Political biases and looming catastrophes

We all have a bit of Chicken Little in us. I think it must be hard wired in our brains to try to look into the future and see where our actions will likely get us in trouble. Being the strong believer is evolutionary concepts, I understand how adoption of such a mindset and embedding biological mechanisms within us to favor such thinking would favor passing on our DNA and whatever culture encouraged such thinking.

I can't help but contrast differing loci of concern which characterize different parts of the political and social spectrum. It is intriguing to me that we use such terms as conservative and liberal when everyone appears to want to conserve something. What I find most intriguing is the different levels of anxiety regarding the potential for certain types of catastrophic events and how that tends to track differently in those of different political bents. On the left, there is much hand wringing about global warming and environmental degradation while on the right the concerns focus more on fiscal calamity and social changes.

What I find remarkable is that we have the luxury of worrying about such things since much of humanity throughout history (and for much of the world now) has been forced to deal with much more short terms concerns, those being finding enough to eat and protecting themselves from the harsh elements? It is only a very recent development that those concerns have been moved on to the back burner for some of us.

I have to ask, what happened to allow for such a dramatic improvement in circumstances for some of us and how easily could we move back to the previous state? The movement from a tenuous subsistence existence to the generation of sufficient wealth to insulate certain substantial populations from immediate concerns of  where their next meal is coming from is a contemporary one and well documented. In addition, certain populations have actually toggled between the tenuous and not so tenuous states, giving us insight into to aspect of the transition.

Perhaps the most important insight is that societies which have moved to producing sufficient wealth to insulate large portions of their population from immediate physical needs can move back to  less desirable states and the human toll is huge.  In my estimation these should be some of the most fundamental questions which should be repeatedly asked and in particular, they should be asked whenever anyone suggests we need to impose fundamental changes to the rules we use to govern human interactions. Various social experiments of the 20th century resulted in social chaos and mass famines and loss of tens of millions of lives. While ecological catastrophes remain possible but theoretical, economic and political catastrophes as a consequence of human tinkering have occurred repeatedly in recent history.

There is not a consensus on the key mechanisms which allow us to consistently fulfill basic human physical needs. Furthermore, the default state is not a world where those needs are fulfilled to a degree which will allow us to focus on other more distant concerns.  All of us live meal to meal and need to be protected from the heat, cold, wet, and disease. For some of us it appears we have forgotten how this actually happens. We have come to the belief that the most likely source for catastrophic disruption comes from man made changes in natural ecosystems, not from man made changes of the critical human constructed systems which have lifted us from our inherently tenuous lives.

Paper, scissors, rock

The week, along with the Heath Care Summit, has come and gone. I make it a point not to underestimate the resourcefulness and will of the Democrat majority to push through a health care reform bill, but at this point simple math points to no legislative product. Unless the entire process begins anew, the only version of the bill that has a chance is the Senate version, passed through the process of reconciliation. The math consists of the number of members of the House of Representatives who will vote for some version of the Senate bill and everything that I read points to the votes not being there. How much the bill can be modified is an open question, based upon the arcane tenants of the Byrd Rule, the opinion of the Senate Parliamentarian, and the willingness and desire of the majority party leadership to challenge any ruling which was not in their favor.

Independent of any Parliamentarian drama, it is not at all clear that the Democratic majority can find a consensus within their own ranks and it is highly doubtful that they can rely on any support from the Republicans. Within the Democratic party, exclusion of elements which explicitly deny finding to abortions likely will withdraw support from specific members while inclusion is unacceptable to a distinct and even larger subset. Scaling back the scope to deal with financial concerns is unacceptable while not scaling back the scope will prompt the Blue Dogs to withdraw support. I could go on and on but the gist of the problem is that multiple groups have drawn lines in the sand regarding non-negotiable items. Each of these groups has essentially veto power over the legislation and  the non-negotiable items are multiplicative and redundant resulting in impasse.

While this is all going on, the Medicare SGR fix has lapsed. I have heard repeatedly that this will get fixed. I am not so sure. We will see what happens tomorrow morning. If it does not get "fixed", this may initiate events independent of Congress which may in fact alter the health care landscape more than any legislative reform. The blunt approach of broad cuts (>21%) will have the most prompt effect on those who are at the bottom end of the payment scheme, primary care care and those who use mostly E&M services. Look for large numbers to throw in the towel and simply withdraw from Medicare like many have withdrawn from Medicaid programs. The ripple effect will diffuse out to affect patients, hospitals, training centers, and a host of other entities downstream from the Medicare funds flow.

While the parties at the lower end of the food chain may be forced to withdraw from Medicare, they are not going to where the most interesting action will happen. As a rule, they are not very leveraged. They have not bet the ranch and made large capital investments which need big Medicare billings to to cover their borrowings. My question is who has made the most leveraged bets contingent upon Medicare money?  I don't know the answer but it will become apparent when they they can't make payroll.

"Bending the Curve" without wishful thinking

This is a great piece on the variables which are drivers of health care inflation. http://online.wsj.com/article/SB10001424052748703787304575075843971534082.html?mod=WSJ_Opinion_LEFTSecondBucket

It all about how complex this issues are and our limited ability to tease out all the drivers. I tend to think about problems like this in terms of complex clinical problems.  I deal mostly with symptomatic but not necessarily life threatening disease, frequently long standing. I am often put in the situation where the patient wants both an explanation for why things have gone wrong and also wants to be relieved of their symptoms. Many times I simply cannot sort out all the drivers of a specific clinical problem. However, I can use some basic therapeutic principles to alleviate their suffering, dependent upon a broad understanding of pathophysiologic processes but short of a complete or even near complete picture. As long as I am in the neighborhood (am I dealing with animal, vegetable, or mineral?), I can make an impact.

Looking at the health care reform debate I feel no particular obligation to understand every small detail of pathology in order to feel comfortable with an approach to improve outcomes. While the health care debate has moral implications, the spiraling costs are primarily an economic problem. Looking at the runaway cost issue in health care economics, one can make a similar assessment using observations of the present state and looking at similar economic scenarios. Based upon history one can be pretty confident the spiraling upward costs happen when t0o much money is chasing after something and/or those spending are spending someone else's money.  In the case of health care it is both. No amount of regulatory complexity or moral posturing will  change how this turns out. Markedly skewed financial incentives will trump everything and appealing to the best in humanity will not succeed when we financially reward our worst impulses.

Moral indignation may drive some to use the blunt force of the state to try to control costs. While the impulse is understandable, even the most modest appreciation of previous attempts to use such an approach (and there have been many) will have to lead even the most ardent proponent of legal cost controls to be a bit leery of pushing this agenda. Perhaps this time is different. Where have I heard that said before?

Conflicted missions - an eye opener

The NEJM published a piece titled "Serving two masters- Conflicts of Interest in Academic Medicine".
http://content.nejm.org/cgi/content/full/362/8/669?query=TOC
Its content is not behind the firewall and is free. Included in this is a table shown below.



I don't know about these guys but I would find academic medicine easy if all I served was two masters but from this table it is relatively easy to see how they have accomplished this. They have left out a few constituencies, primarily medical students, medical residents (as opposed to researchers in training) and patients. I thought somewhere in the mission of academic health centers there should be something included which places a priority on training physicians to be patient centered and providing patient centered as opposed to margin centered patient care. Silly me!

Price controls - at best an exercise in naive wishful thinking

Just when I thought that I could not hear anything any more outrageous I read about the latest proposal to reign in health care costs...price controls on insurance premiums!

http://www.nytimes.com/2010/02/22/health/policy/22health.html

Please tell simply ONE historical precedent where this worked? Yes the cost of specific commodities such as electricity and gas may be set within the context of regulated utilities. These entities produce very specific items and are also guaranteed specific rates of return. Unlike electricity or natural gas, healthcare is an undefinable huge basket of services making it neither definable or regulatable. We would be asking for disaster to create such entities and guarantees in healthcare.

Roll back the clock to Diocletion and his price controls and move forward to any Communist entity of the 20th century. They display a perfect record when it comes to the effects of price controls and administratively set prices. Perfectly awful and prefect failures. It may work for political grandstanding but no matter what the intent, it will accomplish nothing but screw the common man and woman by making essential services affordable but unavailable.

The Tiger Wood's problem and physicians

I recall the night the story broke when Tiger Woods had his late night collision. My wife immediately remarked that he was having marital problems. She was correct but we had no idea of the extent of his problems or how fall he would fall. The events which have unfolded since have served as a source of reflection and the lessons which can be learned from these events have implications which touch upon virtually all facets of human interaction, including health care.

How did Tiger get into such a deep hole? One word sums up the key factor which permitted this to happen…isolation. While Tiger as the golfer was a very public entity, Tiger in his off the course world was isolated from those who could or were willing to give him feedback on his activities. At any number of points in time, he would have benefitted from someone who, upon seeing what he was up to, would candidly and forcefully told him, “DON’T DO THAT!” Each of his individual indiscretions could be viewed as small failures and with appropriate and timely feedback, he could have executed course corrections which could have resulted in avoidance of his catastrophic crash and burn.

Whether we are talking about individual people or organizations, we need to accept something short of perfection in terms of performance. Personal and organizational egos need to be prepared for failure and the lack of any failures is indicative of one of two states, neither desirable. Perhaps the lack of any failures is indicative of an overly risk averse culture where nothing which cannot be guaranteed is attempted. Over time, this type organizational or personal culture virtually guarantees catastrophic failure because it suggests the inability to change and adapt to change.

The second scenario is associated with the lack of mechanisms to detect failures. I suspect that any number of people were privy to Tiger’s Woods ongoing indiscretions when they were ongoing. In an ideal world he would have interacted with a wide range of people, at least some of whom would have had the insight and motivation to provide him with the feedback that these activities represented undesirable activities, prompting a course correction and a different course of events. However, this did not happen. Tiger Woods was isolated from feedback and the fact he was isolated resulted in him ending up at a destination where he really did not want to be.

The broader lessons are obvious.  This sequence of events is not isolated to Tiger Woods. Virtually every personal and organizational failure in recent (and probably distant) memory can be traced to personal or organizational isolation. Financial bubbles and corporate meltdowns can be traced to adoption of flawed financial models by small inbred leadership groups which operated within cultures which stifled dissent and frowned upon any sort of failure, even small ones.

Medicine is vulnerable to these same phenomena, particularly ambulatory practice. For a physician who is not hospital based, how does he (she) get feedback on a regular basis? Who can a physician who practices in this environment rely on to alert them to the small failures in order to make the small course corrections required to avoid the major crashes? We tend to allow our physician colleagues great latitude in terms of their behaviors, but are we respecting their autonomy or are we acting like Tiger Wood’s enablers?

The Regulatory Choke hold and Health Care reform

I like to think about complexity and adaptive systems. There is an increasing appreciation that social systems and biological systems share certain characteristics.  Darwin realized this when he wrote the Origins of the Species and borrowed heavily from concepts initially introduced by Adam Smith and David Ricardo. However, the application of evolutionary biological principles to social sciences in the early 1900s under the description of Social Darwinism  and its adoption to promote specific social agendas resulted in hindering mainstream scholarship in the arena. It is a shame since complex systems are governed by evolutionary principles. Durable entities endure. Fragile ecosystems go away.

What makes systems durable? Redundancy and flexibility make systems enduring. More constraints generally lead to decreasing ability to deal with change. You might ask what this has to do with health care in the US? The health care ecosystem is remarkably fragile and is about to undergo a major stress test. It has been reasonably durable due to the continued infusion of lots of money and when that cash infusion is even simply moderated in an attempt to avoid economic bankruptcy, this will reveal the lack of redundancy and flexibility which is a characteristic of the business entities which take care of patients and train the next generation of health care providers.

I work in both realms and see the business models. They are flawed in a major way. The educational model is based upon an archaic model of training which is now fossilized based upon an alphabet soup mix of regulatory entities such as the ACGME and AAMC. They are all in on the bet that training of health care professionals needs to be non-profit University based and the organ based specialty training which made sense 100 years ago is the model which needs to be maintained into the indefinite future. The financing of these endeavors, particularly residency training is almost entirely based upon Medicare dollars which could easily disappear. There is no fall back position. We are Kuala bears living only off Eucalyptus leaves while we should be like regular bears which can use any number of food sources. 

Clinical care is also precarious in terms of it's support which does not come from a differentiated stream of sources. Medicare forces providers to again play the game in an all in or all out format. Robust systems allow players to hedge their bets. This allows individual actors great latitude and the system as a whole benefits from identification of optimal approaches through an evolutionary approach. Medicare stifles such activities and because it serves as a template for most privater insurers,  it basically insures that Medicare rules and incentives become virtually universal. It will become very interesting when the funds which have kept this system afloat are constrained. In an ideal world, we could have an insurance mediated safety net  which did not constrain innovation which could drive the delivery of better and cheaper care and individual doctors and patients could reside in both realms. The present rules of engagement are both ambiguous and carry the potential for catastrophic, capricious, and unpredictable penalties. The only choices are to stay in and keep you head down or pull completely out. That is a recipe for traumatic disruptions as opposed to a desirable ongoing adaption to change.

None of these issues are being dealt with in health care reform. If anything, the regulatory constraints will be worse. It is possible that health care reform will precipitate an unwinding of this bubble by removing sufficient money to unmask the precariousness of this ecosystem. With or without formal reform, financial constraints will drive this sooner or later. When this happens, we need to have countless unconstrained problem solvers willing and able to apply their efforts to define new and better approaches to deliver care to patients.

Reviving the Health Care Debate Yet Again

While the DC snow event of 2010 has briefly put the brakes on the health care debate, Washington is slowly digging out. With the thaw comes the renewed debate as to where this all goes. The Health Care Summit is scheduled. Whether this forum will actually generate any real debate or product is doubtful. It is a political forum located in a city which is focused on politics and I see it as an opportunity for posturing more than anything else. 

The health care debacle has been years in the making and is based upon an essentially flawed structure which has been baked in at multiple levels. True reform cannot be imposed from above since the drivers of the so called "reform" are those with the largest vested interest in maintaining some form of the status quo. So what is the status quo?

Jeffrey Flier and David Goldhill wrote a nice OpEd piece in the WSJ yesterday which highlights what I believe is the key element of present system and culture which is driving us off the cliff.  http://online.wsj.com/article/SB10001424052748703444804575071083752421338.html?KEYWORDS=Goldhill.  Goldhill, both in the piece with Jeff Flier and an earlier piece in the Atlantic Monthly (which I blogged about earlier - How Health Care Killed my Father), highlight the key concept...you can't fix the problem until you have the correct diagnosis. They state:

 To establish an accurate diagnosis of our health system's flaws, we must examine the symptoms. Medicare is headed for bankruptcy. Its administrative payment system increases costs while suppressing innovation and responsiveness to medical needs. Medicaid delivers suboptimal care while driving state budgets into the red. 

Our system favors treatment—especially costly treatment—at the expense of other options. All payers, whether government agencies or private insurers, seem unable to rein in health-care costs. A majority of Americans with employer-based insurance are seeing their wages stagnate as compensation shifts to funding health benefits, even while they remain at risk if they become ill or change jobs. And ballooning costs are putting health insurance out of reach for an increasing number of people. 

While these symptoms are clear, discussion of their cause has been muddled in recent debates. Instead of blaming insurance companies, hospitals, physicians or government, we need to recognize that over the past 50 years we created incentives that have encouraged more expensive—rather than better—care. 

The two most important incentives are the tax advantage conferred on employer-based and low-deductible insurance and the administrative structure of Medicare and Medicaid. These incentives have helped to create a system that has left most Americans unaware of the enormous sums spent on their care. The government's willingness to meet rising costs with ever greater spending and subsidies has also undermined efforts to discipline costs or to seek alternative approaches to organizing care. 

The result is that neither extending the current system to more people nor maintaining the status quo are acceptable options. A household of average income with children sees roughly one quarter of its compensation fund health benefits, out-of-pocket expenses, and Medicare taxes. The share of seniors' income devoted to out-of-pocket health spending exceeds that borne prior to Medicare. The uninsured are only the tip of this iceberg. For most Americans, health costs crowd out other goods and threaten growth in living standards. A successful approach would aim to reform misplaced incentives.

There is a lot of information in these few brief paragraphs. In my opinion, the barriers to change reside in both the political culture of Washington and the culture of American medicine. The culture of medicine has embraced the aggressive use of more expensive interventions, whether diagnostic or therapeutic on the assumption that any incremental investment which may translate into better patient outcomes is an investment which is always worthwhile, no matter what the cost or limited benefit. We have been able to justify this on the basis of championing the welfare of our patients while simultaneously deriving financial benefit. Any legitimate and effective reform to rein in costs will ultimately come into direct conflict with this dominant culture which hides self interest beneath the veil of patient advocacy.

Perhaps I am being overly harsh upon my own profession since I do believe that most physicians do make decisions driven by what they perceive to be the best interests of their patients. At a micro level, each of the individual decisions is influenced by individual physicians acting as a “choice architect”. Behind their counseling is the assumption that patient resources (time and money), which are always limited and can be invested in any number of arenas, are always best invested in health care. 

Since health insurance has created what amounts to be a giant shell game and shields patients and doctors of the true flow of money, patients don’t actually realize that their commitment to money to any given medical investment takes away resources from something else. What appears to be the use of someone else’s money is ultimately their money. The insurance vehicle (whether public or private) just guarantees that is use will be opaque and likely wasteful.

The culture is Washington is also driven by self interest. Any solution which ultimately shuttles less money and power through Washington diminishes the influence of government. Although it may seem I am stating the obvious, it is worth stating. Those attracted to the political realm are those attracted to politics and they tend to be those who are believers in deploying political solutions to problems in general. Problems arise when one attempts to deploy political solutions to problems not amenable to political approaches. When government, at multiple levels, used political power to deploy a flawed insurance based model to dealing with health care payments, it appeared to address problems in the short term Furthermore, this resulted in increasing funds flow through government and with this increasing political power. For a while, everyone came out ahead. As long as the system was sustainable, patients got care, doctors got rich, and politicians got influence. Everyone was happy.

The problems have arisen because there are no brakes on the system. The incentives are aligned to drive unlimited and uncontrolled growth. None of the parties has incentives to limit their individual harvesting of benefits. If the public can continue to reap increasing use of the health care system without directly impacting their individual bottom lines, why not? Political agents are incentivized to facilitate this either through deficit spending or attempts at administrative price controls. They can buy votes with someone else’s money and the public does not actually see that they are being fleeced.

Physicians and health care systems, when placed in positions where they experience price pressure, have shown themselves to be remarkable adept are ramping up volume or exploiting high margin services. While savings may be identified in specific areas through specific initiatives, overall costs keep on rising. Cost controls initiatives begin to appear like the game of wack-a-mole and the mole always seems to win. The behavior of any given individual or business is not evil or criminal. They are simply acting as rational players and maximizing their returns in a system where the incentives are simply screwed up.

The question is how to fix the incentives and who can fix the incentives? The present system needs to be disrupted or it will bankrupt us and it is not likely to be disrupted by those entities which are presently entrenched.  More later...  

    

My encounter with an urgent care clinic

I have had frequent encounters with the medical care system through my children recently. Today, my college aged son came home with complaints of a severe sore throat, fever, and adenopathy. Student Health at his school is not open on Saturday leaving me with the option of treating him empirically, taking him to the Emergency Department at my own institution, or visiting a local urgent care center. I have driven past this urgent care center for at least a year, always wondering who  staffed this operation and how busy they were. I decided it was worth a try to get an evaluation and perhaps a rapid strep or monspot test.

It was the right decision. We were able to drive right up to the building and park. We enrolled quickly and our insurance information was processed immediately. After a brief wait, we were evaluated by an efficient staff and the Emergency Medicine trained physician quickly identified the suppurative pharyngitis which I missed with my flashlight exam at home.

I got to speaking to one of the owner operators regarding his business and his clients, which included patients sent by a number of prominent department chairs at my own institution. Basically there is no way large integrated healthcare systems to deal with mundane yet urgent medical matters without both substantial costs and inconvenience of patients. Most of us actually realize this. The local urgent care centers have a defined value added model and operate in lower cost real estate. They can truly handle the mundane, generally non-life threatening scenarios better, faster, and cheaper. If we are advocates of our patients, why would we not utilize such resources?

This is an example of what David Ricardo, the famous English economist of the early 19th century described as the law of comparative advantage. the definition on Wikipedia is as follows:

In economics, the principle of comparative advantage refers to the ability of a party (an individual, a firm, or a country) to produce a particular good or service at a lower opportunity cost than another party. It is the ability to produce a product most efficiently given all the other products that could be produced.^[1][2] It can be contrasted with absolute advantage which refers to the ability of a party to produce a particular good at a lower absolute cost than another.

Comparative advantage explains how trade can create value for both parties even when one can produce all goods with fewer resources than the other. The net benefits of such an outcome are called gains from trade. It is the main concept of the pure theory of international trade.

In short what this means is that one does not try to grow pineapples in  Nome, Alaska. The environment is just not right and although you can invest resources to change that environment, it makes more sense to grow the pineapples where the environment is right. Similarly, dealing with mundane but urgent medical problems in an environment constructed to deal with life threatening emergencies is like trying to grow pineapples in Nome. It can be done but is very expensive and does not work well.

The arguments against the development of convenient urgent care centers focus on the need for cross subsidies to support the missions of conventional emergency rooms. If the urgent care centers bleed off the simple patients which so happen to be most lucrative, where does that leave the emergency rooms? That argument might have some merits, but the problem is not with the urgent care centers. It is with the payment system which uses administrative pricing formulas and  sets the prices wrong. No subsidies would be needed if the payment for true emergency room services was actually correct. As long as they are set by administrative fiat, they will always be wrong.

Our fate in the hands of the Parliamentarian?

Just when I thought the Health care bill is dead, stories like this begin to appear in the news. From today's WSJ OpEd page entitled "Truth and Reconciliation":

Those unversed in the arcana of Congressional procedure should familiarize themselves with "reconciliation." It's just another word for nothing left to lose—that is, it's the tactic Democrats seem increasingly likely to use to bypass the ordinary legislative rules and railroad Obama Care into law with a bare partisan majority of 50 Senators, plus Vice President Joe Biden. Speaker Nancy Pelosi announced this week in an interview with Roll Call that Democrats "have set the stage" for reconciliation. "It's up to us to make sure the public knows that this is not extraordinary," she said. "It would be a reflection on us if we could not convince people that this is not an unusual place to go."

I tracked the story back to Roll Call  - "Pelosi Makes Her Case: A Majority Is 51 Votes" By Steven T. Dennis  Roll Call Staff,  Feb. 10, 2010, 2:08 p.m.

The Speaker, who oversaw her chamber’s passage of a $1.2 trillion health care bill last fall, has repeatedly balked at White House suggestions following Brown’s election that the House merely accept the Senate’s version of the overhaul and has been pushing the Senate to adopt a host of changes through a separate, filibuster-proof budget reconciliation bill.  In her interview with Roll Call, Pelosi stopped short of saying the filibuster should be done away with altogether, but she used some of her bluntest language yet to defend the use of reconciliation as something that has been used with regularity by Republican and Democratic presidents alike. http://www.rollcall.com/news/43170-1.html?mostread=1

I am not sure about you but I find the rules a bit arcane. A number of people are weighing in on what this all means.  According to Edward Holman who commented on the WSJ piece:

Reconciliation can only be used to amend the budget items in a bill. Reconciliation is designed to save money by only requiring 51 votes in the Senate on budget items, so the 60 cloture won't stop cost-savings measures of bills already passed by the House and Senate. The House Parliamentarian rules on the association of the fixes to budgetary items only.

Carl Wright also commented: 

It's one thing to pass unpopular legislation. It's yet another thing to violate Senate rules to do it.  Cloture is a Senate rule; it is nowhere specified in the Constitution. Effectively, using the Senate's reconciliation rules and procedures for the purpose as described is equivalent to blowing up its cloture rule. Once that barn door is open, the Senate is back to requiring a bare majority to pass any legislation, and the filibuster is no longer possible.

So where does this come from? I tracked this back to what appears to be the Byrd Rule described in the American Prospect. 

 If you want to know why we do not today have a 50-vote Senate, the Byrd rule is the reason. The Byrd rule imposes a set of sharp constraints on the reconciliation process, limiting what is considered appropriate for reconciliation. The basic theory of the Byrd rule is that any legislation considered under the budget reconciliation process should principally affect federal revenues. A tax cut, for instance, can be considered under the reconciliation process. A new federal holiday cannot. But between those two examples sit crucial ambiguities.

The Byrd rule states that legislation is unfit for reconciliation if it "produce[s] changes in outlays or revenue which are merely incidental to the non-budgetary components of the provision." I asked Jim Horney, a budget expert at the Center for Budget and Policy Priorities, how you define "merely incidental." And what, exactly, is a "provision"?

He sighed. A provision, he said, is "not defined anywhere. It goes well below a title or section of a bill and even below a paragraph. But exactly what it is nobody knows." And the Senate rules offer no more clarity on the definition of "merely incidental." Asked if anyone had developed an accepted meaning, Horney seemed almost apologetic. "No," he said. "Absolutely not."

The matter is not simply academic: The Byrd rule allows senators to challenge the acceptability of any provision (undefined) of a reconciliation bill based on whether or not its effect on government revenues is "merely incidental" (undefined). Thus, if you enter reconciliation with a health-reform bill, it's not clear what's left after each and every provision -- however that is defined -- is challenged and a certain number of them are deleted altogether: the tax portions, certainly. And the government subsidies. But is regulating insurers "merely incidental" to government revenues? How about reforming hospital delivery systems? How about incentives for preventive treatment? Or the construction of a public plan? An individual mandate?

It's hard to say. The ultimate decision is left up to the Senate parliamentarian, whose rulings are unpredictable. Under George W. Bush, Republicans managed to ram tax cuts, oil drilling, trade authority, and much else through reconciliation. But they were as often disappointed: The GOP leaders fired two successive Senate parliamentarians whose Byrd rule rulings angered them.

Taken as a whole, the uncertainty of the reconciliation process transforms it into a game of chicken: If Republicans refuse to cooperate with health reform and force Democrats to resort to reconciliation, no one knows what will emerge out of the other end. Republicans might have no input, but Democrats will be at the mercy of an obscure bureaucrat's interpretation of an undefined Senate rule. It's the legislative equivalent of deciding a bill on penalty kicks.

The Byrd rule states that legislation is unfit for reconciliation if it "produce[s] changes in outlays or revenue which are merely incidental to the non-budgetary components of the provision." I asked Jim Horney, a budget expert at the Center for Budget and Policy Priorities, how you define "merely incidental." And what, exactly, is a "provision"?

He sighed. A provision, he said, is "not defined anywhere. It goes well below a title or section of a bill and even below a paragraph. But exactly what it is nobody knows." And the Senate rules offer no more clarity on the definition of "merely incidental." Asked if anyone had developed an accepted meaning, Horney seemed almost apologetic. "No," he said. "Absolutely not."

The matter is not simply academic: The Byrd rule allows senators to challenge the acceptability of any provision (undefined) of a reconciliation bill based on whether or not its effect on government revenues is "merely incidental" (undefined). Thus, if you enter reconciliation with a health-reform bill, it's not clear what's left after each and every provision -- however that is defined -- is challenged and a certain number of them are deleted altogether: the tax portions, certainly. And the government subsidies. But is regulating insurers "merely incidental" to government revenues? How about reforming hospital delivery systems? How about incentives for preventive treatment? Or the construction of a public plan? An individual mandate?

It's hard to say. The ultimate decision is left up to the Senate parliamentarian, whose rulings are unpredictable. Under George W. Bush, Republicans managed to ram tax cuts, oil drilling, trade authority, and much else through reconciliation. But they were as often disappointed: The GOP leaders fired two successive Senate parliamentarians whose Byrd rule rulings angered them. http://www.prospect.org/cs/articles?article=the_fifty_vote_senate

Who or what are parliamentarians? When the rest of us were running for class president or treasurer, they were those guys and girls who had the noses in the rule books and told us how to run our meetings, as if anything was actually at stake. No one listened to them anyway. We just did what we wanted and our faculty sponsors were clueless. More to the present point, who are the Parliamentarians of the US House of Representatives and Senate? How do they get there? Somewhere along the line much more came into play and the rules and who sets the rules really mattered. Much is at stake!

Parliamentarians of the House and Senate achieve their positions through many years of experience and service but ultimately are said to serve at the behest of the House and Senate majority leaders. When I looked at the Wikipedia entries for House and Senate Parliamentarians I was amazed at how limited the information was. In particular, I noted that there is NO INFORMATION regarding John V. Sullivan, the House parliamentarian and only limited information on Alan Frumin, the Senate Parliamentarian. There are some brief bios published in books which focus on unelected officials which one can find with some snooping.  However, for the most part these are some of the most powerful and influential people that no one seems to know anything about.

What will happen if the parliamentarian threatens to derail a reconciliation process pushed by Democratic leadership? They could not possibly consider firing him, could they? Roll back the clock a few years (2001)  to when then Senate Leader Trent Lott fired Robert Dove, the Senate Parliamentarian.  http://www.slate.com/id/1007647/pagenum/all/.  Hmm... I can see how this might play out, at least in the short term. Either the Parliamentarians play by the ruling party  rules or they are history. Of course the Republicans could cry foul until someone resurrects recent history. I predict that would not take very long. 


 In the longer term, there have been questions being raised about the viability of the filibuster itself and how any strong arm tactics used by the Democrats will alter how or if filibusters can be used in the future. The filibuster is a real pain in the ass for the ruling party. However, everyone now in the majority understands they also must consider not IF they become the minority party, but when. They will need the filibuster rule to serve their purposes when they become the minority party. http://www.slate.com/id/2244060?obref=obinsite. 

As the government controls larger and larger portions of resources, the stakes get higher and higher. The commitment of trillions of dollars hinge on the procedural decisions of obscure unelected individuals who are so stealth they have no Wikipedia identify. The world gets more interesting every day.

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Politics and medicine

It appears that if one includes ethics in the title and apply the appropriate spin, you can almost anything published in the New England Journal of Medicine.
http://content.nejm.org/cgi/content/full/362/4/283

 Medicine's Ethical Responsibility for Health Care Reform — The Top Five List by Harold Brody, PhD, MD

The author takes the moral high ground in the introduction by stating

It is appropriate to question the ethics of organized medicine's public stance. Physicians have, in effect, sworn an oath to place the interests of the patient ahead of their own interests — including their financial interests. None of the for-profit health care industries that have promised cost savings have taken such an oath. How can physicians, alone among the "special interests" affected by health care reform, justify demanding protection from revenue losses?

Not an unreasonable argument, although I am not sure this will sway many physicians on a daily basis. I can tell you it would not carry much weight at my institution. I do not see us firing our lobbyist and giving them the instructions not to protest Medicare's pending 20% pay cut.

Then the article goes from making an elegant but ineffectual plea to outright loss of reality testing:

In my view, organized medicine must reverse its current approach to the political negotiations over health care reform. I would propose that each specialty society commit itself immediately to appointing a blue-ribbon study panel to report, as soon as possible, that specialty's "Top Five" list. The panels should include members with special expertise in clinical epidemiology, biostatistics, health policy, and evidence-based appraisal. The Top Five list would consist of five diagnostic tests ortreatments that are very commonly ordered by members of that specialty, that are among the most expensive services provided, and that have been shown by the currently available evidence not to provide any meaningful benefit to at least some major categories of patients for whom they are commonly ordered. In short, the Top Five list would be a prescription for how, within that specialty, the most money could be saved most quickly without depriving any patient of meaningful medical benefit. Examples of items that could easily end up on such lists include arthroscopic surgery for knee osteoarthritis and many common uses of computed tomographic scans, which not only add to costs but also expose patients to the risks of radiation.^4,5
Having once agreed on the Top Five list, each specialty society should come up with an implementation plan for educating its members as quickly as possible to discourage the use of the listed tests or treatments for specified categories of patients. Umbrella organizations such as the AMA might push hard on specialty societies and pressure the laggards to step up.

Are they serious?  I will be the first to agree that expensive and dubious interventions litter our health care landscape. These particular dubious but lucrative interventions are also ones that likely float many of the major health care entities. Furthermore, in my opinion those individuals and departments which have most effectively exploited these most lucrative intervention now also essentially control major health care entities. No one gains power and influence at either for profit or non-profit by eliminating highly lucrative interventions to save the public money.

 Does the author actually believe that moving these discussions from Congress to these "blue ribbon" panels will move  them out of a political realm? Huge capital investments have been made based upon the business cases of these lucrative diagnostic or therapeutic interventions. Who will be appointed to the panel that will be willing and/or able to undermine the financial model of the very specialty societies which appoint them? They will gain their positions through political wrangling and those perceived to represent the specific interests of a given specialty society are most likely to be appointed. Decisions to be made will be made through a political process with a similar outcome.

As medicine becomes more dependent upon politically sensitive sources of funds, decisions regarding allocation of resources within medicine will move more and more into the political realm. As sums at stake get larger and larger, the political fights will get uglier and uglier. No amount of Utopian yearning will change this.

More on screening for cancer

A good discussion on Medscape:

Nick Mulcahy

The advantages to screening have been exaggerated.

"I'm admitting that American medicine has overpromised when it comes to screening. The advantages to screening have been exaggerated," the ACS's Otis Brawley, MD, told the New York Times in an October 21 article.

With this statement, a long-simmering controversy — about how the benefits of prostate and breast cancer screenings are emphasized at the expense of discussion of the harms — seems to have boiled over, at least momentarily. The story has been covered by many major media outlets, including ABC News, NBC Nightly News, CNN, the Jim Lehrer News Hour, and National Public Radio.

Hours after Dr. Brawley's comments were published, the ACS released an official press statement from Dr. Brawley that shifted focus back to the benefits of screening — and away from his earlier candid interview about the downsides of screening.

"While the advantages of screening for some cancers have been overstated, there are advantages, especially in the case of breast, colon, and cervical cancers. Mammography is effective — mammograms work and women should continue get them," reads Dr. Brawley's statement.

The statement also reiterated the ACS's stand that men should make an "informed decision" about whether prostate cancer screening is "right for them."

Dr. Brawley's original comments apparently arose in an interview with the Times about an essay published in the October 21 issue of the Journal of the American Medical Association about the need to rethink prostate and breast cancer screening.

The essay argues that new approaches to screening for breast and prostate cancer are needed, because the current methods have not led to a "significant reduction in deaths" from the 2 diseases.

Explaining the Case for a Rethink

The essay, written Laura Esserman, MD, MBA, and Yiwey Shieh, AB, both from the University of California, San Francisco, and Ian Thompson, MD, from the University of Texas Health Science Center, San Antonio, calls for a rethink on cancer screening and offers a 4-pronged program for improvement.

They decided to write the essay when they realized how similar prostate and breast cancers and their screening problems are.

A central problem with the screenings for both of these cancers seems to be that they have increased the burden of low-risk cancers without reducing the burden of more aggressive cancers, the essayists write.

We need to refocus and figure out how to tailor screening.

Mammography and prostate-specific antigen (PSA) testing, although having "some effect," have led to the well-documented overdiagnosis and overtreatment of breast and prostate cancers, they note.

"We are not saying that screening is bad. It's what you do with the information that makes it good or bad," Dr. Esserman told Medscape Oncology. "We need to refocus and figure out how to tailor screening," she summarized.

The American Cancer Society should not be afraid of Otis's message.

She supports Dr. Brawley for speaking out on this issue. "Otis had a lot of courage. The American Cancer Society should not be afraid of Otis's message."

The messages about cancer screening need to evolve, suggested Dr. Esserman.

"I think people like the simple message that screening is good and are uncomfortable with complexity. I understand that. However, cancer is a complicated disease. We need to expand our messages to say, among other things, that many screen-detected cancers are slow growing and may not need treatment," she said.

Other messages should include the mention of harm and the fact that screening will not find all cancers early, Dr. Esserman added.

With regard to the latter, Dr. Esserman said that a recent study indicates that most stage II and III breast cancers actually turn up clinically, between normal planned screens.

"It's just not true to say that 'if you get a mammogram, all will be well'," she explained.

Problems With Prostate and Breast Cancer Screening

It is estimated that more than 1 million men have been overtreated for prostate cancer since the advent of widespread PSA testing in the mid-1980s.

Furthermore, as the essayists point out, the intensive PSA screening has not resulted in a significant difference in prostate cancer mortality between the United States and the United Kingdom, where PSA screening was not widely adopted.

The essayists also note that although evidence indicates that breast cancer screening saves lives, 838 women, aged 50 to 70 years, must undergo screening for 6 years to avert 1 death. However, this 1 life saved generates "thousands of screens, hundreds of biopsies, and many cancers treated as if they were life-threatening when they were not," they write.

A critic of mammography recently told Medscape Oncology that such mammography facts are in stark contrastwith what is most publicized about the screening, namely that "mammography saves lives."

While Dr. Brawley's comments have garnered great attention, another ACS official recently suggested toMedscape Oncology that public education about breast cancer screening is in need of improvement. "We all have to do a better job to best inform the public about the benefits and harms of screening mammography," said Bob Smith, PhD, director of cancer screening at the ACS.

Dr. Esserman believes the time is right to improve both patients' and clinicians' understanding of screening. "If you don't take a hard critical look, then you miss the opportunity to improve things," she said.

A Plan for Improved Screening

In their essay, the authors chart a new 4-point course for breast and prostate cancer screening that will "significantly reduce death and morbidity" from the cancers.

First, more powerful markers that identify and differentiate cancers with significant risk from those with minimal risk are needed.

Second, the treatment burden for minimal-risk disease must be reduced. Methods currently exist to identify low- and high-risk cancers in both the breast and prostate, they emphasize. For instance, in prostate cancer, low-volume lesions with low Gleason scores have a low-risk for death. Minimal-risk disease should not be called cancer; it should be called indolent lesions of epithelial origin (IDLE), they say.

Third, improved tools to support informed decisions are needed. "Information about risks of screening and biopsy should be shared with patients before screening," they write. Currently, an estimated one third of PSA tests take place without even the most basic doctor–patient discussion, as reported by Medscape Oncology.

Finally, a greater emphasis on prevention, including the use of proven cancer preventive agents, such as finasteride for preventing prostate cancer and tamoxifen and raloxifene for preventing breast cancer, is needed.

An estimated $20 billion is spent to screen for prostate and breast cancer in the United States. The essayists call for 10% to 20% of that amount to be invested in an effort to improve screening.

This article grew out of collaboration initiated within the National Cancer Institute's Early Detection Research Network and was supported by grants U01CA111234 and U01CA086402. The authors have disclosed no relevant financial relationships.

JAMA. 2009;302:1685-1692. Abstract

The key point they stress is patients on entered into this cascade of intervention without any real discussion as to the tradeoffs. Just check the box on the blood work for the PSA and discuss the results after the cat is out of the bag. The default mode is to send patients for mammograms. Even some of the most thoughtful discussions I have read on blogs point out that even with discussions virtually all patients elect to go forth with the screening. This is either indicative of an inherent patient preference for screening or presentation of choices in a consistently biased fashion. I suspect that patients are steeped in a culture which has aggressively sold the benefits of screening and it is simply not worth the doctor's time to delve into the actual nuances of the merits.

The question is then do we continue the aggressive marketing at a global level? Dr. Brawley is clearly uncomfortable with the science behind this. I share his skepticism.

Follow up on Knowledge vs. Know how

I saw this article via DB Medical Rants blog this morning. It is a good follow up on my piece on knowledge vs. know-how.
http://ow.ly/14d0D

Follow up on the law of small numbers

I was reminded by my son of the chapter in PJ O'Rourke's Parliament of Whores on sudden acceleration incidents (SAI) I had forgotten about this chapter, describing previous problems associated with the Audi 500. The excerpt from Google books in the link below.

http://books.google.com/books?id=aCjt_Wr23hQC&pg=PA86&lpg=PA86&dq=parliament+of+whores+sudden+acceleration&source=bl&ots=QJ1upgObH0&sig=Sp8o9YJHDtoi3xTbn7IhuyiF2P4&hl=en&ei=CT9uS6-DEKimtgeXm5CVBg&s

Gaming and blaming

We saw a poor unfortunate baby last month who ended up dying from a huge hemangioma which was localized to its head and neck. The interventional radiologists tried to embolize the main vessels in the hope that depriving the hemangioma of its blood supply would halt its growth. While the conduits which the radiologists attended to were interrupted, the tumor quickly commandeered alternative vascular elements which ultimately were sufficient to sustain the tumor and destabilize the host. I could not help but think of how this situation shared certain characteristics with human social pathologies. This tumor was not to be denied and attempts to occlude its main feeder vessels was responded to by the development of innumerable small feeders which could not be stopped.

The economy is still in the tank with a few exceptions. Health care costs continue to grow, despite every effort to  control costs. The agents which try to scale back the costs are in some sense like the interventional radiologists, trying to occlude the major payment conduits where money flows to the healthcare tumor. However, individual physicians, groups, or hospitals are remarkably attentive to their cash flow. It is like the blood flow to the tumor and any effort to scale back major conduits results in innumerable "gaming' responses. Vulnerabilities are constantly probed and opportunities for better payment are exploited in real time, the information regarding venues for exploitation spreading at the speed of light.

The continued increasing money supply to the health care tumor shows that under the present rules, it will not be denied, much like the tumor which consumed that unfortunate baby. None of the single agents involved in this drama are inherently evil. Practicing doctors are simply trying to make payroll and cover their overhead. Opportunities to collect for services rendered are simply chances to get what is due to them. Except in the cases where actual fraud is undertaken, the intense probing and assessment constitutes typical gaming behavior. It is what we do because to be human is to be a gamer. The overall effects are very disturbing.

There is a point in the future when the blame game moves to new targets. Already, fingers are beginning to be pointed at the medical industry. This morning there was an op-ed piece in the WSJ, an interview with Angela Braly, the CEO of Wellpoint. She notes in this interview:

""Hospitals come in and ask for major increases," she says. "They come in and say, you know, we need a 40% increase. It would blow your mind, the difference we start with in some of these negotiations. . . . Why does that procedure cost $10,000 in this place and down the street it costs $1,000—and when the hospital that's getting paid $10,000 is asking for a 40% rate increase, you have to say, why?..............The reason costs are rising so fast, Mrs. Braly says, is because the way the health-care market is structured doesn't give providers reason to control costs. The solution is to "reintroduce the consumer to the health-care equation," and on that front, she believes, insurers "are actually the part of the health-care delivery system that is there to create the value."

She more than implies that the source of the runaway costs is not the insurers but the providers.

The insurance industry has taken much of the flak for rising health care costs based primarily upon obscene bonus packages for senior leadership. The health insurance industry is simply not that profitable with returns on equity being rather ordinary or even below average. Assuming that the insurance industry becomes more like a regulated utility and those seeking obscene bonus package migrate to some other realm. Our runaway growth problems with healthcare do not go away. Most physicians have been relatively spared the effects of the economic downturn which can be good news and bad news. The good news is obvious. We have been spared the effects. The bad news is that our efforts to ensure our continued revenues might be viewed in a most unfavorable light, particularly if the perception is that the healthcare tumor is devouring our economy.

Food for thought.

Medical Knowledge vs. Medical Know-how

I have been listening to a series of lectures by Professor Stephen Goldman of the Departments of Philosphy and History at Lehigh University. The lectures are entitled "Great Scientific Ideas that Changed the World". For those of you who have not heard of the Teaching Company, it is a great company. The lectures offered are generally interesting and extremely well delivered by the best professors in the US. If you get them on sale, they are very reasonably priced.

But back to Dr. Goldman's lectures. He traces back the history of knowledge and makes a distinction that I never really gave much thought to, a distinction which I believe has relevance to medicine and medical education. According to Dr. Goldman, knowledge which benefited humanity has existed for tens of thousands of years but Greek thinkers (Plato, Socrates, and Aristotle) made a distinction between knowledge and know-how and this distinction has impacted Western thought in particular since that time.

Know-how knowledge is knowledge practical, concrete, and historical in the sense that it changes over time as experience changes over time. But that would mean, since this  knowledge changes with experience, it cannot be timeless.There were philosophers in ancient Greece, the Sophists, who defended such an idea of knowledge.



Plato and Aristotle defended a totally different definition of knowledge, based upon the mathematical teachings of Pythagoras and Parmenides. They defended a definition of knowledge as universal, necessary, and certain and their definition of knowledge was that something can only be called knowledge only  if
it is universal, necessary, and certain. For them, knowledge was timeless.

"What is fascinating is that this highly abstract and intellectualized definition of knowledge has been dominant in Western cultural tradition, in the Western intellectual tradition, to the very present. And in fact, it was the definition of knowledge that was built into science, built into modern science as it emerged in the 17th century, and continues to be the case. Mathematical knowledge, notice, is timeless, in addition to being universal. We don’t expect triangles to change or to change their properties because we have moved from the 19th century to the 20th century, or because we have moved from the 20th to the 21st, or moved from Europe to Africa, or from Africa to Asia. Mathematical knowledge is universal, it’s timeless, it’s necessary, it’s certain.

It is the paradigm of knowledge for ancient Greece, and it is always referred to, right into the modern period, when there are challenges raised against this definition of knowledge, which flies in the face of experience. So that’s a fascinating fact about Western culture, about Western intellectuals, philosophers and scientists alike, that this definition of knowledge has been absorbed."

Medicine and medical education straddles between these two worlds. Medical educators generally live in the University, which is steeped in the Greek belief system of knowledge. Legitimate scholarship in academic medicine aspires to be timeless, necessary, and certain. However, medicine is also a craft and the effective practice of medicine requires practical knowledge to apply any timeless knowledge which may be the product of scholarship.

Medical education occurs in environments where there are multiple interfaces between knowledge seekers and know-how seekers.  Because of this environment, medical education suffers from the same sort of disdain that Plato and Aristotle had for the Sophists and their reverence they held for practical knowledge. However, without practical knowledge, process suffers, and without effective process, patients will be hurt.

For years, the practical part of medicine was openly self taught. I was trained the environment of see-one, do-one, teach-one. How obvious can one be? It was viewed as essential for me to memorize the details of every available biochemical pathway, an exercise that I now realize was sort of the medical school equivalent of memorizing bible verses. Actually developing the practical skills required to be an effective physician was acquired by basically throwing us in the deep end of the pool and we were expected to swim. The most highly regarded professors were too busy trying to generate knowledge that was timeless, necessary, and certain, not the ones who worked on actually effectively deploying such knowledge to the benefit of patients.

Roll the clock forward and not much has changed. Reward and highest acclaim in academic medicine still goes to those involved in generating knowledge as viewed by Plato and Aristotle and not the practical Sophists. I suspect that as long as medical education is centered in universities who hold fast to the Greek perspective of knowledge, nothing will change.

Education in general is in many respects shares the same schizophrenic role as medical education. Do people go to universities to learn a trade or do they go there to learn knowledge which is timeless, necessary, and universal? The information revolution and the innovations made possible by new tools is set to disrupt this paradigm. Perhaps the time is right for a new Flexner-like revolution in medical education to happen.