The population medicine approach does not respect the separateness of the individual,traditional or Rawlsian social justice nor evidence based medicine

 The population medicine approach does not respect  the separateness and sanctity of the individual and individual liberty. It is antithetical to not only traditional medical ethics but also to the ethics of classic liberalism. Further, it violates a major element in the concept of evidence based medicine, patient autonomy. It is not compatible with the social justice concepts as formulated by John Rawls and does not conform with the generally accepted meaning of social justice as redistribution from the less to the more needy.

The population medicine approach is basically utilitarianism which champions policies and actions that are supposed to bring about the greatest good for the greatest number. I say "supposed" because even the founder of utilitarianism recognized that logically and practically determining the aggregate utility or happiness did not make sense.Jermey Betham realized that adding John's happiness and Mary's happiness and subtracting Fred sadness was nonsense.

Quoting Bentham  "Tis vain to talk of adding quantities which after the addition will continue distinct as they were before, one man's happiness will never be another man's happiness;a gain to one man is no gain to another;you might as well pretend to add twenty apples to twenty pears, which after you had done that could not be forty of any one thing  but twenty of each just as there was before. ( ref. pg 136, A system of Liberty, by George H. Smith.) . Bentham admitted his "hedonic calculus" was based on a fiction  but he felt it was a necessary framework to get things done or legislation passed or policies accepted.

His approach echoes the thinking of the man who approached a psychiatrist and told him that he was very worried about his brother. Why are  you worried? Doctor, he thinks he is a chicken. Well, that is very serious you need to get him hospitalized.No, the man replied, we can't do that, we need the eggs.

 Bentham also needed the eggs.

 Everyone make decisions in everyday lives.It may not involve a formal or explicit cost-benefit analysis but it often involves a trade off. Utilitarianism goes beyond  making a trade-off within a person's life to the making of trade- offs between persons' lives and without their consent throwing the discreteness of individual under the bus. The population medicine approach does just that.

Consider the following quote from Dr. Harold Sox writing in the November 13,2013 issue of the Journal of the American Medical Association:Here he is  writing about allocation of funds occurring in the population medicine approach across patients and programs in which funds would be shifted to program in which the value was higher, as judged by QALY per dollar spent.

"It will take several generations to realize the full benefit of investments in disease prevention.In the short run,these investments draw resources away from tests and treatments from some sick people.In the long run, disease prevention and better low cost technology could reduce the outlay for treatment. In the interim, skillful clinical decision making can made the most of limited resources"
and
"Using the same metric of value and the same decision making principles for patients and for populations would be an important step toward a system that fairly allocates resources between the healthy many and the sick few."

The proponents of population medicine cavalierly admit there will be winners and losers. Dr. David Eddy in a series of articles In JAMA in 1995  said exactly that when he discussed the system that he proposed  as achieving better quality at lower cost. It was simply utilitarianism with cost effectiveness being a key metric in the allocations that would be made.Population Medicine is simply utilitarianism using quality adjusted life years (QALY) per dollar spent as the new metric of happiness or utility.

Sir J.A. Muir Gray writing in the Lancet (Vol 382,July 20,2013 ) in a commentary entitled "The Art of Medicine.The shift to personalized and population medicine" said in part:

'In the 21th century clinicians have a responsibility to the population they serves,to the patients they never see, as well as to the patients who have consulted or have been referred.,individual clinicians, while still focused on the needs of the individual in front of them when in the consultation, also make decisions about the allocation and  use  of resources to maximize value for all the people  the population they serve.This could be a decision that will reduce the amount of care that some would receive and increase the amount of resources for another group of patients,or perhaps put resources into education so that generalists can better manage the patient that specialists do not need to see."

Winners and losers but  more than that- Dr. Muir Grey would have the physicians also use their "charismatic and sapiential authority to promote health and prevent disease and encourages sustainable care , getting the best balance of benefit to harm, while minimizing the amount of carbon generated."

This is  a tall order- to balance care for your patient and everyone else and strive to save the environment.Medical schools will have to get even longer and harder to churn out docs with that skill set.Actually the rank and file docs will not have the allocation problem,the Platonic Guardians of Population Medicine will make the big decisions and the regular physicians will just adhere to guidelines.

The proponents of population medicine seem to think they have solved what Bentham thought impossible summing individual utilities by  using the QALY tool, quality adjusted life years which seem more scientific and objective that the "utils" of the early Benthamites.

 The ACP and ABIM Foundation are popularizing the new medical ethics. It appears that this new medical ethical system is an important prerequisite for population medicine  Here is how a former President of ACP, Dr. Harold Sox, ( ref. JAMA Nov.13.2013,vol310,no 8) explains it.

"Throughout history,codes of professional conduct have called on clinicians to make each patient's interests their highest priority.If resources becomes limited,clinicians will find themselves unable to adhere to that standard of practice for all patients.In 2002,a new code of conduct ,the Charter for Professionalism ,addressed this conflict by calling of physicians to consider the needs of all when treating the individual. While meeting the needs of individual patients,physicians are required to provided health care that is based on wise and cost-effective management of limited clinical resources.The provision of unnecessary  services not only exposes patient to avoidable harm and expense but also diminishes the  the resources available to others.
This remarkable passage indicates that the physician has an ethical imperative to balance the needs of the individual patient with the needs of society.With this foundational  principle of the population health approach, the Charter, in effect calls on clinicians to allocate resources. However, it does not provide specific advice. Recent programs such as the American Board of Internal Medicine  Foundation's Choosing Wisely campaign, are beginning to fill this knowledge gap, as do some practice guidelines." 

Dr. Sox speaks about "if resources become limited". By definition resources are limited. there has never been a limitless amount of medical care available.Apparently fiduciary duty to the  patient was acceptable as long as resources were not limited but by definition resources are limited.There has never been an unlimited amount of medical resources.

In this passage Dr. Sox ties together the Charter, the Choosing Wisely Campaign and the population medicine approach. Although Dr. Sox omitted mention, the Charter inserted a third ethical principle to the physician's ethical responsibility.It added to beneficence and non malfeasance, the furtherance of social justice which they stipulated was the fair and equitable allocation of medical resources which they later clarified  to mean that physicians should follow medical  guidelines based on cost effectiveness. But social justice as expounded by Rawls and as generally understood by many speople means redistribution to the advantage of the most disadvantaged and that is not what population medicine offers. Shifting of resources to one group from another based on comparative QALY calculations may or may not necessary benefit the most disadvantaged in society. The choosing wisely campaign began with a suggestion to which few physicians would object: eliminate tests and treatments that are harmful or wasteful. But it was not necessary to invent a new ethical principle for physicians to accomplish that goal. The ethical precepts of beneficence and non malfeasance covered that.One need not resort to claiming  that such act were required because physicians were the stewards of society's limited medical resource. It was sufficient to require that under the rubric acting a fiduciary agent of the patient.Further, the Choosing Wisely movement is morphing into something that some (see here) would want to be much more transformative.

Population Medicine approach is not compatible with the basic elements of evidence based medicine.Dr. David Sackett said:"Evidence based medicine is not “cookbook” medicine. Because it requires a bottom up approach that integrates the best external evidence with individual clinical expertise and patients' choice, it cannot result in slavish, cookbook approaches to individual patient care."

In the scenario described above by Dr. Sox in which funds might be diverted from someone's treatment to benefit some anonymous future person we hear no mention of consent of the patient.  Is it assumed that everyone will selflessly agree to sacrifice for the good of the collective.?Social and political schemes based on that principle worked out rather poorly in the 20th century.

The goal of EBP is the integration of: (a) clinical expertise/expert opinion, (b) external scientific evidence, and (c) client/patient/caregiver perspectives to provide high-quality services reflecting the interests, values, needs, and choices of the individuals we serv - See more at: http://www.asha.org/members/ebp/#sthash.4MOV9yTv.dpuf

The goal of EBP is the integration of: (a) clinical expertise/expert opinion, (b) external scientific evidence, and (c) client/patient/caregiver perspectives to provide high-quality services reflecting the interests, values, needs, and choices of the individuals we serv - See more at: http://www.asha.org/members/ebp/#sthash.4MOV9yTv.dpuHere is Dr. David Sacket's definition of Evidence Based Medicine (EBM) :"EBP is the integration of clinical expertise, patient values, and the best research evidence into the decision making process for patient care. Clinical expertise refers to the clinician’s cumulated experience, education and clinical skills. The patient brings to the encounter his or her own personal preferences and unique concerns, expectations, and values. The best research evidence is usually found in clinically relevant research that has been conducted using sound methodology". (Sackett D, 2002)What seems lacking in Dr. Sox commentary about population medicine is mention of the patient personal preferences and concerns and values. There is nothing said about how the patient might feel in the scenario Sox describes in which funds that could have been used to treat  some one's illness are diverted to some preventive program in which the result may take generations to be achieved. In a system in which its proponents admit there will be winners and looses we are not told to what extent if any will the values and wishes of the loser be considered .Drs Eddy and Muir Grey seem to assume that patients  will be just fine when funds are directed away from their or their children's or spouses  care to some other use judged to be more valuable or cost effective. Programs which depend on changing human nature have not worked out well.Look at the dismal history of collective planning in the 20th century.

The goal of EBP is the integration of: (a) clinical expertise/expert opinion, (b) external scientific evidence, and (c) client/patient/caregiver perspectives to provide high-quality services reflecting the interests, values, needs, and choices of the individuals we serv - See more at: http://www.asha.org/members/ebp/#sthash.4MOV9yTv.dpuf

I submit that population medicine approach and the usual notion of social justice and in particular John Rawls's definition of social justice are not compatible. In fact much of Rawl's magum opus ,A Theory of Justice,was  written at least in part to refute utilitarianism  which is  a principle on which population medicine depends. Rawls said the utilitarianism did not respect the separateness of the individual and argues strongly against treating people as means some social end,In the case of population medicine , this would be optimizing the QALY or QALY per dollar spent.

To mix the concept of social justice and population medicine as done by spokesmen for the ACP and ABIMF is  a masterful muddle of mixing incompatible concepts and stirring it up with platitudes,gratuitous assertions and non sequiturs.


So, other than  that the population medicine approach contradicts traditional medical ethics,does not further social justice as it is commonly understood, flouts a key element of evidence based medicine,and requires individuals to sacrifice  themselves to some alleged greater good, it seems like a  pretty good idea.



Addendum: Minor editorial changes made 12/14/14.

Does the concept of "value based payments" make any sense at all?

Greg Scandlen at the Health Policy Blog comments on the term "value based" quoting from a worth- reading article by David Carr writing on the site Information Week. Here is link to Scandlen 's thoughts.

Scandlen deftly takes apart a widely quoted article by Michael Porter that appeared in the NEJM in 2010 .

The concepts  of professor Porter are widely quoted and for him value is defined as "health outcome per dollar spent" but he spends considerable effort in explicating how elusive and difficult that is to put into meaningful operational use.

A number of the concepts that Porter has made popular ,after a little thought, seem more to be catchy platitudes than useful,reality based insights.For example the notion of improving performance and accountability by "having a shared goal that unites the interests and activities of all stakeholder.s"Is there any real sense in which the patient has a shared goal with the third party payer?

quoting Scandlen:

" ..I would argue that the whole idea that “value to the patient” can be defined objectively is misguided. Even with precisely the same cost and the same medical outcome, the “value” of a service will be different for every patient. Dick Cheney seems to be very happy with his heart transplant and thrilled to extend his life by several more years. Someone else might think that the ordeal of the surgery and medical attention isn’t worth it. Or they might think that their life is pretty crappy and not worth extending."

In other words, value is subjective and in the eyes of the beholder which should be the patient and  not the cost effectiveness practitioners who can "determine" the value with numbers and regressions, even though at the end of the analysis someone has to make a value judgment call.

I have ranted about this near naked emperor before.  See here.

 The " value based payments" meme seems more and more to be  just another phony-baloney justification for third party payers to limit expenditures for medical care and dress it up with platitudes.

Is the underlying problem with the VA hospitals scandals greed?

Perhaps self-interest in a better word to describe what is going here.

There is a wide spread and naive notion that for-profit institutions,  aka business, are driven by greed and that dishonesty and bad motives dominate their existence and that non-profit organizations are the opposite in every regard; But folks who populate non-profit organizations are cut from the same cloth as the rest of humanity and for them as for everyone incentives matter.

This commentary by Glen Reynolds gets it right.

I quote from  his  comments from USA Today:

"In other words, they cooked the books. And what's more, they did it to ensure bigger "performance bonuses." The performance may have been fake, but the bonuses were real. (One whistle-blower compared the operation to a "crime syndicate.")
And that captures an important point. People sometimes think that government or "nonprofit" operations will be run more honestly than for-profit businesses because the businesses operate on the basis of "greed." But, in fact, greed is a human characteristic that is present in any organization made up of humans. It's all about incentives." ....And, ironically, a for-profit medical system might actually offer employees less room for greed than a government system. That's because VA patients were stuck with the VA. If wait times were long, they just had to wait, or do without care. In a free-market system, a provider whose wait times were too long would lose business, and even if the employees faked up the wait-time numbers, that loss of business would show up on the bottom line. That would lead top managers to act, or lose their jobs."

If you look at the history of the VA system you will see greed and corruption boiling over the top at the very beginning..The historian  Burt Folsom gives a brief review of the origin of the VA system and the corruption and mismanagement that characterized its early days under the administration of President  Warren Harding.

The point is that people act in their self interest ( when their actions rub up against our moral priors we call it greed) and that markets impose the discipline of profit and loss that are lacking in  monopolies such as the socialized medicine of the VA system and often -but not always- direct that greed to the benefit of others.

As Milton Friedman said the question is: under what system will
greed lead to the  least harm,his answer was capitalism.Here is his priceless reply to Phil Donahue .

Wanted: Men of System to manage the Population Medicine Approach and maximize society's health

 Let's begin with explaining Men of System and Population Medicine Approach (PMA)

 Adam Smith , in his first book, The Theory of Moral Sentiments spoke of the "man of system"

"The man of system, on the contrary, is apt to be very wise in his own conceit; and is often so enamoured with the supposed beauty of his own ideal plan of government, that he cannot suffer the smallest deviation from any part of it. He goes on to establish it completely and in all its parts, without any regard either to the great interests, or to the strong prejudices which may oppose it. He seems to imagine that he can arrange the different members of a great society with as much ease as the hand arranges the different pieces upon a chess-board. He does not consider that the pieces upon the chess-board have no other principle of motion besides that which the hand impresses upon them; but that, in the great chess-board of human society, every single piece has a principle of motion of its own, altogether different from that which the legislature might chuse [sic] to impress upon it. "

  Dr. Harold C. Sox, , former President of the American College of Physicians (ACP) and former editor of the Journal of that organization, The Annals of Internal Medicine  explains and seemingly recommends the PMA in a commentary in JAMA (November 33,2013) entitled 'Resolving the Tension Between Population Health and Individual  Health Care ".

In this formulation  it is claimed that  one treats the population much as a physician would treat an individual patient.One uses the same "value metric" and the same few decision making principles. For example one would screen a given patient only if that would maximize that person's welfare and similarly in considering applying  a screening procedure to a group would involve screening only those who would gain QALYs. Cox admits we don't really have all that information yet but "the challenge would be to develop models of the principal high stakes decisions of clinical medicine, perhaps starting by identifying these decisions and developing the evidence to inform them"We would need to determine the frequency,causes and consequences of the common medical conditions in a population and devise strategies for dealing with them over the life span.  The public health system and the health care system  and community leaders need to plan together.

Then resources could be allocated between disease-specific programs so that they would be moved from groups of patients less likely to benefit to groups more likely to benefit.

Sox  then seems to admit there may be some growing pains with this approach but in the long run there will be benefit,. That is my paraphrasing now a quote :

"It will take several generations to realize the full benefit of investments in disease prevention. In the short run, these investments may draw resources away from tests and treatment for some sick people. In the long run,disease prevention and better low cost technology could reduce the outlay for treatment. In the interim, skillful clinical decision making can make the most of limited resources. 


To make the population medicine approach operational it would be necessary for physicians to consider themselves practitioners of population medicine and support a system that "fairly allocates resources between the healthy many and sick few:" The Charter for Professionalism paves the way for that by admonishing physicians that they are the stewards of medical resources and that cost effectiveness is the new polar star.As long as physicians considered themselves to be fiduciary agents of their individual patients the scheme would not work. The publication of "Medical Professionalism in the New Millennium:A Physician charter" in 2002 was an important step in the movement to further the dogma of medical collectivism..

To achieve this medical  utopia the Men of System of whom Adam Smith wrote will be required ; some one will be needed to move the different  members of society around the chess board of utilitarian health care with its fair and cost effective allocation of health care resources. And while only a few physicians can be the Platonic Guardians ,some of whom will likely expend their energies on IPAB, the rank and file docs can work for the common good by adhering to guidelines. 


addendum: Minor grammar and spelling corrections made 7/31/14
addendum: typo regarding date of publication of  "Medical Professionalism.." 3/23/17

Swedish study provides More data but not much definitive useful information regarding levels of exercise and atrial fibrillation risk

A recent article in BMJ has stirred  more comments regards the possibility that there is a "j shaped" curve in regard to the relationship between level of exercise and development of atrial fibrillation (AF).

There have been number of publications addressing this issue and to my eye there is good evidence that there is an increased incidence of AF in long time endurance athletes. The magnitude of this increased risk and what this correlates with is less clear-duration of exercise,intensity, height?, genetic profile, confounding factors, etc etc.

The BMJ article is from Sweden by Nikola Drca and is a long term followup of over 44000 men who completed exercise questionnaires and provided  in part retrospective estimates  of hours per week exercised at ages 15,30, and 50.These questionnaires were then linked with data indicating whether they had developed AF.The AF numbers are relatively hard data the historical data much less so.

Of those men who said they exercised more than 5 hours per week at age 30 there was a relative risk (RR) of 1.19 (CI 1.05-1.36) this increased risk in the greater  than 5 hour per week exercise category was only found for age 30, not at age 15 nor age 50 and the RR was higher for the  high exercise at age 30 group  who then stopped exercising  (RR 1.49).

Several points come to mind

When the number in the study group is very large, very small differences in the measured outcomes become statistically significant.  Relative risks less than 2-3 are generally not considered very convincing evidence that there may be causation.My favorite quote in this regard is from Michale Thur , epidemiologist at the American Cancer Society:,

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

and a RR of 1.19 is pretty little 

In trying to assess significance of RRs  from observational epidemiology studies. it is sometimes useful to consider what is the prior evidence and look at biological plausibility (which old time internists like to think of sometimes as pathophysiology or disease mechanisms.)

There are a number of studies that suggest long term endurance athletes have a increased risk of AF but  that is not what the data here suggest at all.The 30 year old heavy exercisers had  increased risk while the 50 year old exercisers did not and there was even  greater risk  in those 30 year old heavy exercisers  who quit. That does not seem like a dose response relationship, i.e more exercise more AF.

What would be the pathophysiology evoked to explain heavy exercise at 30 but not at 50 being related to increased risk of AF.

So what would be the take home advice? Don't begin heavy exercise until age 50 ? But if you are 30 and exercising a lot , don't quit.. None of that makes sense if we believe the is a j shaped curve regarding duration of exercise  and risk of AF or if there is a positive relationship between  duration of exercise and AF.I n spite of headlines emphasizing the 30 year old heavy exercisers risk I think overall the study is more reassuring to long time endurance athletes than it is concerning.The RR for the 30 year old group could easily be just statistical noise and the lack of increased risk for the others a more reliable finding.

 For a more detailed and less biased discussion of this general topic I suggest the excellent blog written by Dr. Larry Creswell.

Disclosure of conflict of interest: I have been doing long distance running for almost 40 years .(Fortunately I did not begin distance running until after age 30,so there should be no problem). So, my mind set  is to be critical of studies that purport to show a problem with too much running.

Former president of American College of Physicians explains the population medicine approach and we should be afraid,very afraid

Dr. Harold C. Sox has played a leadership role in the American College of Physicians  for many years, serving as President of the ACP and long time editor of the Annals of Internal Medicine.

 In the opening paragraph of a commentary in JAMA entitled "Resolving the Tension between Population health can individual health care" (JAMA November 13, 2013,Volume 310, number 18) he states:

"Perhaps the de facto organizing principle of US health care approaching each patient strictly as in individual is obsolete.The population heath approach is an alternative. It aims to improve and maintain health across a defined population."

Later repeating a major theme of the publication,"Medical Professionalism in the new millennium,a physician charter" , Dr Sox says:

"..the physician has an ethical imperative to balance the needs of the individual patient with the needs of  society."

 Dr. Sox  then explains in broad terms how to practice population medicine.

"Planning to optimize population health will mean determining the frequency,causes and consequences of he common medical conditions in a population and devising strategies for dealing with them over a lifetime. "...
resources must be allocated across program to prevent,detect and treat disease and its risk factors. "...One reasonable principle to move resources from groups of patients less likely to benefit to groups more likely to benefit."

With the application of this utilitarian calculus there will be winners and losers which Sox seems to admit implicitly the following paragraph.

"It will take several generations to realize the benefit of investments in disease prevention.In the short run, these investments may draw resources away from the tests and treatment of some sick people.In the long run, diseased prevention and better low-cost technology could reduce the outlay for treatment."

So, in the short run the population medicine approach might deprive some sick patients of treatments but in the long run "the outlay for treatment " could be reduced. Withholding treatment  for those who are sick now for some  purported,future , hypothetical benefit to anonymous  people is completely antithetical to basic medical ethics and has no place in a nation with any remnant of individual freedom remaining.


Dr. Sox after already seemingly condoning  sacrifice of the individual's welfare to some nebulous greater social good then closes the commentary with the following platitude which seems to contradict his earlier statements;
"Much of medical practice has changed but not the basis of patient -centered care."

The term "patient centered care" is a trendy, feel-good cliche without well defined operational meaning but I cannot believe that any generally accepted understanding of that phrase could possibly include not treating the sick to gain some allegedly future benefit to some some subset  of well people.

As someone who did his medical training in the same time frame as Dr. Sox in which the notion of the  physician as the fiduciary of the patient  was sacrosanct   I find his comments wrong on so many levels that I cannot find the words to express it but to the extent that views such as those expressed in his commentary are more widely accepted there is reason to be afraid,very afraid.

Dr Michel Accad critiqued this creed of medical collectivism in his blog writing in part:

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


addendum: Several spelling errors and typos corrected on 8/6/2014

Is the bait and switch of the new medical professionalism more apparent now?

The concept "social justice" was the bait. The folks at ABIM, ABIMF, ACP and RWJ declared without even a token effort at historical justification that part of professionalism for physicians was social justice. That 2002 publication entitled " Medical Professionalism in the New Millennium.A physician charter "  did not specify exactly how physicians might work for social justice in their role as physicians.Neither did they offer an operational meaning for social justice which is par for course for folks who promote a collectivist agenda, the ambiguity having significant rhetorical  value.Progressive and liberals love the notion of social justice and would readily give their approval to this new and improved medical professionalism. Conservatives and libertarians not so much but  some went alone to get along to avoid accusations of political incorrectness.

Now the switch. Physicians could/should work for social justice by being stewards of  society's scarce medical resources and that could be done by following guidelines and in that way a fair and equitable distribution of resources could be brought about.

Never mind that the most widely acceptable definition of social justice is redistribution of resources from those who can afford it to those more disadvantaged. This in not what is being promulgated. The ABIM (F) and ACP and RWJF are advocating for parsimonious care in their Choosing Wisely campaign which to the degree it is successful  will decrease care for everyone, at least everyone who depends on their insurance ( private or public) for medical care.  Who gains ? The third party payers and the medical progressive elite and fellow travelers who write the guidelines.

Dr, Scott W Atlas writes here about the two tiered health care that Obamacare will intensify, an interesting irony since folks who continue to defend Obamacare insist that one of the success of it is to further social justice. This is a strange social justice in which the poor and middle class  may  get less care while the connected and wealthy will do much better and in which the young and well subsidize the older and sicker folks even though many of the older are financially better off if only because they may have remnants of lifetimes of earnings.

 addendum: minor spelling and grammar corrections made on 8/8/14   

Has the third party medical payers' dream come true,physicians as medical resource stewards practicing parsimonious care working for the common good

No longer do the third party payers (TPP) have to deal with the physicians and patients working against their bottom line. Physicians,  patients and the TPP will work together in harmony in the land of rainbows,unicorns and the big rock candy mountain.All the stakeholders can get together and work on ways to eliminate waste,low value care and conserve the third party payer's society's scarce resources.Actually TPP have not been dealing with physicians for some time now, they interact with providers of health care.

 The following dream of the TPPs might just be coming true:

Careful analysis of aggregate data  in which patients will gladly participate   will allow cost effective guidelines to be written and executed as all players will realize the wisdom in maximizing the health and well being of the population.The utilitarian ethic of the greatest good for the group will be recognized as the only sensible alternative to the selfish pursuit of individual gain which previously motivated both the selfish patient,concerned as she was with her own health and the health of her family  and the avaricious physician,driven as he was by the flawed and destructive fee for service  system. Value not quantity will be served .

Third party payers should be eternally grateful to the progressive thinking leadership of such organizations as the American Board of Internal Medicine and its foundation,the ABIMF (which was generously funded by the thousands of socially minded internists who sat for repeated examinations) and the thought leaders at The American College of Physicians (ACP) who managed to convince many that providing less care is better for everyone not the least of which are the third party payers and the medical progressive elite who alone will have the wisdom and expertise to determine what is best for everyone.

Can the Choosing Wisely campaign be explained by 1)the follow the money principle and 2)the Baptist and Bootlegger story.

Of course , the dream perhaps had not been completely realized yet. There are still obstacles to overcome;

1) the self interest of the patient and the patient's family. Most people do not think when they develop chest pain " I'm going to the Emergency Room to see how the Doctor can balance my immediate needs with those of society. In other words, one aspect of that darned incentive problem.It is hard to stamp out that pesky tendency of folks to try and act in their own interests and in the interest of those they care deeply about.

2 )that pesky Mal-practice issue . So far the argument that Mr..Jones did badly but it was OK because we followed the latest cost effectiveness guideline has not risen to the level of a major legal defense

3) Reminiscent of the WWII. Japanese soldiers who held out for years on isolated islands not aware they had lost, there are still some physicians who,perhaps educated in an earlier era with a different and less enlightened  ethical upbringing , still believe and as if they are the fiduciaries of their patient.Perhaps time will take care of those dead-enders  but until then the TPP utopia will not be completely  realized in spite of the well funded campaign to convince physicians of their duty to conserve medical resources by following guidelines.

Is the "social justice" of ABIMF and ACP what John Rawls had in mind?

The stated reason for the existence of the American Board of Internal Medicine Foundation (ABIMF) is to further medical professionalism.,the three principles of which are patient welfare,patient autonomy and social justice. By social justice they seem to mean the " just and cost effective distribution of finite [medical] resources ".

The Choosing Wisely campaign is promulgated by ABIMF and in its original version was an seemingly innocent and well intentioned suggestion that physicians and patients have a frank discussion about medical procedures and treatments to the end of trying to minimize those that might be wasteful and/or harmful. Of course,everyone want to do away with waste and harm.but it is morphing into something much more than that. Suggestions are being made and gaining momentum that lists should be made of those procedures and treatments that are "low value" which will be defined as falling below some threshold of quality adjusted life years (QALY) per amount of money. A figure  of  $150,000 per QALY is being proposed.Further, there are suggestions that CMS enforce the dictates of the Choosing Wisely campaign.

Note-if it is "determined" that something's value is  "low" i.e  if less than some dollar amount per QALY then physicians should not recommend that procedure and third party payers might just not cover it. So patients dependent on third party payers to obtain  that procedure would not receive it while more affluent folks who  are free to pay for their own treatments would be able to obtain this so called  low value procedures.

Social justice is a slippery term and its ambiguity may serve promotion of a given social movement  but it is generally recognized to be redistributive justice.Rawls said that redistribution would be acceptable only if the most disadvantaged members of society would benefit.

If the plan to suggest that "low value" treatment should not be done, then no one should receive it , at least in theory. But in practice it may well mean that those who cannot afford to pay for it on their own would not receive it, and such a group certainly would include the most disadvantaged members of society. Not a very Rawlian outcome.

Further, Rawls did not support decisions made on utilitarian grounds. The cost effectiveness analysis of the QALY calculus is clearly based on the dictum greatest good for the greatest number. Rawls believed that this approach did not support the autonomy,the individual rights and dignity of the individual.

Dr. Christine Cassel and Dr. Virginia Hood,both leaders of  the American College of Physicians spoke of "parsimonious care". Social justice a la Rawls would champion more care for the most disadvantaged .Parsimonious care is less care for everyone in theory but in practice the affluent may get it anyway. so who gains from that? Third party payers comes to mind.The ACP and ABIMF and others are going on a full court press to convince physicians that they are population doctors and to conserve resources they should follow guidelines. This will achieve the re-defined, non-Rawlian , social  justice imperative that they have said is required of physicians .Adherence to guidelines it is argued will improve the health of the collective though some individuals will suffer but the bottom line of the third party payers and ACOs will not suffer  and the medical elite mandarins will also do well.

Minor spelling,grammar and punctuation changes made on 7/11/14.

Another chapter in the never endling clash between the collective and the individual regarding health care

The following comments were inspired by this insightful and very well written commentary by Margarit Gur-Arie entitled "Is the Nuremberg Code Obsolete?" After reading about where the cronies at IOM and the ideologues at Hasting Institute want to take us, I have to shout "It sure as hell better not be obsolete and do you people even know anything about the events that took place in Europe (or Macon county,Alabama for that matter)  in the 20th century and why we have the Code in the first place."

One of the more troubling developments in recent years in medical care is the seemingly increasing acceptance of the notion of the importance of the health of the collective even if sometimes to the determent of the welfare of the individual and that the latter seem to exist for the welfare of the former.

One of the latest twists here is that some are arguing that certain types of clinical research can be done without getting consent of the participants or even informing them about what it going on.

Quoting Gur-Arie:

" The Office for Human Research Protections (OHRP) held a public hearing in August 2013 regarding the nature of informed consent for randomized clinical trials...., two very distinct opinions regarding consent emerge from reading the various testimonies before the committee. The traditional opinion argues that there is a difference between treatment and research and that informed consent is required for both, including study of “standard care” interventions, CER and QI; that randomization always deprives research subjects of the judgment of their physician and that these issues are governed by law (e.g. the Constitution and such). The progressive view, presented by testimony from members of the Institute of Medicine (IOM), its Clinical Effectiveness Research Innovation Collaborative (CERIC), NIH and other research establishments, posits that randomization of “standard care” interventions poses no additional risks to patients, since doctors’ decisions are essentially like flipping a coin anyway, and therefore patients in this new learning system may be subjected to randomized CER and QI experiments without explicit consent and with minimal, if any, information (e.g. “something posted on the door”)."

 Related is this Hasting Center  report which speaks of   (with my bolding):

"The obligation of patients to contribute to the common

purpose of improving the quality and value of clinical care

and the health care system.

Traditional codes, declarations,

and government reports in research ethics and clinical ethics

have never emphasized obligations of patients to contribute

to knowledge as research subjects. These traditional presumptions

 need to change. Just as health professionals and

organizations have an obligation to learn, patients have an

obligation to contribute to, participate in, and otherwise facilitate learning.

This obligation is justified by what we call a norm of

common purpose. This norm of common purpose is similar

to what John Rawls calls the principle of the common good."

Wow, here is a group composed mainly of several ethicists from Johns Hopkins who presume to define an obligation for everyone and redefine the ethics of medical research, a goal they openly admit to in the first paragraph of their report.Everyone has an obligation to work for the common purpose of better health care.

Once all the health care providers and all the patients work together to participate in and gather the data about various medical tests and treatments the very smart people will be able to analyze it all and determine what is best for the collective. Utopian health care is within the reach of the  very smart people with ideas.

More internists are failing the MOC exam-why could that be? Resistance to ABIM's MOC grows.

Why are more internists failing the Maintenance of Certification (MOC) exam? Kevin Pho on his medical blog offers two suggestions. See here. One reason is what I call the economically driven bifurcation of internists into hospitalists and officists and the disuse atrophy of hospital care skills in the office bound docs and the lack of familiarity with the preventive care changes and routine treatment of non acutely ill patients on the part of the hospitalists. If you don't treat respiratory failure,sepsis and acute heart failure on a regular basis you might just not do as well on the boards. The second reason Pho suggested is that the hassle factor in office care is now so high , with insurance,computer,and quality measures documentation  ever increasing that the fire in the belly to try and keep up with everything may be burning too low to try and keep current on conditions  you no longer are called upon to manage.

The suggestion that there should be one test for the hospital based internist and another for the officist has some merit but what about the dwelling number of dinosaurs who still try to do both. Of course that group is rapidly dying out.

And the more I read and hear about the absurd hoops internists are expected to jump through to try and satisfy the ever onerous non-test aspects of the ABPM's MOC process, the happier I am that I retired.See here for a great presentation of the clown-designed MOC program authored by the leadership at the American Board of Internal Medicine (ABIM).

I am pleased to see that there is at least some organized,as well as much unorganized, effort to resist or maybe even boycott the latest MOC affront imposed by the well paid folks at ABIM. See here and here. Further, mega kudos to Dr. Paul M. Kempen for his efforts to resist the MOC movement. Read what he has to say here. See here for Dr. Wes Fisher's comments re the big business that testing physicians has turned into.

Also of interest are the questions posed by Dr. Marc S. Frager to Dr. Richard J. Baron as well as Dr. Barron's reply.See here.

If you want to sign a petition to urge the ABIM to rescind their latest edicts regarding MOC ,go here. 

It is easy to find much anger and indignation directed towards the ABIM and recent revelations about possible conflicts of interests regarding its leadership has fanned the flames even more.

Adam Smith's Men of Systems and the progressive medical elite

Adam smith spoke of the men of system- men with a dangerous mixture of hubris and naivete  who presumed to know what is best for every one  and how to plan to bring that optimal state into being.

The following commentary highlights the views of some physicians who might be considered the medical men of system.

The following quote from Drs Don Berwick and Troyen Brennan in their appropriately named book, "New Rules" captures the essence of the fundamental nature of how men of system would arrange medical care.
 
"Today, this isolated relationship[ he is speaking of the physician patient relationship] is no longer tenable or possible… Traditional medical ethics, based on the doctor-patient dyad must be reformulated to fit the new mold of the delivery of health care...Regulation must evolve. Regulating for improved medical care involves designing appropriate rules with authority...Health care is being rationalized through critical pathways and guidelines. The primary function of regulation in health care, especially as it affects the quality of medical care, is to constrain decentralized individualized decision making

 

Dr. Robert Berenson strikes a  seemingly different but clearly related note in a commentary in the Annals of Internal Medicine , 1998,pg 395--402.  in which he promotes the health of the collective rather than the individual patient :

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

Berenson recommends a replacement of the fiduciary duty of the physician to the patient with a duty to a group while Berwick and Brennan talk about dissolution of the physician patient relationship and moving the locus of medical decision making  away from the physician and his patient to a reliance of authoritarian rules.

More recently Berenson has this to say:

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

A series of articles in JAMA in 1994 (Rationing Resources while improving Quality) by Dr. David Eddy also recommended a utilitarian type medical care structure in which funds would be  spent on medical tests and treatments that were most likely to benefit some majority subset so that in the aggregate there would allegedly be a greater good for the greatest number.

Dr. John Benson is the former CEO of ABIM and ABIMF and had this to say recently on the ABIMF's website:

"  ABIM could require candidates to achieve a perfect score on questions related to costs and redundant care as a requirement for admission to secure exams for initial certification or MOC."

So, for candidates for certification or the ABIM's Maintenance of Certification to even be allowed to take the tests they would have to recite,perfectly, the catechism of the brainchild of ABIMF ,the "Choosing Wisely" guidelines.

This alone, in my opinion,should qualify Dr. Benson for membership,along with the aforementioned doctors,in the Medical Men of System hall of fame.  

The recommendations of Berwick,Brennan,Berenson and Eddy were met by some vocal resistance as least as documented by letters to the editors in JAMA and the Annal of Internal Medicine . These authors were advocating a paradigm shift ,arguing for a 180 degree reversal of traditional medical ethics for which , I believe, physicians at the time were not ready and I hope are not ready now but...

But there is another way to gather support for a sea change in medical ethics and practice behavior,one that will also bring about greater concern for the collective and aggregate outcomes and that will to a large and ever increasing degree move the locus of medical decision making from the individual dyads to a central decider .

This other way is to nudge physicians and later shove them a bit into the acceptance of the notion that physicians have a duty to work for social justice and to act as stewards of the nation"s finite medical resources.To strive for social justice is a political position, one that does not necessarily have any professional links. To declare, or assert gratuitously , as was done the in the  publication known as the Medical Charter that physicians have an obligation to strive for social justice represented a audacious move,one that I am afraid has been at least nominally successful.

To close with a quote from Adam Smith's "Theory of Moral Sentiments" :

"The man of system, on the contrary, is apt to be very wise in his own conceit; and is often so enamored with the supposed beauty of his own ideal plan of government, that he cannot suffer the smallest deviation from any part of it. He goes on to establish it completely and in all its parts, without any regard either to the great interests, or to the strong prejudices which may oppose it. He seems to imagine that he can arrange the different members of a great society with as much ease as the hand arranges the different pieces upon a chess-board. He does not consider that the pieces upon the chess-board have no other principle of motion besides that which the hand impresses upon them; but that, in the great chess-board of human society, every single piece has a principle of motion of its own,"


addendum: Minor editorial changes made 9/12/14

Breaking news-OBM discovers economics prinicple of "incentives matter"

Several of my favorite economists have said that the real good stuff in economics is revealed in the econ 101 courses. One of the secrets revealed is that "incentives matter".

Milton Friedman said most of economics could be boiled down to two thoughts; 1) there is no free lunch 2)demand curves slope downwards which simply means people tend to buy more if something costs less and tend to buy less if something costs more.

Another principle is that generally supply curves slope upward which means that someone will tend to supply more of something if the price increases and tends to supply less if the price is lower.

The Chicago economist Casey Mulligan has been making that point for some time  in regard to certain aspects of Obamacare.Obamacare provides subsidies for folks when their income falls below a specified threshold.If they work more and earn more and exceed that threshold  they loose that subsidy.Hence the incentive to work less.In other words, less labor will be supplied if the effective pay is less which is what happens when someone works more and loose a subsidy so your net income falls. As Mulligan says you can decrease employment by changes in the supply side as well as by changes in the demand side.

The downward sloping demand curves notion enters into the Obamacare employment issue as well. If an employer has to provide health insurance or be fined if he employes more than 50 people the incentive is to keep his employee count under that number because the cost of hiring the 51th person is too high. He will tend to hire fewer employees when the cost of hiring increases.

See here for a WSJ article on Prof.Mulligan and his work and comments and how OMB finally caught on.

Is this what ABIMF"s Choosing Wisely is really all about?

Dr. John Benson Jr, Emeritus President  of the American Board of Internal Medicine Foundation,makes it clear  what direction he wants the Choosing Wisely  (CW)  Campaign to go. See here for his comments.

 Dr. Benson begins his policy prescription with a gratuitous assertion which seem to be a favorite technique of the folks at ABIMF. (Their mother-of-all gratuitous assertions was that physicians were stewards of medical resources.)

 "The prospect of health care consuming 20% of the GDP by 2020 is unconscionable so corrective actions have enormous urgency."  

This recent commentary from The NEJM seems to share some of Dr. Benson's views which is basically "If you people do not do what we know is right someone needs to make you do it". He speaks of penalties.

He wants the CMS to enforce the  Choosing  Wisely 's wisdom.The NEJM article speaks of linking compliance with MOC ( Maintenance of Certification)as well as tying CW recommendation to CMS actions.

Quoting Dr. Benson:

"The time is well past exhortation. The issue has been recognized for decades. Hard choices and penalties must go beyond training the next generation. 2020 is closing in." ( He does not explain the ominous reference to the year 2020).

He continues

" CMS, which has the ultimate negotiating position in the form of reimbursement for Medicare services, could only accept negotiated bundled charges. It could also refuse payment for non-compliance with the Choosing Wisely recommendations."  (note the current President of ABIM and ABIMF is Dr. Richard Baron who left a post at CMS through the revolving door to assume his duties at ABIM and ABIMF)

and it gets worse

" ABIM could require candidates to achieve a perfect score on questions related to costs and redundant care as a requirement for admission to secure exams for initial certification or MOC." (Maintenance of Certification)

So, a candidate for ABIM certification would have to properly quote the Choosing Wisely catechism before he even gets to take the certification of MOC examination.

Quoting the NEJM article by Dr N.E. Morden and her co-authors from Yale and Harvard:

"..physician-endorsed low-value labels will probably be leveraged to these purposes. [cost containment and quality measures]...We believe that if such efforts are designed and applied carefully they should be embraced as a promising method for reducing low-value services."

...linking the lists ( of tests and procedures not to do ) to specialty specific maintenance of certification act activities such as practice audits and improvement tasks could also advance their dissemination and uptake at very low cost."

"...Choosing Wisely items should also be incorporated into quality-measurement efforts such as Center for Medicare and Medicaid Services Physician Quality Reporting  ...linking low value service use to financial incentives ( translate penalties )  .. should accelerate ...into practice changes."


Remember the CW campaign,which was very low key in 2009. was just to get a dialogue going   so that  the physicians could explain to their patients how at least some of these tests and treatments really don't need to be done because they may be wasteful and sometimes harmful. In 2012 the program was ramped up as the ABIMF "invited various medical professional societies to take ownership of their role as "stewards of finite health resources". And now , in 2014 the movement to give the CW recommendations teeth is ramping up.


The coercive recommendations of Benson and the authors of the NEJM article are in the tradition of those who believe that medical care is too important ( and complex) to be left to the short sighted individual patient and her knowledge and the wisdom challenged physician health care provider.They seem to march to the drum beats orchestrated by  Dr. Don Berwick (the temporary head of CMS) and  Dr.Troyen Brennan (the current executive VP of CVS Caremark) who said in their book, New Rules:

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

 
Berwick and Brennan must be pleased as largely through the efforts of ABIMF and ACP much has been accomplished   in the reformulation of  traditional medical ethics. Those organizations  have shaped the narrative to emphasize the bogus stewards-of- resources concept while letting the fiduciary role of the physician to the patient fall  quietly down the memory hole.Unfortunate  the leaders of other medical professional societies have swallowed the bait.

The progressive medical elite who hold positions variously at major medical societies and medical certification boards ,some of whom rotate through various government medical agencies and sometimes private third party payers, have not been shy about what they want to happen.For those of us who believe that the patient is best served by a physician acting as fiduciary to the patient and advocating for him have much to worry about.

 Addendum:Minor editorial changes to correct some grammar and spelling done on 6/8/2014 and again on 7/23/2014.

Say it isn't so Joe, Medical "thought leaders" might have conflict of interests

 The issue of possible conflicts of interest (COI) has arisen in regard to both the National Quality Forum,  (NQF) and the popular UpToDate.

 This article in the Journal Of Medical ethics discusses that issue in regard to the popular UpToDate which on its web site describes its self as "premier evidence-based clinical decision support resource". The journal article has this to say regarding several sections of UpToDate comparing it to another rival medical resource:

"All articles from the UpToDate articles demonstrated a conflict of interest. At times, the editor and author would have a financial relationship with a company whose drug was mentioned within the article. This is in contrast with articles on the Dynamed website, in which no author or editor had a documented conflict. We offer recommendations regarding the role of conflict of interest disclosure in these point-of-care evidence-based medicine websites."  It should be noted that the journal authors did not review all of sections but selected ones that involved subjects for which treatment was controversial and/or involved recommendations for specific treatments that wee provided by a single supplier.

Much more has been written about possible COI regarding the NQF.

Details regarding Dr. Charles Denham can be found in this article in "Modern Health Care. Quoting that article:
"

"Dr. Charles Denham, co-chair of NQF's Safe Practices Committee in 2010, received $11.6 million from San Diego-based CareFusion to promote the company's ChloraPrep line of skin-preparation products. Denham's committee at the NQF also recommended surgeons use ChloraPrep products to prevent surgical infections, the NQF said."

Dr.Christine Cassel,currently CEO of NQF left little doubt about her assessment of Denham actions saying simply "He lied" when he mislead the NQF regarding his possible COI and business interests. Dr. Cassel was not affiliated with NQF at the time of the allegedly kickback  related activities.

Ironically enough now Dr Casell has the spotlight on her in regard to possible COI  regarding her role at NQF. ProPublica takes up that issue here. I say ironically because one aspect of Dr.Cassel's academic reputation has been in the field of medical ethics.Dr. Cassel has written and lectured extensively on medical ethics, authored or co-authored several publications in the field including "Ethical Dimension in Health Professions" and completed a fellowship in bioethics.

 So what is it that Pro Publica finds of concern in regard to Dr. Cassel's role at NQF. It is in regard to other compensated positions that she holds.For example Dr. Cassel is a board member for Premier Inc with a reported compensation  of  $ 235,000 and stock.Does a board member of a corporation not have a fiduciary duty to the corporation.?

Since she has earned the title of expert in the field of medical ethics it seems astonishing to me that she apparently does not consider it an ethical breach to play a leadership role in the NQF and to  receive compensation  from two organizations that could profit ( or loose) based on some recommendations made by that organization. Two ethicist interviewed by Pro Publica seem to disagree and Dr Roy Poses ( see here) who is absolutely untiring in his efforts to point out issues of COI in health care has this to say regarding Dr. Cassel's dual roles:


"However, in my humble opinion, the issue here goes even beyond a blatant and undisclosed conflict of interest.  That a top steward of a big for-profit health care corporation could simultaneously be the top leader of an influential non-profit health care quality improvement organization suggests that increasingly US health care is run by an insular group of insiders whose influence gets ever larger because of their collective power, not necessarily because of their dedication or ability to improving health care.

 As ProPublica put it,
Rosemary Gibson, an author and senior adviser to The Hastings Center, a research group dedicated to bioethics in the public interest, said she wasn’t surprised at Cassel’s outside compensation. So much money permeates decision-making in Washington, she said, that participants have become oblivious.'The insiders don’t see it,' Gibson said. 'It’s like a fish in water.'

Update: 2/27/2014 Dr Cassel has resigned from her posts at Premier and  Kaiser.

Obamacare may decrease employment but at least more folks can "pursue their dreams"

The situation involving recent projections about job loss and Obamacare from the Congressional Budget Office and the White House's reaction to it falls under the joint headings "you can't make this stuff  up" and  You gotta be kidding me"
Yes, the White House really said that now people will be able to pursue their dreams,which is one way of considering  having no job,and those blessed with less work can spend more time with their family as well as having the opportunity to retire early.


See here for Avik Roy's comments regarding the CBO projection of 2.5 millions job losses and the administration's reaction it which should have destroyed any feeble residue of credibility that Obamacare apologists  may still retain.

 No,CBO is not saying that 2.5 millions folks will be fired but rather there will be "a decline in the number of full time equivalent workers of about 2.0 million in 2017 , rising to about 2.5 million in 2014."

Basically the CBO says Obamacare will decrease employment by the millions.Here is Avik Roy's explanation of how that might be brought about.

"The new, larger estimate of the law’s negative impact on the labor force derives from three factors: (1) Obamacare’s employer mandate, which will discourage hiring and reduce wages offered by employers; (2) Obamacare’s $1 trillion in tax increases, which will discourage work and depress economic growth; and (3) the law’s $2 trillion in subsidies for low-income individuals, which will discourage many from remaining in the labor force."

If you were wondering  what the tax increase would be spent you should be reassured that it will all not be wasted as some of it will go to mitigate losses that insurance companies might experience because the plan is not working out quite as projected.See here for what Humana will get so far.In Obamacare's quirky version of social justice all the redistribution does not seem to go to the most disadvantaged making it seem a bit more like crony capitalism.

Are employee wellness programs just silly or can they be hazardous to health?

Leah Binder, writing in Forbes on line ( see here) argues that the answer is "maybe" at least as regards what she calls badly designed programs. She draws from a book from Al Lewis and Kiv Khanna entitled "Surviving workplace wellness".

Practicing internal medicine and pulmonary disease in the late 1970s I had not heard the term "wellness" until I was approached to consult for a large petrochemical company who believed they had a problem with some type of occupational lung disease at one of their facilities. ( The term risk factor was new to me as well)

Later while working part time at that company I sat in on a presentation from a consulting firm who was selling employee wellness programs.They showed slides with huge alleged savings from the detection of early disease in the employees. One cynical older HR person said yes that maybe be true but if we save those lives while folks are working will  we not  be shelling out more money in longer retirement payment because if we have both a health insurance program and a retirement program we will be paying now or paying later.

That argument aside Lewis and Khanna make a persuasive and humorous case for shelving most of what passes for employee wellness programs, which by the way are encouraged by Obamacare giving us reason 962 for never having passed the biggest crony capitalism con job  windfall ever.

The authors tell us that the "sum of value created when an employer plays doctor" can be put in a very small footnote,

stop smoking
eat better
get off your butt

Their analysis resonate with  the impression I had years ago .The difference is they have data to support their conclusions.

So how's that health care insurance for "nearly everyone" working out for you?

Advocates of Obamacare in defense  of it in spite of all the flaws and the ever increasingly list of unintended and intended- but not advertized- consequences ( eg tax payer subsidies for insurance companies  that might loose money on the exchanges) typically fall back on the twin refrains of "health care will be available for nearly everyone" and social justice is being promoted.

Of course, those folks are conflating health care with having insurance but ignoring that for a moment it looks more and more unlikely that the nearly everyone )(usually estimated to be about 30 million) will  actually get the insurance cards . So far  fewer of the uninsured are actually shining up on the exchanges.McKinsey did a study and their analysis indicates that the vast majority of those who are signing up were already insured and only about 11% were moving from the uninsured group to the insured group. See here for some details of that study. If McKinsey's analysis is even close to be correct the 30 million claim will not likely be reached.

As far the social justice argument let me repeat that Rawls defended inequality if it benefited the most disadvantaged in society but while some of that is happening with Obamacare , a significant number are forced into paying more for insurance and often buying benefits which they can never use.

So the plan seemed to be that the young, healthy would sign  up in sufficient numbers to fund the scheme  and the uninsured would rush to the website and sign up since getting those 30 million insured was the purported reason for the legislation in the first place. So far it seems that neither of those things are actually happening in sufficient numbers to   prevent the so called death spiral.More aspects of the Obamacronycare law come to light, one of the most recent  one being the news that HHS is writing or rewriting the details of subsides to bail insurance companies to make them even more generous.

And this quote from Coyote Blog which comments on the fact that many people who are now getting subsidies had insurance before:


"So, we know that 80% of the people are getting subsidized on the exchanges, and now we know that 70-90% of those previously had a unsubsidized policy beforehand.   This means that what the exchanges are doing is NOT insuring the uninsured, but converting people previously responsible for their own health care into government dependents.  The more cynical out there will argue that was the whole point in the first place."


And for  what party will folks dependent on the government likely  vote?

Can widely accepted guidelines be dangerous?

Projections assuming the wide acceptance of peri operative beta blocker guidelines in Europe suggests the answer is a frightening yes..See here for details of what seems to be a candidate for  the mother of all iatrogenic disasters. The authors of that referenced article suggest deaths may be in the hundreds of thousands.Extrapolations are fraught with great mis -estimates but even with assumptions of much less adherence to the guidelines there have to be a large number of patients that died or experienced non fatal strokes in a terribly misguided effort to save lives. Hubris of the medical planners and the danger of excessive faith in the truth producing power of meta analysis and the dangers of guidelines enforcement  are among the windmills at which I  repeatedly joist. 

I shamelessly quote a slightly re-edited comments which I made in 2007 following the disappointing results of the POISE trial that cast an unfavorable light on the use of peri operative beta blockers in non cardiac surgery which demonstrated an increased risk of stroke in the treatment arm of the trial.


"quality measures  often drive care and influence the way physicians care for their patients. If a physician should exert great care in deciding what to do for an individual patient it would seem a greater level of concern and contemplation should be expended in writing "rules" that will influence the care of many patients.

I do not mean to imply that physicians who author quality rules take their responsibility lightly but events such as the beta-blocker saga should perhaps make us insist on a very high standard of proof of efficacy and safety be shown before we presume to tell others physician what they should do particularly when those rules are "enforced" by economic carrots or sticks. Further if an intervention is to prevent something, i.e to decrease the risk of a bad outcome, the level of certainty should be higher than in the circumstance when the physician is treating a certain medical condition.  I increasingly wonder if those sweeping recommendations should be based to a large degree on meta analyses. In a seriously ill, patient you often have to act, even to use treatments that lack super solid proof of efficacy; when you are in the prevention mode, you had better have a much greater level of certainty.

The individual physicians not only have a fiduciary duty to do what it right for the patient but they are held to a legal duty. At least physicians were taught that duty before the days of the New Professionalism as promoted by the ACP with their new ethic and the ABIM Foundation and the Robert Wood Johnson Foundation.See how often you find the word "fiduciary" in the new ethics or the New Professionalism.

The individual physician deals with the stroke patient and has to answer to him and the family, and perhaps to the family's attorney while the quality rule writers have to answer to whom. Apparently no one. Being a  public health expert or a guideline author seems to confer immunity for having to say you are sorry.  The individual physician strives to do what is the right thing for his patient and hopes that what he does is right, the quality rule makers seem presume to know what is good for everyone. Obviously, they frequently do not. Oh well, you can't make an omelet unless...

When guidelines were operationally what they claim to be now suggestions,their benefit and their potential harm was limited. Enter the ever increasing hegemony of the third party payers (government or private insurers ) which  has morphed guidelines into requirements with greatly increased power to do good or harm but with seeming impunity.

(edited on 4/24/24 to correct several spelling and grammar issues)

Are cuts in Medicare (mainly Medicare Advantage) more of the magical social justice of Obamacare?

As this Forbes article by Scott Gottlieb explains,Medicare Advantage programs are in the cross hairs of the Obama administration as ACA continues to roll out benefits for some and just roll over others.

Obamacare is partly funded by cuts to Medicare Advantage,a program popular among low income seniors,particularly those who may not be able to afford the medicare supplements plans.More of these plan members are being shifted to Medicaid, a health care delivery "system" generally perceived as something less than typical care that one obtains under Medicare. If social justice means redistributing stuff around so that the most disadvantaged are benefited. you have to wonder how diminishing the health care for one group of lower income folks to enable another group of low income folks to have insurance cards( not health care but cards) is any type of justice at all. Cuts to Medicare Advanatage had been postponed so that they kick in after the 2012 election, will they be postponed again with the administration's eye on the 2014 elections?

Quoting Dr. Gottlieb:

"The net effect of all of these cuts is already expected to shrink the program. The Obama Administration is disproportionately shifting these cuts onto so-called Medicare “special needs” plans. These are Medicare Advantage plans that are specifically designed to enroll patients with certain serious and costly chronic illnesses like diabetes and heart disease. Many of these patients are low income, and dually eligible for both Medicare and Medicaid. "

 We are seeing more strange social justice in the situation in which the program at least nominally designed to help the most sick of those in Medicare Advantage will be cut the most (that is unless the administration decides to post pone it again in the run up to the next elections).

John Goodman also covers this issue here.

"About one of 20 seniors on Advantage had to switch plans because their old coverage was cancelled, but the damage has been particularly acute in a category called special needs plans, or SNPs. More than 1.5 million people were covered by about 500 of these plans in 2013, but the consultants at Avalere Health report that 13% were wiped out."

Being old and sick and poor is becoming more dangerous for some to help pay for insurance cards for some others who may also be sick and poor.   

As 2014 sees Obamacare ramp up,another tip of the crony hat to its "architect" is in order

Of course no one person wrote the bill,it took a small village of cronies to put it together being as careful as they could to make sure that the health insurers were among  the beneficiaries as well as a few other crony beneficiaries.

A health care "reform" bill was constructed that forced large numbers of the uninsured to buy health insurance and included safeguards ( particularly Section 1341 and section 1342) for the insurance industry to minimize losses should the overall strategy ( to get 40% of the newly enrolled to be young and healthy) not work out as projected.

The statute was crafted by the senate finance committee lead by Max Baucus. According to Baucus much credit should be given to one of his staffers,Liz Fowler. Quoting Mr. Baucus;

"“I wish to single out one person, and that one person is sitting next to me. Her name is Liz Fowler. Liz Fowler is my chief health counsel. Liz Fowler has put my health care team together. Liz Fowler worked for me many years ago, left for the private sector, and then came back when she realized she could be there at the creation of health care reform because she wanted that to be, in a certain sense, her profession lifetime goal."

From 2001 to 2005 Ms.Fowler was Baucus's top health care adviser.She left in 2006 to become Vice President of the nation's largest health care insurer  (Well Point) and returned to play a major role in crafting Obamacare in 2008.That's right, an executive at the nation's largest health care insurer helped write the bill that forced folks to purchase the product that company sold. But it gets even better. She was then hired by the Obama administration to help implement the bill and subsequently left to become a vice president at a pharmaceutical company about which Glen Greenwald ( see here) said the following:

"The pharmaceutical giant that just hired Fowler actively supported the passage of Obamacare through its membership in the Pharmaceutical Researchers and Manufacturers of America (PhRMA) lobby. Indeed, PhRMA was one of the most aggressive supporters - and most lavish beneficiaries - of the health care bill drafted by Fowler. Mother Jones' James Ridgeway proclaimed "Big Pharma" the "big winner" in the health care bill. And now, Fowler will receive ample rewards from that same industry as she peddles her influence in government and exploits her experience with its inner workings to work on that industry's behalf, all of which has been made perfectly legal by the same insular, Versailles-like Washington culture that so lavishly benefits from all of this."

Also of interest is she is now also a member of the Institute of Medicine.See here. The IOM is touted as being a disinterested organization of health care experts who will recommend what is right for the health of the nation and its citizens and whose members are not driven by any special interests.

Of course, none of this is a state secret.Many have written about it including Bil Moyers,Mother Jones, the Huffington Post to name a few.

And yet what do we hear from the physician's organizations, particularly the AMA and the American college of Physicians? Why do not they speak out denouncing this massive pork barrel project.? I cannot accept ignorance or naivete as credible explanations.these organizations have their people in Washington who know what is going on.Surely AMA and ACP do not sponsor, condone or take part in crony capitalism.

Even the Daily Kos,which is very pro Democratic Party,says in headlines " Thank you Max Baucus and Liz Fowler for turning the AHC into a Rube Goldberg machine".. (see here.) while ACP continues its defense of the legislation.

Even recently one of their blogs defended  Obamacare as providing affordable insurance coverage to "nearly  all Americans" and of course, furthering  social justice. Apparently " nearly all" means all but 31 million, not counting those who recently lost their insurance.  Social justice typically means redistribution to benefit the most disadvantaged.Yes, some of that occurs with AHC as some folks do gain an insurance card (but not necessarily medical care)but it is hard not to realize how much redistribution might occur from the taxpayers to the insurance companies and Big Pharma. These increasingly lame defenses of Obamacare is getting embarrassing.