AMA joins the "gangwaggon" to guilt doctors to become stewards of society's resources

Kudos to Dr Doug Perednia,author of the blog Road to Hellth, for his denunciation (see here) of AMA's latest egregious attack on traditional medical ethics which is a sell out of both physicians and patients. They join the bandwagon,(gangwagon) initiative to destroy the traditional physician-patient relationship which had already been rocked by the alarmingly successful attack from the New Medical Professionalism-New Medical Ethics spearheaded by the folks at the ACP and ABIM and some of their internist colleagues in Europe.

Dr. Perednia quotes Med Page regarding AMA's actions.

CHICAGO — Providing effective medical care includes an “obligation” to prudently manage healthcare resources, according to a report approved by the American Medical Association’s House of Delegates on Monday.

In fact, managing healthcare resources “is compatible with physicians’ primary obligation to serve the interests of individual patients,” the report reads. It further states that considering the welfare of only the patient currently being treated when making recommendations does “not mesh with the reality of clinical practice.”…

So the obligation (whenever the hell that obligation came from) to manage healthcare resources seems to preclude "considering the welfare of only the patient currently being treated".


Are they are throwing the fiduciary duty of the physician to the patient out of the window?Patients seek medical help to get the best advice for their given condition not to engage in some self sacrificial exercise in forgoing the optimal treatment for the nebulous and undefinable good of society . How much concern do you think a worried parent in the physician's office with a sick child cares about some abstract conservation of society's resources or furtherance of social justice.

In contrast to the gobbledygook of such phrases as "doesn't mesh with reality of clinical practice" and the gratuitous assertion of an operationally meaningless obligation. and the unwarranted assumption that physicians all have a collectivist philosophical mindset, Dr. Perednia makes these valid arguments:

The first principle is that, in Western democratic cultures, when any of us seek out a physician for care, our primary goal is finding a solution to our own particular medical problems rather than a cure for the ills of society. In this role and in our minds, a doctor is supposed to be the equivalent of our “medical lawyer”:

• We provide the facts of the case as we know them.
• Our physician is supposed to gather any other relevant evidence and, using his special knowledge, outline all of the possible courses of action we might take and suggest the one that is most compatible with our goals and the resources available to us.
• He is supposed to looking out for our best interests rather than the interests of others. When a doctor or lawyer takes your case, he is supposed to be working for you: not your opponent, not insurers, not government, not world peace or society as a whole.

The New Professionalism brainchild of ACP and friends did not quite say that social justice and the equitable allocation of scarce medical resources was an ethical obligation of physicians but the New Ethics Manual of the ACP made it explicit. It was a definite ethical game changer.See here for earlier comments on that development.

With many (most) professional medical associations mindlessly signing on to the New Professionalism and now with the AMA imprimatur I have little hope that the next generation of newly minted physicians will enter the field inculcated with the (now obsolete) notion that the physician's primary and fiduciary duty is to the patient.

I offer the following in partial proof on this fear as one "leader with ideas" has suggested
that "cost-consiousness and stewardship of resources be elevated by the ACGME and the ABMS to the level of a new seventh general competency." In other words, residents should be schooled and graded on their mastery of the skill set necessary to be good stewards of [society's] resources. ( reference, The Idea and Opinions Section, Annals of Internal Medicine,20 Sept 2011,Vol.155 no.6, by Dr. Steven E. Weinberger,of the American College of Physicians.


What could be more advantageous to the HMOs,ACOs and medical insurance companies than to flimflam the medical profession into accepting an new ethical paradigm that conveniently coincides with the bottom line of those organizations?

The concept "physicians as stewards of society's medical resources" is , in one sense a meaningless abstraction, and in another, a useful fiction. Useful to the HMOs,ACOs and insurers who now can enjoy to a much greater degree than before, physicians working to bolster their bottom line but decreasing costs also known as providing less to patients.

The socially conscientious physician might feel somewhat at loss as to how he might carry out the massive,pretentious and ambiguous task of stewarding society's resources.He should feel reassured ,though, because all it will take will be "follow the guidelines" and by doing so he will do what it right for that patient and for society as a whole. Wasn't that easy.

The litigation to allow seniors to refuse Medicare Part A goes deeper in the rabbit hole

I have written in amazement about this lawsuit before.Several plaintiffs are attempting to assert what they believe to be their right to refuse Medicare Part A without losing their social security benefit payments.See here. The case is Hill v. Sebelius.Of course,I agree you should be able to decline Medicare without penalty.But the trial court and now the appellate court see things differently.

The case has proceed slowly through the legal system and now a three judge panel has ruled against the plaintiffs. It seems that there is a CMS rule book regulation that states if a person refuses Medicare Part A he will not receive the social security benefits he would have otherwise be eligible for. If one accepts Medicare A and then later decides to decline this "entitlement"he will stop receiving SS payments and have to repay what he had previously received. Earlier a judge in the case said in effect that Medicare benefits were a "mandatory entitlement".

Note this draconian rule was not written into the Medicare law or anything else that should have statuary power and came into existence in something called the Program Operations Manuel System (POMS) which apparently is simply advice for the program administrators and never went through any formal rule making process.

See here for the latest development in this case.

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Obamacare's IPAB is not just unconstitutional but is anti-constitution -Cato

An important Cato policy paper can be found here .Among many other important comments in the paper is the charge that Obamacare is not just unconstitutional;it is" anti-constitutional".

I have written about IPAB on several occasions. See here for some of my comments about IPAB and the concept of an "entrenchment provision" which a legal scholar discusses here offering tepid assurance that such a thing could not really happen. Entrenchment means that a legislature passes a law and includes within that statute a provision that prohibit future legislature from repealing or altering the law. There is such wording in ACA.

According to the Cato paper referenced above, the Obama administration has said that of course, IPAB could be abolished by congressional action even though Cato's paper said that statement conflicts with the clear wording of ACA. The legal analysis quoted above does say that apparently the Supreme Court has said they will not allow entrenchment.Whether IPAB is really entrenched on not,one has to assume that the authors of that section wanted IPAB to be an immutable,eternal entity.

So maybe (hopefully) that aspect of IPAB is just a tempest in a teapot but there is much more to be very,very worried about with IPAB . The Cato paper written by Diane Cohen and Michael Cannon discusses those issues in detail.If their analysis is correct the power that this appointed body will have is more than mind numbingly frightening.

Here is a good summary on Cato's web site giving a brief summary of the paper referenced above.

The gift that keeps giving-the stimulus to the electronic medical record industry

The American Recovery and Reinvestment Act had a number of beneficiaries.Part of the legislation was money for physicians to use to purchase electronic health record systems.

Stimulus for whom? Physicians do receive a relatively small payment ( about 40 -60 k) for agreeing to install EHR systems (electronic Medical records system) but were there large numbers of the rank and file physicians out lobbying for that part of the stimulus bill? I think not.But legislative packages do not arise at random out of thin air,there are folks at work lobbying for things that provide them favors.Economists call this behavior rent seeking. .There was much rent seeking going on the stimulus bill .

Maybe we should look to companies that sell the products and services that the goverment was giving money to physicians to purchase. Several of them worked with former Republican presidential candidate N. Gingrich's consultancy known as "Center for Health Transformation" which among other initiatives championed the electronics health record as a means of improving health care. These including Allscripts,Microsoft,Siemens and GE Health Care.

The underlying principle of the universe,there is no free lunch,applies to the faux beneficiaries- the physicians. The golden rule applies .He who has the gold makes the rules. The gift to the docs comes with strings,lots of them linked to Medicaid and Medicare payments. The 19 billion ( or 27 billion,depending on what source you read )given to the EHR companies through the physician checkbooks is just a drop in a big bucket as physicians will now have the obligation to keep the soft and hardware running and of course update regularly with new versions of the various software packages and update their systems as Federal requirement evolve.

Docs will also be tasked with proving their new system are demonstrating "meaningful use" a goverment term of art with very specific details that physicians practices will have to learn and try to comply with.See here for a reference for an explanation of the 25 criterion for meaningful use. Failure to achieve this level of use will at the end of the day ( a five year day) result in decrease in the CMS payments for services to the physicians who are meaninglessly utilizing their EHR.

Many- if not most- examples of rent seeking simply involves transferring tax payer money to a
the entity that successfully lobbyed for the favor. That happened here , of course, but additionally physicians will obliged to keep the systems running providing a continuing income stream to the EHR industry in perpetuity and providing a means of increasing control of the physicians practices.Part of the meaningful use requirements is to maintain a data base registry of patients with a given condition so that the doc can then demonstrate to the central authority the degree to which his practice complies with this or that guideline.


As if that all were not enough to push the older docs to decide right now to retire, part of the stimulus bill ( AKA American Recovery and Reinvestment Act of 2009) contains more stringent and detailed requirement and new penalties under HIPPA, See here for that.

We are the from the government ,we are here to help .

Cahoots ,Obamacare and Big Pharma

Dr. Richard Fogoros in his blog,The Covert Rationing Blog,made the observation that big health insurance companies were on board with Obamacare and helped get that statute passed because the way thing were going that was their only chance to be at least viable for awhile longer and then perhaps exist as a more or less regulated utility.See here for his cogent observations

Now, we have good reason to believe that Big Pharma was in cahoots with the democrats to pass Obamacare.What did Big Pharma get out it? Eliminating the part of the proposed legislation that would allow reimporting of prescriptions drugs and at least resisting price controls for a while. See here for the comments from the blog Health Care BS. See here for the WSJ report for details of the involvement of drug companies in pushing for the passage of ACA using astro turf type front groups (i.e two 501(c)(4) organizations).

WSJ points out that at least Big Pharma got something for their support.What AMA is alleged to have been lobbying for (the doc fix) was not part of the bill.Well,swimming with the sharks (also known as "a seat at the table") has its risks but at least the AMA leadership was able to have claimed a victory for social justice.

Muscle soreness after marathon-what do the muscle biopsies show?

I have completed marathons for 35 years and an interesting ( at least to me) change in the pattern of post marathon recovery time has emerged. When I as younger and more foolish I would train faster ( a relative term) and attempt to hit a target time for the race. For several years, I would strive to finish in under 3 1/2 hours. In the 2-4 days after those races, my quadriceps were sore and tender , the soreness peaking on day 2 and was particularly evident on attempting to walk downstairs.

This phenomenon is called delayed onset muscle soreness (DOMS).Although lactic acid buildup was once said to be the cause now the thinking is that the key element is eccentric exercise with damage to the muscle fibers and lactic acid exonerated.Neither post exercise icing nor use of NSAIDs seem to help but there is some fairly unconvincing data suggesting that post run massage might mitigate the soreness a bit.Well it feels good anyway.

In recent years there is no significant post race soreness in the thighs at anything near the level experienced earlier in my running odyssey. I developed the habit (obsession) of typically covering a long training distance on the weekends, running about 20 miles on a typical Saturday with no soreness on Sunday.

What do muscle biopsies demonstrate after marathons?

Here is a full text article from the American Journal of Pathology 1985 by M.J. Warhol. Muscle biopsies were done on the lateral gastrocnemius muscle of forty runners 48 hours after a marathon and again at one week, one month and 8-10 weeks. Light and electron microscopy were done.

At 48 hours there was damage to the myofibrils with abnormal findings evident in the mitochondria and sarcoplasmic reticulum. The damage was patchy and quite variable in extent from one runner to the next, with some demonstrating very little damage. Type II ( fast-twitch) fibers seemed to be more damaged. By day seven, "ghost cells" (empty muscle cells) were seen and satellite cells appeared. By one month there was continuing evidence of muscle cell regeneration but the pathological changes had largely resolved. There was no inflammatory cellular response reported in this paper but another report did describe some inflammatory cells.Some runners showed evidence of fibrosis. By 12 weeks there was continued electron microscopic evidence of muscle cell regeneration.

Similar light microscopy findings were reported earlier by RS Hikida ( with senior author D Costell ) in the Journal of Neuro Science 1983,May 59(2),195-203. However, their results differed in that they reported evidence of inflammation while Warhol suggested those changes were due to the trauma of the biopsy. Hikada also did pre-race biopsies showing some of the same changes prompting the suggestion that the intensive training for the marathon may have caused similar cellular changes.

A pattern emerges of damage to muscle cells that drop out and are replaced by new cells.

If the type II fibers are disproportionately affected perhaps my slower times and less participation by my type II fibers might account for the lack of post race soreness. Type II fibers kick in as the energy output increases moving toward the maximal oxygen uptake and when glycogen stores are depleted.Further the sarcopenia of aging also disproportionately targets type II cells so I may have less muscle cells at risk and I run so slowly that my fast twitch fibers for the most part have the day off.

What data are available regarding morphological changes in the muscles of athletes who exercise at high levels for many years? So far I have been unable to find any.

More on earlier blog regarding statins,primary prevention,drinking water

My earlier blog commentary on the recent Lancet meta-analysis on outcomes of primary prevention trials in patients designated as "low risk"was done hastily and driven largely by my basic skepticism regarding meta-analyses and betting the farm on a single such study. A much more thoughtful and important analysis can be found here.

It was written by Dr. David Newman,an ER physician who authored the book entitled
Hippocrates Shadow:Secrets from the House of Medicine.

What apparently made the results of the recent Lance Meta-analysis different from a number of meta-analyses which found contradicting results was that the current study looked at the mortality data on those low risk patients who experienced a 40 mg or more decrement in the LDL following the institution of statin therapy.So the measure of interest was not the outcome of all low risk subjects treated with statins just those who had a favorable response to statins.

in Dr. Newman's words:

"Perhaps never has a statistical deception been so cleverly buried, in plain sight. The study answers this question: how much did the people who responded well to the drug benefit? This is, by definition, a circular and retrospective question: revisiting old data and re-tailoring the question to arrive at a conclusion. And to be fair they may have answered an interesting, and in some ways contributory, question. However the authors’ conclusions imply that they answered a different, much bigger question. And that is not a true story."


h/t to the tireless Dr. Roy Poses whose comments on my earlier posting alerted me to this line of thinking.


addendum: added 5/31/2012. I should have known Dr. Newman's comments were not go unchallenged and all such challenges not from hired guns at Pharma. Here are some arguments raised by Newman's critique.Thanks to the always informative and up to date web site ,Cardiobrief.

PSA and "moderate certainty" Don't screen says the central authority

See here for the latest pronouncement of the USPSTF regarding PSA screening.In a word "don't"

I suppose "moderate certainty" is a notch or two below"absolute certainty" The USPSTF made their dictum on the basis of moderate certainty.

Dictum is the correct noun since it seems according to ACA the determinations of the USPSTF will become the rules for CMS and how long will the other third party payers take to follow their lead?

DrRich ( aka Dr. Richard Fogoros of the blog, The Covert Rationing Blog,)seems to actually have read much if not most of the lengthy ACA and said this about the new role of USPSTF quoting chapter and verse.

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.

The conclusions of the USPMTF in regard to PSA are presented as a scientific conclusion although one that apparently only reaches the level of moderate certainty. However, opponents of that conclusion have made cogent arguments. See here.

There is in fact evidence that PSA can save some lives but the disagreement is in how to determine ( or who shall determine) if the benefit exceeds the cost or is the ratio inverted. In the judgement of the panel the benefit does not exceed the risk. This is a value judgement not a scientific judgement. It is not an argument raised only by those who are ignorant of statistical concepts or driven by financial concerns as was claimed recently by the chair of the panel.( See here for my comments regarding that.)

Thomas Sowell has written that in the last fifty or more years there has been a major shift in the " locus of decision making" moving toward a more centrally located site.It has taken several forms; from the family to the state,from the local government to the central government and now from the individual patient with counseling from his physician to a panel whose pronouncements will be determinative.

Is aspirin the new warfarin regarding venous thrombosis-No,but.....

I had thought that aspirin was for the most part not considered very useful as a medication that could prevent venous thrombosis but had an important role in preventing arterial thrombosis .Now we have evidence from a clinical trial that aspirin may be useful in prevention of venous thrombosis.See here. As the discussion section of the NEJM article (linked below) indicated there had been previous published data suggesting aspirin's value in venous thrombosis prevention but for some reason aspirin never seemed to achieve a reputation as a useful venous thrombosis prevention.

The trial,WARFASA,studied patients who had received 6-18 months of standard therapy for venous thromboembolism (VTE) .The treatment group received 100 mg aspirin per day and the recurrence of VTE was significantly less in the treatment group. The recurrence rate was 11.2 events/years in the control group versus 6.6 in the aspirin group with one instance of major bleeding in each group. The recurrence rate seen in the control group is compatible with the usually quoted 10% per year recurrence in patient with unprovoked VTE after anticoagulation therapy is discontinued. See here for the study published in NEJM.

The study was done in Italy where the 100 mg aspirin tablet is available.As far as I can tell in the US,we have only a 80 mg. aspirin.and the regular strength aspirin.

Of course, aspirin is not the new warfarin but might it have a role in the longer term treatment of a patient with unprovoked VTE? Dr. Stephen Moll, a hematologist with special interest in thrombosis offers his take on this study and how he plans to use aspirin in some of his VTE patients. See here for the commentary on his blog ClotConnect.

Another similar trial is underway ( the ASPIRE trial ) is scheduled to offer some results later in 2012 and hopefully will be able to offer confirmation of this rather small trial.

Interestingly,the 9th edition of the ACCP clinical guidelines on antithrombolic therapy and prevention recommends against the use of aspirin in the prevention of VTE in long haul flights.See here.

Coarse grain data aka Big Data medicine and risk of the z-Pak

The EP cardiologist and long time medical blogger, Dr Wes, hits a home run with this commentary about the recent study that claimed a relationship between cardiac death and the use of azitromycin and some of the bigger issues with what he calls "Big Data Medicine".

The article in question appeared in a recent issue of the big impact medicine journal the, NEJM.
See here.

The authors reported an increased risk of cardiovascular death with a hazard ratio of 2.49 (1.38--4.5) and an overall mortality risk of 2.02 (1.24 --3.30). The ratios are a bit too high for me to make my usual comments ( see here ) about relative risks less than 2.

Azitromycin has been associated with a prolonged Q-T interval so the door is open to speculate about a pathophysiological mechanism that could explain the results if the association is real and not the artifact of crunching large numbers through the filters of a cascade of assumptions. How long will it be before we will be treated to an alternative statistical story from the epidemiologists at Pfizer which has been marketing Zithromax since 1991. Meanwhile the FDA promises to take the matter under consideration.

More data to recommend putting statins in the drinking water?

There seems to be little controversy regarding treating patients with coronary artery disease with statins,what we call secondary prevention. Primary prevention, treating patients, who have no clinical evidence of heart disease,with statins is another matter being more than a little controversial.

Now we have a new meta-analysis that concluded primary prevention is a good idea. See here for a discussion of that study which reported a reduction in cardio-vascular mortality and all cause mortality in so called low risk patients. On the other hand (clinicians may yearn for the mythical one handed epidemiologist) a large meta-analysis by Dr. K. Ray and colleagues found no benefit in terms of all cause mortality.see here.

A few years ago I felt reasonably confident that I could a)determine a person's cardiac risk with a risk equation and b) advise that person about taking statins to lower his risk. I am much less sure about both those two things now but I still obstinately take pravastatin. In regard to risk equations I said all I can say about that in this several years old post entitled "Individual risk assessment,a peculiar,elusive,ambiguous concept." I would add another modifier, "faith based".

So how good can the risk equations ( yes there are more than one for predicting risk of coronary heart disease events and death ) be when studies perched on the highest rung on the ladder of evidence based medicines give contradictory results?

Can experts really answer all our health questions?

Drs.Pamela Hartzband and Jerome Groopman offer their views on the advice of health care experts, the too often discordant answers to health care questions and the role of "mind sets" or subjectivity on what is portrayed by some as scientific and objective answers.

See here for their comments in the WSJ Lifestyle section on line corresponding to versions of the column appeared in some of the print versions of the print WSJ on 3/31/2012. The title is "Rise of Medical Expertocracy"

The authors suggest that voices from both sides of what is usually ( and inadequately) labelled the political spectrum are claiming that they have the experts to answer all of our health care questions.They question the assumption that there is a right answer for all such questions and that "best practices" as formulated by a panel of experts will be based entirely on a scientific,objective impartial determination.

"For patients and experts alike, there is a subjective core to every medical decision. The truth is,despite many advances, much of medicine still exists in a gray zone where there is not one right answer"

Of course, expert panels use to varying degrees the available data sets, sophisticated statistical methods and epidemiological reasoning, but at the end of the process some one or some group has to make a value judgment.They have to say the risks are or are not worth the benefit.

The authors talk about "mind sets";the maximalists who tend to prefer doing everything or at least a lot and the "doubters" who worry that many (most?) treatments will be worse that the disease.They suggest that experts , as well, have mind sets that will influence the value judgment that they make after their objective analysis. So two experts can look at the same data and reaching opposite conclusions.Patients do this as well.

Since much of medical care is paid for by third parties,the advice of expert panels will likely have a major impact on their policies.

'Patients and doctors can differ with experts and not be ignorant or irrational.Policy makers need to abandon the idea that experts know what is best.In medical care, the "right" clinical decisions turn out to be those that are based on a patient's goals and values."

Amen, but that flies in the face of the over arching principal of the progressive medical mind set which is "Medicine is too important and too complicated to be left to the individual patient with advice from her patient".

My mind set or "priors" tends to warmly resonate with these views of Drs. Hartzband and Groopman and bristles when faced with the lamentations of some of the experts who accuse those whose advice differs from theirs as being ignorant of statistical concepts and seem themselves to be ignorant of the fact that their own mind sets may influence their conclusions and advice.

Dr. Viriginia Moyer was the Chair of the U.S. Preventive Services Task Force at the time of the release of their recommendations regarding PSA screening for prostate cancedr. In her editorial in the Annals of Internal Medicine ( 6 March 2012,Vol 156,number 5, pg 392-393) she offers a dissection of the reasons why there is opposition to the Task Force's recommendation which advised against PSA screening.

While she mentions the possibility of some financial interests-both from companies and physicians whose daily work is to diagnose and treat certain screened-for conditions- playing a role in promotion of screening,her principal explanation is "physician Innumeracy". Simply put-those opposing the USPTF's PSA position just don't understand statistics. She also neglects to mention the possibility of financial interests ( third party payers) opposing screening. The Mafia rule of"follow the money" might just apply to both sides of that disagreement. Let's see, who would benefit from fewer tests or treatments?  Perhaps the third party payers.

Dr. Moyer does not seem to recognize-or at least does not mention- the possibility that experts who know their way around NNTs (number needed to treat) and other statistical metrics and techniques as well or better than she might just look at the same data and reach a different value judgment. In fact they do and have even in regard to the issue of PSA screening.

Drs Hartzband and Groopman speak of a new form of paternalism "based on the assumption that Americans are not receiving "quality medical care".

" A lucrative industry has grown up to generate ever more medical metrics,to give report cards to doctors and hospitals, and to base payments on compliance with the "best practices".Yet beyond safety protocols, there is scant evidence that such measures improve our health"

More on medical guidelines being hazardous to your health

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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?

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 .

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".

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 .

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?

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.

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:

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.

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.

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.

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.

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."

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.

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.

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.