What might Hayek have said about Ezekiel Emanuel's "fair distribution of life years"

I do not claim to be an expert on the incredibly insightful writing of Friederick Hayek and certainly do not really know what he would said in regard to the system of allocation of health care that Dr. Emanuel and his co-authors at the NIH have proposed.(See here for their Jan 2009 Lancet article in which they describe and advocate for their "life years" system) but this quote from Hayek seems appropriate:


--> “…the conception of a ‘value to society’ is sometimes carelessly used even by economists… there is strictly speaking no such thing and the expression implies [a] sort of anthropomorphism or personification of society…Services can have value only to particular people (or an organization), and any particular service will have very different values for different members of society. To regard them differently is to treat society not as a spontaneous order of free men but as an organization whose members are all made to serve a single hierarchy of ends (Law, Legislation and Liberty, vol. 2., p.75).

The "Complete Lives System"-why so little comment from the medical blogger world?

I missed this when it was published earlier this year in the Lancet and it was called to my attention in the blog "Junkfood Science". Here is the article in which Sandy Szwarc so correctly analyzes the Lancet in this entry of her blog which, by the way, seems to get better all the time.

The title of the Lancet article is Principles for allocation of scarce medical interventions.
I may have missed it but the medical ethics blogs that I regularly read seemed to have missed this or ignored it for some reason and the medical blogs generally have had little to say, with John Goodman (see here) and Sandy Szwarc being notable exceptions.

The basic premise seems to be that since someone or some entity must allocate scare medical resources there should be a "morally" acceptable method for such allocation. The authors, which include Dr. Ezekiel J Emanuel, brother of President Obama's Chief of Staff, and "Special Advisor for Health Policy" to the president presents a detailed proposal of how this allocation should be done. (Using the passive voice here serves the purpose or not having to say that the government will do the allocation.)

The authors begin with a critical review of the currently in existence allocation systems and finding flaws in each proceed to devise their own "hybrid" supposedly salvaging the good and casting out the less desirable elements of the various systems.

Expectedly, this "morally acceptable" allocation process would allocate less to the elderly and those with incurable illnesses. Perhaps unexpectedly, their process would place, for example, a fifteen year person allocation-wise above an infant because they say more social expenditures have been made on the adolescent and society need to get its money's worth.

The underlying theme is that individuals exist for the good of the collective ( state, society, pick one) and in health care decisions the greater good of society, now apparently denominated in "life years", trump the individual every time.

The authors describe their system:

This system incorporates five principles ... youngest-first, prognosis, save the most lives, lottery, and instrumental value. As such, it prioritises younger people who have not yet lived a complete life and will be unlikely to do so without aid. Many thinkers have accepted complete lives as the appropriate focus of distributive justice: “individual human lives, rather than individual experiences, [are] the units over which any distributive principle should operate.”Although there are important differences between these thinkers, they share a core commitment to consider entire lives rather than events or episodes, which is also the defining feature of the complete lives system.

They explain further in regard to the old folks issue.

Unlike allocation by sex or race, allocation by age is not invidious discrimination; every person lives through different life stages rather than being a single age. Even if 25-year-olds receive priority over 65-year-olds, everyone who is 65 years now was previously 25 years. Treating 65-year olds differently because of stereotypes or falsehoods would be ageist; treating them differently because they have already had more life-years is not.

The blog Freerepublic.com summarizes the system in this way.

Infants get minimal treatment, because the State has not invested anything yet in their education. Old people get minimal treatment because their working lives are over.

So if you discriminate because someone is old that is ageism and invidious but if you treat differently because they have lived longer ( i.e. have had more life years) it is not. Talk about contrived nonsense.

Here is another quote that I find chilling.

the complete lives system assumes that, although life-years are equally valuable to all, justice requires the fair distribution of them.” (my bolding)

If you like social justice that sentence should really please you. Not only should most things be distributed fairly but now apparently how many "life-years" you get.

If you like distributive justice you will find a lot to like here. If you are old enough for Medicare or economically unfortunate enough to rely on Medicaid, you might be a little worried that the President's Advisor on health matters thinks this way.

It should be noted ,however, that Emanuel seems to believe that a two-tier system is ethically acceptable and he wrote the following about in 1996 :

... The fundamental challenge to theories of distributive justice for health care is to develop a principled mechanism for defining what fragment of the vast universe of technically available, effective medical care services is basic and will be guaranteed socially and what services are discretionary and will not be guaranteed socially. Such an approach accepts a two-tiered health system-some citizens will receive only basic services while others will receive both basic and some discretionary health services. Within the discretionary tier, some citizens will receive few discretionary services, other richer citizens will receive almost all of available services, creating a multiple-tiered system.

Link for the complete article for the above excerpt is here.

So, even though justice demands a fair distribution of life years, you can opt out of that distribution system by being rich enough.

After reading Dr. Emanuel's writings that seem to give his ethical blessing to a multiple-tiered system, my inner libertarian was somewhat relieved. Yet the chilling nature of the notion that life-years should be distributed fairly frightens the hell out of me.

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

An argument can be made for either candidate.

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

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

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

Can we really save the economy by spending more?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Comment writer asks retired doc about single payer

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

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

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

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

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

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

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

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

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

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

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

"Transformation to the PCMH Requires Personal Transformation of Physicians

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

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

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

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

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

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

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

Ignoring history-doomed to repeat it ?

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

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

I quote from section 1801:

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

So how has that worked out?

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Does ultra sound help decisions regarding length of anticoagulation for DVT

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

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

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

Annals Internal Medicine commentary laments imminent death of internal medicine

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The IOM speaks: mandatory nap time for house staff

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

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

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

More and More data is ganging up on Proton pump inhibitors

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

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

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

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

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

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

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