Here are two real docs telling a story that seems to be lost to many of the medical elite who smoke the progressive pipe and sing the manta "medicine is too complex and important to be left in the hands of the individual physician and patient". See this commentary from the blog In my Humble Opinion and these remarks from a practicing ophthalmologist in Texas which was featured on Dr. G.Keith Smith's website,Surgerycenterofoklahoma.
Wednesday, July 31, 2013
Wednesday, July 17, 2013
Will Obamacare bring social justice(as claimed by AMA and ACP) or "Shatter the Backbone of the Middle Class"?
Obamacare was lauded by some democratic senators and some medical organizations ( e.g. the AMA and ACP) as finally delivering long awaited social justice to health care in the U.S. Labor unions supported Obama's candidacy as well as the bill. Now as some of the devilish details are oozing out of the hundreds of pages of dense legislative verbiage,labor union leaders are realized they may well not get the really good deal they believe they had been promised.
Now three unions are demanding that the administration make changes in the interpretation of the statute ( can you say "waivers") to lessen any negative impact on various unions health care plans.See here for details.
One brief quote from a letter to Democratic leaders in the House and Senate that was signed by Jimmy Hoffa :
" We have a problem; you need to fix it. The unintended consequences of the ACA are severe. Perverse incentives are already creating nightmare scenarios."
Perhaps Obamaconcare might be a more appropriate name as more and more folks are realizing they were conned.
Now three unions are demanding that the administration make changes in the interpretation of the statute ( can you say "waivers") to lessen any negative impact on various unions health care plans.See here for details.
One brief quote from a letter to Democratic leaders in the House and Senate that was signed by Jimmy Hoffa :
" We have a problem; you need to fix it. The unintended consequences of the ACA are severe. Perverse incentives are already creating nightmare scenarios."
Perhaps Obamaconcare might be a more appropriate name as more and more folks are realizing they were conned.
Sunday, July 07, 2013
How/why/when did physicians get tasked with being "stewards of resources"?
Let's take at look at the the strange journey of physician's ethics from fiduciary duty to the patient to stewards of society's medical resources.
When I trained as an internist in the late 60s and early 70s,medical ethics seemed very straight forward and was so uncontroversial that is was rarely the topic for discussion.The physician had a fiduciary duty to the patient and he was to place the patient's interests first and do what was right for the patient and to do no harm to the patient.
It was a time when the hegemony of the third party medical payers (insurance companies and CMS) was not an issue. It was the era of "retail medicine" in which indemnity insurance followed the patients and the payments for physician's services were dispensed according to what was said to be "customary,reasonable and prevailing". Insurance companies did not determine which hospital a physician used,which consultants to be used for referrals nor what medications were approved for use.Physicians who vigorously advocated for their patients as it involved some hospital practice were not summoned before a kangaroo court on charge of being "disruptive".
As time passed there appeared on the scene a perfect storm of forces and events that accelerated medical costs.There were new diagnostic tests (mainly imaging procedures),new therapies,patients were spending what they considered to be other people's money and physicians believed they were ethically bound to do what they thought was right for the patient which often included more rather than fewer tests .
As medical care costs and expenditures increased, third party payers including large corporations who provided health insurance ( those who were self insured) took measures to control costs. There were larger deductibles and co-payments and more scrutiny by insurance companies on what exactly they would pay for. There were guidelines and pre approval rules for testing.The concept of gate keeper was born. These counter measures probably mitigated price increases a bit but costs continued to rise and continue they would as basically this was folks spending someone else's money and the fingers on the cost guns were in the hands of hundreds of thousands of physicians many in sole or small group practices whose actions continued to be largely outside of the control of the third part payers.
The problem was how to control the activities on these physicians who had been inculcated for many decades with the ethical imperative of do what is right for the patient. For one trained in that ethical environment, cost to " the system", be it United Health Care,Exxon, or Medicare,was not a major priority in their value or decision making calculus.
So various variations of carrots and sticks were employed by the third party payer.Pay for performance grew up as a type of bribe to docs to follow the cost cutting guidelines which went by the wink,wink,nudge, nudge name of quality guidelines.
Although carrot and stick techniques have a proven history of changing behaviors to some degree,what would be even better is to have at the triggers of medical cost initiation e.g physicians (or some alternative "health care provider", i.e NPs, PAs) who really believe their duty lies at least to a significant operational degree in cost saving and to preserving the medical collective's resources.
Enter the concept of physicians as stewards of society's resources.
I have not developed a detailed chronology of that part of the literature which deals with medical policy matters to be able to date with any precision when and how this concept arose. I have written before on some of the earlier papers in the mainstream medical literature.
In 1988 Hall and Berenson writing in the Annals of Internal Medicine said that "the traditional ideal" [the prime duty to the patient ] was "not compatible with the role that existing insurance contracts and manged care arrangements define for physicians." Their comments were not subtle when they said :
"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."
Note:Berenson and Hall glibly justify that ethical sea change because the role that insurance contracts define for the physicians. Here we might pause and remember that one of the defining characteristics of a profession is that members are bound by a ethical code that is largely self defined.
Over the next 20 years far from that proposal being dismissed out of hand as medical ethical heresy which is how many physicians at the time would have characterized it, it has become part of the generally accepted medical ethical package nestled in professionalism statements by many professional medical organizations and has become part of medical education .
The fiduciary duty to the patient seem to have been demolished ( or at least made secondary) with unsuccessful attempts by physicians of the old school to battle the propaganda juggernaut . The dogs bark and the caravan moves on.
We have traveled a long way since the Berenson article.Now we read of a suggestion that "cost-consciousness and stewardship of resources be elevated by the ACGME and the ABMS to the level of a a new seventh general competency." In other words, residents should be schooled and graded on their mastery of the skill set necessary to be good stewards of [society's] resources. ( reference, The Idea and Opinions Section, Annals of Internal Medicine,20 Sept 2011,Vol.155 no.6, by Dr. Steven E. Weinberger,of the American College of Physicians.
Interestingly, in the 1999 Ethics Statement of the council of Medical Specialty Societies (CMSS) there was no mention of physicians as stewards of medical resources but rather the document talked about physicians as stewards of medical knowledge.(As best I can determine the 1999 Ethic statement is the most recent)
A CFO of a HMO or now a ACO could not devise a better ethical precept- at least for their bottom line- than for physicians to be ethically bound to "conserve medical resources".
Operationally to be a good steward one need only adhere to the organization's guide lines which may be derived from aggregate data and the statistical utilitarianism of outcome research or at times the opinion of self designated experts. Just ask the economist Fucks how to resolve the ethical conflict for the physician facing with the good of his patient or the good of the group. Who better to give ethical advise to physicians than an economist? See here for comments on Fuchs' "solution".
So we have gone from the primacy of the welfare of the individual patient and the fiduciary duty of the physician to the patient to a Two Master concept of professionalism.
Dr. Accad of the blog,Alert and Oriented, has commented that "Medicine is dominated by the collectivist Ideology". I agree and one striking manifestation of that dominance chiefly driven by medical academia, is the acceptance of the concept of the physician as medical resource steward. What place does/will the traditional physician-patient relationship have in this formulation?
The medical ethicist Dr. Edmund Pellegrino in 1995 asked ...can physicians change the ethics of the profession at will ( as proposed by Berenson and Hall or Berwick and Brennan)) or is there a more fundamental and universal foundation for the ethics of medicine found in the special nature of the physician-patient relationship?
Pellegrino is quoted from an article entitled "Guarding the Integrity of Medical Ethics-Some Lessons from Soviet Russia" . The subversion of medical ethics that occurred in Russia suggested to Pellegrino two lessons.
1) corruption will afflict any health system not designed with care of the patient as the its primary driving force. 2) medical ethics must be independent of political exigency. "... a morally responsive profession is an indispensable safeguard for the sick against the statistical morality of utilitarian politics, even in democracies."
How did it happen? How did the ideological certitude that we had as residents in the 1970s in regard to our ethical obligations morph into the divided loyalties and the two master concept that now seem destined to become codified in the training program? Following the Mafia rule, we look to the third party payer who are the obvious beneficiaries of the stewardship concept but what did they do to achieve that change? Did the academic medical progressives pave the way with their rhetoric and lobbying?
Language can be used as a tool of change. Dr. Thomas Szazz, one of my favorite iconoclasts, said "Define or be defined". Physicians, once a profession that defined its ethics now has been and is being defined by a relatively small group of academic physicians . Patients are now designated as consumers of health care or customers,Both terms leave no room for discussion of the physician patient relationship.Physicians are redefined as stewards of resources.
New terms have been slipped into discussion about health care. These include "professionalism" which seems to be a pattern of behaviors and a system of values that has been unilaterally grafted onto the top of medical ethics largely as the results of a group ( not necessarily an organized group per se but they are active in some internists organizations) of internists whose views are basically liberal ( not in the sense of classical liberalism) or more accurately progressive. Then the term professionalism was used as a vehicle to dictate a series of given policies which according to the definers are the necessary characteristics of physician's professionalism , This include a striving for social justice and to be "stewards of medical resources". The operational meaning of the later terms is to conserve resources by following guidelines that to some degree and sometimes derived in part from cost effectiveness and cost comparative studies.
So here is how is worked. Physicians not only have to adhere to the usual medical ethical principles but they must also behave according to the new guidelines of professionalism ( which were conceived and promoted by a small group of like minded internists) which include being stewards of resources which practically means following guidelines.
So back to the title. The how was largely through the perhaps well intentioned persistent and well funded efforts ( think the Robert Wood Johnson Foundation et al) of the progressive medical elite subset of physicians to flim flam physicians to accept the 180 degree turn in professional ethics,the why was the increasing concern of the third payers for the increasing cost of medical care fueled in part by folks spending other people's money .The when is not identifiable as one specific date or event but rather more like the process of frog boiling over the post 25 to 30 years.
Addendum: 7/8/13 An apology is in order. On 7/7/13 I was drafting this posting and I hit post instead of save . As as result a rough form was published . The above is a rushed effort to smooth the edges.
When I trained as an internist in the late 60s and early 70s,medical ethics seemed very straight forward and was so uncontroversial that is was rarely the topic for discussion.The physician had a fiduciary duty to the patient and he was to place the patient's interests first and do what was right for the patient and to do no harm to the patient.
It was a time when the hegemony of the third party medical payers (insurance companies and CMS) was not an issue. It was the era of "retail medicine" in which indemnity insurance followed the patients and the payments for physician's services were dispensed according to what was said to be "customary,reasonable and prevailing". Insurance companies did not determine which hospital a physician used,which consultants to be used for referrals nor what medications were approved for use.Physicians who vigorously advocated for their patients as it involved some hospital practice were not summoned before a kangaroo court on charge of being "disruptive".
As time passed there appeared on the scene a perfect storm of forces and events that accelerated medical costs.There were new diagnostic tests (mainly imaging procedures),new therapies,patients were spending what they considered to be other people's money and physicians believed they were ethically bound to do what they thought was right for the patient which often included more rather than fewer tests .
As medical care costs and expenditures increased, third party payers including large corporations who provided health insurance ( those who were self insured) took measures to control costs. There were larger deductibles and co-payments and more scrutiny by insurance companies on what exactly they would pay for. There were guidelines and pre approval rules for testing.The concept of gate keeper was born. These counter measures probably mitigated price increases a bit but costs continued to rise and continue they would as basically this was folks spending someone else's money and the fingers on the cost guns were in the hands of hundreds of thousands of physicians many in sole or small group practices whose actions continued to be largely outside of the control of the third part payers.
The problem was how to control the activities on these physicians who had been inculcated for many decades with the ethical imperative of do what is right for the patient. For one trained in that ethical environment, cost to " the system", be it United Health Care,Exxon, or Medicare,was not a major priority in their value or decision making calculus.
So various variations of carrots and sticks were employed by the third party payer.Pay for performance grew up as a type of bribe to docs to follow the cost cutting guidelines which went by the wink,wink,nudge, nudge name of quality guidelines.
Although carrot and stick techniques have a proven history of changing behaviors to some degree,what would be even better is to have at the triggers of medical cost initiation e.g physicians (or some alternative "health care provider", i.e NPs, PAs) who really believe their duty lies at least to a significant operational degree in cost saving and to preserving the medical collective's resources.
Enter the concept of physicians as stewards of society's resources.
I have not developed a detailed chronology of that part of the literature which deals with medical policy matters to be able to date with any precision when and how this concept arose. I have written before on some of the earlier papers in the mainstream medical literature.
In 1988 Hall and Berenson writing in the Annals of Internal Medicine said that "the traditional ideal" [the prime duty to the patient ] was "not compatible with the role that existing insurance contracts and manged care arrangements define for physicians." Their comments were not subtle when they said :
"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."
Note:Berenson and Hall glibly justify that ethical sea change because the role that insurance contracts define for the physicians. Here we might pause and remember that one of the defining characteristics of a profession is that members are bound by a ethical code that is largely self defined.
Over the next 20 years far from that proposal being dismissed out of hand as medical ethical heresy which is how many physicians at the time would have characterized it, it has become part of the generally accepted medical ethical package nestled in professionalism statements by many professional medical organizations and has become part of medical education .
The fiduciary duty to the patient seem to have been demolished ( or at least made secondary) with unsuccessful attempts by physicians of the old school to battle the propaganda juggernaut . The dogs bark and the caravan moves on.
We have traveled a long way since the Berenson article.Now we read of a suggestion that "cost-consciousness and stewardship of resources be elevated by the ACGME and the ABMS to the level of a a new seventh general competency." In other words, residents should be schooled and graded on their mastery of the skill set necessary to be good stewards of [society's] resources. ( reference, The Idea and Opinions Section, Annals of Internal Medicine,20 Sept 2011,Vol.155 no.6, by Dr. Steven E. Weinberger,of the American College of Physicians.
Interestingly, in the 1999 Ethics Statement of the council of Medical Specialty Societies (CMSS) there was no mention of physicians as stewards of medical resources but rather the document talked about physicians as stewards of medical knowledge.(As best I can determine the 1999 Ethic statement is the most recent)
A CFO of a HMO or now a ACO could not devise a better ethical precept- at least for their bottom line- than for physicians to be ethically bound to "conserve medical resources".
Operationally to be a good steward one need only adhere to the organization's guide lines which may be derived from aggregate data and the statistical utilitarianism of outcome research or at times the opinion of self designated experts. Just ask the economist Fucks how to resolve the ethical conflict for the physician facing with the good of his patient or the good of the group. Who better to give ethical advise to physicians than an economist? See here for comments on Fuchs' "solution".
So we have gone from the primacy of the welfare of the individual patient and the fiduciary duty of the physician to the patient to a Two Master concept of professionalism.
Dr. Accad of the blog,Alert and Oriented, has commented that "Medicine is dominated by the collectivist Ideology". I agree and one striking manifestation of that dominance chiefly driven by medical academia, is the acceptance of the concept of the physician as medical resource steward. What place does/will the traditional physician-patient relationship have in this formulation?
The medical ethicist Dr. Edmund Pellegrino in 1995 asked ...can physicians change the ethics of the profession at will ( as proposed by Berenson and Hall or Berwick and Brennan)) or is there a more fundamental and universal foundation for the ethics of medicine found in the special nature of the physician-patient relationship?
Pellegrino is quoted from an article entitled "Guarding the Integrity of Medical Ethics-Some Lessons from Soviet Russia" . The subversion of medical ethics that occurred in Russia suggested to Pellegrino two lessons.
1) corruption will afflict any health system not designed with care of the patient as the its primary driving force. 2) medical ethics must be independent of political exigency. "... a morally responsive profession is an indispensable safeguard for the sick against the statistical morality of utilitarian politics, even in democracies."
How did it happen? How did the ideological certitude that we had as residents in the 1970s in regard to our ethical obligations morph into the divided loyalties and the two master concept that now seem destined to become codified in the training program? Following the Mafia rule, we look to the third party payer who are the obvious beneficiaries of the stewardship concept but what did they do to achieve that change? Did the academic medical progressives pave the way with their rhetoric and lobbying?
Language can be used as a tool of change. Dr. Thomas Szazz, one of my favorite iconoclasts, said "Define or be defined". Physicians, once a profession that defined its ethics now has been and is being defined by a relatively small group of academic physicians . Patients are now designated as consumers of health care or customers,Both terms leave no room for discussion of the physician patient relationship.Physicians are redefined as stewards of resources.
New terms have been slipped into discussion about health care. These include "professionalism" which seems to be a pattern of behaviors and a system of values that has been unilaterally grafted onto the top of medical ethics largely as the results of a group ( not necessarily an organized group per se but they are active in some internists organizations) of internists whose views are basically liberal ( not in the sense of classical liberalism) or more accurately progressive. Then the term professionalism was used as a vehicle to dictate a series of given policies which according to the definers are the necessary characteristics of physician's professionalism , This include a striving for social justice and to be "stewards of medical resources". The operational meaning of the later terms is to conserve resources by following guidelines that to some degree and sometimes derived in part from cost effectiveness and cost comparative studies.
So here is how is worked. Physicians not only have to adhere to the usual medical ethical principles but they must also behave according to the new guidelines of professionalism ( which were conceived and promoted by a small group of like minded internists) which include being stewards of resources which practically means following guidelines.
So back to the title. The how was largely through the perhaps well intentioned persistent and well funded efforts ( think the Robert Wood Johnson Foundation et al) of the progressive medical elite subset of physicians to flim flam physicians to accept the 180 degree turn in professional ethics,the why was the increasing concern of the third payers for the increasing cost of medical care fueled in part by folks spending other people's money .The when is not identifiable as one specific date or event but rather more like the process of frog boiling over the post 25 to 30 years.
Addendum: 7/8/13 An apology is in order. On 7/7/13 I was drafting this posting and I hit post instead of save . As as result a rough form was published . The above is a rushed effort to smooth the edges.
Thursday, July 04, 2013
Obamacare in action substitutes "Rule by Rulers" for Rule of Law
The term "Rule of Law" may be discussed in at least three different contextual frameworks. The formal or so called thin interpretation states that law must be prospective,well known, and have the features of equality and certainty. The law must be clear and apply to everyone. The substantive or so called thick interpretation says that the law protects individual rights. In the functional approach rule of law is defined by contrast with rule of man. FA Hayek talks about the rule of law as contrasted with arbitrary government edicts or proclamations.
Whatever framework you prefer, the manner in which Obamacare so far has been administered by the government exemplifies rule by arbitrary governmental order or as Michael Cannon phrased it in his Cato commentary "Rule by Rulers" (see here). Quoting Mr. Cannon:
"...the IRS’s unilateral decision to delay the employer mandate is the latest indication that we do not live under a Rule of Law, but under a Rule of Rulers who write and rewrite laws at whim, without legitimate authority, and otherwise compel behavior to suit their ends. Congress gave neither the IRS nor the president any authority to delay the imposition of the Patient Protection and Affordable Care Act’s employer mandate. In the section of the law creating that mandate, Congress included several provisions indicating the mandate will take effect in 2014. In case those provisions were not clear enough, Section 4980H further clarifies:
Read all of Cannon's essay in which he lists some of the various ways that the current administration has behaved like "rulers" exercising powers not delegated by the statute to protect Obamacare's image and to lessen any negative impact it may have on their supporters (think unions) and on elections (think Medicare advantage and the 2014 mid term congressional and fallout from the disruption of the employer mandate.)
So both houses of congress pass a law,with great fanfare the President signs the law and then SCOTUS declares most the law is constitutional. And now an administrative agency simply ignores the letter and intent of the law and postpones a portion of it even though it has no statutory authority to do so. Will Madisonian checks and balances kick it to play and somehow order the IRS to obey the law? I think not- most of the times legality or fear of judicial action does not impede the current trend of ruling by rulers.More and more no one complains and the courts are not called upon. The barking dogs in the blog world and the non Main Stream Media bark away (along with the occasional legislator) and the ruler caravan moves on.
Addendum: 7/5/2013 It just gets more and more unclear as more analyses are offered. See here for a detailed discussion about the issue of what exactly is being postponed.Does the administration really have the authority to do whatever they think they did?Does anyone have legal standing to bring legal action to force the administration of a statute? And even if the courts found for the plaintiff ( if one could be found) could the court really force the executive to do anything? I'll bet that James Madison thought his checks and balances and "sufficient virtue" of the American people would have worked out better.
Addendum: 7/8/2013. More delays in Obamacare. In this posting from the Washington Post we learn that some elements of Obamacare will be on the "honor system", at least for a while.Somehow I have a problem thinking about the IRS overseeing a honor system arrangement.
Whatever framework you prefer, the manner in which Obamacare so far has been administered by the government exemplifies rule by arbitrary governmental order or as Michael Cannon phrased it in his Cato commentary "Rule by Rulers" (see here). Quoting Mr. Cannon:
"...the IRS’s unilateral decision to delay the employer mandate is the latest indication that we do not live under a Rule of Law, but under a Rule of Rulers who write and rewrite laws at whim, without legitimate authority, and otherwise compel behavior to suit their ends. Congress gave neither the IRS nor the president any authority to delay the imposition of the Patient Protection and Affordable Care Act’s employer mandate. In the section of the law creating that mandate, Congress included several provisions indicating the mandate will take effect in 2014. In case those provisions were not clear enough, Section 4980H further clarifies:
(d) EFFECTIVE DATE.—The amendments made by this section shall apply to months beginning after December 31, 2013.It is hard to see how the will of the people’s elected representatives – including President Obama, who signed that effective date into law – could have been expressed more clearly, or how it could be clearer that the IRS has no legitimate power to delay the mandate."
Read all of Cannon's essay in which he lists some of the various ways that the current administration has behaved like "rulers" exercising powers not delegated by the statute to protect Obamacare's image and to lessen any negative impact it may have on their supporters (think unions) and on elections (think Medicare advantage and the 2014 mid term congressional and fallout from the disruption of the employer mandate.)
So both houses of congress pass a law,with great fanfare the President signs the law and then SCOTUS declares most the law is constitutional. And now an administrative agency simply ignores the letter and intent of the law and postpones a portion of it even though it has no statutory authority to do so. Will Madisonian checks and balances kick it to play and somehow order the IRS to obey the law? I think not- most of the times legality or fear of judicial action does not impede the current trend of ruling by rulers.More and more no one complains and the courts are not called upon. The barking dogs in the blog world and the non Main Stream Media bark away (along with the occasional legislator) and the ruler caravan moves on.
Addendum: 7/5/2013 It just gets more and more unclear as more analyses are offered. See here for a detailed discussion about the issue of what exactly is being postponed.Does the administration really have the authority to do whatever they think they did?Does anyone have legal standing to bring legal action to force the administration of a statute? And even if the courts found for the plaintiff ( if one could be found) could the court really force the executive to do anything? I'll bet that James Madison thought his checks and balances and "sufficient virtue" of the American people would have worked out better.
Addendum: 7/8/2013. More delays in Obamacare. In this posting from the Washington Post we learn that some elements of Obamacare will be on the "honor system", at least for a while.Somehow I have a problem thinking about the IRS overseeing a honor system arrangement.
Tuesday, June 18, 2013
"The fundamental problem with state and employer-based programs"..[in regared to health care]
The title comes from the following paragraph written by Nobel prize winning economist Vernon Smith in his 2008 book entitled "Rationality in Economics" which is found on page 96:
"The fundamental problem with state and employment-based programs to solve the problem of extending medical care to all risk classes is as follows:
A (the physician,hospital,or other medical service supplier) recommends to B (the patient) what he or she should buy from A and C (the insurance company or government) reimburses A for the services. This is an incentive nightmare and it explains why the price of medical services persistently rises faster than almost all other economic products and services..."
Smith then comments that educational services are analogous and continues "These are examples in which consumer sovereignty is compromised by lack of direct experience and knowledge, and the supplier who harbors an inherent conflict of interest, is considered best capable of deciding what the consumer should buy."
If Smith analysis is on target what can we expect fromthe massive crony capitalism health care bill Obamacare? Many more folks are eligible for Medicaid (depending on what various states do) and will get health care paid for by government money also known as someone else's money and possibly more will be covered by employers health insurance which is typically spent by employees in the belief that they are spending someone else's money. So the incentive nightmare of Smith's ABCs made even worse.
The incentive issue is what Milton Freedman talks about when he talked about the various way people can spend money.
"The fundamental problem with state and employment-based programs to solve the problem of extending medical care to all risk classes is as follows:
A (the physician,hospital,or other medical service supplier) recommends to B (the patient) what he or she should buy from A and C (the insurance company or government) reimburses A for the services. This is an incentive nightmare and it explains why the price of medical services persistently rises faster than almost all other economic products and services..."
Smith then comments that educational services are analogous and continues "These are examples in which consumer sovereignty is compromised by lack of direct experience and knowledge, and the supplier who harbors an inherent conflict of interest, is considered best capable of deciding what the consumer should buy."
If Smith analysis is on target what can we expect from
The incentive issue is what Milton Freedman talks about when he talked about the various way people can spend money.
Friday, May 24, 2013
Will Obamacare's success depend of the kindness and goodwill of strangers (young , healthy ones)?
Dr. Ezekiel Emanuel seems to make exactly that point in this WSJ opinion piece.
Quoting Dr. Emanuel :
"Here is the specific problem: Insurance companies worry that young people, especially young men, already think they are invincible, and they are bewildered about the health-care reform in general and exchanges in particular. They may tune out, forego purchasing health insurance and opt to pay a penalty instead when their taxes come due.
The consequence would be a disproportionate number of older and sicker people purchasing insurance, which will raise insurance premiums and, in turn, discourage more people from enrolling. This reluctance to enroll would damage a key aspect of reform."
Dr. Emanuel goes on with this bit of wishful thinking.
"... The president connects with young people, too, so he needs to use that bond and get out there to convince them to sign up for health insurance to help this central part of his legacy....
Second, we need to make clear as a society that buying insurance is part of individual responsibility. If you don't have insurance and you need to go to the emergency room or unexpectedly get diagnosed with cancer, you are free- riding on others."
Question for the day. How often have mammoth ,disruptive and costly social programs succeed on the basis of exhorting people to do the "right thing"? Is this a sign of desperation on the part of the diminishing number of vocal advocates for Obamacare that they resort to a plea for some to act mainly in the interest of others?
Plans and schemes that ignore the persistent and widespread tendency of humans to act in their own self interest have seldom enjoyed lasting success.
Mises and Hayek in their efforts in the Socialist Calculation debate emphasized that central planing would fail because of two problems;the knowledge problem and the incentive problem. Planning would fail in the absence of the guidance from prices derived from the free market and because of the inherent persistent characteristic of humans to act in their own self interest. The history of the 20th century should have made clear to all but the clueless that depending on the transformation of human nature for something to work was not a viable plan.
h/t to Dr. Paul Hsieh for his insightful, recent commentary in PJ Media ("Is Obamacare's Fatal Flaw taking effect?") in which he discusses Emmanuel's essay as well as other developments strongly suggesting that Obamacare is unraveling before it is fully implemented as increasing number of former supporters seem to be jumping ship.See here.
Quoting Dr. Emanuel :
"Here is the specific problem: Insurance companies worry that young people, especially young men, already think they are invincible, and they are bewildered about the health-care reform in general and exchanges in particular. They may tune out, forego purchasing health insurance and opt to pay a penalty instead when their taxes come due.
The consequence would be a disproportionate number of older and sicker people purchasing insurance, which will raise insurance premiums and, in turn, discourage more people from enrolling. This reluctance to enroll would damage a key aspect of reform."
Dr. Emanuel goes on with this bit of wishful thinking.
"... The president connects with young people, too, so he needs to use that bond and get out there to convince them to sign up for health insurance to help this central part of his legacy....
Second, we need to make clear as a society that buying insurance is part of individual responsibility. If you don't have insurance and you need to go to the emergency room or unexpectedly get diagnosed with cancer, you are free- riding on others."
Question for the day. How often have mammoth ,disruptive and costly social programs succeed on the basis of exhorting people to do the "right thing"? Is this a sign of desperation on the part of the diminishing number of vocal advocates for Obamacare that they resort to a plea for some to act mainly in the interest of others?
Plans and schemes that ignore the persistent and widespread tendency of humans to act in their own self interest have seldom enjoyed lasting success.
Mises and Hayek in their efforts in the Socialist Calculation debate emphasized that central planing would fail because of two problems;the knowledge problem and the incentive problem. Planning would fail in the absence of the guidance from prices derived from the free market and because of the inherent persistent characteristic of humans to act in their own self interest. The history of the 20th century should have made clear to all but the clueless that depending on the transformation of human nature for something to work was not a viable plan.
h/t to Dr. Paul Hsieh for his insightful, recent commentary in PJ Media ("Is Obamacare's Fatal Flaw taking effect?") in which he discusses Emmanuel's essay as well as other developments strongly suggesting that Obamacare is unraveling before it is fully implemented as increasing number of former supporters seem to be jumping ship.See here.
Monday, May 13, 2013
James Madison on Obamacare
"It will be of little avail to the people that the laws are made by those they elected, if laws be so voluminous that they cannot be read, or so incoherent that they cannot be understood."
James Madison, Federalist no. 62.
According to this source while the House bill and the Senate version contained over 2,000 pages a PDF file of the final law has "only" 906 pages.I could find no link attempting to quantify its incoherence.
Thursday, April 25, 2013
To discuss "high value" medical care do we need to begin with what is value
Apparently in the history of economics for a while the early thinkers in the field were a bit perplexed by what was known as the diamond-water paradox.Why was is that diamonds were worth so much more that water even though water was necessary for life.
The story goes that in the late 1800s three economists working independently devised what became known as the subjective marginal theory of value. Their notion was that value was not inherent in an object but value was in the eye and mind of the valuer.There is no such thing as value without a valuer.Further the valuers made their evaluation at the margin. (Economist like to talk about margins a lot) A man living by a lovely stream of potable water would pay little or nothing for a glass while a person lost in the desert without supplies would pay almost anything for a drink.The early economists were considering things from the view point of mankind in general for whom water was essential for life but the value of a given increment of water was evaluated by individual people each with their own set of values and needs and circumstances which could change over time.It was the value at the margin, the marginal value, and it was subjective.
The American College of Physicians (ACP) has announced a program called" High value,cost conscious care" ( HVCC). See here for some details.
Value is not inherent in things but is subjective but there may be objective proxy-measures of value such a market value. However, these measures in turn depend on the subjectivity of the individuals who make the choices. I have no reason to believe that the leaders of ACP have anything but good intentions in this initiative but I wonder if their notion of value is stuck somewhere in the early 19th century.
Here is a quote from ACP that seems to say we can have our cake and eat it too.
"[ the initiative is] to help physicians and patients understand the benefits, harms, and costs of an intervention and whether it provides good value, and to slow the unsustainable rate of health care costs while preserving high-value, high-quality care."
My question is in regard to how will "good" or "high "value be determined. It seems like the history of the notion of value in the world of economics has lead to the widely accepted concept that value is subjective.Does this now say that after all value can really be objectively determined? So the advocates and practitioners of cost effectiveness would seem to say. I should add in fairness that the authors of the quoted Annals article do state that in the final analysis a subjective judgement in required.At the end of the analytic process someone or some group makes a subjective judgment.Is the benefit greater than the risks or does treatment x cost "too much".Too much in the judgment of whom. Will the value be decided by the patient to whom the risk and benefits accrue or will the value be decided by a group of medical experts after making a cost effectiveness "determination".
In the March 7,2013 issue of the NEJM there is a thoughtful commentary by Dr. Lisa Rosenbaum entitled "The Whole Ball Game-Overcoming the Blind Spots in Health Care Reform" which addresses certain aspects of the notion of value in health care. She says:
"Value in health care, however,depends on who is looking , where they look and what they expect to see....". Are we fooling ourselves if we believe that efforts to reign in health care cost can be done by only eliminating things of low value?"
That quote seems to express the notion of subjective value- that individuals subjectively evaluate a given event ( test or treatment ) from her own point of view which may or may not coincide with a determination of value by practitioners of cost effectiveness and cost benefit analysis who after they carry out the various elements of their statistical package make their own subjective evaluation cloaked though it may be in the robes of a purported objective analysis. Is the real bottom line here the accounting bottom line of the third party payers?
5/30/14. several minor corrections made in spelling and punctuation.
The story goes that in the late 1800s three economists working independently devised what became known as the subjective marginal theory of value. Their notion was that value was not inherent in an object but value was in the eye and mind of the valuer.There is no such thing as value without a valuer.Further the valuers made their evaluation at the margin. (Economist like to talk about margins a lot) A man living by a lovely stream of potable water would pay little or nothing for a glass while a person lost in the desert without supplies would pay almost anything for a drink.The early economists were considering things from the view point of mankind in general for whom water was essential for life but the value of a given increment of water was evaluated by individual people each with their own set of values and needs and circumstances which could change over time.It was the value at the margin, the marginal value, and it was subjective.
The American College of Physicians (ACP) has announced a program called" High value,cost conscious care" ( HVCC). See here for some details.
Value is not inherent in things but is subjective but there may be objective proxy-measures of value such a market value. However, these measures in turn depend on the subjectivity of the individuals who make the choices. I have no reason to believe that the leaders of ACP have anything but good intentions in this initiative but I wonder if their notion of value is stuck somewhere in the early 19th century.
Here is a quote from ACP that seems to say we can have our cake and eat it too.
"[ the initiative is] to help physicians and patients understand the benefits, harms, and costs of an intervention and whether it provides good value, and to slow the unsustainable rate of health care costs while preserving high-value, high-quality care."
My question is in regard to how will "good" or "high "value be determined. It seems like the history of the notion of value in the world of economics has lead to the widely accepted concept that value is subjective.Does this now say that after all value can really be objectively determined? So the advocates and practitioners of cost effectiveness would seem to say. I should add in fairness that the authors of the quoted Annals article do state that in the final analysis a subjective judgement in required.At the end of the analytic process someone or some group makes a subjective judgment.Is the benefit greater than the risks or does treatment x cost "too much".Too much in the judgment of whom. Will the value be decided by the patient to whom the risk and benefits accrue or will the value be decided by a group of medical experts after making a cost effectiveness "determination".
In the March 7,2013 issue of the NEJM there is a thoughtful commentary by Dr. Lisa Rosenbaum entitled "The Whole Ball Game-Overcoming the Blind Spots in Health Care Reform" which addresses certain aspects of the notion of value in health care. She says:
"Value in health care, however,depends on who is looking , where they look and what they expect to see....". Are we fooling ourselves if we believe that efforts to reign in health care cost can be done by only eliminating things of low value?"
That quote seems to express the notion of subjective value- that individuals subjectively evaluate a given event ( test or treatment ) from her own point of view which may or may not coincide with a determination of value by practitioners of cost effectiveness and cost benefit analysis who after they carry out the various elements of their statistical package make their own subjective evaluation cloaked though it may be in the robes of a purported objective analysis. Is the real bottom line here the accounting bottom line of the third party payers?
5/30/14. several minor corrections made in spelling and punctuation.
Thursday, April 18, 2013
High value health care-who gets to decide?
In the 1 Feb 2011 issue of the Annals of Internal Medicine,an ACP committee offers up a entry entitled
High-Value, Cost Conscious Health Care: Concepts for clinicians to Evaluation, and Costs of Medical Intervention" with Douglass K. Owens, the lead author.
They begin with their definition of value which is " an assessment of the benefit of a intervention relative to expenditures." So balancing benefit and cost is considered value.
As a possible counterpoint I quote the following from the blog, "Politics & Prosperity" :
The Annals authors then make what they believe to be critical distinction -the distinction between cost and value. So that a high cost item may or may not provide high value and low cost may have little benefit , therefore low value.The price ( or cost?) of things in micro-economic theory results from the subjective valuation of things by people.
The authors then redefine rationing (or in the authors words " more appropriately define) to mean "restricting the use of effective, high-value care". So that if an intervention that is "determined" to be low value is restricted this would not be considered rationing. One can see what power this puts in the hands of those who determine what is high and low value.We will not have rationing-in the ACP definition- if we only eliminate those interventions that some one ( government? an ACP committee, United health Group ?) has determined to be low value. You think the power to define the words we use and the power to control the narrative is not important.
If a treatment is both better and cheaper than an alternative there is no problem in deciding between the two. More complexity emerges when an alternative provides more benefits but also costs more. What to do here gets to the core issue. How much is health worth.?In the authors terms- what is the choice of the " cost effectiveness threshold".
Owens et al in regard to determining how much health care is worth say that we need cost effective analysis which they say requires "specialized expertise and training" attributes that just happen to be apparently possessed by the authors themselves. Note we are moving from comparative effectiveness analysis to cost effectiveness analysis which is an entirely different matter. The authors tell us that such analysis is expensive and is "typically performed by investigators". In this way the value of competing interventions to patients and to society can be determined. Determining the "value to society"-no hubris there.
But here is the money quote in which he authors admit the obvious.
"The choice of a cost effectiveness threshold is itself a value judgment and depends on several factors, including who the decision maker is."
After all of the gathering of various costs and developing estimates of the quality adjusted life years (QALY) and the aggregation of costs and aggregation of estimated benefits and using various analytic tools , a value judgment has to be made. Ultimately it is a human value judgment- not simply the objective analysis or simply solving a set of equations. The big question question is who will decide; whose judgment will settle the issue..Seemingly, the authors have assumed or gratuitous announced they ( or similar experts with special training and expertise) should be the ones whose subjective evaluation is determinative.
High-Value, Cost Conscious Health Care: Concepts for clinicians to Evaluation, and Costs of Medical Intervention" with Douglass K. Owens, the lead author.
They begin with their definition of value which is " an assessment of the benefit of a intervention relative to expenditures." So balancing benefit and cost is considered value.
As a possible counterpoint I quote the following from the blog, "Politics & Prosperity" :
The theory of subjective value, which is a cornerstone of microeconomics, says that
value is not inherent in things. There may be objective proxy-measures of value—like market value—but these depend primarily on the subjectivity of the individuals who make the choices. The prices of things, in other words, result from people’s subjective valuations of things.The often quoted,Harvard Business School professor, M.E. Porter defines as: Value =outcome/cost. See here for my earlier comments on Porter,value and its determination.
The Annals authors then make what they believe to be critical distinction -the distinction between cost and value. So that a high cost item may or may not provide high value and low cost may have little benefit , therefore low value.The price ( or cost?) of things in micro-economic theory results from the subjective valuation of things by people.
The authors then redefine rationing (or in the authors words " more appropriately define) to mean "restricting the use of effective, high-value care". So that if an intervention that is "determined" to be low value is restricted this would not be considered rationing. One can see what power this puts in the hands of those who determine what is high and low value.We will not have rationing-in the ACP definition- if we only eliminate those interventions that some one ( government? an ACP committee, United health Group ?) has determined to be low value. You think the power to define the words we use and the power to control the narrative is not important.
If a treatment is both better and cheaper than an alternative there is no problem in deciding between the two. More complexity emerges when an alternative provides more benefits but also costs more. What to do here gets to the core issue. How much is health worth.?In the authors terms- what is the choice of the " cost effectiveness threshold".
Owens et al in regard to determining how much health care is worth say that we need cost effective analysis which they say requires "specialized expertise and training" attributes that just happen to be apparently possessed by the authors themselves. Note we are moving from comparative effectiveness analysis to cost effectiveness analysis which is an entirely different matter. The authors tell us that such analysis is expensive and is "typically performed by investigators". In this way the value of competing interventions to patients and to society can be determined. Determining the "value to society"-no hubris there.
But here is the money quote in which he authors admit the obvious.
"The choice of a cost effectiveness threshold is itself a value judgment and depends on several factors, including who the decision maker is."
After all of the gathering of various costs and developing estimates of the quality adjusted life years (QALY) and the aggregation of costs and aggregation of estimated benefits and using various analytic tools , a value judgment has to be made. Ultimately it is a human value judgment- not simply the objective analysis or simply solving a set of equations. The big question question is who will decide; whose judgment will settle the issue..Seemingly, the authors have assumed or gratuitous announced they ( or similar experts with special training and expertise) should be the ones whose subjective evaluation is determinative.
I am not speaking against comparative effectiveness research (CER). It is important that we be able to say, for example, if carotid stenting gives better results that carotid endarterectomy and in what groups of patients.Presuming to be able to determine which is the better value if the higher price intervention gives superior results than the less costly alternative is another matter altogether and in my opinion falls into what I call type 2 hubris.See here for the woefully under utilized Gaulte classification of hubris in which type 2 is the type that some self defined exceptional persons never outgrow their sense of hypertrophied self worth and instead enlarges to know what is best for everyone .
The authors of the article clearly admit the exercise ultimately is a value judgment. The authors modestly admit that folks with their skillful use of utilitarian statistics of the aggregate are best able to make those judgments.
Econ 101 courses often talk about economics as involving the allocation of scarce resources to competing ends and scarcity leading to trade offs. People in their everyday lives make trade offs that involve some type of formal or more likely informal balancing of costs and benefits. Mark Pennington in his book "Robust Political Economy" said :
"Utilitarianism,however,extends the principle of making trade-offs within a person's life to the trade-offs between lives, and thus fails to respect the discreteness of individual lives."
John Rawls criticized utilitarianism as being inattentive to the separateness of persons and being guilty of treating people as means for the achievement of various social ends. The utilitarianism of cost effectiveness based decisions regarding health care is in opposition to both the egalitarianism of Rawls and the libertarian views of Nozick but dovetails nicely with the notion of physician as steward of society's medical resources and the medical progressives' overarching principle that medicine is too important and complicated to be left to the individual patient with his individual separate life and his physician.
(Note: I have written before on the Owens article discussing in why that approach will deliver much less than they claim and have also commented on the bogus nature of the concept of Quality adjusted life year (QALY) which was actually recognized by the father of utilitarianism and other questionable assumptions involved in cost benefit analysis.)
Sunday, April 07, 2013
Another chapter in the story of Obamacare and crony capitalism
Since many states have not and may not ever establish insurance exchanges,a key component of ACA,the federal government is moving ahead to put in place a federal insurance exchange.
The key to that is the "hub" which will be a gigantic computer system which will house information on everyone in the country. Data will be imputed from CMS (Center for Medicare and Medicaid Services),the IRS,Homeland Security and the Justice Department as well as various state agencies.
A Maryland company QSSI ( Quality Software Services Inc ) has been awarded the contract. QSSI is now owned by a division of United Health Group known as Optum.See here.
Now consider the revolving door part. Steve Larsen now works for Optum.Mr. Larsen with a resume of variously working for state insurance agencies (including being Maryland's Insurance Commisioner) and health insurance companies and then HHS most recently lead a group at HHS charged with setting up rules for insurance coverage for the exchanges.His new job is- according to the Optum web site-executive vice president in charge of "government solutions". See here for more details about the contract with QSSI and concern about possible cahoots by expressed by folks in both the Senate and House.
Soon after Obamacarewas rammed through passed by Congress folks at ACP and AMA offered praise in part because of their claim that social justice was forwarded.More realistically its passage and efforts aimed at subsequent implementation seems a embarrassing monument to crony capitalism and rent seeking.
The key to that is the "hub" which will be a gigantic computer system which will house information on everyone in the country. Data will be imputed from CMS (Center for Medicare and Medicaid Services),the IRS,Homeland Security and the Justice Department as well as various state agencies.
A Maryland company QSSI ( Quality Software Services Inc ) has been awarded the contract. QSSI is now owned by a division of United Health Group known as Optum.See here.
Now consider the revolving door part. Steve Larsen now works for Optum.Mr. Larsen with a resume of variously working for state insurance agencies (including being Maryland's Insurance Commisioner) and health insurance companies and then HHS most recently lead a group at HHS charged with setting up rules for insurance coverage for the exchanges.His new job is- according to the Optum web site-executive vice president in charge of "government solutions". See here for more details about the contract with QSSI and concern about possible cahoots by expressed by folks in both the Senate and House.
Soon after Obamacare
Thursday, March 28, 2013
Here is a shocker- Bogus "commission" recommends abolition of physician fee for service
Fee for service has increasingly become the bogus reason for all of what is wrong with health care in the U.S. Now a group of self designated experts deliberated and concluded what they all likely believed at the onset namely that we must eliminate fee for service (ffs) in medical care.Reference here is to the "National Commission on Physician Payment Reform". See here for the report.
One could get a idea regarding their likely recommendations by considering some who are on the commission. Here are some of the participants:
Dr. Troyen Brennan who wrote with Dr. Don Berwick about replacing the physician patient dyad in their 1996 book, "New Rules" was formerly a VP at Aetna and now an executive VP at CVS Caremark. Here is a quote from Drs.Berwick and Brennan from that book:
Guess how the author of that paragraph would feel about fee for service for physicians.
Dr. Judy Bigby is Secretary of HHS for Massachusetts.
Dr. Lisa Lotts is a VP at Well Point.
Somehow the image of a commission of prominent foxes gathering to make recommendations regarding hen house security comes to mind.
One thing most of the fee for service critics propose is that physicians become part of Accountable Care Organizations (ACOs) and therefore they will be compensated for "quality and not volume of care". Does anyone really believe that physician employees of a ACO will not have volume requirement?
Dr John Goodman in this blog commentary says it better than I can in regard to fee for service and ACOs.
"There is absolutely no support for the notion that ACOs will do anything ― anything ― to reduce costs or improve quality (see this recent NCPA blog, “Question: Why Did Anyone Ever Believe in ACOs?”). It is nothing more than a wish dressed up with high-falutin’ language (sustainable, cost-effective, high-quality, interoperable, coordinated, etc.) In fact, virtually all of the evidence indicates just the opposite ― that the elements of ACOs (disease management, pay-for-performance and so on) are useless or worse."
And here is the money quote:
" ... the problem in health care is not fee-for-service, but third-party payment. Almost everything we do during the course of a day is done on a fee-for-service basis and none of it results in high inflation or poor quality. Quite the opposite. The only difference in health care is that someone else is paying the bill, so there is no constraint on the consumer or the provider of services."
Exactly-health care is largely paid for with some one else's money and those some one elses are doing all they can to limit that spending and increase their bottom lines and demonizing ffs and promoting the new bigger and better HMO ( now renamed as ASOs) seems to be their current tactic.
Sadly, the major medical professional organizations are complicit in this push into the ACOs which cannot possibly fix the health care problems but can put many more nails in the coffin of the fiduciary duty of the physician to the patients. How much individual patient advocacy are you going to see in a large organization in which the physician are the employees? To what extent will physicians trained in the era in which the world medical view is that physicians are stewards of society's resources and that their actions should be controlled by utilitarian based cost effectiveness analysis and directives be dedicated advocates for their patients?
One could get a idea regarding their likely recommendations by considering some who are on the commission. Here are some of the participants:
Dr. Troyen Brennan who wrote with Dr. Don Berwick about replacing the physician patient dyad in their 1996 book, "New Rules" was formerly a VP at Aetna and now an executive VP at CVS Caremark. Here is a quote from Drs.Berwick and Brennan from that book:
“Today, this isolated
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.”
Guess how the author of that paragraph would feel about fee for service for physicians.
Dr. Judy Bigby is Secretary of HHS for Massachusetts.
Dr. Lisa Lotts is a VP at Well Point.
Somehow the image of a commission of prominent foxes gathering to make recommendations regarding hen house security comes to mind.
One thing most of the fee for service critics propose is that physicians become part of Accountable Care Organizations (ACOs) and therefore they will be compensated for "quality and not volume of care". Does anyone really believe that physician employees of a ACO will not have volume requirement?
Dr John Goodman in this blog commentary says it better than I can in regard to fee for service and ACOs.
"There is absolutely no support for the notion that ACOs will do anything ― anything ― to reduce costs or improve quality (see this recent NCPA blog, “Question: Why Did Anyone Ever Believe in ACOs?”). It is nothing more than a wish dressed up with high-falutin’ language (sustainable, cost-effective, high-quality, interoperable, coordinated, etc.) In fact, virtually all of the evidence indicates just the opposite ― that the elements of ACOs (disease management, pay-for-performance and so on) are useless or worse."
And here is the money quote:
" ... the problem in health care is not fee-for-service, but third-party payment. Almost everything we do during the course of a day is done on a fee-for-service basis and none of it results in high inflation or poor quality. Quite the opposite. The only difference in health care is that someone else is paying the bill, so there is no constraint on the consumer or the provider of services."
Exactly-health care is largely paid for with some one else's money and those some one elses are doing all they can to limit that spending and increase their bottom lines and demonizing ffs and promoting the new bigger and better HMO ( now renamed as ASOs) seems to be their current tactic.
Sadly, the major medical professional organizations are complicit in this push into the ACOs which cannot possibly fix the health care problems but can put many more nails in the coffin of the fiduciary duty of the physician to the patients. How much individual patient advocacy are you going to see in a large organization in which the physician are the employees? To what extent will physicians trained in the era in which the world medical view is that physicians are stewards of society's resources and that their actions should be controlled by utilitarian based cost effectiveness analysis and directives be dedicated advocates for their patients?
Tuesday, March 19, 2013
"physicians as stewards of society's medical resources" is not just bogus but is a dangerous concept
The "physician as a steward" idea is implicit in Medical Professionalism as defined and promoted by a number of physicians who I label medical progressives and notably by the ABIM Foundation. In their own words they are advocates for " a just and cost effective distribution of finite resources." See here for source of quote.
I argue that the physician-steward is a bogus and dangerous concept.
To consider physicians as stewards is to consider the medical care resources as a collective entity.
This is to say that Individually possessed resources or assets should be considered as part of a collective pool owned by everyone and that all have an equal right to some share of the pool.That is the core concept implicit in the physician as a steward phrase.
In regard to a private property system the rights of the owner in general terms are clear. He has the right to use his property,exclude others from use of the property and dispose of the property through sale,gift or inheritance.
In contrast , the rights are in a common ownership system are vague and indeterminate. It is not clear how one can be said to "own" something if no one in principle is excluded from making a claim .
Once the common ownership idea is accepted it then seems to make sense to talk about allocating resources and to consider some one or some group or groups as the appropriate allocators. With common ownership it simply would not work for all of society to willy-nilly feed on the medical commons as soon the resources would be depleted Rather there needs to be a rational plan so that just and cost effective distribution can take place.
The first thing wrong with considering medical resources as collectively owned is that they are not collectively owned in any real ,literal or legal sense in a free or even semi free society. U.S.medical resources are not like a grassy field in which all of the town folks sheep can come to graze.
While a grassy field for the villager's sheep to graze can be defined by a specific surveyor description, the "medical commons" is a extremely large,always changing, amorphous array,the elements of which defy enumeration. Various entities own various elements of this array-society owns none even though various government entities own some but the government is not society.It is an amorphous abstraction.
The skills,and knowledge of thousands of physicians and others involved in health care are aggregated and then allocate. Further, to speak of allocation means some one or some elite group will do the allocating not individual physician patient units.You know the "dyads" that Drs.Berwick and Brennan wanted to eliminate as the decision making unit in matters of health care.(See here for what Berwick and Brennan has to say about that.)
The dangerous element of the concept is that when medical decisions are made on the basis of cost effectiveness as judged by some third party the individual is at risk of being harmed in the name of some aggregate benefit allegedly exceeding the aggregated cost. It is the utilitarian enterprise -the greatest good for the greatest number. there will be winners and losers and as long as the "utility" of the winners exceeds the utility lost by the losers we have a cost effective outcome. As since society as a whole is better off it must be fair by definition. Never mind that individuals may be sacrificed to some abstract aggregate benefit .
This utilitarian approach is not just opposed by libertarians but the egalitarian thinker, John Rawls says of utilitarianism that individual rights may be breached in its effort to bring about the happiness or utility of the greatest number and objects to utilitarian decisions because it ignores the separateness and distinctness of individuals.
The ABIM foundation and committees of the ACP both are promoting cost effectiveness analysis. Note this is not comparative effectiveness analysis but recommending the technique to determine for example if two treatments are both effective that the one with a more favorable cost effective ratio be used.
The idea that medical data analysis technocrats should be the allocators or at least advisers to the actual allocators is what one would expect from the medical progressives whose major tenet appears to be that medical decisions and too complex to be made by the individual physician patient dyads and is also a died-and- gone- to- heaven moment for the third party payers who could not be more pleased that is the medical profession itself ( or certain elements of it) who are advocating cost effectiveness .
Social justice was the Trojan horse on which cost effectiveness allocation of finite resources and guideline adherence rode. Operationally it seems that to the ABIM Foundation social justice is mainly all about fair and cost effective allocation of resources. In that scheme there will be two tiers of physicians.
There will be the highly trained cost effectiveness analysts who will determine what is just and cost effective and the worker bee physicians who by adhering to the allocators' guidelines will be promoting social justice in their stewardship role.
I argue that the physician-steward is a bogus and dangerous concept.
To consider physicians as stewards is to consider the medical care resources as a collective entity.
This is to say that Individually possessed resources or assets should be considered as part of a collective pool owned by everyone and that all have an equal right to some share of the pool.That is the core concept implicit in the physician as a steward phrase.
In regard to a private property system the rights of the owner in general terms are clear. He has the right to use his property,exclude others from use of the property and dispose of the property through sale,gift or inheritance.
In contrast , the rights are in a common ownership system are vague and indeterminate. It is not clear how one can be said to "own" something if no one in principle is excluded from making a claim .
Once the common ownership idea is accepted it then seems to make sense to talk about allocating resources and to consider some one or some group or groups as the appropriate allocators. With common ownership it simply would not work for all of society to willy-nilly feed on the medical commons as soon the resources would be depleted Rather there needs to be a rational plan so that just and cost effective distribution can take place.
The first thing wrong with considering medical resources as collectively owned is that they are not collectively owned in any real ,literal or legal sense in a free or even semi free society. U.S.medical resources are not like a grassy field in which all of the town folks sheep can come to graze.
While a grassy field for the villager's sheep to graze can be defined by a specific surveyor description, the "medical commons" is a extremely large,always changing, amorphous array,the elements of which defy enumeration. Various entities own various elements of this array-society owns none even though various government entities own some but the government is not society.It is an amorphous abstraction.
The skills,and knowledge of thousands of physicians and others involved in health care are aggregated and then allocate. Further, to speak of allocation means some one or some elite group will do the allocating not individual physician patient units.You know the "dyads" that Drs.Berwick and Brennan wanted to eliminate as the decision making unit in matters of health care.(See here for what Berwick and Brennan has to say about that.)
The dangerous element of the concept is that when medical decisions are made on the basis of cost effectiveness as judged by some third party the individual is at risk of being harmed in the name of some aggregate benefit allegedly exceeding the aggregated cost. It is the utilitarian enterprise -the greatest good for the greatest number. there will be winners and losers and as long as the "utility" of the winners exceeds the utility lost by the losers we have a cost effective outcome. As since society as a whole is better off it must be fair by definition. Never mind that individuals may be sacrificed to some abstract aggregate benefit .
This utilitarian approach is not just opposed by libertarians but the egalitarian thinker, John Rawls says of utilitarianism that individual rights may be breached in its effort to bring about the happiness or utility of the greatest number and objects to utilitarian decisions because it ignores the separateness and distinctness of individuals.
The ABIM foundation and committees of the ACP both are promoting cost effectiveness analysis. Note this is not comparative effectiveness analysis but recommending the technique to determine for example if two treatments are both effective that the one with a more favorable cost effective ratio be used.
The idea that medical data analysis technocrats should be the allocators or at least advisers to the actual allocators is what one would expect from the medical progressives whose major tenet appears to be that medical decisions and too complex to be made by the individual physician patient dyads and is also a died-and- gone- to- heaven moment for the third party payers who could not be more pleased that is the medical profession itself ( or certain elements of it) who are advocating cost effectiveness .
Social justice was the Trojan horse on which cost effectiveness allocation of finite resources and guideline adherence rode. Operationally it seems that to the ABIM Foundation social justice is mainly all about fair and cost effective allocation of resources. In that scheme there will be two tiers of physicians.
There will be the highly trained cost effectiveness analysts who will determine what is just and cost effective and the worker bee physicians who by adhering to the allocators' guidelines will be promoting social justice in their stewardship role.
Monday, March 11, 2013
Social Justice quote for the day from F.A. Hayek
Since the medical progressive leadership has at least nominally enshrined the pursuit of social justice as a ethical requirement for all physicians I think it is appropriate to at least look at what various prominent philosophers have had to say about the concept of social justice. Such a look is justified if for no other reason that the various polemics promoting a social justice imperative for physicians were bereft of any consideration of the impressive body of thought which rejects social justice as a meaningful concept.
FA Hayek's writings are prominence in that regard .The following quote is from his lengthy treatise "Law,Legislation and Liberty" Volume 2,The Mirage of Social Justice"
"[I]n...a system in which each is allowed to use his knowledge for his own purposes the concept of `social justice' is necessarily empty and meaningless, because in it nobody's will can determine the relative incomes of the different people, or prevent that they be partly dependent on accident. `Social justice' can be given a meaning only in a directed or `command' economy (such as an army) in which the individuals are ordered what to do; and any particular conception of `social justice' could be realized only in such a centrally directed system...In a free society in which the position of the different individuals and groups is not the result of anybody's design--or could, within such a society, be altered in accordance with a generally applicable principle--the differences in reward simply cannot meaningfully be described as just or unjust." (pp. 69-70)
One Sociology text book version of what the concept of social justice typically involves is the following:
Why the views of classical liberalism should be excluded from medical ethics without discussion and the standard welfare state progressive's notion of social justice be included is by no mean clear nor was a cogent argument for that presented in either the New Professionalism on the new ACP ethics.
FA Hayek's writings are prominence in that regard .The following quote is from his lengthy treatise "Law,Legislation and Liberty" Volume 2,The Mirage of Social Justice"
"[I]n...a system in which each is allowed to use his knowledge for his own purposes the concept of `social justice' is necessarily empty and meaningless, because in it nobody's will can determine the relative incomes of the different people, or prevent that they be partly dependent on accident. `Social justice' can be given a meaning only in a directed or `command' economy (such as an army) in which the individuals are ordered what to do; and any particular conception of `social justice' could be realized only in such a centrally directed system...In a free society in which the position of the different individuals and groups is not the result of anybody's design--or could, within such a society, be altered in accordance with a generally applicable principle--the differences in reward simply cannot meaningfully be described as just or unjust." (pp. 69-70)
One Sociology text book version of what the concept of social justice typically involves is the following:
- Historical inequities insofar as they affect current injustices should be corrected until the actual inequities no longer exist or have been perceptively "negated".
- The redistribution of wealth, power and status for the individual, community and societal good.
- It is government's (or those who hold significant power) responsibility to ensure a basic quality of life for all its citizens.
Why the views of classical liberalism should be excluded from medical ethics without discussion and the standard welfare state progressive's notion of social justice be included is by no mean clear nor was a cogent argument for that presented in either the New Professionalism on the new ACP ethics.
Friday, March 08, 2013
Is medical practice moving from "What can I do for you" to "What can't I do for you"?
In a society in which individuals are more or less free to interact with one another and seek each other's services and goods the following phrase is routine; "What can I do for you?" or "how can I help you?"
I have said that said many times to a patient at the beginning of an office visit.
It seems to me that that phrase captures an important aspect of the mind set of the clinician as she relates to her patients. What can I do for you, how can I help you, what are you concerned about all speak to the role of the physician in her fiduciary duty to the patient.
Why is it that clinicians seems to be concerned with what they can do for patients and so often health policy wonks emphasize how we as physicians can limit what patients receive? To talk of the need to limit resource use is to assume that a vaguely defined or undefined too much is being done for patients which translates further to a third party ( either a third party payer or a third party self appointed expert) deciding that the individual decisions of doctors and patients about clinical management issues results in "overuse" of resources.There is a body of thought that maintains physicians are not only obligated to serve the best interests of their individual patient but somehow they are ethically obligated to be the stewards of resources that somehow in other than a metaphorical sense are owned by society.
Overuse seems to lie in the eye of the third party payer. Could it be that many in the health policy arena and many of the self appointed thought leaders of major medical professional organizations believe that patient treatment is too important to leave to the myopic lens of doctor and patient and that their selfish interests are no basis for appropriate medical decisions and that the experts' enduring wisdom should over ride the archaic physician patient dyad.Perhaps first advice and "education" would be enough to disabuse the practicing physician and her relentlessly self centered patient from doing too much. However if discussions about cost savings did not prevail more carrots and sticks might be required.
Of course "what can I do for you" is not an boundless,open ended agreement to do all and everything a patient may request. If a patient concerned about difficulty with word finding and misplacing his car keys possibly indicating early dementia you might reasonably refuse to comply with his request for a referral for a brain biopsy. The physician can give informed and reasoned advice about how to proceed taking into account the views and wishes and concerns of the individual patient.
The new initiative lead by the ABIM Foundation (does anyone else wonder why a organization ostensibly tasked to test the competence of internists needs a foundation ) labelled Choosing Wisely appears to be a list of "thou shall not s"- sort of a hundred commandments. OK, they are currently phrased not as absolutes but are presented as the much softer and gentler opportunities to have a discussion with your patient not as rules not to be broken.Suggestions first, guidelines later and then perhaps extra payment for compliant socially conscious stewards of society's resources namely the physicians (make that health care professionals) and reduced payment for the recalcitrant and selfish.
Of course some tests and treatments are ordered and carried out in instances in which no patient benefit is obtained and in some cases harm may done but for numerous medical professional organizations to proclaim that numerous tests and procedures should not be done ( however gently this is currently presented) seems to me to be efforts to change to mind set from the traditional what can I do for you to what I can not allow you to have.
I have seen few comments ( see here for one) in anyway critical of the specific recommendation of the Choosing Wisely campaign but there should be thoughtful analysis of each of them before there is any widespread acceptance.Remember evidence based medicine. What is the evidence behind for example no pap tests before age 21.Are there randomized clinical trials ? Is it based on expert opinion? Are we told about potential conflicts of interests of the authors of the recommendations? Are there published systematic reviews or cost effectiveness analysis for each of the recommendations or for any?
Any of the numerous ( current count is 130 but stay tuned) recommendations made by various medical professional organization may well pass the tests of coherence and correspondence with valid evidence but you have to be skeptical of some many recommendations appearing seemingly so quickly and their manner of presentation appears more authority based or expert based than evidence based.
No one is in favor of tests and procedures that are of no benefit and/or are harmful.No one is against Mom and apple pie or in favor of the nation going broke from run away medical costs, but to rush to publish 100 plus prohibitions under the banner of preventing harm or waste may end up itself doing much more harm than good and even costing more if each specific recommendation is not based on sound evidence based analysis. Making recommendations that might affect the health and lives of thousands of people is serious and heady business and time after time we have seen well meaning medical recommendations turn out to be very bad advice ( remember HRT for just about all post menopausal women and then for none and then again for some). Doctor,were you wrong then or are you wrong now?
American Board of Internal Medicine President Christine Cassel, MD, said such rules of thumb (those suggested by various medical professional organizations regarding certain tests and procedures) seek to change the mindset of physicians and patients alike that "more is better," which can lead to wasteful spending and sometimes harm to the patient.
"What you're talking about is a culture change," Dr. Cassel told Medscape Medical News in a recent published interview. Let's hope the hoped for cultural change does not include discarding the fiduciary role.Yet I believe it is significant that neither the New Medical Professionalism nor the New medical ethics of the ACP talks about the fiduciary responsibility of the physician to the patient.I believe that de-
emphasizing the fiduciary role of the physician and claiming a role of resource steward for physicians is
conceptually dangerous and to the extent it is incorporated into day to day medical thinking destructive to the traditional physician patient relationship doling damage to both physicians and patients.
For each of the recommendations published by the Choosing Wisely campaign physicians and their patients need to know what is the nature of the evidence? For some probably the evidence is strong and convincing for others maybe not so much.Let's not replace "more is better" with" less is better" because neither is a universal all encompassing decision rule and clinical decisions should not be based on empty catch phrases such as "less is more" and the vacuous "the right treatment for the right patient at the right time".
I have said that said many times to a patient at the beginning of an office visit.
It seems to me that that phrase captures an important aspect of the mind set of the clinician as she relates to her patients. What can I do for you, how can I help you, what are you concerned about all speak to the role of the physician in her fiduciary duty to the patient.
Why is it that clinicians seems to be concerned with what they can do for patients and so often health policy wonks emphasize how we as physicians can limit what patients receive? To talk of the need to limit resource use is to assume that a vaguely defined or undefined too much is being done for patients which translates further to a third party ( either a third party payer or a third party self appointed expert) deciding that the individual decisions of doctors and patients about clinical management issues results in "overuse" of resources.There is a body of thought that maintains physicians are not only obligated to serve the best interests of their individual patient but somehow they are ethically obligated to be the stewards of resources that somehow in other than a metaphorical sense are owned by society.
Overuse seems to lie in the eye of the third party payer. Could it be that many in the health policy arena and many of the self appointed thought leaders of major medical professional organizations believe that patient treatment is too important to leave to the myopic lens of doctor and patient and that their selfish interests are no basis for appropriate medical decisions and that the experts' enduring wisdom should over ride the archaic physician patient dyad.Perhaps first advice and "education" would be enough to disabuse the practicing physician and her relentlessly self centered patient from doing too much. However if discussions about cost savings did not prevail more carrots and sticks might be required.
Of course "what can I do for you" is not an boundless,open ended agreement to do all and everything a patient may request. If a patient concerned about difficulty with word finding and misplacing his car keys possibly indicating early dementia you might reasonably refuse to comply with his request for a referral for a brain biopsy. The physician can give informed and reasoned advice about how to proceed taking into account the views and wishes and concerns of the individual patient.
The new initiative lead by the ABIM Foundation (does anyone else wonder why a organization ostensibly tasked to test the competence of internists needs a foundation ) labelled Choosing Wisely appears to be a list of "thou shall not s"- sort of a hundred commandments. OK, they are currently phrased not as absolutes but are presented as the much softer and gentler opportunities to have a discussion with your patient not as rules not to be broken.Suggestions first, guidelines later and then perhaps extra payment for compliant socially conscious stewards of society's resources namely the physicians (make that health care professionals) and reduced payment for the recalcitrant and selfish.
Of course some tests and treatments are ordered and carried out in instances in which no patient benefit is obtained and in some cases harm may done but for numerous medical professional organizations to proclaim that numerous tests and procedures should not be done ( however gently this is currently presented) seems to me to be efforts to change to mind set from the traditional what can I do for you to what I can not allow you to have.
I have seen few comments ( see here for one) in anyway critical of the specific recommendation of the Choosing Wisely campaign but there should be thoughtful analysis of each of them before there is any widespread acceptance.Remember evidence based medicine. What is the evidence behind for example no pap tests before age 21.Are there randomized clinical trials ? Is it based on expert opinion? Are we told about potential conflicts of interests of the authors of the recommendations? Are there published systematic reviews or cost effectiveness analysis for each of the recommendations or for any?
Any of the numerous ( current count is 130 but stay tuned) recommendations made by various medical professional organization may well pass the tests of coherence and correspondence with valid evidence but you have to be skeptical of some many recommendations appearing seemingly so quickly and their manner of presentation appears more authority based or expert based than evidence based.
No one is in favor of tests and procedures that are of no benefit and/or are harmful.No one is against Mom and apple pie or in favor of the nation going broke from run away medical costs, but to rush to publish 100 plus prohibitions under the banner of preventing harm or waste may end up itself doing much more harm than good and even costing more if each specific recommendation is not based on sound evidence based analysis. Making recommendations that might affect the health and lives of thousands of people is serious and heady business and time after time we have seen well meaning medical recommendations turn out to be very bad advice ( remember HRT for just about all post menopausal women and then for none and then again for some). Doctor,were you wrong then or are you wrong now?
American Board of Internal Medicine President Christine Cassel, MD, said such rules of thumb (those suggested by various medical professional organizations regarding certain tests and procedures) seek to change the mindset of physicians and patients alike that "more is better," which can lead to wasteful spending and sometimes harm to the patient.
"What you're talking about is a culture change," Dr. Cassel told Medscape Medical News in a recent published interview. Let's hope the hoped for cultural change does not include discarding the fiduciary role.Yet I believe it is significant that neither the New Medical Professionalism nor the New medical ethics of the ACP talks about the fiduciary responsibility of the physician to the patient.I believe that de-
emphasizing the fiduciary role of the physician and claiming a role of resource steward for physicians is
conceptually dangerous and to the extent it is incorporated into day to day medical thinking destructive to the traditional physician patient relationship doling damage to both physicians and patients.
For each of the recommendations published by the Choosing Wisely campaign physicians and their patients need to know what is the nature of the evidence? For some probably the evidence is strong and convincing for others maybe not so much.Let's not replace "more is better" with" less is better" because neither is a universal all encompassing decision rule and clinical decisions should not be based on empty catch phrases such as "less is more" and the vacuous "the right treatment for the right patient at the right time".
Thursday, February 21, 2013
The language of academic medicine has become the language of the collective
One of the many changes that have occurred in medicine over the last 40 years ( my professional lifetime) has been the framing of certain aspects of medical care into the language of the collective. I have written before abut the bogus nature of the concept of the "Medical commons" (see here for critique of the medical commons bogus analogy ) but that is only a small example of the dominant themes found in medical literature and not just just in the policy wonk journals and editorials such as those found in the NEJM but also in throw away comments found in the boiler plate like introductions to what otherwise are serious medical research papers. How many medical journal articles have you seen that begin with commenting that disease x, y or z is an important pubic health problem? Defining everything as a public health problem cries out for public health solutions. Are there any health issues that are simply a matter between the patient and his physician?
The concept of social justice as an ethical imperative of physicians which has though the efforts of a small group of prolific academic writers,certain foundations with deep pockets and medical insurance industry shills has become the de facto default position of medical academia and the self proclaimed thought leadesr and will become standard catechism for the present and future generations of medical students.Aspects of this con job (better word?) has aspects of the features of the classic Baptist and Bootlegger phenomenon. As some members of the medical academia promote this view and move out of and into the medical insurance upper level management and various government positions of power it become difficult to identify who are really the baptists and who is conning whom. Yet,I continue to believe that many of those who advocate social justice and believe that physicians should be the stewards of society's medical resources do so with sincerity and in the belief that these are meaningful terms and worthy goals while at least a few of us believe that allegiance to bogus concepts usually does not work out very well.
Ask not what you can do for your patient but what you can do for the greater good of the group,ACO or payment panel which you and your patients by random chance have become part of.After all if you do what is cost effective the group will benefit and through some type of metaphysical fairy dust so will your patient even if she or he is deprived on a beneficial test of procedure or medication because he/she is part of the group.Rather than comments like the preceding being shouted down with a John McEnroe like " you've gotta be kidding" we see that that type commentary in the NEJM offered by a well known medical economist.See here for the comments of Victor Fuchs and my criticism.
Since few would doubt that academia in general is populated by a preponderance of liberals, progressives and egalitarians ( See here for some survey data) why be surprised that medical academia is no exception? The question is why is it that only fairly recently has the rhetoric of medical publications so strongly reflected that mind set appearing not just in editorials and commentaries and in health policy publications but regularly in the boilerplate introductions to otherwise ordinary presentations of a medical studies.
The concept of social justice as an ethical imperative of physicians which has though the efforts of a small group of prolific academic writers,certain foundations with deep pockets and medical insurance industry shills has become the de facto default position of medical academia and the self proclaimed thought leadesr and will become standard catechism for the present and future generations of medical students.Aspects of this con job (better word?) has aspects of the features of the classic Baptist and Bootlegger phenomenon. As some members of the medical academia promote this view and move out of and into the medical insurance upper level management and various government positions of power it become difficult to identify who are really the baptists and who is conning whom. Yet,I continue to believe that many of those who advocate social justice and believe that physicians should be the stewards of society's medical resources do so with sincerity and in the belief that these are meaningful terms and worthy goals while at least a few of us believe that allegiance to bogus concepts usually does not work out very well.
Ask not what you can do for your patient but what you can do for the greater good of the group,ACO or payment panel which you and your patients by random chance have become part of.After all if you do what is cost effective the group will benefit and through some type of metaphysical fairy dust so will your patient even if she or he is deprived on a beneficial test of procedure or medication because he/she is part of the group.Rather than comments like the preceding being shouted down with a John McEnroe like " you've gotta be kidding" we see that that type commentary in the NEJM offered by a well known medical economist.See here for the comments of Victor Fuchs and my criticism.
Since few would doubt that academia in general is populated by a preponderance of liberals, progressives and egalitarians ( See here for some survey data) why be surprised that medical academia is no exception? The question is why is it that only fairly recently has the rhetoric of medical publications so strongly reflected that mind set appearing not just in editorials and commentaries and in health policy publications but regularly in the boilerplate introductions to otherwise ordinary presentations of a medical studies.
Subscribe to:
Posts (Atom)