To contact us Click HERE
Goodhart's law expresses one of those insights to human behavior that we see play out again and again and increasing so in medical care as the farce of P4P expands in spite of all evidence indicating its negative effects. According to Charles Goodhart - When a measure become a target it looses its value as a measure.
History is replete with examples of Goodhart's law.The targets of various Soviet industrial centrally planned programs,the cash for clunkers program and high school teachers teaching to the test are just some of the many.The economist,David Henderson, wrote this excellent essay on Goodhart's law and the GDP .
See here for this Forbes article by Dr. Paul Hsieh for how we will see that story again with tragic results with the new Medicare rule about re-admission to hospital within 3o days for patients with certain medical conditions.The debacle of the four hour pneumonia rule seemingly taught the Medicare hierarchy absolutely nothing.See here. Similarly targeting wait times in British NHS hospital had deleterious results predictable from Goodhart' s law.See here for my earlier comments
So many factors outside of the hospital's control and the treating physician's control influence likelihood of a patient's condition exacerbating and necessitating readmission that considering readmission rate as a quality measure at all is absurd on its face.But whether the proposed measure is a valid measure or not does not matter, there will be unintended consequences.
People respond to incentives which can be positive or negative. If someone is penalized economically for not reaching a target or rewarded economically for reaching one, either way the person 'Teaches to the test".
30 Kasım 2012 Cuma
When you urge coercion by the government,don't be shocked if you get coerced as well
To contact us Click HERE
The following quote explains the title.See here for further details
All people have the moral obligation to care for those who are less fortunate. But replacing morality with legality is the first step in replacing church, religion and conscience with government, politics and majority vote. Coercing people to feed the poor simply substitutes moral poverty for material poverty.Dancing with the devil is dangerous business.
The bishops dance with the devil when they invite government to use its coercive power on their behalf, and there’s no clearer example than the Affordable Care Act. They happily joined their moral authority to the government’s legal authority by supporting mandatory health insurance. They should not have been surprised when the government used its reinforced power to require Catholic institutions to pay for insurance plans that cover abortions and birth control.
The corporate physician - he is not your father's doctor
To contact us Click HERE
Dr. Roy Poses has tirelessly written about the loss of professionalism in the medical profession.Here is the link for a recent commentary by Dr. Poses about the rise and likely consequences of the corporate physician.
There was a time when the AMA vigorously opposed the corporate practice of medicine and a number of states outlawed it.But now times have changed and few states have strong statutes limiting it.
Texas still has a residual- but significantly watered down- corporate practice of Medicine statute. See here for a history of the corporate practice of medicine idea with emphasis on the exceptions even in Texas which has one of the strongest prohibitions against the corporate practice.In Texas the most widely used exception is the situation in which a "non-profit health corporation"-so certified according to defined statutory criteria-can hire physicians.See here for a discussion of what is referred to as a 501(a) entity.The rational of the original opposition to corporate practice was simply that the business entity would control the doctor's practice and profit-not the patients best interest would be controlling.There is much to suggest that the same objection is valid today but few voices are heard in that regard.It should be noted that the "non-profit health corporations" included the "not for profit hospitals". As is obvious Non-profit as well as successful for profit hospitals annually have revenue greater than cost;otherwise they would not be able to keep expanding with more and more branch offices and purchasing physician practices let alone keep operating.
Recently, I attended a seminar sponsored by the local medical society labelled as eligible for CME credit under the ethics category of required annual CME credit in Texas.The topic was how to promote your medical practice and , of course, advertizing was one way recommended.
There are at least two negative consequences of physician being employed by hospitals or large medical aggregations ( that includes the latest incarnation, the highly touted ACO):
1)Increased costs to the patient
2)decreased quality of care
Poses give illustrative examples of how the same procedure can cost more when ordered by or performed by a physician working for the hospital versus a free standing doctor not compensated by the hospital. Read Dr. Poses's posting referenced above for details about these negative consequences.
People respond to incentives.Physicians employed by health care corporation inevitably will face the situation in which the incentives generated by corporate goals and targets with which the docs will be tasked will conflict with the primary directive ( or what used to be the prime directive ) of a physician namely doing what is right for the individual patient.I am afraid that the physician's role as a patient advocate in the corporate health care organization may go the way of the AMA's prohibition against physicians advertizing,a quaint historical artifact.Once the physician accepts the new ethics position that they are responsible for the health of the collective ( the ACO may be the collective ),then the greater good for the greatest number will just happen to coincide with the financial health of the organization.
There was a time when the AMA vigorously opposed the corporate practice of medicine and a number of states outlawed it.But now times have changed and few states have strong statutes limiting it.
Texas still has a residual- but significantly watered down- corporate practice of Medicine statute. See here for a history of the corporate practice of medicine idea with emphasis on the exceptions even in Texas which has one of the strongest prohibitions against the corporate practice.In Texas the most widely used exception is the situation in which a "non-profit health corporation"-so certified according to defined statutory criteria-can hire physicians.See here for a discussion of what is referred to as a 501(a) entity.The rational of the original opposition to corporate practice was simply that the business entity would control the doctor's practice and profit-not the patients best interest would be controlling.There is much to suggest that the same objection is valid today but few voices are heard in that regard.It should be noted that the "non-profit health corporations" included the "not for profit hospitals". As is obvious Non-profit as well as successful for profit hospitals annually have revenue greater than cost;otherwise they would not be able to keep expanding with more and more branch offices and purchasing physician practices let alone keep operating.
Recently, I attended a seminar sponsored by the local medical society labelled as eligible for CME credit under the ethics category of required annual CME credit in Texas.The topic was how to promote your medical practice and , of course, advertizing was one way recommended.
There are at least two negative consequences of physician being employed by hospitals or large medical aggregations ( that includes the latest incarnation, the highly touted ACO):
1)Increased costs to the patient
2)decreased quality of care
Poses give illustrative examples of how the same procedure can cost more when ordered by or performed by a physician working for the hospital versus a free standing doctor not compensated by the hospital. Read Dr. Poses's posting referenced above for details about these negative consequences.
People respond to incentives.Physicians employed by health care corporation inevitably will face the situation in which the incentives generated by corporate goals and targets with which the docs will be tasked will conflict with the primary directive ( or what used to be the prime directive ) of a physician namely doing what is right for the individual patient.I am afraid that the physician's role as a patient advocate in the corporate health care organization may go the way of the AMA's prohibition against physicians advertizing,a quaint historical artifact.Once the physician accepts the new ethics position that they are responsible for the health of the collective ( the ACO may be the collective ),then the greater good for the greatest number will just happen to coincide with the financial health of the organization.
More aspects of Obamacare being challenged in court
To contact us Click HERE
Some states are still refusing to set up the insurance exchanges contained in ACA.Subsidies are an important part of the exchanges.The IRS claims that when the federal government sets up an exchange when an individual state refuses to it can offer the same subsidies.However the claim underlying another challenge to ACA is that there is no statutory authority to do so.
See here for details.
Also the Liberty University litigation has been resurrected by the the Supreme Court. See here for details.The dogs keep barking but the pessimists believe the caravan has moved on and will not be recalled.
See here for details.
Also the Liberty University litigation has been resurrected by the the Supreme Court. See here for details.The dogs keep barking but the pessimists believe the caravan has moved on and will not be recalled.
Will states opting out of insurance exchanges unravel Obamacare?
To contact us Click HERE
Michale Cannon of Cato seems to argue that.See here.
Michigan is the latest state to say no thanks to the insurance exchange deal.Cannon has argued that while the federal government can establish an exchange it cannot have the subsidies that were to be part of the state exchanges. The IRS has issued a ruling that claims the opposite. Cannon and his co authors argue that both the legislative history and the statutory language make it clear that ACA did not authorize the subsidies to the federal run exchanges.
The key thing seems to be how the courts rule regarding the federal established exchanges legal authority to issue subsidies .Ultimately if the issue reaches SCOTUS , will Justice Roberts act in a way to redeem himself in the eyes of his former conservative supporters or will he once again dazzle us with innovative legal reasoning? My pessimistic prediction is for more bedazzlement.
Even if the IRS ruling holds as Dr. Scott W. Atlas of Hoover Institute argues here ,Obamacare may prove to be unworkable as costs rise and access to health care actually decreases (insurance cards do not magically generate physician) and the public or interests groups and politicians clamor for a solution we may well face the single payer option. Some have argued that was the plan all along even though that assumes greater wisdom in those who planned ACA than I think they likely possess.
Michigan is the latest state to say no thanks to the insurance exchange deal.Cannon has argued that while the federal government can establish an exchange it cannot have the subsidies that were to be part of the state exchanges. The IRS has issued a ruling that claims the opposite. Cannon and his co authors argue that both the legislative history and the statutory language make it clear that ACA did not authorize the subsidies to the federal run exchanges.
The key thing seems to be how the courts rule regarding the federal established exchanges legal authority to issue subsidies .Ultimately if the issue reaches SCOTUS , will Justice Roberts act in a way to redeem himself in the eyes of his former conservative supporters or will he once again dazzle us with innovative legal reasoning? My pessimistic prediction is for more bedazzlement.
Even if the IRS ruling holds as Dr. Scott W. Atlas of Hoover Institute argues here ,Obamacare may prove to be unworkable as costs rise and access to health care actually decreases (insurance cards do not magically generate physician) and the public or interests groups and politicians clamor for a solution we may well face the single payer option. Some have argued that was the plan all along even though that assumes greater wisdom in those who planned ACA than I think they likely possess.
29 Kasım 2012 Perşembe
ACP celebrates 10th anniversary of A Physician Charter -but all physicians may not agree
To contact us Click HERE
In the August 21,2012 issue of the Annals of Internal Medicine Drs.Christine K. Cassel,Virginia Hood and Werner Bauer have offered the readers a largely celebratory , somewhat self congratulatory and slightly cautious piece recognizing the 10th year anniversary of the Charter. They are referring to A Physician Charter.
In 2002, a group of internists from the American College of Physicians and the European Federation of Internal Medicine jointly authored a commentary that was designed to "supply a concise foundation that would shape how physicians viewed the practice of medicine."In this they not only emphasized how physicians would behave in regard to their patients but " toward society". It was this relationship to society which the authors said distinguished their work from previous professional codes. and there is no doubt about that.
The Charter spoke of a professionalism that consisted of three fundamental principles:patient welfare,patient autonomy and social justice. It was the term social justice that the charter authors used to designate this new emphasis on the relationship of physicians to society.
The term social justice has a long history but in general use in western democratic societies refers to a trend of thought that favors a greater degree of equality in regard to income and wealth and access to various institutional opportunities and equality of outcome in instances in which equality of opportunity does not achieve some notion of appropriate outcome. Redistribution to correct or mitigate various inequalities is considered part of its conceptual package.Social justice also emphasizes equality in general and human rights and human dignity.
The term social justice has a long history in religious thought, both Christian and Jewish and aspects of it play a prominent role in parties of the political left and is prominent in the expressed political philosophy of the the European social democracies.
Unfortunately for purposes of clarity of meaning the term social justice is often controverted and assumes variable meanings. Of course, from a tactical point of view those characteristics may have an advantage in a debate as opponents may find a elusive target.
The authors of the recent Annals article note that 130 organizations have endorsed the Charter and medical schools have embraced the professionalism that the charter defines.
However,as much progress as they claim has been made to make the idea of the medical profession as depicted in the Charter a reality, more needs to be done.There are gaps,according to the authors.
In regard to one such gap,I was surprised but pleased that the authors actually recognized that there remains some controversy.They admit that some object to the notion that physicians bear an obligation to serve the needs of society and to work to ensure a just distribution of health care resources. Of course that is where the controversy lies, there is no serious opposition of the ides of patient welfare and patient autonomy.
There was no scarcity of audacity in the charter when it a relatively small group of internists declared that to be ethical professionals one had to necessarily accept and work towards a political philosophy whose acceptance in United States was far from universal.
It is another chapter in the ancient tension between the individual and the collective. Physicians' ethics has traditionally been that of a fiduciary duty to the patient with a co-duty to some collective only being gratuitously added to discussion of medical ethics in the last twenty or so years,most famously in the Physicians Charter .
There are several-not necessarily mutually exclusive-lines of argument that disagree with the inclusion of a quest for social justice as a key element of medical ethics and which may well resonate with some physicians.
Here is a small sampling of some of those arguments:
1)Some may accept that social justice is a valid concept and one worth pursuing but see no reason to have social justice as one of the three fundamental precepts of medical ethics having heard no convincing argument for its inclusion. From my reading, a convincing argument for its inclusion was not found in the text of the Charter but seemed to be a gratuitous assertion.
2)Others believe that the concept of social justice itself is bogus,bereft of useful,meaningful intellectual content and operational details.Advocates of this position find support from the writings of Nobel laureate FA Hayek and economists Thomas Sowell and Anthony de Jasay and others.
Quoting Jasay.
...one of the pathetic infirmities of social justice, namely that it has no rules by which a socially just state of affairs could ever be identified.
What rules do they advocate that would bring about an equitable distribution of health care resources.? Who decides what is equitable?
De Jasay speaks of justice as a property of an act and that an unjust state of affairs results from unjust acts. Who has committed the acts that lead to the unjust conditions that the social justice advocate yearn to rectify? (from The Collected Papers of Anthony de Jasay.Political Economy Concisely.)
Are the better-off obligated to help the worse-off even if their condition is no fault of theirs. What perversion of justice is it that places the " obligation of redressing an injustice on those who have not committed it."?
Social justice is when you blame someone for an inequality that they did not bring about and then make them pay to correct it.
By this line of argument social justice is not justice at all but a rhetorical tool to justify any and all plans for redistribution to rectify inequality in regard to any number of characteristics.
What is the argument for the claim that this egalitarian view with corrective redistribution must be a part of a physician's ethical package ? Would not one's choice in this regard be a matter for political philosophy and not professional ethics?
DeSay's arguments echo Hayek's ideas. To speak of notions of justice regarding the relative holding across an entire society is confused thinking in Hayek's view. Quoting Hayek:
Social justice does not belong to the category of error but to that of nonsense,like the term 'a moral stone'.
3) Others believe that the insertion of social justice into the medical ethical framework may or may not be unjustified intellectually and may or may not have meaningful operational content but more importantly it is harmful and has the potential to destroy medical ethics as it has been known and practiced for hundreds of years.
Dr Richard Fogoros on his blog The Covert Rationing Blog explains how the Charter and the New Ethics of the ACP differs from and conflicts with the old time medical ethics and warns of its harms.
The New Ethics takes classical medical ethics (which obligates doctors to always place the welfare of their individual patients first) and adds on to it a new ethical obligation, called Social Justice, which obligates doctors to work toward “the fair distribution of healthcare resources.” This new obligation (which is to society) will inherently conflict, at least some of the time, with the physician’s traditional obligation to the individual patient. So, under the New Ethics, the doctor’s loyalty is now officially divided. DrRich asserts that this divided loyalty (which is now declared to be entirely ethical) leaves the patient in a dangerous position, and breaks the profession of medicine.
You will not find "fiduciary duty" discussed in the new ethics.New ethics advocates hope that if the word is not used that the obligation will go down the memory hole.Plaintiff attorneys may think otherwise.
Maybe the Mafia Rule (Cui Bono) does not always lead one to a useful insight but it often does. Who might benefit from this transformation of medical ethics ? The third party payers benefit because physician's ethics now include the precept to act for the good of the collective (third party payers and the ACOs will play the role of the collective) and if cost benefit analysis concludes that a given treatment is not cost effective then the ethical doc (by the Charter definition) will do what it right for the good of the collective. The medical elite might gain because they will be the ones who play a major role in writing the rules (guidelines) that will direct the ethical physician to act in the cost effective manner than will in the end benefit the group if not the individual patient and conserve society's resources. Are we looking at the old story of the baptist and bootleggers here?
Minor editorial changes made on 9/4/2012
In 2002, a group of internists from the American College of Physicians and the European Federation of Internal Medicine jointly authored a commentary that was designed to "supply a concise foundation that would shape how physicians viewed the practice of medicine."In this they not only emphasized how physicians would behave in regard to their patients but " toward society". It was this relationship to society which the authors said distinguished their work from previous professional codes. and there is no doubt about that.
The Charter spoke of a professionalism that consisted of three fundamental principles:patient welfare,patient autonomy and social justice. It was the term social justice that the charter authors used to designate this new emphasis on the relationship of physicians to society.
The term social justice has a long history but in general use in western democratic societies refers to a trend of thought that favors a greater degree of equality in regard to income and wealth and access to various institutional opportunities and equality of outcome in instances in which equality of opportunity does not achieve some notion of appropriate outcome. Redistribution to correct or mitigate various inequalities is considered part of its conceptual package.Social justice also emphasizes equality in general and human rights and human dignity.
The term social justice has a long history in religious thought, both Christian and Jewish and aspects of it play a prominent role in parties of the political left and is prominent in the expressed political philosophy of the the European social democracies.
Unfortunately for purposes of clarity of meaning the term social justice is often controverted and assumes variable meanings. Of course, from a tactical point of view those characteristics may have an advantage in a debate as opponents may find a elusive target.
The authors of the recent Annals article note that 130 organizations have endorsed the Charter and medical schools have embraced the professionalism that the charter defines.
However,as much progress as they claim has been made to make the idea of the medical profession as depicted in the Charter a reality, more needs to be done.There are gaps,according to the authors.
In regard to one such gap,I was surprised but pleased that the authors actually recognized that there remains some controversy.They admit that some object to the notion that physicians bear an obligation to serve the needs of society and to work to ensure a just distribution of health care resources. Of course that is where the controversy lies, there is no serious opposition of the ides of patient welfare and patient autonomy.
There was no scarcity of audacity in the charter when it a relatively small group of internists declared that to be ethical professionals one had to necessarily accept and work towards a political philosophy whose acceptance in United States was far from universal.
It is another chapter in the ancient tension between the individual and the collective. Physicians' ethics has traditionally been that of a fiduciary duty to the patient with a co-duty to some collective only being gratuitously added to discussion of medical ethics in the last twenty or so years,most famously in the Physicians Charter .
There are several-not necessarily mutually exclusive-lines of argument that disagree with the inclusion of a quest for social justice as a key element of medical ethics and which may well resonate with some physicians.
Here is a small sampling of some of those arguments:
1)Some may accept that social justice is a valid concept and one worth pursuing but see no reason to have social justice as one of the three fundamental precepts of medical ethics having heard no convincing argument for its inclusion. From my reading, a convincing argument for its inclusion was not found in the text of the Charter but seemed to be a gratuitous assertion.
2)Others believe that the concept of social justice itself is bogus,bereft of useful,meaningful intellectual content and operational details.Advocates of this position find support from the writings of Nobel laureate FA Hayek and economists Thomas Sowell and Anthony de Jasay and others.
Quoting Jasay.
...one of the pathetic infirmities of social justice, namely that it has no rules by which a socially just state of affairs could ever be identified.
What rules do they advocate that would bring about an equitable distribution of health care resources.? Who decides what is equitable?
De Jasay speaks of justice as a property of an act and that an unjust state of affairs results from unjust acts. Who has committed the acts that lead to the unjust conditions that the social justice advocate yearn to rectify? (from The Collected Papers of Anthony de Jasay.Political Economy Concisely.)
Are the better-off obligated to help the worse-off even if their condition is no fault of theirs. What perversion of justice is it that places the " obligation of redressing an injustice on those who have not committed it."?
Social justice is when you blame someone for an inequality that they did not bring about and then make them pay to correct it.
By this line of argument social justice is not justice at all but a rhetorical tool to justify any and all plans for redistribution to rectify inequality in regard to any number of characteristics.
What is the argument for the claim that this egalitarian view with corrective redistribution must be a part of a physician's ethical package ? Would not one's choice in this regard be a matter for political philosophy and not professional ethics?
DeSay's arguments echo Hayek's ideas. To speak of notions of justice regarding the relative holding across an entire society is confused thinking in Hayek's view. Quoting Hayek:
Social justice does not belong to the category of error but to that of nonsense,like the term 'a moral stone'.
3) Others believe that the insertion of social justice into the medical ethical framework may or may not be unjustified intellectually and may or may not have meaningful operational content but more importantly it is harmful and has the potential to destroy medical ethics as it has been known and practiced for hundreds of years.
Dr Richard Fogoros on his blog The Covert Rationing Blog explains how the Charter and the New Ethics of the ACP differs from and conflicts with the old time medical ethics and warns of its harms.
The New Ethics takes classical medical ethics (which obligates doctors to always place the welfare of their individual patients first) and adds on to it a new ethical obligation, called Social Justice, which obligates doctors to work toward “the fair distribution of healthcare resources.” This new obligation (which is to society) will inherently conflict, at least some of the time, with the physician’s traditional obligation to the individual patient. So, under the New Ethics, the doctor’s loyalty is now officially divided. DrRich asserts that this divided loyalty (which is now declared to be entirely ethical) leaves the patient in a dangerous position, and breaks the profession of medicine.
You will not find "fiduciary duty" discussed in the new ethics.New ethics advocates hope that if the word is not used that the obligation will go down the memory hole.Plaintiff attorneys may think otherwise.
Maybe the Mafia Rule (Cui Bono) does not always lead one to a useful insight but it often does. Who might benefit from this transformation of medical ethics ? The third party payers benefit because physician's ethics now include the precept to act for the good of the collective (third party payers and the ACOs will play the role of the collective) and if cost benefit analysis concludes that a given treatment is not cost effective then the ethical doc (by the Charter definition) will do what it right for the good of the collective. The medical elite might gain because they will be the ones who play a major role in writing the rules (guidelines) that will direct the ethical physician to act in the cost effective manner than will in the end benefit the group if not the individual patient and conserve society's resources. Are we looking at the old story of the baptist and bootleggers here?
Minor editorial changes made on 9/4/2012
Government ignores Goodhart's law again
To contact us Click HERE
Goodhart's law expresses one of those insights to human behavior that we see play out again and again and increasing so in medical care as the farce of P4P expands in spite of all evidence indicating its negative effects. According to Charles Goodhart - When a measure become a target it looses its value as a measure.
History is replete with examples of Goodhart's law.The targets of various Soviet industrial centrally planned programs,the cash for clunkers program and high school teachers teaching to the test are just some of the many.The economist,David Henderson, wrote this excellent essay on Goodhart's law and the GDP .
See here for this Forbes article by Dr. Paul Hsieh for how we will see that story again with tragic results with the new Medicare rule about re-admission to hospital within 3o days for patients with certain medical conditions.The debacle of the four hour pneumonia rule seemingly taught the Medicare hierarchy absolutely nothing.See here. Similarly targeting wait times in British NHS hospital had deleterious results predictable from Goodhart' s law.See here for my earlier comments
So many factors outside of the hospital's control and the treating physician's control influence likelihood of a patient's condition exacerbating and necessitating readmission that considering readmission rate as a quality measure at all is absurd on its face.But whether the proposed measure is a valid measure or not does not matter, there will be unintended consequences.
People respond to incentives which can be positive or negative. If someone is penalized economically for not reaching a target or rewarded economically for reaching one, either way the person 'Teaches to the test".
History is replete with examples of Goodhart's law.The targets of various Soviet industrial centrally planned programs,the cash for clunkers program and high school teachers teaching to the test are just some of the many.The economist,David Henderson, wrote this excellent essay on Goodhart's law and the GDP .
See here for this Forbes article by Dr. Paul Hsieh for how we will see that story again with tragic results with the new Medicare rule about re-admission to hospital within 3o days for patients with certain medical conditions.The debacle of the four hour pneumonia rule seemingly taught the Medicare hierarchy absolutely nothing.See here. Similarly targeting wait times in British NHS hospital had deleterious results predictable from Goodhart' s law.See here for my earlier comments
So many factors outside of the hospital's control and the treating physician's control influence likelihood of a patient's condition exacerbating and necessitating readmission that considering readmission rate as a quality measure at all is absurd on its face.But whether the proposed measure is a valid measure or not does not matter, there will be unintended consequences.
People respond to incentives which can be positive or negative. If someone is penalized economically for not reaching a target or rewarded economically for reaching one, either way the person 'Teaches to the test".
When you urge coercion by the government,don't be shocked if you get coerced as well
To contact us Click HERE
The following quote explains the title.See here for further details
All people have the moral obligation to care for those who are less fortunate. But replacing morality with legality is the first step in replacing church, religion and conscience with government, politics and majority vote. Coercing people to feed the poor simply substitutes moral poverty for material poverty.Dancing with the devil is dangerous business.
The bishops dance with the devil when they invite government to use its coercive power on their behalf, and there’s no clearer example than the Affordable Care Act. They happily joined their moral authority to the government’s legal authority by supporting mandatory health insurance. They should not have been surprised when the government used its reinforced power to require Catholic institutions to pay for insurance plans that cover abortions and birth control.
The corporate physician - he is not your father's doctor
To contact us Click HERE
Dr. Roy Poses has tirelessly written about the loss of professionalism in the medical profession.Here is the link for a recent commentary by Dr. Poses about the rise and likely consequences of the corporate physician.
There was a time when the AMA vigorously opposed the corporate practice of medicine and a number of states outlawed it.But now times have changed and few states have strong statutes limiting it.
Texas still has a residual- but significantly watered down- corporate practice of Medicine statute. See here for a history of the corporate practice of medicine idea with emphasis on the exceptions even in Texas which has one of the strongest prohibitions against the corporate practice.In Texas the most widely used exception is the situation in which a "non-profit health corporation"-so certified according to defined statutory criteria-can hire physicians.See here for a discussion of what is referred to as a 501(a) entity.The rational of the original opposition to corporate practice was simply that the business entity would control the doctor's practice and profit-not the patients best interest would be controlling.There is much to suggest that the same objection is valid today but few voices are heard in that regard.It should be noted that the "non-profit health corporations" included the "not for profit hospitals". As is obvious Non-profit as well as successful for profit hospitals annually have revenue greater than cost;otherwise they would not be able to keep expanding with more and more branch offices and purchasing physician practices let alone keep operating.
Recently, I attended a seminar sponsored by the local medical society labelled as eligible for CME credit under the ethics category of required annual CME credit in Texas.The topic was how to promote your medical practice and , of course, advertizing was one way recommended.
There are at least two negative consequences of physician being employed by hospitals or large medical aggregations ( that includes the latest incarnation, the highly touted ACO):
1)Increased costs to the patient
2)decreased quality of care
Poses give illustrative examples of how the same procedure can cost more when ordered by or performed by a physician working for the hospital versus a free standing doctor not compensated by the hospital. Read Dr. Poses's posting referenced above for details about these negative consequences.
People respond to incentives.Physicians employed by health care corporation inevitably will face the situation in which the incentives generated by corporate goals and targets with which the docs will be tasked will conflict with the primary directive ( or what used to be the prime directive ) of a physician namely doing what is right for the individual patient.I am afraid that the physician's role as a patient advocate in the corporate health care organization may go the way of the AMA's prohibition against physicians advertizing,a quaint historical artifact.Once the physician accepts the new ethics position that they are responsible for the health of the collective ( the ACO may be the collective ),then the greater good for the greatest number will just happen to coincide with the financial health of the organization.
There was a time when the AMA vigorously opposed the corporate practice of medicine and a number of states outlawed it.But now times have changed and few states have strong statutes limiting it.
Texas still has a residual- but significantly watered down- corporate practice of Medicine statute. See here for a history of the corporate practice of medicine idea with emphasis on the exceptions even in Texas which has one of the strongest prohibitions against the corporate practice.In Texas the most widely used exception is the situation in which a "non-profit health corporation"-so certified according to defined statutory criteria-can hire physicians.See here for a discussion of what is referred to as a 501(a) entity.The rational of the original opposition to corporate practice was simply that the business entity would control the doctor's practice and profit-not the patients best interest would be controlling.There is much to suggest that the same objection is valid today but few voices are heard in that regard.It should be noted that the "non-profit health corporations" included the "not for profit hospitals". As is obvious Non-profit as well as successful for profit hospitals annually have revenue greater than cost;otherwise they would not be able to keep expanding with more and more branch offices and purchasing physician practices let alone keep operating.
Recently, I attended a seminar sponsored by the local medical society labelled as eligible for CME credit under the ethics category of required annual CME credit in Texas.The topic was how to promote your medical practice and , of course, advertizing was one way recommended.
There are at least two negative consequences of physician being employed by hospitals or large medical aggregations ( that includes the latest incarnation, the highly touted ACO):
1)Increased costs to the patient
2)decreased quality of care
Poses give illustrative examples of how the same procedure can cost more when ordered by or performed by a physician working for the hospital versus a free standing doctor not compensated by the hospital. Read Dr. Poses's posting referenced above for details about these negative consequences.
People respond to incentives.Physicians employed by health care corporation inevitably will face the situation in which the incentives generated by corporate goals and targets with which the docs will be tasked will conflict with the primary directive ( or what used to be the prime directive ) of a physician namely doing what is right for the individual patient.I am afraid that the physician's role as a patient advocate in the corporate health care organization may go the way of the AMA's prohibition against physicians advertizing,a quaint historical artifact.Once the physician accepts the new ethics position that they are responsible for the health of the collective ( the ACO may be the collective ),then the greater good for the greatest number will just happen to coincide with the financial health of the organization.
How Medicare CMS payment schemes push physicians to be employees
To contact us Click HERE
The health care economist John Goodman explains one more incentive for the private practice doctor to become an employee of a hospital or some other vertically integrated health care corporation and for the vector that is pointing in the direction of increased health care costs.
Differential price controls benefit some and harm others. See here for how much more CMS pays for the same procedure based on where it is provided.Wonder which group has the more effective rent seeking mechanisms-hospitals or private practice physicians.
In regard to the differential payments,Cui bono.Obviously the hospitals- but why would CMS adopt that tactic? I suggest it is in the interest of all third party payers not just CMS to eliminate the private practice of medicine by thousands of small, individual physician practices.If the goal is control of how physicians practice medicine, then to nudge them to become employees of a medical collective would appear to be a good tactic.
More on the movement away from small medical practices to hospitals can be found here in the discussion on the effect of ACA (Bronco care) on that issue.
Differential price controls benefit some and harm others. See here for how much more CMS pays for the same procedure based on where it is provided.Wonder which group has the more effective rent seeking mechanisms-hospitals or private practice physicians.
In regard to the differential payments,Cui bono.Obviously the hospitals- but why would CMS adopt that tactic? I suggest it is in the interest of all third party payers not just CMS to eliminate the private practice of medicine by thousands of small, individual physician practices.If the goal is control of how physicians practice medicine, then to nudge them to become employees of a medical collective would appear to be a good tactic.
More on the movement away from small medical practices to hospitals can be found here in the discussion on the effect of ACA (Bronco care) on that issue.
28 Kasım 2012 Çarşamba
Cyber Monday deals
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Sean Taylor
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Sean Michael Maurice Taylor (April 1, 1983 – November 27, 2007) was an American college and professional football player who was a free safety for the Washington Redskins of the National Football League (NFL) for four seasons. He played college football for the University of Miami, was a member of the Hurricanes' 2001 BCS National Championship team, and earned unanimous All-American honors. The Washington Redskins chose Taylor with the fifth overall pick of the 2004 NFL Draft.[1] Due to his ferocious hits,[2] several of his Redskins teammates nicknamed him "Meast," a portmanteau word from the expression "half man, half beast."[3][4] Taylor died at the age of 24 on November 27, 2007, from critical injuries from a gunshot by intruders at his Miami area home.[5] His death led to an outpouring of national support and sympathy, especially in the Washington area, where Taylor had been a fan favorite as a Redskin,[6] and the Miami area, where Tay! lor had starred for the Miami Hurricanes, after leading Gulliver Prep to a Florida state high school championship and setting a state record for most touchdowns in a season (44) . In honor of Taylor, on the first play of the first game after he was murdered, the Redskins defense lined up with only 10 players which left the area Taylor lined up at free safety open against the Buffalo Bills.[7] Contents 1 Early years 2 College career 2.1 2001 season 2.2 2002 season 2.3 2003 season 3 Professional career 3.1 2004 NFL draft 3.2 Washington Redskins 3.2.1 2004 rookie season 3.2.2 2005 season 3.2.3 2006 season 3.2.4 2007 season 4 Legal issues 4.1 2004 DUI arrest in Virginia 4.2 2005 Aggravated assault arrest in Miami 4.2.1 Aggravated assault plea agreement and resolution 5 Death 5.1 Arrests 5.2 Law enforcement theories 5.3 Disproven rumors 5.4 Media reaction and controversy 5.5 Memorial service 5.6 National Football League 5.7 Washington Redskins 5.8 University of Miami! 5.9 Trial 6 Memorial 6.1 Ring of Fame Induction 7 References ! 8 External links [edit] Early years Taylor was born in [[Miami[8], Florida]] to Pedro Taylor, a policeman, and Donna Junor. He spent his early years growing up with his great-grandmother Aulga Clarke in Homestead, Florida and later moved to his father's home at the age of 10. He grew up in a low-income neighborhood in Miami, on a street lined with candy-colored houses.[9] Taylor played high school football in Pinecrest, a suburb of Miami. He originally began his high school football career at Miami Killian High School, a Class 6A public school, but transferred to Gulliver Preparatory School, a Class 2A prep school, where he could play both offense and defense. Despite missing the first game of the season (the team's only loss), he helped Gulliver win the Florida Class 2A State Championship in 2000 with a 14–1 record. Taylor was a star on both sides of the ball during that season, playing running back, defensive back and linebacker.[10] He rushed for 1,400 yards and a stat! e-record 44 touchdowns and on two separate occasions, rushed for more than 200 yards during Gulliver's state playoff run. He also compiled more than 100 tackles during the season and scored three touchdowns (two receiving, one rushing) in the state title game victory over Marianna High School. Taylor was considered the No. 1 prospect in Miami-Dade County by the Miami Herald. He was also rated the nation's No. 1 skill athlete and an All-American by super prep. Taylor was also an Orlando Sentinel Super Southern Team selection, the No. 1 athlete on the Florida Times-Union Super 75 list and rated the No. 1 player in Florida by The Gainesville Sun. In 2007 he was also named to the Florida High School Association All-Century Team, which selected the Top 33 players in the 100-year history of high school football in the state. After his death, Taylor was honored at Gulliver by a plaque that was placed in the school's cafeteria.[11] The football field at Gulliver Prep was renamed ! Sean Taylor Memorial Field on September 5, 2009. [edit] College career ! [edit] 2001 season Taylor was recruited to play for coach Larry Coker's Miami Hurricanes football at the University of Miami, and he carved a niche for himself in Miami's secondary in nickel and dime defensive schemes as a freshman (he was one of just four true freshmen to play for the team). During the season, Taylor was named Big East Special Teams Player of the Week for his performance against the Pittsburgh Panthers.[10] The Hurricanes won the national championship in 2001, their fifth national championship since 1983. [edit] 2002 season In 2002, his first season as a starter, Taylor was a second-team All-Big East selection by the league's head coaches. He finished third on the team in tackles with 85 (53 solo), broke up 15 passes, intercepted 4 passes, forced one fumble, blocked one kick and returned a punt for a touchdown. He led all Miami defensive backs in tackles, interceptions and passes broken up, and had a career-high 11 tackles (2 solo) and intercepted 2 passes! in the Fiesta Bowl loss to Ohio State. One interception occurred on an infamous play where he was stripped by Maurice Clarett on the return, allowing the Buckeyes to retain possession. [edit] 2003 season Taylor produced a historic season during his final year at Miami that culminated with a plethora of honors and awards. He was named a unanimous first-team All-American, the Big East Conference Defensive Player of the Year and a finalist for the Jim Thorpe Award, given to the nation's best defensive back. He led the Big East Conference and ranked first nationally in interceptions with 10, tying the record for interceptions in a season with former Hurricanes standout Bennie Blades. Taylor also finished first in total tackles with 77 (57 solo). He intercepted two passes in Miami's impressive 28-14 win over Pittsburgh, playing a key role as the Hurricanes limited All-American receiver Larry Fitzgerald to just two receptions for 13 yards. He returned interceptions for an averag! e of 18.4 yards, including a 67-yard touchdown return at Boston College! , a 50-yard scoring runback at Florida State and a 44-yard scoring runback against Rutgers University. His three touchdown returns of interceptions is a Miami single-season record. [edit] Professional career [edit] 2004 NFL draft Following his 2003 season, Taylor announced that he was entering the NFL draft. Taylor was drafted in the first round (fifth overall) by the Washington Redskins. He also was the first University of Miami player drafted in 2004, which was somewhat surprising since most experts thought former Hurricanes tight end Kellen Winslow II would be the first selection. Winslow was drafted right after Taylor by the Cleveland Browns. The drafting of Taylor by the Redskins in the first round began an NFL Draft record where an unprecedented six players from the University of Miami were drafted in the first round (the other five players were Kellen Winslow II, Jonathan Vilma, D. J. Williams, Vernon Carey and Vince Wilfork). Pre-draft measureables Wt 40y 20ss 3-con! e Vert BP Wonderlic 230 lb* 4.51 sec.* X X 39" 11 10*[12] (* represents NFL Combine) [edit] Washington Redskins Following his selection by the Redskins, Taylor signed a seven-year, $18 million contract with the team.[10] However, problems soon began for Taylor as he fired his agent and then skipped part of the NFL's mandatory rookie symposium, drawing a $25,000 fine. Over his first three seasons, Taylor also was fined at least seven times for late hits, uniform violations and other infractions. [edit] 2004 rookie season On the field during the 2004 season, Taylor was successful, emerging as the Redskins' starting free safety by the third game of his rookie year. Starting the remaining 13 games of the season, Taylor finished the year with 89 tackles, two forced fumbles, one sack, 9 passes defended and 4 interceptions (second-highest on the team). [edit] 2005 season Before the season started, Taylor switched his jersey number from #36 to #21 after the cornerback who had ! worn number 21 the year before. Fred Smoot, a close personal friend of ! Taylor, had left the team and signed with the Minnesota Vikings. Taylor kept the number when Smoot rejoined the Redskins in 2007, with Smoot opting to wear #27 (his number from Minnesota). Taylor continued his effective play in the 2005 season, finishing with 70 tackles, 2 sacks, 2 forced fumbles, 2 interceptions, 10 passes defended and 1 fumble returned for a touchdown. Taylor, along with fellow University of Miami and Redskins teammate Clinton Portis, was fined $5,000 in the home game against the Philadelphia Eagles for violating the NFL dress code by wearing socks that did not match the Redskins' standard uniform. Taylor had ups and downs during a January 7, 2006 wild card game against the Tampa Bay Buccaneers. Although he scored a touchdown that proved to be the Redskins' game-winning touchdown, he was ejected after spitting at Buccaneers running back Michael Pittman. He was subsequently fined $17,000, the amount of his game bonus check. [edit] 2006 season In 2006 Sean ! Taylor finished the year leading the Redskins' defense with 129 tackles and also had 1 interception, 6 passes defended and 3 forced fumbles. During the season, Washington Redskins assistant coach Gregg Williams frequently called Taylor the best athlete that he had ever coached.[5] In Week 9, Taylor returned a blocked Mike Vanderjagt field goal into Dallas Cowboys territory and was awarded a 15 yard penalty after Kyle Kosier grabbed his facemask. This set up the winning field goal by Nick Novak. Three weeks later in Week 12, Taylor had his best game of the season against the Carolina Panthers.[13] Though he played well throughout the game, his presence was felt most sharply in the final minutes in which he made a key 4th-down tackle to prevent a 1st down and intercepted Jake Delhomme to seal the victory. He earned NFL Defensive P
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Tue., Nov. 27, 2012 5:30PM - 6:00PM EST Redskins Nation. COMCAS! T SPORTSNET Redskins Nation is a half-hour show devoted to giving fans ! unfiltered access to the day's Read the rest
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Sean Taylor . Height: 6-2 Weight: 212 Deceased Born: 4/1/1983 Miami , FL College: Miami (Fla.) Read the rest
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Sean Michael Maurice Taylor (April 1, 1983 – November 27, 2007) was an American college and professional football player who was a free safety for the Washington Read the rest
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Sean Taylor (Born 29 December 1983) is a singer-songwriter from Kilburn, North-West London. He has released five albums. Read the rest
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Actor: The Mangler (1995) · Tarzan and the Lost City (1998) · The Stick (1988) · Gums and Noses (2004). Self: Hey, Mr. Producer! The Musical World of Cameron Read the rest
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27 Kasım 2012 Salı
Wise Massachusetts Solons realize value of central planning of health care
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The Massachusetts legislature and governor realizing the incredible success of central economic planning from their study of the history of the 2oth century have acted decisively to control the amount of medical expenditures for the state and as a bonus to increase the quality of medicine.
See here for a news item on the new Mass. Plan to control all health care costs and here for my earlier comments.
The lessons of the Soviet collectivizing the farms and controlling the economy were not lost to the folks in Boston . The value of central planning could not have been more clear as they studied the success of the communist Chinese implementing collective farming . They could see from the iconic night time view of North and South Korea the success of a rationally controlled economy. The legislators were able to discern the real reason for the Berlin Wall was to exclude the west Germans from sharing in the economic miracle of East Germany.
They followed in the foot steps of fellow Massachusetts residents such as Paul Samuelson whose text book as late as the 1960s lauded the superiority of the soviet economic planning over the less efficient, plodding relatively free marker economy of the US and of John Kenneth Galbraith who advised a struggling Indian economy to adopt the successful five year type planning of USSR. Probably they had studied basic economics and learned that there was no way better than wage and price controls to abolish shortages and increase quality of goods and services.
As much praise as they they deserve for their historical and economic scholarship perhaps they should only receive a grade of B+ for they missed one important lesson that the Soviet leaders soon learned in their efforts to turn a sleepy backward agrarian nation into an industrial behemoth. That lesson put poetically is you have to crack eggs to make an omelet or more crudely you may have to starve a few million citizens to nudge them to get with the program.
The legislator failed to put any real teeth in the program.Without penalties for failure to meet the growth guidelines (ie not grow too much) the program mostly consisted of a suggestion to not spend too much on health care. Of course, that oversight can easily be corrected at the next session of the legislature should the citizens of the state fail to prudently act in the interest of the collective.
Satire and sarcasm aside, three hundred plus pages of dense,self referential prose do not get written solely on the basis of economic ignorance and historical illiteracy. ( OK sometimes they seem to) . Public policy theory suggests that things happen for a reason and that self interest of groups often initiate and devise legislation. Who profits from this bill? I don't know but the laudatory comments of the Massachusetts Hospital Association and Blue Cross regarding the legislation makes me think of a place to start in the inquiry.
See here for a news item on the new Mass. Plan to control all health care costs and here for my earlier comments.
The lessons of the Soviet collectivizing the farms and controlling the economy were not lost to the folks in Boston . The value of central planning could not have been more clear as they studied the success of the communist Chinese implementing collective farming . They could see from the iconic night time view of North and South Korea the success of a rationally controlled economy. The legislators were able to discern the real reason for the Berlin Wall was to exclude the west Germans from sharing in the economic miracle of East Germany.
They followed in the foot steps of fellow Massachusetts residents such as Paul Samuelson whose text book as late as the 1960s lauded the superiority of the soviet economic planning over the less efficient, plodding relatively free marker economy of the US and of John Kenneth Galbraith who advised a struggling Indian economy to adopt the successful five year type planning of USSR. Probably they had studied basic economics and learned that there was no way better than wage and price controls to abolish shortages and increase quality of goods and services.
As much praise as they they deserve for their historical and economic scholarship perhaps they should only receive a grade of B+ for they missed one important lesson that the Soviet leaders soon learned in their efforts to turn a sleepy backward agrarian nation into an industrial behemoth. That lesson put poetically is you have to crack eggs to make an omelet or more crudely you may have to starve a few million citizens to nudge them to get with the program.
The legislator failed to put any real teeth in the program.Without penalties for failure to meet the growth guidelines (ie not grow too much) the program mostly consisted of a suggestion to not spend too much on health care. Of course, that oversight can easily be corrected at the next session of the legislature should the citizens of the state fail to prudently act in the interest of the collective.
Satire and sarcasm aside, three hundred plus pages of dense,self referential prose do not get written solely on the basis of economic ignorance and historical illiteracy. ( OK sometimes they seem to) . Public policy theory suggests that things happen for a reason and that self interest of groups often initiate and devise legislation. Who profits from this bill? I don't know but the laudatory comments of the Massachusetts Hospital Association and Blue Cross regarding the legislation makes me think of a place to start in the inquiry.
Government ignores Goodhart's law again
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Goodhart's law expresses one of those insights to human behavior that we see play out again and again and increasing so in medical care as the farce of P4P expands in spite of all evidence indicating its negative effects. According to Charles Goodhart - When a measure become a target it looses its value as a measure.
History is replete with examples of Goodhart's law.The targets of various Soviet industrial centrally planned programs,the cash for clunkers program and high school teachers teaching to the test are just some of the many.The economist,David Henderson, wrote this excellent essay on Goodhart's law and the GDP .
See here for this Forbes article by Dr. Paul Hsieh for how we will see that story again with tragic results with the new Medicare rule about re-admission to hospital within 3o days for patients with certain medical conditions.The debacle of the four hour pneumonia rule seemingly taught the Medicare hierarchy absolutely nothing.See here. Similarly targeting wait times in British NHS hospital had deleterious results predictable from Goodhart' s law.See here for my earlier comments
So many factors outside of the hospital's control and the treating physician's control influence likelihood of a patient's condition exacerbating and necessitating readmission that considering readmission rate as a quality measure at all is absurd on its face.But whether the proposed measure is a valid measure or not does not matter, there will be unintended consequences.
People respond to incentives which can be positive or negative. If someone is penalized economically for not reaching a target or rewarded economically for reaching one, either way the person 'Teaches to the test".
History is replete with examples of Goodhart's law.The targets of various Soviet industrial centrally planned programs,the cash for clunkers program and high school teachers teaching to the test are just some of the many.The economist,David Henderson, wrote this excellent essay on Goodhart's law and the GDP .
See here for this Forbes article by Dr. Paul Hsieh for how we will see that story again with tragic results with the new Medicare rule about re-admission to hospital within 3o days for patients with certain medical conditions.The debacle of the four hour pneumonia rule seemingly taught the Medicare hierarchy absolutely nothing.See here. Similarly targeting wait times in British NHS hospital had deleterious results predictable from Goodhart' s law.See here for my earlier comments
So many factors outside of the hospital's control and the treating physician's control influence likelihood of a patient's condition exacerbating and necessitating readmission that considering readmission rate as a quality measure at all is absurd on its face.But whether the proposed measure is a valid measure or not does not matter, there will be unintended consequences.
People respond to incentives which can be positive or negative. If someone is penalized economically for not reaching a target or rewarded economically for reaching one, either way the person 'Teaches to the test".
When you urge coercion by the government,don't be shocked if you get coerced as well
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The following quote explains the title.See here for further details
All people have the moral obligation to care for those who are less fortunate. But replacing morality with legality is the first step in replacing church, religion and conscience with government, politics and majority vote. Coercing people to feed the poor simply substitutes moral poverty for material poverty.Dancing with the devil is dangerous business.
The bishops dance with the devil when they invite government to use its coercive power on their behalf, and there’s no clearer example than the Affordable Care Act. They happily joined their moral authority to the government’s legal authority by supporting mandatory health insurance. They should not have been surprised when the government used its reinforced power to require Catholic institutions to pay for insurance plans that cover abortions and birth control.
The corporate physician - he is not your father's doctor
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Dr. Roy Poses has tirelessly written about the loss of professionalism in the medical profession.Here is the link for a recent commentary by Dr. Poses about the rise and likely consequences of the corporate physician.
There was a time when the AMA vigorously opposed the corporate practice of medicine and a number of states outlawed it.But now times have changed and few states have strong statutes limiting it.
Texas still has a residual- but significantly watered down- corporate practice of Medicine statute. See here for a history of the corporate practice of medicine idea with emphasis on the exceptions even in Texas which has one of the strongest prohibitions against the corporate practice.In Texas the most widely used exception is the situation in which a "non-profit health corporation"-so certified according to defined statutory criteria-can hire physicians.See here for a discussion of what is referred to as a 501(a) entity.The rational of the original opposition to corporate practice was simply that the business entity would control the doctor's practice and profit-not the patients best interest would be controlling.There is much to suggest that the same objection is valid today but few voices are heard in that regard.It should be noted that the "non-profit health corporations" included the "not for profit hospitals". As is obvious Non-profit as well as successful for profit hospitals annually have revenue greater than cost;otherwise they would not be able to keep expanding with more and more branch offices and purchasing physician practices let alone keep operating.
Recently, I attended a seminar sponsored by the local medical society labelled as eligible for CME credit under the ethics category of required annual CME credit in Texas.The topic was how to promote your medical practice and , of course, advertizing was one way recommended.
There are at least two negative consequences of physician being employed by hospitals or large medical aggregations ( that includes the latest incarnation, the highly touted ACO):
1)Increased costs to the patient
2)decreased quality of care
Poses give illustrative examples of how the same procedure can cost more when ordered by or performed by a physician working for the hospital versus a free standing doctor not compensated by the hospital. Read Dr. Poses's posting referenced above for details about these negative consequences.
People respond to incentives.Physicians employed by health care corporation inevitably will face the situation in which the incentives generated by corporate goals and targets with which the docs will be tasked will conflict with the primary directive ( or what used to be the prime directive ) of a physician namely doing what is right for the individual patient.I am afraid that the physician's role as a patient advocate in the corporate health care organization may go the way of the AMA's prohibition against physicians advertizing,a quaint historical artifact.Once the physician accepts the new ethics position that they are responsible for the health of the collective ( the ACO may be the collective ),then the greater good for the greatest number will just happen to coincide with the financial health of the organization.
There was a time when the AMA vigorously opposed the corporate practice of medicine and a number of states outlawed it.But now times have changed and few states have strong statutes limiting it.
Texas still has a residual- but significantly watered down- corporate practice of Medicine statute. See here for a history of the corporate practice of medicine idea with emphasis on the exceptions even in Texas which has one of the strongest prohibitions against the corporate practice.In Texas the most widely used exception is the situation in which a "non-profit health corporation"-so certified according to defined statutory criteria-can hire physicians.See here for a discussion of what is referred to as a 501(a) entity.The rational of the original opposition to corporate practice was simply that the business entity would control the doctor's practice and profit-not the patients best interest would be controlling.There is much to suggest that the same objection is valid today but few voices are heard in that regard.It should be noted that the "non-profit health corporations" included the "not for profit hospitals". As is obvious Non-profit as well as successful for profit hospitals annually have revenue greater than cost;otherwise they would not be able to keep expanding with more and more branch offices and purchasing physician practices let alone keep operating.
Recently, I attended a seminar sponsored by the local medical society labelled as eligible for CME credit under the ethics category of required annual CME credit in Texas.The topic was how to promote your medical practice and , of course, advertizing was one way recommended.
There are at least two negative consequences of physician being employed by hospitals or large medical aggregations ( that includes the latest incarnation, the highly touted ACO):
1)Increased costs to the patient
2)decreased quality of care
Poses give illustrative examples of how the same procedure can cost more when ordered by or performed by a physician working for the hospital versus a free standing doctor not compensated by the hospital. Read Dr. Poses's posting referenced above for details about these negative consequences.
People respond to incentives.Physicians employed by health care corporation inevitably will face the situation in which the incentives generated by corporate goals and targets with which the docs will be tasked will conflict with the primary directive ( or what used to be the prime directive ) of a physician namely doing what is right for the individual patient.I am afraid that the physician's role as a patient advocate in the corporate health care organization may go the way of the AMA's prohibition against physicians advertizing,a quaint historical artifact.Once the physician accepts the new ethics position that they are responsible for the health of the collective ( the ACO may be the collective ),then the greater good for the greatest number will just happen to coincide with the financial health of the organization.
How Medicare CMS payment schemes push physicains to be employees
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The health care economist John Goodman explains one more incentive for the private practice doctor to become an employee of a hospital or some other vertically integrated health care corporation and for the vector that is pointing in the direction of increased health care costs.
Differential price controls benefit some and harm others. See here for how much more CMS pays for the same procedure based on where it is provided.Wonder which group has the more effective rent seeking mechanisms-hospitals or private practice physicians.
In regard to the differential payments,Cui bono.Obviously the hospitals- but why would CMS adopt that tactic? I suggest it is in the interest of all third party payers not just CMS to eliminate the private practice of medicine by thousands of small, individual physician practices.If the goal is control of how physicians practice medicine, then to nudge them to become employees of a medical collective would appear to be a good tactic.
More on the movement away from small medical practices to hospitals can be found here in the discussion on the effect of ACA (Bronco care) on that issue.
Differential price controls benefit some and harm others. See here for how much more CMS pays for the same procedure based on where it is provided.Wonder which group has the more effective rent seeking mechanisms-hospitals or private practice physicians.
In regard to the differential payments,Cui bono.Obviously the hospitals- but why would CMS adopt that tactic? I suggest it is in the interest of all third party payers not just CMS to eliminate the private practice of medicine by thousands of small, individual physician practices.If the goal is control of how physicians practice medicine, then to nudge them to become employees of a medical collective would appear to be a good tactic.
More on the movement away from small medical practices to hospitals can be found here in the discussion on the effect of ACA (Bronco care) on that issue.
26 Kasım 2012 Pazartesi
What's the Sherpa Up To?
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I have decided to write an update to what the Sherpa is Up To. Why? Well, after 5 years of hard work, Lee Gutkind is about to publish a work of creative nonfiction. I am one of the main characters. The other characters are also very compelling.
I was able to preview a copy and am very excited.
But, after reading, I thought I should give you an update on what the Sherpa is doing. Let me explain my madness. Here is my thought. As my good friend John Setaro MD would say.
"There isn't any genetic advantage that can't be overcome with aggressive environmental modification."
This was me. I was overweight, the practice was stressing me and killing me. I needed to lose weight. I did. 30 pounds of weight. Mostly fat. This changed my life. How did I do it? FitBit, metabolic testing using gas exchange, calorie tracking, some things that a guy like Eric Topol MD would call mobile health.
I began to pay attention to obesity. I noticed that obesity is a huge familial disease and an epidemic in the US. But, the genetic markers soft at best. So I say again, family history matters more. I studied fat metabolism and began to realize this disease was very similar to some mitochondrial deficiencies. I began to align genetics, family history, obesity and preventative care. Truly personalized medicine. I will sit for the obesity boards this year.
I understand the future of medicine and the potential of personalized medicine to enhance disease cure and prevention. In this case, I have been able use my understanding of metabolic genetics, clinical genetics, bariatric medicine, pedigree analysis, mobile health, medicine and wellness, to help cure diabetes, hypertension and depression. It is amazing how people feel better when they are no longer obese.
I along with 2 other physicians, my 3 nurse practitioners and our 3 offices (yes, a long way from a genetic counselor and a part time office on Park Avenue, NYC) devote every day to early detection of disease and prevention of disease.
You will soon be able to see the fruits of our labors. We are modifying environment aggressively to overcome genetic and familial risks. We take family history, environmental history, genetic testing (if indicated), mobile health tools, technology, social history and use these tools to maximize human life.
A concept we call Arete (R-eh-Tee). The Sherpa is creating the best system to cure disease, using the model developed from his own 30 pounds of weight loss and journey to health. Come see us, we are still in Greenwich, 115 East Putnam Avenue, 23 Maple Avenue, 49 Lake Avenue. 203-869-0451.
The Sherpa Says: We have made camp, 1/3rd up the mountain, beans and lamb are on the fire, with quite an ascent coming. Genomes, Environmental, Technology. Coming soon! But for now, go buy Lee's book!
I have decided to write an update to what the Sherpa is Up To. Why? Well, after 5 years of hard work, Lee Gutkind is about to publish a work of creative nonfiction. I am one of the main characters. The other characters are also very compelling. I was able to preview a copy and am very excited.
But, after reading, I thought I should give you an update on what the Sherpa is doing. Let me explain my madness. Here is my thought. As my good friend John Setaro MD would say.
"There isn't any genetic advantage that can't be overcome with aggressive environmental modification."
This was me. I was overweight, the practice was stressing me and killing me. I needed to lose weight. I did. 30 pounds of weight. Mostly fat. This changed my life. How did I do it? FitBit, metabolic testing using gas exchange, calorie tracking, some things that a guy like Eric Topol MD would call mobile health.
I began to pay attention to obesity. I noticed that obesity is a huge familial disease and an epidemic in the US. But, the genetic markers soft at best. So I say again, family history matters more. I studied fat metabolism and began to realize this disease was very similar to some mitochondrial deficiencies. I began to align genetics, family history, obesity and preventative care. Truly personalized medicine. I will sit for the obesity boards this year.
I understand the future of medicine and the potential of personalized medicine to enhance disease cure and prevention. In this case, I have been able use my understanding of metabolic genetics, clinical genetics, bariatric medicine, pedigree analysis, mobile health, medicine and wellness, to help cure diabetes, hypertension and depression. It is amazing how people feel better when they are no longer obese.
I along with 2 other physicians, my 3 nurse practitioners and our 3 offices (yes, a long way from a genetic counselor and a part time office on Park Avenue, NYC) devote every day to early detection of disease and prevention of disease.
You will soon be able to see the fruits of our labors. We are modifying environment aggressively to overcome genetic and familial risks. We take family history, environmental history, genetic testing (if indicated), mobile health tools, technology, social history and use these tools to maximize human life.
A concept we call Arete (R-eh-Tee). The Sherpa is creating the best system to cure disease, using the model developed from his own 30 pounds of weight loss and journey to health. Come see us, we are still in Greenwich, 115 East Putnam Avenue, 23 Maple Avenue, 49 Lake Avenue. 203-869-0451.
The Sherpa Says: We have made camp, 1/3rd up the mountain, beans and lamb are on the fire, with quite an ascent coming. Genomes, Environmental, Technology. Coming soon! But for now, go buy Lee's book!
Dealing with other people's pregnancies
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This is something I've been asked about a few times, and something I was just thinking about, so thought I'd share. In the months after Joshua's death, some people were hesitant to tell us they were pregnant in case they upset us, some tell us before anyone else because they want to tell us in person rather than on the grapevine. That really didn't bother me, I'm generally excited to hear about friends pregnancies. Ultrasounds were hard to look at, and baby showers were hard to go to, and still are. Joshua died 2 days after our baby shower, so baby showers just don't have that same level of fun anymore, memories of our loss just come flooding back.
The other thing that's hard to deal with is other people's loss, but for a slightly different reason - my heart just aches for them. A very close friend had an early miscarriage a few months ago, and my heart ached for her. Another good friend who has also had a rough year has just suffered a 2nd trimester loss, and it breaks my heart. I don't want anyone to ever feel the weight of loss like we did. I know a loss earlier in the pregnancy is probably a bit easier to deal with, but it's never easy, and once you start planning names, planning how the room will look, what you'll need, changes you'll need to make, and start thinking about the future they're going to have, it's so hard to have it all ripped away.
It's something that really affects you for a long time, and I think it's important for people to understand that.
Catching up (yes I'm still alive)
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It's been a really busy few months! I'll go back to September.
We went on holiday to the Seychelles and Dubai for 2 weeks in September which was fabulous. My aunt Vicki lives there with her husband Chris and their two boys, Jack and Harry. Chris has a job as part of the United Nations, which is based in the Seychelles and they've been living there about 4 years now.
The Seychelles was fascinating. The economy is completely broken - they have the highest level of debt of any other country, and since we were there the International Monetary Fund has agreed on a $26 million rescue package, and the currency has floated and been devalued. A lot of things were run down, the roads were terrible, there's a big divide between the rich and poor and everything has to be imported, so the black market is rife.
But the beaches were gorgeous, the weather was fabulous, the sky was oh so clear at night, and the stars were stunning. Sitting out on Vicki and Chris' deck every evening watching the night sky was an amazing way to relax. We were a very short walk from the beach, and just enjoyed our 10 days there relaxing.
It was great to spend quality time with Vicki, Chris and the boys. Vicki lived with us for a few years when I was younger, so I've always felt very close to her, and Jack and Harry are such great kids, we had a lot of fun with them.
Here's a few pics from the trip:
The markets
Amazingly clear water
Full moon over the fishing boats that were at port due to the worries over the Somalian pirates
We hiked to a beach called Anse Major, which was quiet, and so pretty
On our way to Anse Major
View from Vicki and Chris' balcony
Everyone. Vicki doesn't usually look so grim, and no, Andrew didn't bother with shaving while away :)
A couple of gorgeous sunrises
After Seychelles we spent a few days in Dubai on the way home since we were flying with Emirates (best airline I've ever flown with by a long shot), and stopping in Dubai anyway.
It was Ramadan, so we couldn't eat or drink in public during daylight hours, and a number of places were either closed for the month, or closed for a few hours in the afternoon, but it wasn't a big deal. We had a really nice hotel which we got a great deal on due it being Ramadan, and therefore the low season, the city in general wasn't too busy, and we just did a double decker open top tour bus tour the 2 days we were there, which supplied us with complimentary cold bottles of water which we guzzled as soon as we got on the bus - so we probably drank more water than we would have otherwise.
It was stinking hot - over 40 c, and about 90% humidity, and the heat was disgustingly oppressive. We had a fabulous time though. It was such an interesting place, and there was so much to see and do. And being so hot, it made us very aware that we were in a desert, and the regular calls to prayer from the temples made the whole experience more authentic. It's a place I would like to go back to some time to further explore - 2 and a bit days definitely wasn't enough!
Some pics:
Down on the water - there were boats coming and going loading up with goods to be transported to other nearby countries, carrying tourists around, and general water taxis for transport.
A small selection of gold in one of the windows at the Gold Souk (market)
A shopping centre called Wafi - it had designer shops, and an upmarket "traditional" souk area - the place was deserted due to Ramadan, and most of the shops weren't opening the entire month.
One of the water taxis
Dubai is a construction zone! There were cranes everywhere you looked. The sky was never clear, it's pretty much one big sand storm. And this highway made American highways look tame!
The new Metro system they are building which will make a huge difference to traffic - you can see Burj Dubai in the background which will be the world's tallest building
In front of Burj Al Arab, Jumeirah - the water there was toasty warm!
And then Ski Dubai... so bizarre!
One of the big mosques
One of the mosques near us. They were having the evening iftar buffet (breaking of the daily fast)
And Andrew on Dubai Creek at sunset
The rest of the photos are here
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