing Blog by DrRich. See here.
Everyone should read it and share it with a colleague .Here is one quote:
To summarize, by the turn of the millennium doctors were being coerced to withhold healthcare from their patients at the bedside, and thus to violate their time-honored primary professional directive. The intent of the 2002 Charter on medical professionalism was to repair the problem (i.e., to cure the “frustration”), not by confronting the forces of evil doing the coercion, but rather, by simply changing medical ethics to make bedside rationing OK. And that’s just what the document did, though only after careful re-editing to make this radical change to medical ethics sound as benign as possible.
By explicitly endorsing the 2002 Charter on medical professionalism, the Sixth Edition of the ACP Ethics Manual thereby endorses healthcare rationing at the bedside – but it does so quietly, at arm’s length, so as not to stir up unwanted passions.
DrRich's topic for this essay is actually the New Ethics Manuel authored by the ACP and comments on the New Professionalism are offered in that context. Read his blog to learn about what Dr. Ezekiel Emanuel found particularly praise worthy regarding the new ethics.Thursday, January 05, 2012
Bryan Caplan tears apart Jonathan Gruber's graphic novel on health care reform
Jonathan Gruber is a major player in the health care wonk games and has recently written a graphic novel ( aka comic book) on health care" reform", an area in which he has written and worked extensively. See here for GMU economist Bryan Caplan's detailed shredding of that work.
I have blogged before on the paper by a MIT economist see here which "startled" the health care wonk world with the data driven observation that when folks have access to a government financed health care programs ( ie. Medicare) the demand for health care services increases about that which occurred when folks paid for those services with their own money.
On that issue Caplan says the following:
Gruber explains the basic facts about health care costs: they're rising, and government picks up much of the tab. But he almost totally neglects the connection between the two. Medicare and Medicaid vastly increase demand for health care. There's no denying it. Imagine how much more affordable health care would be if these programs had never been adopted - or if they were abolished.
Let's see if I get it.People tend to spend other people's money with less prudence that when spending their own. I think Milton Freeman might have made that point.
I have blogged before on the paper by a MIT economist see here which "startled" the health care wonk world with the data driven observation that when folks have access to a government financed health care programs ( ie. Medicare) the demand for health care services increases about that which occurred when folks paid for those services with their own money.
On that issue Caplan says the following:
Gruber explains the basic facts about health care costs: they're rising, and government picks up much of the tab. But he almost totally neglects the connection between the two. Medicare and Medicaid vastly increase demand for health care. There's no denying it. Imagine how much more affordable health care would be if these programs had never been adopted - or if they were abolished.
Let's see if I get it.People tend to spend other people's money with less prudence that when spending their own. I think Milton Freeman might have made that point.
Tuesday, January 03, 2012
In the Accountable Care Organizations (ACOs) to whom is the physician accountable?
Hint: It is not the patient, at least not in the structure or intent of the ACOs. See here for Paul Hsieh 's discussion of this issue.
Dr.Hsieh succinctly nails it here:
... under ObamaCare, your doctor will be increasingly pressured into sacrificing your individual medical interests for a nebulous “social justice.”
Exactly
He references some key quotes from physicians and physician organizations who favor and have been lobbying for the substitution of the pursuit of an elastic and nebulous collective good for the long standing fiduciary duty of the physician to the patients.
A now-famous article in the 1998 Annals of Internal Medicine recommended that “devotion to the best medical interests of each individual patient be replaced with an ethic of devotion to the best medical interests of the group...” The American College of Physicians ethics charter now states that physicians should balance traditional principles of patient welfare and patient autonomy with “social justice” to achieve “a just distribution of finite resources.” A 2011 New England Journal of Medicine article urged abandoning “the primacy of patient welfare” in favor of “collectively caring for a defined population within a fixed annual budget.”
Read the entire piece. It is excellent. Dr.Hsieh has been working tirelessly to support the concept of freedom and individual rights particularly in regard to the individual rights of doctors and the practice of medicine. Read more from him here.
Dr.Hsieh succinctly nails it here:
... under ObamaCare, your doctor will be increasingly pressured into sacrificing your individual medical interests for a nebulous “social justice.”
Exactly
He references some key quotes from physicians and physician organizations who favor and have been lobbying for the substitution of the pursuit of an elastic and nebulous collective good for the long standing fiduciary duty of the physician to the patients.
A now-famous article in the 1998 Annals of Internal Medicine recommended that “devotion to the best medical interests of each individual patient be replaced with an ethic of devotion to the best medical interests of the group...” The American College of Physicians ethics charter now states that physicians should balance traditional principles of patient welfare and patient autonomy with “social justice” to achieve “a just distribution of finite resources.” A 2011 New England Journal of Medicine article urged abandoning “the primacy of patient welfare” in favor of “collectively caring for a defined population within a fixed annual budget.”
Read the entire piece. It is excellent. Dr.Hsieh has been working tirelessly to support the concept of freedom and individual rights particularly in regard to the individual rights of doctors and the practice of medicine. Read more from him here.
Monday, December 12, 2011
In health care we don't need no stinking rule of law
The concept of rule of law at a minimal means clarity of laws and regulations and uniform enforcement.
Consider the recent action of the Centers for Medicare and Medicaid (CMS) in regard to the imposition of pre-payment audits of certain procedures ( cardiac,joint replacements,spinal fusions)but only in certain states. See here.
This means that for these procedures hospitals will not be paid until government auditors review patient records and confirm that the procedure was "appropriate". How will that determination be made? What criteria will be applied to conclude that something was appropriate. Why does this only apply to NY,Texas,Florida,Michigan ,Ohio,North Carolina,Missouri and Pennsylvania? Uniform enforcement ? Clear Rules? According to CMS, some of the states have a high number of error or fraud cases while others just have a high volume of the procedures.
Rule of law fans have had little to cheer about since Obamacare was passed. The Secretary of HHS has issued exceptions to certain provisions of the law only to certain firms.See here for more on the waivers.
Dr.Wes has commented on the CMS plan suggesting that CMS may not actually have the expertise and organizational skills to render decisions in anything approaching a timely manner or to employ a rational evidence based decision making process. See here.
The blog "Secondhand Smoke" offered a commentary on Obamacare and its assault on the rule of law.
Richard Epstein has commented on Obamacare and Rule of Law. See Here.
Ambiguity in laws and regulations coupled with discretionary implementation are the friends of politicians and bureaucrats and lobbyists and the enemies of the rest of us.
Consider the recent action of the Centers for Medicare and Medicaid (CMS) in regard to the imposition of pre-payment audits of certain procedures ( cardiac,joint replacements,spinal fusions)but only in certain states. See here.
This means that for these procedures hospitals will not be paid until government auditors review patient records and confirm that the procedure was "appropriate". How will that determination be made? What criteria will be applied to conclude that something was appropriate. Why does this only apply to NY,Texas,Florida,Michigan ,Ohio,North Carolina,Missouri and Pennsylvania? Uniform enforcement ? Clear Rules? According to CMS, some of the states have a high number of error or fraud cases while others just have a high volume of the procedures.
Rule of law fans have had little to cheer about since Obamacare was passed. The Secretary of HHS has issued exceptions to certain provisions of the law only to certain firms.See here for more on the waivers.
Dr.Wes has commented on the CMS plan suggesting that CMS may not actually have the expertise and organizational skills to render decisions in anything approaching a timely manner or to employ a rational evidence based decision making process. See here.
The blog "Secondhand Smoke" offered a commentary on Obamacare and its assault on the rule of law.
Richard Epstein has commented on Obamacare and Rule of Law. See Here.
Ambiguity in laws and regulations coupled with discretionary implementation are the friends of politicians and bureaucrats and lobbyists and the enemies of the rest of us.
Monday, December 05, 2011
Hayek's decades old comments as applied to Obamacare
See here for a posting on John Goodman's blog which features comments by Ed Feulner on how appropriate are FA Hayek's comments from Road to Serfdom are to how Obamacare is working.
Read the entire commentary but here is a flavor:
Hayek :"the legislative body will be reduced to choosing the persons who are to have practically absolute power."
Remember IPAB? See here to refresh memory of the power that this board of presidential appointees will have.
What could possibly go wrong with the IPAB? For those who seem to believe that government officials typically act in some nebulous "public interest"- nothing. For those who cynically think that people tend to respond to incentives and act in their own interests and believe that "regulatory capture" is real-a lot.
Obamacare is the prototypical progressive legislation.The progressive mindset is what Hayek talked about with his notion of the "fatal conceit".This is the belief that government will and should make the world better by social and economic planning and not by letting people free to coordinate their private plans.
Read the entire commentary but here is a flavor:
Hayek :"the legislative body will be reduced to choosing the persons who are to have practically absolute power."
Feulner :"Sound a bit like the Independent Payment Advisory Board (IPAB) of 15 unelected bureaucrats who will arbitrarily determine Medicare payment rates?"
Remember IPAB? See here to refresh memory of the power that this board of presidential appointees will have.
What could possibly go wrong with the IPAB? For those who seem to believe that government officials typically act in some nebulous "public interest"- nothing. For those who cynically think that people tend to respond to incentives and act in their own interests and believe that "regulatory capture" is real-a lot.
Obamacare is the prototypical progressive legislation.The progressive mindset is what Hayek talked about with his notion of the "fatal conceit".This is the belief that government will and should make the world better by social and economic planning and not by letting people free to coordinate their private plans.
Saturday, November 12, 2011
Physicians have group data but treat individual patient-
Physicians are informed by studies which examine group data but deal with individual patients. How to apply the group data in clinical setting is not as easy as it might appear at first glance.
I blogged about this general topic several years ago.See here.
The term "Heterogeneity of treatment effects" (HET) is the translation into the jargon of the statistician of the basic fact that everyone does not respond the same to a particular treatment. Can the patient in the doctor's office be assumed to have the average response to a given treatment reported in a medical journal article? In a given group treated with a certain medication some subjects will fare better than average along some parameter of interest while others respond not at all and some in either group may have adverse effects,some serious some minor.You cannot expect every patient receiving a given treatment to do well let alone better than average which only occurs in the statistically impossible world of the children highlighted by Garrison Keillor.
RL Kravitz,N Duran and J Braslow authored the classic article on the issue of HET. See here for full text of the article which should be part of every medical student's education.
Dr. Michel Accad in his Blog Alert and Oriented discusses a recent paper that offers suggestions for ways to tame the problem of HET. The suggestions are aimed as those who carry out the clinical trials . See here for Accad's discussion entitled "Dealing with variable risk" and see here for a link to the full text of the article by Kent et al that he references.
I blogged about this general topic several years ago.See here.
The term "Heterogeneity of treatment effects" (HET) is the translation into the jargon of the statistician of the basic fact that everyone does not respond the same to a particular treatment. Can the patient in the doctor's office be assumed to have the average response to a given treatment reported in a medical journal article? In a given group treated with a certain medication some subjects will fare better than average along some parameter of interest while others respond not at all and some in either group may have adverse effects,some serious some minor.You cannot expect every patient receiving a given treatment to do well let alone better than average which only occurs in the statistically impossible world of the children highlighted by Garrison Keillor.
RL Kravitz,N Duran and J Braslow authored the classic article on the issue of HET. See here for full text of the article which should be part of every medical student's education.
Dr. Michel Accad in his Blog Alert and Oriented discusses a recent paper that offers suggestions for ways to tame the problem of HET. The suggestions are aimed as those who carry out the clinical trials . See here for Accad's discussion entitled "Dealing with variable risk" and see here for a link to the full text of the article by Kent et al that he references.
Friday, November 04, 2011
Is retainer medicine unethical?
Drs Thomas S. Huddle and Robert M. Centor answer that question with a well reasoned and emphatic "no". Surprising to me was that their commentary appeared in a prominent medical journal,Annals of Internal Medicine, that generally has been the site of a number of commentaries and articles promoting the notion of social justice and inserting into the basket of medical ethical principles the obligation of the physician to promote social justice. The "New Medical Professionalism " was introduced to U.S. medical audiences in the Annals.See here for abstract of the Huddle-Centor article.
A dual premise criticism of the retainer practice model is that is damages the furtherence of social justice as it applies to health care and that physicians have a ethical obligation to act to further social justice. Social justice is a usefully elastic concept and reasonable people may differ as to what it means in a given situation . It is also a key arrow in the quiver of those who favor a progressive and re-distributional agenda. It was inserted into the area of medical ethics by the New Professionalism by a small group of energetic and prolific medical "thought leaders" whose views may or may not be representative of the group whose thoughts they were leading.Nevertheless , many professional organizations accepted the package deal giving at least lip service to the notion and in my opinion without fulling vetted the concept or thinking through the consequences.To convince many medical professional organizations that to be "professional" a physician had to work for social justice was a very significant propaganda accomplishment.
Huddle and Centor cut to the chase with this:
..we should not assume that the pursuit of social justice is an integral aspect of physician identity,despite numerous assertions to that effect.We contend that social justice is a civic virtue that makes its claims upon physician as citizens.If we are obligated to further health care access for every member of society,we have that obligation as members of society,not as physicians.Promoting nonprofessional virtues or ethical imperatives is not the province of professional ethics.
Yes and amen. The authors of the New Professionalism did simplify assert that medical professionalism should include the obligation of the physician to strive for social justice.
Three years ago I wrote about the issue of social justice and retainer practice and framing the debate.See here. Once the nose of social justice was in the ethics tent we could expect that it would be used to rhetorically justify a given agenda or criticize opposition to it.It seems that some critics of retainer medicine are proposing banning the practice as they allege it decreases access to health care and is socially unjust. Well, a little coercion and restriction of individual freedom in name of social justice is occasionally necessary.
Previously I have suggested that the new professionalism project was a way,and increasingly it seems a successful way to high jack medical ethics for a social agenda.See here.
A dual premise criticism of the retainer practice model is that is damages the furtherence of social justice as it applies to health care and that physicians have a ethical obligation to act to further social justice. Social justice is a usefully elastic concept and reasonable people may differ as to what it means in a given situation . It is also a key arrow in the quiver of those who favor a progressive and re-distributional agenda. It was inserted into the area of medical ethics by the New Professionalism by a small group of energetic and prolific medical "thought leaders" whose views may or may not be representative of the group whose thoughts they were leading.Nevertheless , many professional organizations accepted the package deal giving at least lip service to the notion and in my opinion without fulling vetted the concept or thinking through the consequences.To convince many medical professional organizations that to be "professional" a physician had to work for social justice was a very significant propaganda accomplishment.
Huddle and Centor cut to the chase with this:
..we should not assume that the pursuit of social justice is an integral aspect of physician identity,despite numerous assertions to that effect.We contend that social justice is a civic virtue that makes its claims upon physician as citizens.If we are obligated to further health care access for every member of society,we have that obligation as members of society,not as physicians.Promoting nonprofessional virtues or ethical imperatives is not the province of professional ethics.
Yes and amen. The authors of the New Professionalism did simplify assert that medical professionalism should include the obligation of the physician to strive for social justice.
Three years ago I wrote about the issue of social justice and retainer practice and framing the debate.See here. Once the nose of social justice was in the ethics tent we could expect that it would be used to rhetorically justify a given agenda or criticize opposition to it.It seems that some critics of retainer medicine are proposing banning the practice as they allege it decreases access to health care and is socially unjust. Well, a little coercion and restriction of individual freedom in name of social justice is occasionally necessary.
Previously I have suggested that the new professionalism project was a way,and increasingly it seems a successful way to high jack medical ethics for a social agenda.See here.
Monday, October 24, 2011
The new PSA screening recommendation is not just a recommendation
What has mostly been neglected by the press in reporting the latest pronouncement of the USPSTF is that their conclusion that PSA measurements should not be done to screen men for prostate cancer is much more than a recommendation. Before the passage of ACA it was merely a recommendation but now the rules of the game have changed.
Dr. Rich at The Covert Rationing Blog gives us his excellent analysis of the the panel's recommendations and the data they emphasized as well as the data they underplayed.Here is a quote from that commentary that explains why what the panel at the Task Force says really matters.
Obamacare, which is now the law of the land, makes the USPSTF the final arbiter of which preventive services are to be covered by private insurers (Section 2713), by Medicare (Section 4105), and by Medicaid (Section 4106). Only those that have achieved a grade of A or B by the USPSTF will be covered. And if you believe you will be able to purchase for yourself PSA screening (or any other medical service which Obamacare has decided not to cover) you have not been paying attention. Perhaps you can do so today (if you’re not on Medicare or Medicaid), but probably not for long.
So CMS (Medicare and Medicaid ) will not pay for the tests.How long will it take private insurers to follow suit?The question remains can you pay for the test yourself.It is not clear that you cannot but I share Dr.Rick's concern that prohibiting private choices paid for with private money for health care issue may become illegal.
Cato has recently published their report on economic freedom. Freedom fans will not be pleased with the falling economic freedom indicators in the U.S. noted in their report. Health care freedom is incompatible with the vision that medical progressives have for the U.S.,namely that medical care is too important to be left in the control of individual physicians and individual patients. From the perspective of the progressives, Obamacare is a great step forward and has been heralded by certain medical organizations as promoting social justice while loss of individual freedom to make one's health care choices seems to be part of the price of that "justice".
Dr. Rich at The Covert Rationing Blog gives us his excellent analysis of the the panel's recommendations and the data they emphasized as well as the data they underplayed.Here is a quote from that commentary that explains why what the panel at the Task Force says really matters.
Obamacare, which is now the law of the land, makes the USPSTF the final arbiter of which preventive services are to be covered by private insurers (Section 2713), by Medicare (Section 4105), and by Medicaid (Section 4106). Only those that have achieved a grade of A or B by the USPSTF will be covered. And if you believe you will be able to purchase for yourself PSA screening (or any other medical service which Obamacare has decided not to cover) you have not been paying attention. Perhaps you can do so today (if you’re not on Medicare or Medicaid), but probably not for long.
So CMS (Medicare and Medicaid ) will not pay for the tests.How long will it take private insurers to follow suit?The question remains can you pay for the test yourself.It is not clear that you cannot but I share Dr.Rick's concern that prohibiting private choices paid for with private money for health care issue may become illegal.
Cato has recently published their report on economic freedom. Freedom fans will not be pleased with the falling economic freedom indicators in the U.S. noted in their report. Health care freedom is incompatible with the vision that medical progressives have for the U.S.,namely that medical care is too important to be left in the control of individual physicians and individual patients. From the perspective of the progressives, Obamacare is a great step forward and has been heralded by certain medical organizations as promoting social justice while loss of individual freedom to make one's health care choices seems to be part of the price of that "justice".
Friday, October 21, 2011
Two great blog commentaries on "Diagnostic skepticism" and why we are seeing less of that?
Dr. RW Donnell in this blog commentary outlines some of the factors that are impeding the diagnostic skepticism that traditionally internists had drummed into their heads during their training period. Dr. Donnell carried forward and expanded comments made by Dr. Robert Centor in his recent blog offering.
Guidelines,the worse aspects of EMRs,time pressures and the metrics by which hospitalists are too often graded are some of the factors that make it more difficult than it used to be to ask "what else could the diagnosis be".
Guidelines,the worse aspects of EMRs,time pressures and the metrics by which hospitalists are too often graded are some of the factors that make it more difficult than it used to be to ask "what else could the diagnosis be".
Tuesday, October 18, 2011
Have we seen the last of the CLASS act fraud?
The CLASS Act was a long term care plan appended to Obamacare to give the impression that the total cost would be less than one trillion dollars,which was a slight psychological barrier to its passage.It was a spending program that magically would reduce the defect.It was purported to contribute some 80 billion to the projected health care savings that the Obama health care plan would bring about.
See here for the economist Alex Tabarrok's commentary on this fraud that contributed to the passage of Obamacare. Now, the Secretary of HHS has admitted the plan can't work and will be dropped,but even later breaking news is that the White House hints maybe not yet.
See here for the economist Alex Tabarrok's commentary on this fraud that contributed to the passage of Obamacare. Now, the Secretary of HHS has admitted the plan can't work and will be dropped,but even later breaking news is that the White House hints maybe not yet.
Friday, October 14, 2011
Thomas Szasz's "define or be defined" and Physicians morphed in to health care providers
The husband and wife physician writing team of J. Groopman and P. Harztband make strong points in their commentary found in the Perspective section of the October 13,2011 issue of the NEJM. The title is The New Language of Medicine.
They relate certain changes in language related to health care to the movement to industrialize and standardize health care. These changes include the word "consumer" or "customer" for "patient" and lumping doctors,nurses,PAs,and NPs together under the designation of "health care provider".
The relationship and interaction between physician and patient fades out and is minimized by referring to the generic "health care", as if is in the words of the authors " fundamentally a prepacked commodity on a shelf that is "provided" to the "consumer".
What happens to considerations about the physician-patient relationship when you speak about providers and consumers.
Thomas Szasz wrote brilliantly about the power of language.
Their commentary closes with:
"We believe doctors and nurses,and others engaged in care should eschew the use of such terms (consumer,health care provider) that demean patients and professional alike and dangerous neglect the essence of medicine."
Amen.
They relate certain changes in language related to health care to the movement to industrialize and standardize health care. These changes include the word "consumer" or "customer" for "patient" and lumping doctors,nurses,PAs,and NPs together under the designation of "health care provider".
The relationship and interaction between physician and patient fades out and is minimized by referring to the generic "health care", as if is in the words of the authors " fundamentally a prepacked commodity on a shelf that is "provided" to the "consumer".
What happens to considerations about the physician-patient relationship when you speak about providers and consumers.
Thomas Szasz wrote brilliantly about the power of language.
"The struggle for definition is veritably the struggle for life itself. In the typical Western two men fight desperately for the possession of a gun that has been thrown to the ground: whoever reaches the weapon first shoots and lives; his adversary is shot and dies. In ordinary life, the struggle is not for guns but for words; whoever first defines the situation is the victor; his adversary, the victim. For example, in the family, husband and wife, mother and child do not get along; who defines whom as troublesome or mentally sick?...[the one] who first seizes the word imposes reality on the other; [the one] who defines thus dominates and lives; and [the one] who is defined is subjugated and may be killed."In short, define or be defined. There was a time not long ago when physicians in many ways defined their role.Their role was to act as a fiduciary to their patients to follow Hippocrates's game plan namely,to do no harm and act in the interest of their patient.Now their role is being redefined as in part acting as stewards of resources.Yes, it has been members of the medical profession,largely a small group of internists, who have helped considerably in this effort to redefined medical ethics and have been able to implant those views in the medical school and post graduate curriculum. While I would not impugn the motives and sincerity of those physicians who have promoted that view and value system,I cannot resist applying the venerable Mafia Rule. Follow the money.Who gains from transforming physicians into health care providers and tasking them with saving money for the health care collective?
Their commentary closes with:
"We believe doctors and nurses,and others engaged in care should eschew the use of such terms (consumer,health care provider) that demean patients and professional alike and dangerous neglect the essence of medicine."
Amen.
Monday, October 10, 2011
Obamacare-A great opportunity for Medical Hubris
In 2005, I outlined a few thoughts about what I would include in a lecture to medical students about hubris and the practice of medicine. See here. At the time, I had no idea about the surge of exuberant hubris that the next few years would bring although I should have because of the strikingly hubristic five part series in JAMA which was a plea for utilitarian planning for allocation of health care resources.
Hubris is defined as excessive pride or self confidence.From Wikipedia we read that the word implies an overestimation of one's own competence and capabilities particularly as exhibited by someone in a position of power. In Greek tragedy it leads to nemesis, or the end result of harm or ruin. However,in the context of public health expert advice and edicts, it seems to be the beneficiaries of the edits that run into harm's way and not the expert.
Several thinkers have issued warnings to those who would take portions of the scientific wisdom of the day and go forward with hypertrophied self confidence and idealistic certitude to make the world (or their little sector of interest) better.
Boris Pasternak said; " What is laid down, ordered, factual is never enough to embrace the whole truth.Life always spills over the rip of every cup." The medical elite in the public health sector who would tell everyone how to eat, or treat all folks with a given medical condition think "Well, not my cup" and charge ahead as if the concept of unintended consequences had never been formulated and that individual variation , personal circumstances and values would not have to be contended with and progress in medical knowledge would be frozen in time so as to not make necessary changes in their determinations.
Morton Hadler ( J.O.M.,Vol 31, pg 823,1989) spoke of various categories of truth including the distinction between scientific truth and clinical truth,the latter informed in part by the former and is determined by the joint efforts of the physician and the patient.
Karl Popper said "We know a great deal but our ignorance is sobering and boundless.All things are insecure and in a state of flux."
Ian Stewart and Jack Cohen in their book "Figments of Reality" spoke of "what science offers is not facts but understanding, not answers but contingency plans"
Those type comments could be considered life advice to the newly minted practitioners of various discipline, and in particular, in this commentary to medical doctors.
The type of hubris often seen in novices is typically what I am calling the more benign form and is often cured by experience and seeing highly regarding paradigms and treatment plans replaced by others often 180 degrees from the discarded notion.This is what I call Type 1 hubris. It is an unwarranted and persistent belief in the correctness and permanence of contemporary consensus views.It is a failure to realize they are working with concepts that are often more contingency plans than permanent solutions.This type of hubris often dissipates as the practitioner gains more experience and sees the various ways disease patterns play out and how patient's disease scripts differ from the text book. Aristotle spoke of phronesis or practical wisdom which is the result of combining the lessons of experience with empirical knowledge (episteme) and technical knowledge (teche).
However, there is a second type of hubris, a more dangerous form, logically named Type 2. Type 2 includes the over blown pride and hypertrophied confidence in one's beliefs and idealistic certitude as is found Type 1 but in addition includes the internalized imperative to to bring about widespread practice (s) consistent with their version of current medical wisdom or truth. Starkly put" I'm know what should be done,everyone should do it " and when someone with Type 2 hubris is in a position of power ",let's make them do it".
The five part series of articles published in JAMA in 1994 by David Eddy is , in my opinion,a candidate for the most hubristic series ever published in a major medical journal.Reference is "Rationing Resources while Improving Quality", Eddy, DM, JAMA,1994:272,817-824)
Eddy's answer to the problem of how to save resources while improving quality was to employ the utilitarian maxim/imperative strategy to do the greatest good for the greatest number or make the herd healthier along some metric even though some cows might be worse off.The herd here was a medical collective such as a HMO.This also applies to the ACOs put into play by Obamacare to the extent those entities based as they are on an Underware Gnome type plan will survive .
Dr. Don Berwick speaks of the need for "leaders with ideas" and the need to replace the physician-patient "dyad" with a group outcome oriented decision process authored by the wise leaders with ideas. ( You have to worry when someone talks about "dyads"). Those views conform with the Progressive Medical Axiom of " medicine is too complex and too important to be be left in the hands of the individual physicians and patients."
For most physicians, the Type 1 hubris wears off or withers away after the realities of a few years of clinical experience bump up against the overly simplistic concepts of the novice. Type 2 is what we need to worry about and to fear those leaders in positions of authority (or advisers to those in power) who never caught on to the Hayekian notion of "how little men know about what they imagine they can design..." But no matter, being a public health expert or a medical planner means you have never say you are sorry.
With Obamacare and IPAB's unprecedented powers as well as CMS's control over Medicare,there are great opportunities for leaders with ideas and the requisite amount of hubris to do unprecedented damage to the practice of medicine.
Minor syntactic,spelling and punctuation change made 8/18/14.
Hubris is defined as excessive pride or self confidence.From Wikipedia we read that the word implies an overestimation of one's own competence and capabilities particularly as exhibited by someone in a position of power. In Greek tragedy it leads to nemesis, or the end result of harm or ruin. However,in the context of public health expert advice and edicts, it seems to be the beneficiaries of the edits that run into harm's way and not the expert.
Several thinkers have issued warnings to those who would take portions of the scientific wisdom of the day and go forward with hypertrophied self confidence and idealistic certitude to make the world (or their little sector of interest) better.
Boris Pasternak said; " What is laid down, ordered, factual is never enough to embrace the whole truth.Life always spills over the rip of every cup." The medical elite in the public health sector who would tell everyone how to eat, or treat all folks with a given medical condition think "Well, not my cup" and charge ahead as if the concept of unintended consequences had never been formulated and that individual variation , personal circumstances and values would not have to be contended with and progress in medical knowledge would be frozen in time so as to not make necessary changes in their determinations.
Morton Hadler ( J.O.M.,Vol 31, pg 823,1989) spoke of various categories of truth including the distinction between scientific truth and clinical truth,the latter informed in part by the former and is determined by the joint efforts of the physician and the patient.
Karl Popper said "We know a great deal but our ignorance is sobering and boundless.All things are insecure and in a state of flux."
Ian Stewart and Jack Cohen in their book "Figments of Reality" spoke of "what science offers is not facts but understanding, not answers but contingency plans"
Those type comments could be considered life advice to the newly minted practitioners of various discipline, and in particular, in this commentary to medical doctors.
The type of hubris often seen in novices is typically what I am calling the more benign form and is often cured by experience and seeing highly regarding paradigms and treatment plans replaced by others often 180 degrees from the discarded notion.This is what I call Type 1 hubris. It is an unwarranted and persistent belief in the correctness and permanence of contemporary consensus views.It is a failure to realize they are working with concepts that are often more contingency plans than permanent solutions.This type of hubris often dissipates as the practitioner gains more experience and sees the various ways disease patterns play out and how patient's disease scripts differ from the text book. Aristotle spoke of phronesis or practical wisdom which is the result of combining the lessons of experience with empirical knowledge (episteme) and technical knowledge (teche).
However, there is a second type of hubris, a more dangerous form, logically named Type 2. Type 2 includes the over blown pride and hypertrophied confidence in one's beliefs and idealistic certitude as is found Type 1 but in addition includes the internalized imperative to to bring about widespread practice (s) consistent with their version of current medical wisdom or truth. Starkly put" I'm know what should be done,everyone should do it " and when someone with Type 2 hubris is in a position of power ",let's make them do it".
The five part series of articles published in JAMA in 1994 by David Eddy is , in my opinion,a candidate for the most hubristic series ever published in a major medical journal.Reference is "Rationing Resources while Improving Quality", Eddy, DM, JAMA,1994:272,817-824)
Eddy's answer to the problem of how to save resources while improving quality was to employ the utilitarian maxim/imperative strategy to do the greatest good for the greatest number or make the herd healthier along some metric even though some cows might be worse off.The herd here was a medical collective such as a HMO.This also applies to the ACOs put into play by Obamacare to the extent those entities based as they are on an Underware Gnome type plan will survive .
Dr. Don Berwick speaks of the need for "leaders with ideas" and the need to replace the physician-patient "dyad" with a group outcome oriented decision process authored by the wise leaders with ideas. ( You have to worry when someone talks about "dyads"). Those views conform with the Progressive Medical Axiom of " medicine is too complex and too important to be be left in the hands of the individual physicians and patients."
For most physicians, the Type 1 hubris wears off or withers away after the realities of a few years of clinical experience bump up against the overly simplistic concepts of the novice. Type 2 is what we need to worry about and to fear those leaders in positions of authority (or advisers to those in power) who never caught on to the Hayekian notion of "how little men know about what they imagine they can design..." But no matter, being a public health expert or a medical planner means you have never say you are sorry.
With Obamacare and IPAB's unprecedented powers as well as CMS's control over Medicare,there are great opportunities for leaders with ideas and the requisite amount of hubris to do unprecedented damage to the practice of medicine.
Minor syntactic,spelling and punctuation change made 8/18/14.
Friday, September 30, 2011
More worrisome news about hazards of long term marathoning
I have written before about the troubling reports of certain test results following endurance events.
There is evidence that in the early hours after a marathon or an Ironman type triathlon there sometimes are elevations of troponin in the range seen in myocardial infarctions.There are also reports of echocardiographic changes that could be described as cardiac "fatigue". The changes are those of altered relaxation characteristics and a decreased contractility all of which, along with the elevated troponins returned to normal in 48 hours.There is the hope that all of this is just analogous to the sore leg muscles and raised total CK values that remit in a few days and is of as little consequence but there may be more to it that that.There is at least one report of some of the more subtle echo changes persist at least for one month after a race.
One post marathon study suggested that the above mentioned abnormalities were less marked in the better conditioned runners and another paper found the alterations more likely in first time runners versus more seasoned veteran marathoners. See here for my earlier blog entry discussing some of the issues involved in assessing the harm or absence thereof in marathoners.It should be noted that not all runners show the echo changes and there is a suggestion that the type of ACE gene pattern may play a role in that.
Well,all of the above really address the issue of over use damage that certainly is at least acute and some worry may lead to long lasting permanent cardiac damage, i.e. myocardial fibrosis or an endurance exercise induced cardiomyopathy.
Now for something completely different. There is a report suggesting that many years of marathon running may increase (not a typo) the risk of coronary artery disease at least as possibly indicated by increased coronary artery calcification.This seems counter intuitive as conventional wisdom tells us that exercise may decrease the risk of coronary disease but could this be an instance of " too much of a good thing".See here for that study.
Drs Robert and Jonathan Schwartz reported on a CTA (Coronary Computed Angiogram) study that involved 25 runners who had been running in the 26.2 mile races for 25 years or more and had completed 25 or more marathons.They found a statistically significant increase in calcified coronary plaques and an increase in non-calcified plaques that did not reach the level of statistical significance as compared with 25 controls.
There is evidence that in the early hours after a marathon or an Ironman type triathlon there sometimes are elevations of troponin in the range seen in myocardial infarctions.There are also reports of echocardiographic changes that could be described as cardiac "fatigue". The changes are those of altered relaxation characteristics and a decreased contractility all of which, along with the elevated troponins returned to normal in 48 hours.There is the hope that all of this is just analogous to the sore leg muscles and raised total CK values that remit in a few days and is of as little consequence but there may be more to it that that.There is at least one report of some of the more subtle echo changes persist at least for one month after a race.
One post marathon study suggested that the above mentioned abnormalities were less marked in the better conditioned runners and another paper found the alterations more likely in first time runners versus more seasoned veteran marathoners. See here for my earlier blog entry discussing some of the issues involved in assessing the harm or absence thereof in marathoners.It should be noted that not all runners show the echo changes and there is a suggestion that the type of ACE gene pattern may play a role in that.
Well,all of the above really address the issue of over use damage that certainly is at least acute and some worry may lead to long lasting permanent cardiac damage, i.e. myocardial fibrosis or an endurance exercise induced cardiomyopathy.
Now for something completely different. There is a report suggesting that many years of marathon running may increase (not a typo) the risk of coronary artery disease at least as possibly indicated by increased coronary artery calcification.This seems counter intuitive as conventional wisdom tells us that exercise may decrease the risk of coronary disease but could this be an instance of " too much of a good thing".See here for that study.
Drs Robert and Jonathan Schwartz reported on a CTA (Coronary Computed Angiogram) study that involved 25 runners who had been running in the 26.2 mile races for 25 years or more and had completed 25 or more marathons.They found a statistically significant increase in calcified coronary plaques and an increase in non-calcified plaques that did not reach the level of statistical significance as compared with 25 controls.
Thursday, September 22, 2011
If Health care planning is like green energy planning, hold on to your seats
In this article in Investor Business Daily we see how well government planning is working out in the Green area.
Here is in in a nutshell. The government gives a 527 million dollar loan guarantee to a solar panel manufacturing company whose business plan worked out badly and the company went broke.Now the employees have applied for a government funded jobs retraining program to cost another 14 million dollars.
On the one hand we have the government tossing away half a billion dollars on a company who was not viable in the market and on the other we have the government raiding and closing down ( hopefully only temporarily) a company on the basis on vague foreign laws.See here for DrRick's take on the Gibson Guitar Company raid by the Fish and Wildlife police and how that exemplifies the principle of Regulatory Speed Trap.
And speaking of regulations,it makes one feel warm and fuzzy and very secure to know that hundreds ( thousands ?) of government technocrats are working on the details that will give ambiguous and flexible operational meaning to the hundreds of pages of Obamacare. Yes, the very same government that gave us Solargate and raids a viable US company for using the wrong kind of wood is busy at work finishing the details that will shape health care for the country.What could go wrong with that??
Here is in in a nutshell. The government gives a 527 million dollar loan guarantee to a solar panel manufacturing company whose business plan worked out badly and the company went broke.Now the employees have applied for a government funded jobs retraining program to cost another 14 million dollars.
On the one hand we have the government tossing away half a billion dollars on a company who was not viable in the market and on the other we have the government raiding and closing down ( hopefully only temporarily) a company on the basis on vague foreign laws.See here for DrRick's take on the Gibson Guitar Company raid by the Fish and Wildlife police and how that exemplifies the principle of Regulatory Speed Trap.
And speaking of regulations,it makes one feel warm and fuzzy and very secure to know that hundreds ( thousands ?) of government technocrats are working on the details that will give ambiguous and flexible operational meaning to the hundreds of pages of Obamacare. Yes, the very same government that gave us Solargate and raids a viable US company for using the wrong kind of wood is busy at work finishing the details that will shape health care for the country.What could go wrong with that??
Monday, September 19, 2011
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
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
Thursday, August 18, 2011
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.
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.
Monday, August 08, 2011
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.
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.
Sunday, August 07, 2011
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.
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.
Monday, August 01, 2011
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.
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.
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