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A Nexus Between Medical Journals and Government.

Monday, July 5th, 2010

The Wall Street Journal has one more article on the effect of Obamacare on doctors. A couple of interesting statements bring up some statements on an excellent medical blog I read.

First the WSJ points about Obamacare.

The act will reinforce the worst features of existing third-party payment arrangements in both the private and public sectors — arrangements that already compromise the professional independence and integrity of the medical profession.

Doctors will find themselves subject to more, not less, government regulation and oversight. Moreover, they will become increasingly dependent on unreliable government reimbursement for medical services. Medicare and Medicaid payment, including irrational government payment updates, are preserved (though shaved) and expanded to larger portions of the population.

The Act creates even more bureaucracies with authority over the kinds of health benefits, medical treatments and procedures that Americans get through public and private health insurance. The new law provides no serious relief for tort liability. Not surprisingly, various surveys reveal deep dissatisfaction and demoralization among medical professionals.

I’ve been posting about this for a couple of years and it is no surprise.

Now here is where it gets interesting.

On top of existing payment rules, regulations and guidelines, the new law creates numerous new federal agencies, boards and commissions. There are three that have direct relevance to physicians and the practice of medicine, and the nature and scope of the regulatory regime will be decisive.

Under section 6301, the new law creates a “non-profit” Patient-Centered Outcomes Research Institute. It will be financed through a Patient Centered Outcomes Research Trust Fund, with initial funding starting at $10 million this year, and reaching $150 million annually in Fiscal Year 2013, with additional revenues from insurance fees.

Don’t you think the “Patient Centered” touch is a nice one ?

In effect, the Institute will be examining clinical effectiveness of medical treatments, procedures, drugs and medical devices. Much will depend upon how the findings and recommendations are implemented, and whether the recommendations are accompanied by financial incentives or penalties or regulatory requirements.

Under section 3403, there will be an Independent Payment Advisory Board, with 15 members appointed by the president. The goal of the board is to reduce the per capita growth rate in Medicare spending, and make recommendations for slowing growth in non-federal health programs. It’s hard to imagine any other outcome other than continued payment cuts.

Now, we turn to the blog I mentioned. The author, a cardiologist mostly retired, discusses a recent randomized clinical trial. The way we decide on “clinical effectiveness” in an ideal world is randomized trials. They are the Gold Standard. So how was a recent randomized trial treated in a major medical journal? From the blog.

This week, the Archives of Internal Medicine published four (four!) articles assaulting the legitimacy and the importance of the JUPITER trial, a landmark clinical study published in 2008, which showed that certain apparently healthy patients with normal cholesterol levels had markedly improved cardiovascular outcomes when taking a statin drug.

Superficially, at least, the JUPITER study appears to have been pretty straightforward. Nearly 18,000 men and women from 26 countries who had “normal” cholesterol levels but elevated C-reactive protein (CRP) levels were randomized to receive either the statin drug Crestor, or a placebo. CRP is a non-specific marker of inflammation, and an increased CRP blood level is thought to represent inflammation within the blood vessels, and is a known risk factor for heart attack and stroke. The study was stopped after a little less than two years, when the study’s independent Data Safety Monitoring Board (DSMB) determined that it would be unethical to continue. For, at that point, individuals taking the statin had a 20% reduction in overall mortality, a dramatic reduction in heart attacks, a 50% reduction in stroke, and a 40% reduction in venous thrombosis and pulmonary embolism. All these findings were highly statistically significant.

This is a dazzling result for a randomized trial. Usually, you are looking at small changes and trying to calculate the “p value” to see if it is significant. Why would a journal publish attacks on such a dramatic study ?

If medicine were practiced the way it ought to be – where the doctor takes the available evidence, as imperfect as it always is, and applies it to each of her individual patients – then the incompleteness of answers from the JUPITER trial would present no special problems. After all, doctors never have all the answers when they help patients make decisions. So, in this case the doctor would discuss the pros and cons of statin therapy – the risks, the potential benefits, and all the quite important unknowns – and place the decision in the perspective of what might be gained if the patient instead took pains to control their weight, exercise, diet, smoking, etc. At the end of the day, some patients would insist on avoiding drug therapy at all costs; others would insist on Crestor and nothing else; yet others would choose to try a much cheaper generic statin; and some would even opt (believe it or not) for a trial of lifestyle changes before deciding on statin therapy.

This is the way we all want to practice. “Best Practice” they call it.

But in recent years, and especially now, as we bravely embark on our new healthcare system, this is not how doctors will practice medicine. Instead, they will practice medicine by guidelines. These guidelines (which, in modern medical parlance, is a euphemism for “directives”) are to be handed down from panels of experts, identified and assembled by members of the executive branch of the federal government.

And this makes the stakes very high when it comes to a clinical trial like JUPITER. For guidelines do not permit a range of actions tailored to fit individual patients (consistent with the uncertainties inherent in the results of any clinical trial). Instead, guidelines will seek to take one of two possible positions. That is, under a paradigm of medicine-by-guidelines, the results of clinical trials generally cannot be permitted to remain imperfect or nuanced or subject to individual application, but must be resolved by a central panel of government-issue experts into a binary system – yes (do it) or no (don’t do it). In the case of JUPITER, the guidelines must decide whether or not to recommend Crestor to patients like the ones enrolled in the study, at a potential cost of several billion dollars a year. It should be obvious that the answer which would be more pleasant to the ends of the central authority, and by a large margin, would be: No, don’t adopt the JUPITER results into clinical practice.

Well, we shouldn’t worry because all doctors, and especially well known academics are ethical. Right ?

Right ?

Now comes the interesting part and I think he is absolutely correct.

This, DrRich submits for your consideration, is likely what instigated the almost violently anti-JUPITER issue of the Archives this week. DrRich theorizes that what we’ve got here is a bunch of wannabe federally-sanctioned experts, auditioning for positions on the expert panels. What better way to get the Fed’s attention than to let them know that you are of the appropriate frame of mind to assiduously seek out scientific-sounding arguments to discount the straightforward and compelling, but fiscally unfortunate, results of a well-known clinical trial?

Of the four papers appearing in this week’s Archives, three are more-or-less legitimate academic articles that make reasonable points, but do no harm to the main result of JUPITER. The fourth is a straightforward polemic, which has no place in a peer-reviewed medical journal, and whose very presence, DrRich believes, very strongly suggests that the editors of the Archives themselves must be auditioning for the Fed’s expert panel.

Most doctors resent guidelines unless they are obviously data driven. Most of that data comes from randomized trials.

What we are seeing her is the erosion of the ethics of those who publish and conduct such studies and who use them to establish guidelines. There is another type of guideline, call “consensus guidelines” in which a committee of “experts” debates the best practice. These are the guidelines most doctors distrust. Now we see the corruption of even the randomized trial as a source of data driven guidelines.

Posted in corruption, economics, health reform, medicine, science | 9 Comments »

How not to reform health care.

Friday, June 11th, 2010

The academic world of health care likes the Obama health “reform” act. They are now figuring out how it will affect healthcare since it is a slapdash combination of pork barrel projects and untested assumptions. For example, it uses all the old command and control theory to deal with utilization and cost.

For years, the debate over health care has rested on the assumption that the uninsured should be brought into the health-care system the rest of us use. But what if something like the opposite is true? What if the best way to help the uninsured is to make the health-care delivery system they already use — the St. Elsewhere model — better, more efficient, and more affordable — in short, more like the VA? And what if, eventually, the rest of us could join that system?

Longman says the first step is covering the uninsured, particularly low income people. We’re on that path now with the passage of health reform. But we don’t have to put all the newly covered people into the current strained fee for service system and Medicaid. He proposes creating the “Vista Health Care Network” (VistA is the name of the VA’s electronic medical record system). Invite the “St. Elsewheres” and individual doctors to join an integrated delivery system to serve the newly insured. Like the VA, it would have a team approach, use health IT and comparative effectiveness protocols. Doctors would be salaried, and rewarded for quality not quantity. In other words, it would be what has now become known as an “accountable care organization.”

This is the standard fantasy of the political left. If we could just get rid of those evil profits and monetary incentives, everyone would adopt the virtues of the Utopia. Marx said “to each according to his need and from each according to his ability.” That may work well in religious communities where everyone is concerned with salvation. It doesn’t work in the real world, as anyone who studied the Soviet Union or Cuba should attest.

Longman predicts many struggling hospitals would see it as a lifeline. “Reimbursement rates would be set much higher than in Medicaid, and when combined with the efficiency in the VA model of care, they’d be high enough to guarantee the solvency of participating providers.”

Does anyone really believe that ?

The hospitals that take Vista’s offer would have to radically change the way they do business. They’d have to join the twenty-first century and integrate health IT into the practice of medicine. They’d have to embrace the VA’s safety culture. They’d also have to shed acute care beds and specialists and invest in more outpatient clinics in which, for example, diabetics could learn how to manage their disease, or people with high blood pressure could join smoking-cessation and exercise programs.

Where would the sick people go, if not to the hospital ? The graveyard ?

As with the VA, there would also be much more emphasis on integrated mental health-care and substance-abuse programs. Also as with the VA, doctors who work for these hospitals would be salaried and earn bonuses for effective performance (keeping their patients well). No longer would doctors have financial incentive to engage in overtreatment.

Yes they would have an incentive to under treatment. Sort of like the Netherlands ER doctors who give emphysema patients a lethal injection of morphine rather than admit them to the hospital. A doctor who admits an emphysema patient with respiratory failure is fired. Period. NO appeal. Everyone knows the rules. Except the families.

There is another opinion, well summarized in another medical blog. His posts are heavily embellished with humor that not all will appreciate. His ideas, however, are right on the money.

Until quite recently, DrRich counted himself among the stalwarts of scientific strict constructionism. He was truly dismayed that the NIH and some of our most well-regarded academic centers (under the guise of wanting to conduct objective “studies” of alternative medicine) have lent an aura of respectability and legitimacy to numerous bizarre ideas and fraudulent claims masquerading as legitimate medical practices. To DrRich, such developments were yet another clear and unmistakable sign of the End Times.

Furthermore, DrRich (a well-known paranoid when it comes to covert rationing) saw a more sinister advantage to the official and well-publicized support that government-funded institutions were giving to the alternative medicine movement. Namely, fostering a widespread impression among the unwashed rabble that alternative medicine is at least somewhat worthwhile (and plenty respectable) advances the cause of covert rationing. That is, the more you can entice people to seek their diagnoses and their cures from the alternative medicine universe, the less money they will soak up from the real healthcare system. With luck, real diagnoses can be delayed and real therapy put off until it’s far too late to achieve a useful outcome by more traditional (and far more expensive) medical means.

I think there is some truth to this. Chiropractors, for example, have made good use of the myth that their services are far cheaper than conventional medicine and therefore a money saver. The legislators who vote for these “money saving” changes in the law have never spent much time looking at the house size of chiropractors compared to MDs. In the Workers Compensation world, I have seen a case in which a disabled worker received 900 chiropractic treatments in one year.

Rather than a term of opprobrium, “alternative medicine” may actually be our most direct road to salvation. Indeed, DrRich thinks that far from damning alternative medicine, we should be blessing it, nurturing it, worrying over it, in the precise manner that a mountaineer trapped in a deadly blizzard would worry over the last embers of his dying campfire.

What turned the tide for DrRich was a recent report, issued by the U.S. Centers for Disease Control and Prevention, estimating that in 2007, Americans spent a whopping $34 billion on alternative medicine. That’s $34 billion, for healthcare (in a manner of speaking), out of their own pockets.

The implications of this report should be highly encouraging to those of us who lament the impending creation of a monolithic government-controlled healthcare system, and who have been struggling to imagine ways of circumventing the legions of stone-witted, soul-eating bureaucrats now being prepared (Sauron-like) to descend upon us all, doctor and patient alike.

This is why DrRich has urged primary care physicians to break the bonds of servitude while they still can, strike out on their own, and set up practices in which they are paid directly by their patients. Such arrangements are the only practical means by which individual doctors and patients can immediately restore the broken doctor-patient relationship, and place themselves within a protective enclosure impervious to the slavering soul-eaters.

This is the lesson to be drawn. We’ll see how many physicians take the hint. The seriousness of the trend is suggested by the efforts of the government, especially in Massachusetts, to make private practice of medicine illegal.

DrRich has speculated on various black market approaches to healthcare which could be attempted by American doctors (and investors) should restrictive, government-controlled healthcare become a reality. But now, thanks to the success of alternative medicine, there is a direct and straightforward path for American primary care physicians to re-establish a form of now-long-gone “traditional” American medicine, replete with a robust doctor-patient relationship, right out in the open – the kind of practice where patients pay their doctors themselves.

Simply declare this kind of practice to be a new variety of alternative medicine. Likely, PCPs will need to come up with a new name for it (such as “Therapeutic Allopathy,” or “Reciprocal Duty Therapeutics”), and perhaps invent some new terminology to describe what they’re doing. But what’s clear is what they will be doing is so fundamentally different from what PCPs will be doing under government-controlled healthcare as to be unrecognizable, and nobody will be able to argue it’s not alternative medicine. In fact, it will seem nearly as wierd as Reiki.

There is a novel suggestion.

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Posted in health reform, medicine | 1 Comment »

Cash medical practice

Friday, May 21st, 2010

I am also blogging at Chicago Boyz and have a new post up there about the trend to cash practice. Rather than repost it here, I suggest you look over there for the post. That is a very interesting blog and I was flattered to be invited to be a member.

Posted in geriatrics, health reform, medicine | 1 Comment »

Dartmouth and health care reform

Monday, May 17th, 2010

I am a Dartmouth alum and received this message today. It is interesting but not my direction for reform, I suspect.

May 17, 2010

Dear Members of the Dartmouth Community,

Today we are announcing the creation of The Dartmouth Center for Health Care Delivery Science, supported by a spectacular commitment of $35 million from an anonymous donor. The donor believes that Dartmouth is uniquely positioned to lead the advancement of this critical field. More about this new enterprise is included in the following press release and at TDC.dartmouth.edu.

Provost Carol Folt and I expect we will identify other major initiatives that draw upon Dartmouth’s unique strengths as the strategic planning process continues.

This is an exciting moment for Dartmouth. This gift recognizes the excellent work of our faculty and the collaborative strength of this academic community. The gift also expresses the will of a generous donor to help us tackle one of the most challenging issues of our time.

Sincerely,

Jim Yong Kim
President, Dartmouth College

****************************************************************
Press Release
EMBARGO: FOR RELEASE AT 12:01 A.M. MONDAY, MAY 17, 2010

CONTACT: Roland Adams, (603) 646-3661

The Missing Piece in Health Care Reform: Health Care Delivery Science

Hanover, NH Dartmouth College has received a $35 million commitment to establish The Dartmouth Center for Health Care Delivery Science, President Jim Yong Kim announced today. The anonymous gift will advance a new field of study, harnessing the knowledge and expertise of faculty across multiple disciplines from the arts and sciences as well as from the medical, business and engineering schools.

Kim said the gift will speed Dartmouth’s work on the next stage of needed health care reform: “The passage of health reform was a historic event that will result in millions of Americans having access to our health care system. Health Care Delivery Science is about ensuring that the care they receive is the best it can be.”

“We know and this has been documented by the Dartmouth Atlas of Health Care that there are glaring variations in how medical resources are used in the U.S. More care and more expensive care do not guarantee high quality care,” Kim said. “What we need is a new field that brings the best minds from management, systems engineering, anthropology, sociology, the medical humanities, environmental science, economics, health services research, and medicine to focus on how we deliver the best quality care, in the best way, to patients nationally and globally. Those people are here at Dartmouth.”

Senators Judd Gregg, R-NH, and Jeanne Shaheen, D-NH, applauded the new Center:

Senator Gregg noted that studies from The Dartmouth Institute for Health Policy and Clinical Practice “are constantly turned to by policymakers in Washington, especially as they relate to getting better health care at a more affordable cost. The establishment of this new Center will put the findings of Dartmouth researchers into practice and will further the Institute’s efforts to advance health care innovation, rein in health care costs, and provide quality care for people throughout the country.”

Said Senator Shaheen: “The formation of the Center for Health Care Delivery Science is great news. This will help Dartmouth remain on the cutting-edge of studying our health system and developing new practices to make health care delivery more efficient and cost effective. I look forward to working with and supporting President Kim and the Center in their efforts, especially as we implement new laws that will provide affordable health coverage to millions more Americans.”

In addition to integrating across the Arts and Sciences (undergraduate and graduate), the Tuck School of Business, the Thayer School of Engineering, Dartmouth Medical School, and The Dartmouth Institute for Health Policy and Clinical Practice, Health Care Delivery Science creates a unique partnership between the College and Dartmouth-Hitchcock, its affiliated academic health system. Dartmouth-Hitchcock will provide the base for innovation and implementation in clinical practice, said Co-Presidents James N. Weinstein and Nancy Formella.

Jim Weinstein was a classmate of mine in 1994-5 and is a really great fellow. He was offered a job at the end of the master’s program and has continued to move up the line, becoming Chief of Orthopedics, then Chief of the program. Not all of what this means is objectionable. The focus on quality of care, which drove me to Dartmouth instead of retirement, is valuable but has no support outside of theory and rhetoric. The people who are trying to transform health care have no interest in quality unless it costs less. That has always been the case in my experience with insurance or government.

“In the past decade, Dartmouth-Hitchcock has created a number of innovative models in clinical care, including the Spine Center, the first-in-the-nation Center for Shared Decision-Making, and the Comprehensive Breast Program,” Weinstein said. “This is a fantastic opportunity to build new partnerships within the College, and take advantage of President Kim’s experience in tackling the challenge of health care delivery in some of the most difficult settings in the world.”

One of the first initiatives will be a new Masters program in Health Care Delivery Science, offered jointly by The Dartmouth Institute and the Tuck School of Business. Traditional health care management courses have been built around general “best business” practices from a wide range of professions. The Dartmouth curriculum will be unique in its singular focus on discovery and analysis of innovations and real-time implementation in health care. Executive education and distance learning will be incorporated into the new degree program, scheduled to enroll its first class in July 2011. Undergraduate offerings in this field will be developed as well, Kim said.

Dartmouth Provost Carol L. Folt said: “Health care is now one-sixth of the U.S. economy, and arguably as important as any issue we face today. Our undergraduate students, whatever their career path, will be affected by its impact on our economy, national discourse, and of course, will experience health care first-hand as patients or family members of patients. We know that teaching political science, economics, sociology, philosophy, etc. to our students is critical to their liberal arts education. The opportunity to study health care and its impact on society in its broadest form will only enhance our ability to produce enlightened graduates and leaders.”

Jeff Immelt, Chairman and CEO of General Electric and a Dartmouth trustee said: “As an employer of 300,000 people around the world and with $3 billion of our resources going into health care for our people each year, there are few issues more important to me and to GE than the quality and cost of health care. I’m proud of Dartmouth for taking this on, for applying expertise from across the College to the challenges, and for partnering so effectively with the Dartmouth-Hitchcock health system.”

The Dartmouth Center for Health Care Delivery Science will focus on five areas with a goal of improving the quality, effectiveness, and value of health care for patients, their families, providers, and populations. Priorities will include:

Research:
* An expanded research agenda at Dartmouth and with partners around the country, building on the pioneering work of The Dartmouth Institute for Health Policy and Clinical Practice, and focusing on high-impact aspects of health care delivery.
* An international research network that will bring together innovation centers to develop, study and disseminate best practices.
* A grant award program to encourage research in the field.
Education:
* A new curriculum in the delivery of health care to be incorporated into medical education at Dartmouth.
* A consortium of medical schools committed to integrating Health Care Delivery Science into their academic programs.
* Undergraduate courses, cross-disciplinary offerings through the Tuck School of Business, Thayer School of Engineering, Dartmouth Medical School and the Arts and Sciences, and new distance and executive learning opportunities.
* A journal of health care delivery science, to advance dissemination, research, and learning.
Collaboration:
* Partnerships across a diversity of health care systems in the U.S. and beyond, to define best practices and integrate them into clinical practice.
* Joint efforts with academic institutions nationally and internationally to expand the new field of Health Care Delivery Science.
* Intellectual “lab” spaces for leaders in business, industry, government, academia, to create new synergies and pathways for innovation.
Implementation:
* Demonstration projects to provide proof of concept, e.g. The Spine Center at Dartmouth-Hitchcock, Shared Decision-Making, and initiatives to improve population health.
* Development and deployment of measures that go beyond clinical outcomes, to evaluate quality and value of care, with patient-reported data and longitudinal tracking incorporated into enhanced Health Information Technology.
* On-the-ground teams and distance-teaching to facilitate adoption and integration of proven “best practices” in diverse clinical environments nationally and internationally.
Advocacy:
* New Communities of Practice nationally and internationally that demonstrate quality and value in health care.
* Advocacy for changes in policy at the federal and state levels and globally to promote and support new models of care.
* Comprehensive outreach across a range of audiences health care providers and systems, policymakers, consumers, and others to inform, educate, and engage.

Michael E. Porter, Bishop William Lawrence University Professor at Harvard Business School and author of Redefining Health Care: Creating Value-Based Competition on Results, said: “For 30 years, researchers at Dartmouth have pioneered the measurement of performance variation in U.S. health care, and given us clear evidence of the serious value problem in health care delivery. This Center, with its multidisciplinary approach and unique partnership with a leading medical center, is poised to become a leader in advancing measurement and devising new delivery solutions. I look forward to working closely with the Center and its leaders.”

Kim said the anonymous donor chose Dartmouth as the place to lead in this area, based on the institution’s record of accomplishment in health systems research and implementation, its established graduate programs, history of collaboration and innovation across campus, and the investment the Trustees have already made in pursuing health reform through establishment of The Dartmouth Institute.

“This is a donor who believes deeply in the moral and economic imperatives of changing the way health care is provided in this country and throughout the world,” said Ed Haldeman, Chair of the College Board of Trustees.

“The donor also chose Dartmouth because of President Kim’s background and his ability to lead one of the great institutions of the world to mobilize its strengths and tackle one of the great challenges of our time. The Trustees and I fully expect that this is the first of a number of initiatives Dartmouth will launch in the coming years. This spring President Kim and Provost Folt are launching a strategic planning process that will identify other initiatives that build upon Dartmouth’s many strengths,” Haldeman said.

For more information about the Dartmouth Center for Health Care Delivery
Science, please visit http://tdc.dartmouth.edu
************************

Posted in health reform | 3 Comments »

“Moderate” Bart Stupak Retiring – UPDATED

Friday, April 9th, 2010

By Bradley J. Fikes

No, no, the Tea Party didn’t scare off Michigan Democrat Bart Stupak from seeking re-election. The political moderate was going to retire anyway, but held on until he could help health care reform  passed.

That’s the spin in an Associated Press article about Stupak’s sudden announcement. that he is retiring from Congress. Well, to be fair, the Associated Press was simply reporting Stupak’s explanation for his retirement, although it didn’t seriously challenge it.

But the labeling of Stupak as a political “moderate” was the AP’s counterfactual spin:

“A political moderate, Stupak is known for an independent streak that sometimes put him at odds with his party’s leadership. He voted against the North American Free Trade Agreement and an assault weapons ban in the 1990s, despite appeals from then-President Bill Clinton.”

NAFTA was extremely controversial among liberal Democrats, while Republicans generally liked the agreement. NAFTA passed the House with the votes of 132 Republicans and 102 Democrats, while it was opposed by 156 Democrats, 43 Republicans and one independent. Since most House Democrats opposed the bill, Stupak’s opposition hardly counts as an example of an “independent streak.” This is just the ahistorical spin of the AP story’s author, John Flesher. Or maybe like many of his MSM peers, Flesher just doesn’t know how to use Google.

Stupak’s putative moderation is easily invalidated by a look at his voting record, as compiled by both the left-leaning Americans for Democratic Action and the conservative Americans for Constitutional Union.

In 2008, Stupak got a 90 percent liberal rating from the ADA, as liberal as John Dingell. Here’s the list of his Michigander congressional delegation:

The "moderate" Bart Stupak

The "moderate" Bart Stupak

If anything, Stupak has turned more leftist in recent years. The ACU, whose ratings are almost a mirror image of ADA’s, rates Stupak’s lifetime conservative voting record as 21 percent.

Stupak’s alleged moderation is almost entirely the result of his stand on abortion, which indeed has been more moderate than most Democrats. It allowed Stupak to portray himself as being in the political middle, while voting left almost all the time.

And media outlets like AP let Stupak get away with it.

UPDATED — Here’s another gem of a John Flesher article spinning against the Tea Party people “gloating” over Stupak’s withdrawal:

Michigan’s northernmost district tends to favor moderates more concerned with federal money for local projects than with ideology.

Stupak announced Friday he wouldn’t seek a 10th term. He fit the district mold so well he repeatedly won re-election by large margins.

A “moderate” with a 90 percent liberal rating from the ADA? Well, moderate by Flesher’s own politics. He’s an environmental writer, which is as good as an ADA membership. Of course, Flesher does PR for the global warming movement, such as writing a mostly unskeptical story about how reducing greenhouse gas emissions in Michigan can supposedly help the state’s economy.

Flesher’s assertions about the political views of northern Michigan are, of course, unsupported by any evidence than his word.

Another example of negative value reporting from the Associated Press — if you believe it, you know less than you did before.

(DISCLAIMER: This article represents my opinions, and does not necessarily reflect the views of my employer, the North County Times.)

Posted in health reform, media, politics | 2 Comments »

Afterthoughts

Tuesday, March 23rd, 2010

The HCR bill passed the House and, since it is identical to the Senate bill (which was an amendment by substitution of another House bill), it will go to the president for his signature. The “Reconciliation” bill will probably die in the Senate. What now ?

First comes the election. I don’t think the anger and determination to punish the Democrats will die down. I think they could lose 100 seats this fall. The Senators were less visible in the health care debate but there are a number of small scandals that will doom a number of members’ chances for re-election.

The first provisions to become effective in the bill will be the “shall issue” provision which prevents health insurance companies from turning down applicants for “pre-existing conditions.” Thus, we now have the case of the man whose house is burning down, buying fire insurance. This will have several effects. It will remove the motivation to buy insurance from all but the most conservative. The “mandate” does not take effect initially and the penalties are weak, so it will have little effect. Worse, it requires the purchaser to buy a product larded up with coverage for low probability events and unnecessary treatment types. This is a lobbyists dream, as it is in most states.

The taxes apply to income and investments, so there will be more drain on the economy. Take a look at a leftist’s account of the myths and fallacies in the bill which will become law tomorrow.


1. Myth This is a universal health care bill.

Truth The bill is neither universal health care nor universal health insurance.
Per the CBO:

Total uninsured in 2019 with no bill: 54 million
Total uninsured in 2019 with Senate bill: 24 million (44%)

2. Myth Insurance companies hate this bill

Truth This bill is almost identical to the plan written by AHIP, the insurance company trade association, in 2009. The original Senate Finance Committee bill was authored by a former Wellpoint VP. Since Congress released the first of its health care bills on October 30, 2009, health care stocks have risen 28.35%.

3. Myth The bill will significantly bring down insurance premiums for most Americans.

Truth The bill will not bring down premiums significantly, and certainly not the $2,500/year that the President promised.

Annual premiums in 2016, status quo / with bill:

Small group market, single: $7,800 / $7,800

Small group market, family: $19,300 / $19,200

Large Group market, single: $7,400 / $7,300

Large group market, family: $21,100 / $21,300

Individual market, single: $5,500 / $5,800*

Individual market, family: $13,100 / $15,200*

4. Myth The bill will make health care affordable for middle class Americans.

Truth The bill will impose a financial hardship on middle class Americans who will be forced to buy a product that they can’t afford to use.

A family of four making $66,370 will be forced to pay $5,243 per year for insurance. After basic necessities, this leaves them with $8,307 in discretionary income — out of which they would have to cover clothing, credit card and other debt, child care and education costs, in addition to $5,882 in annual out-of-pocket medical expenses for which families will be responsible.

5. Myth This plan is similar to the Massachusetts plan, which makes health care affordable.
Truth Many Massachusetts residents forgo health care because they can’t afford it.

A 2009 study by the state of Massachusetts found that: 21% of residents forgo medical treatment because they can’t afford it, including 12% of children. 18% have health insurance but can’t afford to use it

Read the rest of it at the link. Jane Hamsher favors single payer on the model of Canada or the NHS and I disagree but this is an interesting picture of the bill from an intelligent leftist. I don’t understand some of her numbers. I don’t know why individual policies would be cheaper than individuals in the large and small group markets unless the policies are not the same in provisions. For example, many individual policies are high deductible. Her description of the early provisions is a bit different from what I understand but I have not made a detailed study of the bills.

Six months from the date of passage, children could not be excluded from coverage due to pre-existing conditions, though insurance companies could charge more to cover them. Children would also be allowed to stay on their parents’ plans until age 26. There will be an elimination of lifetime coverage limits, a high risk pool for those who have been uninsured for more than 6 months, and community health centers will start receiving money.

I thought the ban on pre-existing condition exclusion applied to all ages.

Long term effects, assuming the bill stands, would erode the level of reimbursement to providers, would not reduce the number of people going to ERs, and would result in waits for care, especially primary care, as doctors retire and drop out of the system to practice for cash.

I also think the bill could be amended to remove most of the objectionable provisions and leave the few helpful ones, like insurance exchanges. We have to get some market structures in place if there is to be any effort at reducing costs. None of this will happen unless the political culture ion Washington changes. That is what we have to do in November.

Here is more on Obamacare’s early provisions.

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Posted in health reform | 9 Comments »

Congressman McDermott speaks his mind

Sunday, March 21st, 2010

Congressman McDermott, a former psychiatrist and Saddam supporter, spoke his mind yesterday in the House, ending with a biblical quote. This is James 2:15-17.

15 If a brother or sister is naked and lacks daily food, 16 and one of you says to them, “Go in peace; keep warm and eat your fill,” and yet you do not supply their bodily needs, what is the good of that? 17 So faith by itself, if it has no works, is dead.

That is not exactly the version McDermott uses but it is an interesting point. Which political philosophy, liberal or conservative, gives more to charity ? That biblical quote does not admonish the faithful to pass a law requiring everyone to give money to the poor brother or sister. It speaks of you.

yet you do not supply their bodily needs

The Congressman, aside from his rant about “teabaggers,” needs some Bible study. I don’t recall Jesus admonishing anyone to run for office or to force others to contribute to the poor.

McDermott has some odd friends, one of whom was hanged several years ago.

The alleged Saddam Hussein spy money that paid for Rep. Jim McDermott’s trip to Iraq in 2002 came after a stranger called a Seattle anti-war activist and offered to finance the prewar visit.

The Seattle activist, Bert Sacks, said he was making arrangements for the trip at McDermott’s request when he got the call out of the blue from a man who identified himself as a concerned Iraqi-American.

Federal prosecutors believe the money was illegally funneled from Saddam’s intelligence officials, through an unnamed intermediary, and to a Dearborn Heights, Mich., activist named Muthanna Al-Hanooti.

The Justice Department has said McDermott and two other Democratic congressmen on the trip did not know Saddam’s regime paid for it. They have not been accused of any wrongdoing.

Al-Hanooti was indicted Wednesday for his alleged work on behalf of Saddam’s regime, including setting up the trip under the direction of Iraqi intelligence officials. He has pleaded not guilty and his attorney said he would “vigorously defend” himself against the charges.

Yes, McDermott could use some Bible study.

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Posted in corruption, health reform, politics | 3 Comments »

The pleasures of medicine; or not.

Sunday, March 7th, 2010

UPDATE: Nearly half of all physicians plan to quit if Obamacare passes. Many will phase out but it will be a disaster. I’m sure Obama has plans to fix it.

I have been a physician for almost 44 years. I graduated from medical school in 1966 and finished my residency training as a surgeon in 1972. Since I began medical school in 1962 (For the second time but that’s another story), I spent ten years learning to do what I did until I retired from surgery in 1994 after back surgery. I have gone on doing medical things since then but I had to give up surgery. The 27 years I spent as a surgeon (including my training) were the best years of my life. Had I not injured my back in college, I would still be practicing, even at 72. The early years of my career as a surgeon were the golden age of medicine in this country. We still could not cure some diseases and we especially were limited in our ability to deal with infection in some cases but the life of a physician or a surgeon was the best it would ever be.

About 1987, things really began to change for the worse. Some of it was the fault of the profession, some the fault of politics and some the fault of human nature. In 1978, the first political reaction to the rapid growth in the cost of medicine appeared. It was called PSRO, or Professional Standards Review Organization. Of course, it had little relationship to professional standards and everything to do with cost. We all had to participate like some Red Guards self examination in Mao’s China. We learned how to analyze care for what were purportedly quality issues but we all immediately recognized as cost. All the doctors of the hospital staff had to attend these classes and learn how to do this. Then we had to “volunteer” for committees to review cases to see if they met the standards. The standards always seemed to focus on cost issues, such as length of stay. Length of stay is an American obsession. A few years after this first experience with self examination, we began to have demands from Medicare and insurance companies for AM admissions before surgery.

AM admission is one of the examples of the lunatic aspect of government intervention in medicine. People who were to have major operations were expected to get up at 4 AM the day of surgery and come to the hospital at 5:00 for a 7:30 surgery. They were given instructions about not eating or drinking after midnight or whatever. Why not just have them come in at 6 PM the night before and be prepared then. ? They would sleep better with a sleeping pill, we would know for sure that they hadn’t had a late snack in spite of instructions and the hospital staff would know they were there, ready for surgery.

When this began, I asked what I thought was a logical question. Why are we doing this ? Cost, I was told. Why charge for the admission day before surgery? We could just make that a free day since the patients came in after 3 PM anyway. Nobody ever answered. The hospital had to add staff for the early morning shift. Sometimes a patient would not show up or arrive too late for their 7:30 case. Then we would scramble around to see if the next patient could come in early instead of the 10 o’clock they had been told. The schedule would be shifted around and the charge nurse would call the next surgeon to see if he could come in early, only to find he was doing surgery in another hospital at that time. I was sure, and still am, that the costs were no different and the aggravation and even the danger was increased for no good reason. It’s a bit like the Army. “Why are we doing this sir?” “Because I said so !” “Thank you sir.” A stint in the Army is helpful in understanding how government works.

That was the beginning. Next came calling the insurance company for permission to do surgery. In 1987 came the new way of being paid for care. It was called Resource Based Relative Value Scale, or RBRVS. A Harvard professor came up with a new way to pay for care. The methodology was supposed to account for the value of inputs in determining what Medicare (and quickly all insurance companies followed suit) would pay. It is related to the “Labor Theory of Value.” If you follow the link, you will see who thought this up. The original Relative Value System was developed by the California Medical Association in the 1930s. It was constructed by doctors to rate services, relative to each other, on what the price should be. I have previously covered some of this in a post on “How we got here.” Now, we have arrived at a system that is so onerous and counterintuitive that doctors have lost a lot of the pleasure of private practice. As usual, Thomas Sowell has something to say about it that concisely summarizes the foolishness of the present situation. If that is not enough, there are numerous examples of what government medicine eventually looks like. If you remove the pleasure, pretty soon everyone turns into the DMV or the Post Office employee. I mean no insult to those people but psychology has rules about behavior. Read the Thomas Sowell article. He always has something worth while to say. This is even better than most.

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Posted in economics, health reform, medical history | 17 Comments »

Clueless experts on health reform

Wednesday, March 3rd, 2010

Today Gail Wilensky, who was Medicare administrator under Bush I, tries to explain where we are in a New England Journal article. Since the NEJM is firmly socialist on health care, the article holds no surprises.

The third option is to create a new, more limited bill, which essentially means starting over. This strategy seems unlikely to be acceptable to Democrats, and it’s hard to know whether Republicans really want a new bill, either, though they say they do. In reality, there seems to be little inclination on either side to change the positions already staked out. Republican support has coalesced around two different bills: the Common Sense Health Care Reform and Affordability Act developed by the Republican House leadership last July and the Coburn–Burr Patient Choice Act of 2009 sponsored by Senators Tom Coburn (R-OK) and Richard Burr (R-NC) and Congressmen Paul Ryan (R-WI) and Devin Nunes (R-CA). However, as happens too often with Republicans and health care, neither proposal was pursued with the single-mindedness and passion that characterizes the Democratic pursuit of health care reform.1

That might have something to do do with the fact that nothing is better than any of the Democratic proposals. Will none of these people ever recognize that command economies don’t work ? Health care is an economic system that has been wrecked by perverse incentives and moral hazard for 60 years. There is no reason why employer provided health insurance should be tax exempt. It goes back to World War II and wage and price controls.

Most of these people are bureaucrats who have spent their lives managing other people’s lives, usually poorly. Gail Wilensky was no great shakes as Medicare administrator. The academics who write about this have no experience and are using their own theories of management based on a life on salary with clinic patients arranged for their convenience. They know nothing of paying a staff or rent or running a private practice.

My own preference for some time has been the French system, which uses fee-for-service to control utilization and which requires patients to pay first and be reimbursed later.

The Obama system has no market mechanism to control utilization and is a disaster requiring an intricate command and control system that would make the Soviet Union envious.

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Posted in health reform | 1 Comment »

Lies about malpractice reform

Friday, February 26th, 2010

I looked at Washington Monthly today, as I usually do to see what the far left is thinking. They were, as usual, obsessing about the health “reform” legislation and yesterday’s summit. I noticed a link to another article about malpractice reform.

First, from Wash Monthly,

John McCain recommended malpractice reform modeled on California and Texas.

There’s two examples right now of medical malpractice reform that is working. One is called California and the other is called Texas. I won’t talk about California because we Arizonians hate California because they’ve stolen our water.

“But the fact is that Texas has established a $750,000 cap for non-economic damages; caps doctors at $250,000; hospitals at $250,000; and any additional institution, $250,000; and patients harm to a finding of medical malpractice are not subject to any limitations on recoveries for economic losses. And I hope you’ll examine it.”

Wash Monthly comes back with a response that is based on lies.

I hope policymakers will examine it, too, because the results of the experiments in California and Texas offer some important lessons.

McCain preferred to ignore California’s experience, not because of water rights, but because the caps haven’t worked the way conservatives would have liked.

This is a lie. The “source” he links to is Jamie Court who is a really far left anti-insurance zealot and part of the phony Prop 103 auto insurance “rollback” that passed a decade ago and screwed up California’s auto insurance for a while. Here is what Court says:

Data from the National Assn. of Insurance Commissioners show that doctors’ malpractice premiums nearly tripled in the first dozen years after the 1975 California law. Premiums fell sharply and stabilized only after Californians passed insurance reform Proposition 103 in 1988.

Under 103, $135 million was refunded by malpractice insurers. The insurance measure also created an elected insurance commissioner who imposed a rate freeze for his entire first term, implemented stringent regulation and ended price fixing.

This is just a lie. I was practicing surgery in California the entire time he refers to. I began my private practice in 1972. My malpractice premium was $3500 per year. In 1974, following the stock market decline which devastated insurance company investments, my malpractice carrier raised my (and my partner’s) premium to $35,000 per year, but we learned that the company was insolvent. For a while, there was no insurance available except at stratospheric rates we could not afford. Thousands of California doctors practiced without insurance for several years. In 1974, there was a statewide doctor’s strike. Many doctors refused to treat any but emergency cases until the state did something about medical malpractice. Governor Jerry Brown called an emergency special session of the state legislature in January 1975. They passed a very good law called AB1XX, named for the special session. Since that time, it has been called MICRA, The Medical Injury Compensation Reform Act.

It has been attacked many times by the trial lawyers, with whom Court is affiliated. Eventually, the State Supreme Court upheld the reform act, in spite of furious attacks by the medical malpractice bar. It has resisted further attacks every few years for the past 25 years.

Court claims that premiums tripled and that Prop 103 affected the rates. Both are lies. My partner and I practiced without insurance for three years. In 1978, when we added another surgeon to our practice, we decided to start buying insurance again and we joined a company called CAP/MPT. That stands for Cooperative of American Physicians/ Medical Protection Trust. It is a non-profit cooperative of doctors who are self insuring. We each deposited $20,000 into a trust fund. We were than assessed an amount each year according to our specialty. Surgery is higher risk than General Practice, for example. My assessment remained at about $6,000 per year for the next 20 years.

I was sued several times although most were nuisance suits. For example, when we did apply to CAP/MPT, I learned that I had eight wrongful death suits filed against me. When we investigated, we found that these were ER patients, mostly trauma cases, that had died. Some, I had not even been involved with their care. I wrote letters to each law firm asking them to dismiss the suits or be subject to a suit by me for malicious prosecution. All were quickly dismissed. I was threatened with suits a couple of times by disgruntled patients. One woman kept coming back complaining because she had a tiny scar from a varicose vein injection. I couldn’t see it from ten feet away. I finally (a mistake) asked her why she was so obsessed with this scar that no one else could see. She had been warned that these injections can cause scars. I even asked her if she was having personal problems, with her husband, for example. That was a big mistake. She threatened to sue me but she could never find a lawyer to take her case.

Ironically, she had originally come to me because I had saved her mother’s life. Her mother, a smoker, had been in California to help her daughter with a new baby. While here, she had a catastrophic vascular accident that resulted in her entire small intestine dying. I put together her duodenum and colon but did not expect her to live. She had no remaining bowel that could absorb nutrients. Also, the connection of the bowel was tenuous because of the poor blood flow. Amazingly, it healed but she had no way to absorb food. We put her on total parental nutrition and she did well but there was no known way to keep the catheter from getting infected. They had never been used for a chronic IV nutrition situation.

I had been to the American College of Surgeons meeting a couple of months before and had seen a new catheter that was intended for long term IV use. It was still experimental. I called Belding Scribner, who had invented the first shunt that allowed chronic dialysis for renal failure. He was the one at the meeting who was showing the new catheter. He told me the name of the small company that was making them and they agreed to send me one. They are now commonly used for chemotherapy but this was probably the first use for a patient who lost her entire small bowel. It worked and she went home to Bethesda, Maryland after we taught her husband how to care for it. I called the National Institutes of Health to find someone who could help the husband with the care and she did well for several years, finally dying of a heart attack. Ten years later, her daughter sued me for a 2 mm scar.

I had a couple of other suits, one of which went to trial and I was exonerated, including being awarded the court costs. In 1994, after a major back operation for an old injury, I retired. A couple of years later, my $20,000 trust fund contribution was refunded. Court is lying about the malpractice situation in California and trying to puff up the role of his anti-insurance Prop 103. There was no refund until I retired and that had nothing to do with Court and his Naderite pals.

The fact that the left has to lie to support their position is excellent evidence that they have nothing else on their side.

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Posted in health reform, medicine, politics | 7 Comments »

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