The Grand Unification Theory of Healthcare

DrRich | February 1st, 2013 - 9:47 am

In the spirit of the times – times which behoove thoughtful and observant people to simplify, consolidate, get back to the basics, and decide what’s really important and thus worth fighting for – I am de-complexifying my on-line activities.  To further this objective, I will be shutting down a website which has been a companion of this one, a site about the Grand Unification Theory of Healthcare.  In doing so, I will be moving a few key articles from that site over to the Covert Rationing Blog.

The first and most important of these articles is this one, which lays out the Grand Unification Theory itself.  The GUTH remains the foundation of almost all my thinking and writing on the American healthcare system.  It is fully laid out, of course, in my book Fixing American Healthcare – Wonkonians, Gekkonians and the Grand Unification Theory of Healthcare.

Being Thankful for the Uninsured

DrRich | November 23rd, 2011 - 8:15 am

Podcast:

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(In what has become a tradition over the past few years, DrRich proudly reprises his annual Thanksgiving message to his beloved readers.)

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Gathered around the Thanksgiving table, DrRich’s large extended family, carrying out a longstanding tradition, each offered in their turn one reason for being thankful on this most reflective of American holidays. DrRich listened respectfully as each of his loved ones, and each of the ones he was obligated to tolerate benignly because they had married (or in some other manner had committed to) one of his loved ones, recounted a cause for thanks. There is no need for DrRich to recite their utterances here, because they were all perfectly predictable and fairly mundane, having mostly to do with items such as maintaining good health, finding a job, being able to afford one’s mortgage payments, getting a passing grade in French, receiving a new puppy, Mr. Obama’s remarkable Presidency, the apparent continued structural integrity of the Universe despite Mr. Obama’s Presidency, &c., &c.

When it was at last DrRich’s turn, he, in retrospect perhaps somewhat inadvisedly, was unable to refrain from displaying his keen insight and superior analytical abilities on matters related to healthcare (a topic, anyone would have to admit, about which most of us would very much like to feel thankful). Lifting his glass, DrRich pronounced that he was most deeply and humbly thankful for the 47 million Americans without health insurance; and further, especially thankful that their ranks  must surely be growing, given the recession, advancing unemployment, imminent collapses of businesses and indeed entire industries, &c. And even though Obamacare promises to significantly reduce that number, DrRich went on to express his fervent wish that large numbers of the uninsured might still be with us a year and two years and even ten years hence, for the great and good benefit of us all.

Enjoying the remainder of his Thanksgiving meal out on the back porch with the new puppy, DrRich composed in his mind this explanation which you now behold for the keen appreciation he has developed for the uninsured. He now offers this explanation both to his readers, and to the few members of his extended family who, he believes, might have been inclined to hear him out, had Mrs. DrRich not offered at that moment to consider remaining married to him only if he would retire from the table immediately. (Believing his marriage to be a union sanctified in heaven, he did so.)

In any case, for those who have an open mind, there are two compelling reasons we should be thankful for the uninsured, and should be particularly loath to allow them to disappear.

The first reason is that it is largely thanks to the uninsured that we are able to maintain the fundamental and dearly-held American fiction that there need be no limits on healthcare. (The image DrRich conjures up when he says “dearly held” is that of Gollum caressing the Ring.) Simply put, when we have tens of millions of uninsured Americans who don’t have ready access to regular and routine healthcare, then it’s relatively easy to pretend that “healthcare” should include everything we might want it to include.

Our current healthcare system relies heavily on using the uninsured as a huge fiscal safety valve. That is, in lean times (such as now), we open up the valve, increasing the number of people who are ineligible to consume routine healthcare. Increasing the number of uninsured Americans has become perhaps our most effective mechanism of covert healthcare rationing.

This simple expediency alone goes a long way toward enabling us to avoid having to consider or discuss limits. Openly recognizing the unavoidable limits to healthcare, much less having to figure out how to implement such limits fairly and rationally, would be exquisitely painful and disruptive. (Just ask Gollum how unpleasant it is to be forcibly separated from that which we love and deeply value.) For helping us to avoid such pain and societal disruption, we clearly owe a great debt of thanks to our uninsured brethren.

The second reason came to light recently in an article in the Journal of the American Medical Association.* This article showed that – contrary to both popular lore and to stern pronouncements by policy experts bent on convincing us that (next to global warming) reducing the number of uninsured Americans is the most important task of mankind – the overcrowding in American emergency rooms is NOT due to the uninsured. Rather, it is due to insured Americans who cannot get in to see their primary care physicians.

DrRich has discussed at some length the primary care crisis and its causes. That is a very important topic, but it’s not the topic of this particular posting. This posting is about the great and abiding value of the uninsured.

It really should not be a great surprise that emergency room overcrowding doesn’t have all that much to do with the uninsured. While it is difficult to generalize about such things, a large proportion of the uninsured are people who have assets. (If they had no assets they likely would be eligible for Medicaid.) That is, they are people who have jobs, homes, cars, &c., but their employers (who, in many cases, are themselves) cannot afford to provide them with health insurance. The chief point being, of course, that these individuals have something to lose.

These are not the people who will voluntarily enter an emergency room for their healthcare, at least, not for a medical problem that they can somehow convince themselves might go away on its own if they give it a chance (such as, perhaps, crushing chest pain, or paralysis of the left side, or some other such eventuality which might cause some of us less circumspect, more insured people to just go ahead and dial 911, all willy-nilly). They realize that the moment they set foot into an emergency room they will generate a bill of at least several thousand dollars, which they will either have to pay, or spend months or years fighting off the increasingly aggressive bill collection professionals being dispatched these days by their local hospitals. They are putting their assets and their futures at risk if they come to the emergency room.

Rather, the overcrowding is due to people who have insurance – whether it’s Medicare, Medicaid or private insurance – and who are therefore entitled to their healthcare by whatever means they calculate is the most convenient for them. Increasingly, because primary care practices are hard to find, are booked for weeks in advance, and are less and less user-friendly by the day, the convenience calculation tends to default (incredibly) to the emergency room. (That insured people are choosing emergency rooms – notoriously one of the most unpleasant experiences American citizens can encounter in peacetime – instead of the offices of their primary care physicians should itself set off major alarms about the state of American primary care.)

This is all fairly intuitively obvious, and the JAMA article really should surprise only those who habitually believe all the prevarications being promulgated as Gospel today by politicians, media, and various authorities on healthcare.

It should be plain that suddenly providing tens of millions of Americans with health insurance will decidedly not relieve emergency room overcrowding, as the policy “experts” all promise us (the same experts, apparently, who promised us that the stimulus package would rescue the economy and prevent increased and prolonged unemployment, and who confidently spout a host of predictions which fly in the face of history, common sense, and laws of economics, physics, and human nature). On the contrary, creating tens of millions of newly insured individuals, without simultaneously revolutionizing our attitudes and policies toward primary care medicine, will quite obviously make our already overcrowded emergency rooms absolutely burst at the seams, and render even more hellish than it is today – even deeper down within “grief’s abysmal valley” – the prospect of entering such a place. Indeed, if we suddenly insure all these people, the rest of us who currently have insurance really won’t have anywhere to go to get our healthcare.

So. QED. As DrRich said at the Thanksgiving meal, thank God for the uninsured.

Clearly if DrRich had been permitted a mere five minutes to explain himself, not only might he have avoided eating runny mashed potatoes in a steady drizzle, but he also might have salvaged his reputation among some of the more remote members of his extended family, who really don’t know what a swell and reasonable guy he can be. Next year when his turn comes, DrRich will choose to be thankful for some more traditional value, in the hopes of being allowed to eat his meal in a warmer, drier, friendlier environment – perhaps he can be thankful for the growing number of obese Americans, and the great service being provided by these patriots-to-mankind as they reduce global warming.

* Newton MF, Keirns CC, Cunningham R, et al. Uninsured Adults Presenting to US Emergency Departments: Assumptions vs Data JAMA. 2008;300(16):1914-1924.

Are Medical Screening Tests A Bad Idea?

DrRich | October 31st, 2011 - 6:08 am

Podcast:

Just last week, DrRich wrote a post explaining why medical screening tests, under our new paradigm of centralized healthcare, will always be found to be ineffective and harmful. Therefore, it will be the job of the United States Preventive Services Task Force (USPSTF)*, after making a great show of examining randomized clinical trials as if the result is not a foregone conclusion, to declare such tests useless.

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*Regular readers will recall that the Obamacare legislation has transformed the USPSTF from its former status as a mere (one might say milquetoasty) advisory board, which made recommendations on preventive health that doctors and patients could take or leave alone, into an extraordinarily powerful GOD panel (Government Operatives Deliberating) that determines, definitively, which preventive services are to be covered and not covered by private insurers, Medicare, and Medicaid.
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DrRich thought his observation would be viewed by many as a bit “out there,” and that proponents of Obamacare would accuse him (as they so often do) of being paranoid and reactionary. So imagine his surprise when, just yesterday, the New York Times published a “news analysis” which aggressively begins selling the public on that very notion – that medical screening tests are, by and large, a bad thing to do.

Even DrRich thought the Progressives would be somewhat circumspect about breaking such remarkable and counter-intuitive news to us in the great unwashed – especially considering that they have just spent the last three decades teaching us just the opposite.  But then he recalled their smooth, unapologetic and entirely unremarked transition, around twenty years ago, from sounding the alarm about global cooling to catarwauling about global warming.

And he reminded himself that when you are a Progressive, history always began 10 minutes ago.  And this turns out to be a great convenience.

In this case it is particularly convenient, when you consider the passionate declarations by Ms. Pelosi and others in 2009 that the watchword of Obamacare – indeed, the very key to the dramatically lower costs we would realize with this new legislation – would be “prevention, prevention, prevention.”

It is always risky to speculate on what is actually going on in Ms. Pelosi’s head, but certainly the public health experts who helped devise Obamacare understood the truth all along.  Namely, it is axiomatic that medical screening tests will always, without exception, cost the healthcare system far more money than they can ever save the healthcare system. And therefore, medical screening tests will have to be suppressed – which is precisely why our new healthcare law provides the mechanism for doing so.

While readers should never doubt DrRich, he is aware that, sadly, many do.  And so it may be necessary to review why screening tests are invariably a money-losing proposition:

  • The screening tests themselves are often expensive.
  • Screening tests often produce false positive results, so additional (often invasive and always costly) testing will need to be done to confirm or deny the diagnosis.
  • If the diagnosis is made, treatment will be applied which is often dreadfully expensive.
  • The diagnostic testing is often “too sensitive,” such that it may make a positive diagnosis for a very early condition that, if it had been left alone, may not have done serious harm. The cost of treatment will therefore be wasted.
  • The screening test, the confirmatory tests, and the treatments that will be applied as a result of screening all carry the risk of complications, and the treatment of these complications can be extraordinarily costly.
  • If the patient’s life is saved by the screening test and subsequent therapy, that patient (who is often an Old Fart like DrRich) will persist, for several more years, to soak younger, worthier Americans for Social Security and Medicare payments; and worse, will ultimately develop some other expensive medical problem everyone else will have to pay for.

Q.E.D.

The fact is, the best we can hope for from medical screening tests is that they might save a life here and there, which is hardly a public health victory. But whether they save a few lives or not, they’re inevitably going to cost us a lot of money.

And clearly, from the public health standpoint, a standpoint from which we’re paying for all healthcare collectively from pooled resources (and working hard to deny people the legal right to spend their own money on their own healthcare), it makes no sense to do screening tests.

Screening tests only make sense to the individuals who are at risk for the medical condition being screened, not to the collective.

The New York Times goes on at length to explain how screening for early cancers causes harm and inconvenience for many people in order to help a few. It mentions several of the points in DrRich’s bullet list above. It quotes several public health experts who, shaking their heads sadly, allow as how perhaps the medical profession has “oversold” screening tests in the past decades. These experts lament the fact that the public will need to be re-educated about the limitations and the harm being done by these tests. The Times worries that, perhaps, people will think the new de-emphasis on screening tests is related to healthcare costs, when nothing could be further from the truth.  The worthlessness of screening tests is a new revelation, made clear by recent clinical trials. What can we do but follow the science?

DrRich is not arguing that medical screening tests are invariably a good idea. In fact, he has just given his readers an entire list of reasons they are often not a good idea.

What he is arguing is that the whole framework for our current debate over screening tests is wrong.

The proper way to deal with the imperfections of screening tests is as follows. We should carefully explain to each individual who is a candidate for screening (because they are at risk for the medical condition being screened), all of the risks of embarking on a screening pathway – the potential discomfort, inconvenience, medical risks, and costs of the screening test, of the possible follow-up tests that may be required, and of the treatments that may become necessary if the testing is positive.  The individual can then weigh these negatives against the possibility of failing to discover a treatable disease while it is still treatable. And, taking into account everything that people take into account when making such momentous personal decisions, the individual can do what they believe is right for them. And either decision – to have or not have the test – would be reasonable, rational, and evidence-based – for that individual.

But we are arguing this question as if taking individual preferences into account is not even on the table. We are arguing as if we must make a sweeping decision regarding screening – yes or no – that will apply across the board, to all Americans, regardless of how they would personally weigh the relative risks and benefits.

We are arguing in this way because that’s precisely the approach that Obamacare has codified into law.  Medical decisions from now on will be centralized, and not individualized.  The GOD panelists will determine which decision is best for the collective. And what’s best for the collective is best for us individuals.

But the “screening test debate” graphically illustrates a truth that modern medical ethicists at least implicitly (and often explicitly) deny: What’s best for the collective is NOT always what’s best for the individual. And when we must only make medical decisions collectively, individual Americans will be systematically harmed. And that includes, according to the USPSTF’s own documentation, several thousand women and men each year whose early, currently treatable, but ultimately lethal breast and prostate cancers will no longer be detected early enough to do any good.

DrRich thinks these individuals should be given the opportunity to consider their options regarding medical screening, and make the choice that’s right for them. Progressives – especially the GOD panelists, the public health experts, and most of the American media  – do not.

That’s the debate we should be having.

Why People Think Obamacare Has Death Panels

DrRich | May 23rd, 2011 - 6:49 am

Podcast:

In the epic debate that has played out recently between Shadowfax and DrRich over the transcendent implications of the IPAB (Independent Payment Advisory Board), Shadowfax accused DrRich of being one of those unsophisticates who refer to the IPAB  as a “death panel.”

Nothing could be further from the truth. DrRich does not use – has never used – the term “death panel” to refer to any of the multitude of expert commissions created by Obamacare, whose charge will be to dispassionately examine the scientific evidence in order to determine which patients will get what, when and how. These bodies, in fact, will be explicitly aiming to optimize the medical outcomes of the entire population (titrated to the amount of money we’re allowed to spend on healthcare), and not actively prescribing death for anyone.

Judging from the histories of governments which have adopted a collectivist philosophy, if death panels should appear on the scene they will not be aimed at determining which patients may live or die. That job, of course, will fall to the doctors at the bedside, who will offer or withhold medical services according to the dictates (i.e., “guidelines”) handed down by those sundry expert commissions. Rather, any death panels which eventually materialize will more likely be aimed at keeping those doctors themselves (and any other functionaries whose job is to do the bidding of the bureaucracy) in thrall.

So why has the term “death panel” caught on to such an extent that conservatives so often use it as shorthand to express what they see as the “sense” of Obamacare, and Progressives so often use it to accuse rational and mild-mannered critics of Obamacare (such as DrRich) of belonging to the Neanderthal persuasion?

While most would blame Sarah Palin for coming up with this unhelpful phraseology, it is DrRich’s view that President Obama himself must carry at least an equal part of the blame. If Progressives have not created death panels, they at least created the environment in which those words, when Ms. Palin first uttered them, immediately caught fire.

As readers will recall, Ms. Palin first used the fateful words, “death panels” as the Obamacare legislation was being slowly and painfully shoved through a surprisingly reluctant Democrat Congress. And as a result she caused many of our more complacent legislators to abruptly bestir themselves into a higher state of arousal, if not outright agitation. Palin’s accusation caught more than a few of them utterly unawares, and embarrassingly flatfooted.

They felt, no doubt, like they were in that dream where you unaccountably find yourself naked in a crowd. But this time, rather than reaching to hide their sadly exposed nether parts, they reached instead for their pristine copies of the monstrous Obamacare legislation which had been laid before them, and which they famously (and understandably and logically) never read. One could almost pity them, desperately rifling through the 2700 virgin pages, muttering to themselves, “Death panels? This damned thing has death panels?”

But in fact, their initial instincts were correct as regarded the advisability of actually reading the legislation. There was in truth no reason for them to waste their time. DrRich has subsequently read large swatches of the thing, and he can assure one and all that it was not designed for reading, comprehensibility, or (for that matter) imparting any actual information of any sort.

And besides, Obamacare contained no death panels, so had they read the bill they would not have discovered any. (In their state of sudden and stark panic, however, our newly-aroused legislators quickly moved to strike the section the bill that provided for end-of-life counseling, which, of course, had nothing to do with death panels.)

The very notion of death panels seems to have many supporters of Obamacare nonplussed. How can someone as inarticulate and obviously illiterate as Sarah Palin get away with accusing our highly-educated healthcare reformers of setting up such a thing as death panels?  And even more perplexingly why did so many Americans believe her – even, apparently, hundreds of thousands of Americans who had been enlightened enough to vote for President Obama less than a year earlier?

DrRich thinks it is this: When Sarah Palin said, “death panels,” she was dropping one last, tiny crystal into a supersaturated solution. Her words took what had been an amorphous and even chaotic sense of unease about healthcare reform, and immediately crystallized it into an organized latticework of directed rage and fear. So the real question is not how Sarah Palin came to be savvy enough to know just the right words. (Progressives know that even a distinguished panel of monkeys, given enough time and enough typewriters, will eventually produce King Lear.) Rather, the real question is: What put the rabble in such a supersaturated state to begin with? Why did the absurd-on-its-face idea of “death panels” so resonate with them? What made those words galvanize their shapeless disquiet into a solid mass of resistance?

DrRich is very sorry to have to tell his friends of the Progressive persuasion the sad truth. For it was President Obama himself who created this circumstance. Sarah Palin may have first named the death panels, but before she ever thought of the phrase the President had already described them in detail.

During his first year in office, President Obama offered several homilies relating just what a “death panel” would look like. He described their function, how they would operate, and who they would target. Perhaps the most instructive example is the one he gave on ABC television during his June 24, 2009 National Town Hall meeting.

DrRich refers, of course, to the famous question put to him by the granddaughter of a 100-year-old woman who had received a pacemaker. The questioner pointed out that her grandmother had badly needed this pacemaker, but had been turned down by a doctor because of her age. A second doctor, noting the patient’s alertness, zest for life, and generally youthful “spirit,” went ahead and inserted the pacemaker despite her advanced age. Her symptoms resolved, and Grandma was still doing quite well 5 years later. The question for the President was: Under Obamacare, will an elderly person’s general state of health, and her “spirit,” be taken into account when making medical decisions – or will these decisions be made according to age only?

President Obama’s answer was clear. It is really not feasible, he indicated, to take “spirit” into account. We are going to make medical decisions based on objective evidence, and not subjective impressions. If the evidence shows that some form of treatment “is not necessarily going to improve care, then at least we can let the doctors know that – you know what? – maybe this isn’t going to help; maybe you’re better off not having the surgery, but taking the pain pill.”

DrRich will give President Obama the benefit of the doubt regarding his suggestion that a 100-year-old women who needs a pacemaker might be better off with a pain pill. Mr. Obama is not actually a doctor, and cannot be expected to understand that using a “pain pill” to treat an elderly woman who is lightheaded, dizzy, weak and possibly syncopal because of a slow heart rate might justifiably be considered a form of euthanasia rather than comfort care. DrRich does not believe the President was intentionally suggesting the old woman’s death should be actively hastened by means of a pain pill. Indeed, given that repeated falls from lightheadedness would likely have led to a hip fracture, a pain pill might eventually have been just the thing for granny had the pacemaker been withheld.

Still, President Obama’s clear and unflinching answer in this case tells us several important things. 1) Under Obamacare, there will be at least one panel, or commission, or body of some sort, that is going to examine the medical evidence on how effective a certain treatment is likely to be in a certain population of patients. 2) This, let’s call it a “panel,” will “let the doctors know” whether that treatment ought to be used in those patients. (“Letting the doctor know” is a euphemism for “guidelines,” which itself is a euphemism for legally-binding and ruthlessly enforced directives.) 3) “Subjective” measures ought not to influence these treatment recommendations. Non-objective parameters – such as the doctor’s medical experience, intuition, or personal knowledge of the patient; or the patient’s “spirit,” or will to live, or likelihood of tolerating and complying with with the proposed proposed treatment; or even extenuating circumstances that might increase or decrease the success of the proposed treatment – simply cannot be evaluated or controlled by expert panels, and thus must be discounted. 4) But since our government is a compassionate and caring one, and wishes to reduce unnecessary suffering, palliative care will be made available in the form of pain control, even while withholding potentially curative care.

What the American public accurately heard the President say was that we will have an omnipotent “panel,” acting at a distance and without any specific knowledge of particular cases, that will tell a doctor whether he/she can offer a particular therapy to a particular patient – or whether, instead, to offer a “pain pill.”  His description of this process, repeated with variations over the next several months in several venues, obviously made quite an impact on the people.  Of course, Mr. Obama is widely known to be a gifted communicator.

In any case, all that remained was for Sarah Palin to give the President’s panel a catchy name. And when she did, the American people knew exactly what she was talking about. They knew, because President Obama himself had been spelling it all out for them in plenty of detail for six months.

Indeed, it seems to DrRich that, if not for President Obama’s having so carefully laid the groundwork,  Palin’s accusations of “death panels” would have fallen flat. It would have been regarded by most people as the absurdity that Progressives insist that it is, rather than the epiphany it turned out to be.

Progressives who strenuously object to its usage in reference to the expert commissions created by Obamcare can blame Sarah (or, for that matter, DrRich) if they want to – but by all rights they should actually be taking
up the matter with their dear leader, who is the chief source of the misapprehension, if misapprehension there be.

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Open Wide and Say Moo Now read the rest of the story!

DrRich explains it all in Open Wide and Say Moo! The Good Citizen’s Guide to Right Thoughts and Right Actions Under Obamacare

Available On Kindle

Now available in the audiobook version!

Advice to Medical Tourists From the American College of Surgeons

DrRich | March 29th, 2011 - 2:41 pm

Podcast:

In an earlier post, DrRich offered several potential strategies for doctors and patients to consider should healthcare reformers ultimately succeed in their efforts to make it illegal for Americans to seek medical care outside the auspices of Obamacare. To those readers who persist in thinking that DrRich is particularly paranoid in worrying about such a thing, he refers you to his prior work carefully documenting the efforts the Central Authority has already made in limiting the prerogatives of individual Americans within the healthcare system, and reminds you that in any society where social justice is the overriding concern, individual prerogatives such as these must be criminalized. Indeed, whether individuals will retain the right to spend their own money on their own healthcare is ultimately the real battle. The outcome of this battle will determine much more than merely what kind of healthcare system we will end up with.

DrRich, despite his paranoia on the matter, is a long-term optimist, and believes that the American spirit will ultimately prevail. So, to advance this happy result DrRich (in the previously mentioned post) graciously offered several creative options that could be employed to establish a useful Black Market in healthcare, which will allow individuals to exercise their healthcare-autonomy against the day when such autonomy again becomes legal. His suggestions included offshore, state-of-the-art medical centers on old aircraft carriers; combination Casino/Hospitals on the sovereign soil of Native American reservations; and cutting-edge medical centers just south of the border (which would have the the added benefit of encouraging our government to finally close the borders to illegal crossings once and for all).

As entertaining as it might be to imagine such solutions, a readily available, though much more mundane, option exists today, which is to say, medical tourism.

Medical tourism is where one travels outside one’s own country in order to obtain medical care elsewhere. It is becoming a booming business. A number of superb state-of-the-art medical centers expressly aimed at attracting medical tourists have been established in the Middle East, Singapore, India, China and elsewhere in Asia. These institutions cater to citizens of the world whose own healthcare systems cannot (or will not) provide in a timely fashion (or at all) the level of care patients may desire. Many of these institutions offer modern hospitals, numerous amenities, luxurious accommodations, attentive nursing care, and top-notch doctors – and they do it all for a tiny fraction of what the same care might cost (if you can even find it) in the U.S. and other “first world” nations.

Obviously, medical tourism is not particularly feasible for medical emergencies such as heart attack or stroke, or for chronic illnesses such as diabetes, congestive heart failure, or Parkinson’s disease, which require frequent visits and long-term management.  What is feasible is to become a medical tourist for those one-time medical services that can be scheduled and planned, for which there is a long waiting period at home, or which is simply too expensive in one’s own country. Such medical services often include coronary artery bypass surgery, hip replacements, knee replacements, and numerous minimally-invasive and not-so-minimally-invasive surgical procedures. In other words, medical tourism to a large extent is something one does for elective (i.e., non-emergency) surgery.

These are the very procedures, as DrRich has pointed out, which are now being covertly rationed in the U.S. thanks to the “never events” policy adopted by CMS and private insurers. As a result, certain categories of individuals may soon find it more difficult to obtain elective surgical services than they might have just a few years ago, and medical tourism may accordingly become a more compelling alternative.

It ought not be a surprise, therefore, that the first organization of American physicians to issue a formal policy statement regarding medical tourism is the American College of Surgeons.

The reaction of American surgeons to medical tourism ought to be obvious. They hate it. Elective surgical procedures – the very procedures for which Americans become tourists – are the bread and butter of most surgical specialties. It pains them to think of their prospective patients going off to Singapore for their lucrative bypass surgeries. American cardiac surgeons, for instance (already underemployed, thanks to American cardiologists throwing stents at every tiny coronary artery indentation they they can justify as a “blockage”), are nearly apoplectic at the idea.

It’s always a delight to read formal policy statements which attempt to disguise an entirely self-serving message as a selfless public gesture. The actual message of the surgeon’s policy statement, of course, is, “We hate medical tourism, and if you do it we’ll hate you,” but they say so on a manner which is designed to be polite, politically correct, non-judgmental, helpful and even friendly.

The surgeons in general have made a good effort, as you can see if you’d like to read the policy statement for yourself. It’s pretty much what you would expect – “Go ahead and have your knee replaced in Timbuktu if you want to. It’s your right, so go ahead and devil take the hindmost. Just don’t come crying to me when things go south a month later.”  They do so, however, in an extraordinarily collegial way.

The artful style of their policy statement aside, DrRich is struck by two aspects of the actual substance of the document.

First, the surgeons begin with a litany of dire warnings regarding all the medical considerations one must take into account before trusting one’s health to foreign medical hands:

“Some of the intangible risks include variability in the training of medical and allied health professionals; differences in the standards to which medical institutions are held; potential difficulties associated with treatment far from family and friends; differences in transparency surrounding patient discussions; the approach to interpretation of test results; the accuracy and completeness of medical records; the lack of support networks, should longer-term care be needed; the lack of opportunity for follow-up care by treating physicians and surgeons; and the exposure to endemic diseases prevalent in certain countries. Language and cultural barriers may impair communication with physicians and other caregivers.”

Obviously, these are all very important considerations. What strikes DrRich, however, is that these are the very same considerations (even the warning about endemic diseases, when one considers the MRSA infections which are secretly “endemic” in some American hospitals) which patients must also take into account before agreeing to receive care in any American institution. It may turn out that these considerations are more an issue in top-notch foreign hospitals than in your average American hospital, but DrRich is not convinced this is the case, and the surgeons do not provide any evidence that it is. In other words, DrRich sees this very good advice as being equally applicable whether one is considering becoming a medical tourist, or just a typical American patient.

Second, and more astonishingly, DrRich notes – not so much with interest, but more with awe – that the surgeons are beseeching their patients to consider just how difficult it might be to launch a malpractice suit against foreign doctors. (DrRich himself does not know how difficult this would be. Given that we are being so strongly urged these days to merge the American legal system with several varieties of international law, it might not be such a big problem.) Indeed, a careful reading of this policy statement reveals that the potential difficulty in suing foreign doctors is offered as the chief differentiator, and thus it has become the primary argument in favor of good-old-American-surgery. The surgeons, in essence, are saying, “Let us do your surgery, because we’re easier to sue if we screw up.”

This, from the very body of American physicians who are most at risk for malpractice suits, and who traditionally have been most vociferous in favor of malpractice reform.

DrRich can only shake his head in wonderment. If medical tourism is viewed by surgeons as such a dire threat that they have embraced, as their chief weapon against it, a celebration of the ease of suing American doctors, why, one can only conclude that medical tourism must have caught on far more than most of us realize.

As an American physician who has always been proud of American medicine, DrRich’s innate tendency is to lament the fact that Americans are finding it to their advantage to travel to Mumbai for their hip replacements. But as a patriot, he celebrates the fact that his fellow citizens are willing to go to such lengths to exercise their individual autonomy. He finds it a hopeful sign.

Our would-be oppressors might find it more difficult to hold us down than they may think.

The Real Utility of Never Events

DrRich | March 23rd, 2011 - 8:21 am

Podcast:

In 2008, the Centers for Medicare and Medicaid Services (CMS) announced it would no longer pay for the treatment of “never events,” i.e., certain medical conditions in hospitalized patients which the Feds deem to be universally avoidable under all circumstances. These conditions included:

* Decubitus ulcers
* Two kinds of catheter-associated infections
* Air embolism
* Mediastinitis after coronary bypass surgery
* Transfusing patients with the wrong blood type
* Leaving objects inside surgery patients
* In-hospital falls

Then, having been delighted with the results of its original list (or dismayed that healthcare costs continued to skyrocket despite its original list) CMS subsequently proposed declaring several new conditions as “never events,” including:

* Surgical site infections following certain elective procedures
* Legionnaires’ disease
* Extreme blood sugar derangement
* A collapse of the lung resulting from medical treatment
* Delirium
* Ventilator-associated pneumonia
* Deep vein thrombosis or pulmonary embolism
* Staph infection in the bloodstream
* Disease associated with Clostridium difficile infection

Numerous commentators have expounded on the advisability of declaring these particular conditions to be “never events.” All agree that while certain of them clearly should never be permitted to happen (e.g., leaving sundry tools inside a patient’s abdomen, or transfusing the wrong blood), certain other ones are going to continue happening to some patients no matter how high the quality of the institution and the medical professionals.

Because this topic has been so well-covered in the medical blogosphere, DrRich does not need to comment any further on the unfairness of insisting that doctors prevent every single instance of conditions that are often not particularly preventable; or on the fact that insurance companies quickly followed Medicare’s lead and now also refuse to pay for these “never events;” or that hungry attorneys have voraciously begun suing doctors and hospitals for unavoidable complications because those complications have been federally designated as avoidable; or even the fact that, having so deftly expanded the horizons of what can be considered a “never event,” the feds have cleared the path for defining virtually any medical condition they choose as a “never event.”

(As a case in point, DrRich notes that the feds’ own guidelines on preventing delirium, referred to in their own “fact sheet” that purports to justify the expanded list of “never events” admits that there are no effective means of reliably preventing delirium.)

There’s also no point in physicians complaining publicly about this expanded list of “never events,” since the public is foursquare behind the notion that no medical complications should ever occur, and if they do occur it is somebody’s fault, and equally behind the notion that the Feds can squeeze quality into the system simply by demanding it to be so. Therefore, any doctors who openly objects to these new, tough quality measures will reveal themselves to be both anti-quality and low-quality doctors.

Rather, DrRich will refer back to the true mission of this blog, and simply explain to his readers how this new “never event” strategy furthers the true mission of Medicare and the insurers, which is to say, the covert rationing of healthcare.

For covert rationing is the chief operating principle of both the Feds and the private insurers. Indeed, their behavior resembles nothing more than the behavior of the closet, white-collar narcotic addict: while smiling their pasty smiles and desperately pretending to us that all of their new initiatives are only concerned with quality and nothing else, in reality, with every ounce of their being, their devious minds are constantly inventing new schemes to manipulate, deceive and twist each and every opportunity into some means of scoring their next covert-rationing “hit.”

Consequently, we cannot go wrong if we ask, every time we see some new healthcare program ostensibly aimed at quality improvement: Where’s the rationing?

One might think the rationing in this case is easy to spot. After all, if the feds stop paying for “never events” that actually cannot be avoided, they will save dollars right up front simply by refusing to pay for services rendered. But Medicare itself has estimated that its up-front annual savings from its original list of “never events” will be only about $20 million. And that seems hardly worth the effort.

The real savings will come from a place far more sinister than that.

The “never events” initiative – just as the Feds insist to us – is aimed at changing physicians’ behavior. But quite predictably, that behavioral change will not be in the arena of quality improvement (since no amount of quality improvement can stop “never events” that are inevitable). Rather, the behavioral change will be in the arena of risk avoidance.

While it is unlikely that doctors will ever refuse to care for high-risk patients who are experiencing genuine medical emergencies, it is quite likely they will stop recommending elective medical therapy for high-risk patients. Patients who seem particularly prone to infection, bed sores, falls, blood sugar abnormalities, blood clots, delirium, or who seem likely to need intravenous antibiotics (which predispose to C. difficile) will be particularly targeted. Roughly speaking, these patients will include diabetics, the elderly, anyone with a clotting abnormality or a history of blood clots, the obese, people with immune disorders, and the chronically ill. Physicians know by experience and instinct the sorts of patients to whom they ought to avoid offering elective medical services.

But in an era of evidence-based medicine, it is inevitable that savvy doctors will not want to rely on instinct and experience in this important matter. In order to conduct their risk avoidance in the most cost-effective way, they will want to base it on firm statistical evidence.

Accordingly, it is notable that investigators reporting in the Archives of Surgery last year began the important work of providing the kind of evidence-based risk avoidance which today’s physician actually needs. They published a large study designed to show which sorts of patients are most likely to experience post-operative “never events.” To the authors’ credit, their article was not written with the overt goal of providing a roadmap for risk avoidance. Instead it was written to show that “never events” are not really “never events” at all, but rather, are sometimes unavoidable complications; and that in certain readily-identifiable and (and obvious) subpopulations of patients, the incidence of “never events” is particularly high. That is, the authors were trying to convince the Central Authority that its policy on “never events” is far too Draconian, and that some leeway ought to be made for doctors who care for these higher-risk patients.

But of course the Central Authority already knows this, and also knows that the public fully supports its “never events” policy just as it is. The Central Authority, DrRich suspects, will see the Archives article for what it will end up becoming – a roadmap for surgeons who want to avoid the risk of encountering career-threatening “never events.” DrRich thinks Central Authority is quite satisfied with this study, and hopes to see more like it.

Conducting a risk/benefit analysis is nothing new to doctors. Doctors have always computed a risk/benefit analysis before recommending elective services to their patients (such as hip replacement, coronary artery bypass grafting, back surgery, gall bladder surgery, anti-obesity surgery, &c.) And in making those risk/benefit estimates, they have always taken into account the increased risk of complications faced by the elderly, the sick, the fat, and the malnourished.

But now, the “risk” part of the risk/benefit analysis suddenly must include three important new risks, and this time they are risks to the doctor him/herself, and not to the patients: 1) If any of these complications occur, no payment will be made for the (often very expensive) treatment the complication will require; 2) If a complication occurs, another “never event” will be tabulated in the federal database next to the doctor’s (and the hospital’s) name, which will inevitably show up in a public report card; and 3) Such a complication, previously considered a predictable risk, will now engender malpractice suits, based on the declaration by the Feds that these “never events” always constitute, by definition, grievous examples of poor-quality medicine.  The Archives article serves to place this new variety of risk analysis on firmer ground, and as such is an important new addition to the medical literature.

Lest anyone think that doctors would not really stop recommending clinically indicated care to patients just because of the personal risk it would entail, remember that it’s already happened, and is well documented. The government and the insurance companies have already conducted that experiment; it’s been completed, the results have been tabulated, reported, and duly noted. It turns out that doctors, like most other people, respond quite logically to negative incentives.

CMS knows exactly what it’s doing here.

Fugitive Busted By His Pacemaker (And His Doctor)

DrRich | January 3rd, 2011 - 6:35 am

Podcast:

In Durango, Florida the week before Christmas, the FBI arrested fugitives Roger Gamlin, 62, and his wife Peggy, 54, at Mercy Regional Medical Center after a doctor determined their real identities through Roger’s pacemaker.

Wanted by the feds for 2 1/2 years on suspicion of embezzling millions of dollars from their south Florida title company, Roger and Peggy had been living quiet and unassuming lives as Ron and Nancy Jenner in Durango.

Then Peggy brought Roger to Mercy Medical Center after he developed a nose bleed that would not stop. The hospital (in accordance with the sage advice of its attorneys) is not saying exactly what happened next. But we know that Roger’s true identity was determined through his pacemaker, and the FBI quickly showed up to arrest him and his wife. Roger and Peggy waived their rights to an identification and detention hearing, were placed into custody, and will be transported to south Florida to face embezzlement charges.

The reason this story made the newswires, of course, is because the fugitives were identified through a pacemaker. Pacemakers can be electronically scanned to reveal information about the patient’s cardiac condition. Every implanted pacemaker also stores information that identifies the patient. That’s apparently what did Roger and Peggy in.

The “angle” that has made this a news story is the pacemaker angle. And yes, it’s true that when you receive a pacemaker or an implantable defibrillator, it’s like receiving a subcutaneous electronic identity chip, like the one you have in your dog. Anyone with the right scanner can find out who you are. So if you plan to become a fugitive from the law, it is best not to have one of these. (Alternately, get your pacemaker AFTER you change your identity, so that it matches with your alias.)

But really, you don’t need to have an implanted medical device in order for a hospital to learn your true identity. A medical facility could find out who you are any time they wanted, by surreptitiously obtaining DNA samples, for instance, or – for extremely rapid identification – dusting your drinking cup for fingerprints and doing a computer match. DrRich doubts whether such things are occurring today. His point is that it could happen whenever somebody wanted it to happen, whether you have a pacemaker or not.

To DrRich, the interesting part of the storyline only peripherally involves the pacemaker. The real story is this:

  • A patient goes to a hospital for medical help.
  • A medical procedure is done which generates certain data for the medical record.
  • The data in the medical record is immediately cross-referenced with data from a federal database that lists persons of interest.
  • The FBI shows up at the bedside in less time than it takes to raise a nurse with a bedpan.

Now, that’s actually a pretty interesting story.

(And people wonder why the Central Authority is so hot to have electronic medical records.)

But even that is not the most interesting angle. What DrRich wants to know – the angle he would explore if he were writing this up for the Sunday Times – is: What was the doctor thinking?

You’re an ER doc. A guy comes in with a bad nosebleed. You stabilize the bleeding, but the guy looks pretty pasty and you’re worried about his heart, so you interrogate his pacemaker. (Here’s the first red flag. For an ER doc, interrogating a pacemaker – not a routine procedure in most emergency rooms, and one which yields only sparse information about the status of a patient’s heart – is generally pretty far down the list of things to do. Could it be that Roger is acting suspiciously, and you want to find out whether he is who he says he is? If so, you are no longer acting as a doctor, but as an agent of the government.) In any case, whether intentionally or not, you learn that the patient has checked in under an alias.

So now what do you do?

There are some things you need to consider as you decide what to do. First, you have established a doctor-patient relationship with Roger, which binds you to confidentiality – unless you believe Roger is an imminent threat to himself or others. But simply using an alias does not constitute an imminent threat to anyone. Besides, using an alias is not necessarily illegal. Samuel Clements used one, and so do most people who work in Hollywood. And how many times has Barack Obama changed the name he answers to?

Second, you yourself might get into trouble if you look into the matter. For instance, if Roger were an illegal alien and you took it upon yourself to escalate the matter of false identity, you could get into serious trouble. After all, the U.S. Attorney General has determined that an Arizona law is unconstitutional which would permit police officers to investigate the actual identities of suspected illegals who are detained for other offenses. And you are not even a police officer, and Roger is not being detained for an offense, but has come in to seek medical assistance. Furthermore you are well aware that if a suspected illegal alien shows up in your ER, you are supposed to treat him/her without asking any questions about identity or legal status.

But you determine that Roger does not look Hispanic (or Arabic) – a determination that by any reasonable definition would constitute racial profiling – and so is not likely to be a member of a protected group.

DrRich thinks you are thinking like this: “This man is obviously using an alias – so what is my obligation here? In the old days my obligation would be to honor the confidentiality of my patient, who, for possibly very legitimate reasons, has altered his identity. But it’s not the old days. Now, I’m obligated to do what’s best for the collective, and only secondarily what’s best for this patient. I suspect the collective would like to know about this guy, to check him out. It’s a little risky – what if he turns out to be an illegal from, say, Argentina? A lot of people from Argentina look European. But that risk seems small, and if he is some kind of fugitive from the law I would be doing a great service to my overlords.”

So you rat him out.

We indeed have come a long way. Not only have our doctors apparently lost their scruples, but we also appear to have already arrived at a place where medical records can relatively seamlessly interface with other federal databases. Once medical records become fully electronic, patients needing medical aid will have a lot to consider. Are you an embezzler on the lam? Are you behind in paying your income taxes? Are you a parking ticket scofflaw? Do you have erectile dysfunction, or venereal disease? (These latter conditions cannot get you arrested – as of yet – but we know that all databases controlled by the government, no matter how “confidential,” also interface seamlessly with WikiLeaks, and so the publication of lists of patients with embarrassing medical conditions always remains a possibility.)

Once again, DrRich marvels at the fact that, soon, the only safe way to get your healthcare will be through the black market.

Patients, Doctors and Remote Third Parties

DrRich | December 27th, 2010 - 3:02 pm

Podcast:

From the ominously-titled book, “New Rules,” by Donald Berwick MD and Troyen Brennan MD:

“Today, this isolated relationship [between doctor and patient] is no longer tenable or possible. . . Traditional medical ethics, based on the doctor-patient dyad, must be reformulated to fit the new mold of the delivery of health care. . . The primary function of regulation in health care…is to constrain decentralized individualized decision making.”

Unfortunately, Dr. Berwick’s straightforward formulation of the appropriate role of the individual physician in our reformed healthcare system is not isolated to thinkers of the Progressive persuasion. The notion that most clinical decisions can be usefully made by a centralized authority is attractive even to some conservatives.

For example, a few years ago the noted economist Arnold Kling strongly defended the idea. “My own view is that a remote third party probably can use statistical evidence to make good recommendations for a course of treatment.”

Now, Kling is no far-left radical, pushing for centralized control of healthcare (and everything else). Indeed, he is now with the Cato Institute, and before that he taught economics at George Mason University. So he has earned his conservative and/or libertarian chops.

And to be fair, he is not really calling here for “remote third parties” to have final authority on what’s best for individual patients. Rather, he thinks patients should make that decision for themselves, weighing the recommendations of data-driven guidelines promulgated by remote experts, against the ego-toss’d recommendations from their all-too-fallible doctors, or, as Kling sarcastically refers to them, their “heroic personal saviors.” (Such sarcasm, regular readers will know, is as abhorrent to DrRich as it probably is to you.) Kling is saying: trust patients, armed with good evidence-based recommendations handed down from experts, to make the right decisions for themselves.

In concept even DrRich supports this latter notion. Indeed, a chief theme of this blog has been that doctors have been coerced into such a compromised position by the government and the insurance carriers that wise patients will no longer simply trust their doctors’ advice explicitly. As things now stand, patients who place full reliance on their doctors, assuming that they’ll get all the information they need to make good medical decisions, are putting themselves in peril. Smart patients will seek out all the information they can about their own medical conditions, so they can confirm that their doctors are indeed presenting them with all their reasonable options, and so they can more intelligently evaluate those options. And certainly, expert-endorsed guidelines would be an important part of that research.

But Kling’s remedy – that patients rely on the treatment recommendations made by expert panels as a remedy to the conflicted advice being doled out by their own doctors – is seriously flawed.

The first flaw, of course, is the idea that remote third parties, wielding evidence-based data, can make good treatment recommendations for individual patients. Evidence-based guidelines, almost by definition, are designed to improve the average outcome across a population of individuals, and are specifically designed not to optimize outcomes for each individual within that population.

Second, Kling apparently assumes that the remote third parties who are producing evidence-based treatment recommendations will be acting in a completely objective and unbiased manner. But this can never be the case. A major theme of the Covert Rationing Blog this past year has been to demonstrate that a) clinical science is probably the least exact of the sciences; b) the design and interpretation of clinical studies is inevitably attended by significant bias; and c) therefore, no matter who is producing them – whether it is medical professionals or GOD panelists (Government Operatives Deliberating) – these guidelines will always be produced with a particular agenda in mind. To assume that such agendas will be primarily – or even remotely – related to optimizing the outcomes of individual patients will often be a serious error.

Third, the idea that patients, even very intelligent patients armed with “perfect information,” can by themselves reliably sort through the morass of conflicting evidence and conflicting opinions that invariably inform any set of clinical recommendations (whether made by vaunted teams of completely objective experts from on-high, or by one’s inherently flawed, conflicted and ego-driven personal physician) is simply false. This would be the case even if the healthcare system were perfectly aligned to help patients. Which, of course, it is not. (It is aligned to affect the covert rationing of healthcare.)

Finally, while the advice patients get from their doctors is indeed biased, more and more it is biased (thanks to heavy-handed coercion) in favor of those same central authorities that are commissioning the expert panels.

As a result, patients – especially when they are sick and least able to fend for themselves – are generally incapable of negotiating the gratuitous complexities and hidden hazards laid out before them by a hostile healthcare system, a system which silently prays they will, in frustration, just go buy themselves some alternative medicine remedy, then crawl under a bush and die while contemplating their qi. Indeed, patients are as incapable of successfully navigating such a system as are accused felons of navigating a complex and hostile legal system that’s bent on sending them away for 15-20 years.

It is for this very reason that accused felons are assigned an advocate, an individual who is ethically and legally obligated to take their part, to help them navigate all the legal hazards, to do everything possible to see they are treated fairly, and that they are given every reasonable chance to prove their innocence. Lawyers, as much as we physicians might like to castigate them, are absolutely critical to a civil society.

And this is the reason why patients (according to traditional, though now quaint, medical ethics) are also supposed to have a personal advocate, an individual who is obligated to take their part, to help them navigate all the medical hazards, to do everything possible to see that they are treated fairly and that all available medical options are made open to them, and that they are given every reasonable chance of a good clinical outcome. Patients, in other words, need doctors who are devoted to the classic precepts of their profession. Such doctors, as much as Kling and others might like to diminish their importance, are also absolutely critical to a civil society.

But, as we have seen, and as has been publicly celebrated by Dr. Berwick and others, severing the classic doctor-patient relationship has been Job One under our system of covert rationing – whether that rationing is managed by insurance companies or by the government. Doctors simply cannot be allowed any longer to place their patients first. They’ve got to place the needs of their true masters first. They’ve got to keep the government and the insurers happy or they’re out of a job. They are no longer permitted to tailor clinical choices to best fit their individual patients, but they are simply to apply treatment directives as they are handed down by (from now on, government-appointed) panels of experts.

And this brings us back to Kling. DrRich of course agrees with his notion that patients ought to be armed with the high-quality information they need to determine their own medical destiny. DrRich can even agree that relying solely on the information provided by today’s doctor is generally not advisable. But DrRich cannot agree with the reason it’s not advisable. Doctors aren’t so much inherently flawed by ego and other intrinsic character flaws (at least, no more than any other group of humans), as they are operating under duress, under imposed constraints, and under external coercions that systematically and purposefully prevent them from discharging their professional obligations.

Nor can DrRich agree with Kling’s proposed solution. No centralized set of recommendations, evidence-based or not, can fix this problem for patients – especially when the expert bodies that make those recommendations are controlled by the same entities that have, with malice aforethought, killed the medical profession for the express purpose of stripping patients of their advocates, and therefore, of their medical options.

DrRich has trouble seeing a solution to this problem that is not radical. He does not see how doctors can resume their rightful place as their patients’ advocates and remain in what has become of the traditional healthcare system. Perhaps enough doctors to make a difference will leave the traditional healthcare system, shedding themselves of the third parties who now control their behavior, and re-establishing their practices (and revitalizing their profession) with a new commitment to the doctor-patient relationship. If not, then perhaps some brand new profession will establish itself (call it “personal healthcare advocates”) to fill the great void that threatens the safety of every American patient.

So yes, let individual patients weigh all the evidence and choose the healthcare option that suits them best. But unless they have a personal advocate to help them navigate the morass of biased choices – whether that advocate is their PCP like it’s supposed to be, or some new variety of professional advocate – those options will be limited to whatever healthcare is deemed best by the central planners.

A fine economist such as Dr. Kling should realize that a remote third party can no more make good recommendations for individual patients trying to survive in the rough and tumble of the healthcare system, than can a remote third party make good recommendations for individual businesses trying to compete in the rough and tumble of the marketplace. It is one thing for Progressives to hold to such a notion. It is far more disturbing to see respected conservative thinkers doing so.

How Will Progressives Ration Healthcare?

DrRich | October 25th, 2010 - 7:46 am

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In prior posts DrRich introduced his readers to Ezekiel Emanuel, MD, PhD, brother of Rahm, eminent medical ethicist, and one of the White House’s chief advisers on healthcare policy. Dr. Emanuel was one of the authors of that recent paper in the Annals of Internal Medicine which admonished American physicians that resistance is futile. He has also famously called upon American physicians to abandon the obsolete medical ethics expressed in the Hippocratic Oath.

The reason the ideas (and pronouncements) of Dr. Emanuel are important is that he presumably will be a major “decider” in determining who will serve on the GOD panels, and how those panels will operate to advance his (and Mr. Obama’s) program of healthcare reform.

So, before we leave Dr. Emanuel to his important duties, let us take one more pass at the views he has expressed, regarding the direction of American healthcare, which we can expect to see manifested in government guidelines and policies in the coming years.

In particular, and especially relevant to the subject of this blog, let us view how Dr. Emanuel would direct the rationing of our healthcare.

His ideas in this regard were probably spelled out most clearly in an article Dr. Emanuel co-authored in The Lancet, in January, 2009, which proposed a system of healthcare rationing based on what he and co-authors call the “complete lives system.” Most notably, the complete lives system proposes rationing healthcare on the basis of age, in a way that frankly “discriminates against older people” (The Lancet, Vol 373, p 429).

While Emanuel has taken a lot of heat from the right wing for espousing such a thing, his argument for doing so is unique and thoughtful, and DrRich finds it worthy of more careful consideration.

First, we should note that the outrage we often hear expressed at the very idea of healthcare rationing (with each side accusing the other of wanting to ration) only applies to politicians. When healthcare ethicists get together for instance, they (like DrRich) understand that healthcare rationing is utterly unavoidable, and that in fact we’re already not avoiding it. Ethicists argue, instead, about how to do it. In this way, DrRich feels a certain sense of brotherhood with these ethicists (a group which, in nearly every other way, DrRich most often feels a sense of disgust).

So let us consider the ethical argument most often made for discriminating against the elderly in a system of healthcare rationing. Almost always, the argument is a utilitarian one. Saving the life of a 90-year-old might “buy” him only an extra two or three years of life, whereas spending the same amount of money to save a 10-year-old might buy him another 70 – 80 years of life. So society gains much more if it spends the money on the younger person, and withholds it from the older one. From a utilitarian viewpoint the argument for discriminating against the elderly is unassailable.

Non-utilitarian ethics asserts that all individuals have equal value, so discriminating against any person should be avoided, and therefore the 10-year-old and the 90-year-old should have an equal opportunity to receive the medical service in question. (That is, either both should get it or neither should get it.)

DrRich believes that most people would sympathize with the idea that if only one life can be saved, saving a young person’s life might make more sense than saving a very old person’s life. He thinks that even most 90-year-olds he has known would agree with this proposition. The problem, DrRich believes, is with the rationale we use for making such a decision.

The utilitarian argument for discriminating against the elderly in a rationing system rests on the idea (as does all utilitarian ethical reasoning) that individuals are not of equal value, at least, not from society’s point of view. And since they are not equivalent in value, it is right and proper for some agent of society to determine the relative value of individuals, so that resources can be distributed accordingly.

Obviously, utilitarian ethics opens the door for differentiating the intrinsic values of individuals for reasons other than age. That is, if you can devalue the elderly to optimize the public good, then you can also devalue the disabled, the stupid, the lazy, the left-handed, and the obese (for instance) to optimize public good.

Emanuel’s “complete lives system,” he argues, is NOT a utilitarian one. Emanuel would favor treating the 10-year-old over the 90-year-old not to maximize public good, but to maximize the opportunity of individuals to enjoy “complete lives” over the entire age spectrum. That is, under his system all individuals are taken as having equal intrinsic value. And during the course of their lives, everyone experiences an equal spectrum of priorities – first, the priority of a 10-year-old, and later (if lucky enough to live that long) the priority of a 90-year-old. While in practical terms this still means discriminating against the elderly, it does so in a way that cannot be extended to other groups of people (i.e, the disabled and so forth), and that, in fact, yields equal age-based priorities across individuals through the course of their complete lives. In other words, when one considers the entire course of an individual’s complete life, he or she is treated the same as any other individual during the entire course of their lives.

In this way, Emanuel asserts, the complete lives system is not a utilitarian system; while it would allow us to withhold medical care from the elderly, based on their age, it would do so in a way that would not open the door for discriminating against others, for other reasons.

DrRich understands this reasoning because he proposed something entirely similar in his book, as an option for dealing with the age issue in a rationing system. In fact, since DrRich wrote his book a few years before Emanuel published his “complete lives system,” it is entirely possible that Emanuel got his idea from yours truly.

DrRich does not expect any thanks from Dr. Emanuel in this regard, however, and in fact he wishes to thank Dr. Emanuel for showing him the fatal flaw in such thinking. Indeed, thanks to Dr. Emanuel, if DrRich were to produce a new edition of his book, he would propose no such thing.

For, no sooner does Dr. Emanuel propose his complete lives system as an alternative to utilitarian ethical reasoning, than he demonstrates, in the very same article, how easily his system can be twisted to the ends of utilitarian ethics.

Specifically, Emanuel argues that a healthcare rationing system should also discriminate against the very young, and asserts that his “complete lives system” justifies such discrimination (since every individual, at one time in their lives, is very young). But in explaining why it would be desirable to withhold medical services from the very young, Emanuel reveals that his rationale, in fact, is entirely utilitarian:

“Consideration of the importance of complete lives also supports modifying the youngest-first principle by prioritizing adolescents and young adults over infants (figure). Adolescents have received substantial education and parental care, investments that will be wasted without a complete life. Infants, in contrast, have not yet received these investments.” (The Lancet, vol 373, p. 428)

livessavedSo, Emanuel holds that it is OK to discriminate against infants, toddlers and young children on the grounds that society has not “invested” a lot of resources in them yet. That is, their worth to society is not all that great.

This provision is extremely disturbing, to DrRich at least. For it essentially discards the notion that all human lives are of equal intrinsic value, in favor of the idea that an individual’s real value ought to be determined by their worthiness to the collective. And so society has the right and the duty to determine which individual lives are valuable enough to save, and which are not. Note that the rationale for discriminating against the elderly in the complete lives system was framed specifically to avoid having to do this.

In DrRich’s view, this provision against the young entirely negates the purported ethical premise of “complete lives.” This provision is what finally places the state, the insurers, or the GOD panels in the position of assigning intrinsic value to individual human lives, from a distance, as a matter of policy. If this can be done based on extreme youth, then it can also be done based on any other factor which some empowered panel decides will influence the worth of individuals to society.

The above figure, from Emanuel’s article on the complete lives system, reduces the question to a stark graph, with age on the X axis and value to society on the Y axis. Your age is determined by God. Your value to society is determined by the state.

It is easy to envision other, similar graphs, with your worthiness to society plotted on the Y axis, and certain personal features other than age plotted on the X axis – your income, your IQ, your disabilities, your BMI, etc.

DrRich reminds his readers that eugenics has been, from the beginning, an intrinsic part of the Progressive program. The idea that society can (and must) be perfected hinges, to a large extent, on the idea that mankind can (and must) be perfected. And perfecting mankind will require at least some culling of the herd. Indeed, early Progressives unabashedly embraced eugenics as an essential feature of societal perfection – and said so. Theodore Roosevelt, Woodrow Wilson, Bertrand Russell, H. G. Wells, and Margaret Sanger are only the most well-known of the Progressives who openly extolled eugenics.

Openly espousing eugenics became politically inadvisable after the Nazi atrocities came to light. But, since you can never achieve a perfect society while you are “carrying” a large proportion of people who are defective in their bodies, or minds, or thoughts, finding an acceptable way to eliminate such undesirables remains intrinsic to Progressivism.

DrRich believes that gaining control of the healthcare system, and gaining control of who gets what, when and how, provides both a new venue and a new language for Progressives to bring their program to fruition.

He humbly suggests that Dr. Emanuel’s “complete lives system” is an example of this new language, and that it offers a glimpse of what a system of Progressive healthcare rationing will look like.

DrRich’s Theory Of Progressive Thought

DrRich | September 8th, 2010 - 10:52 am

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DrRich has now read large portions of the “Patient Protection and Affordable Care Act,” i.e., Obamacare. He finds in it the very essence of Progressivism.  To understand Obamacare, then, we must understand the basics of Progressive thought.

DrRich has always found American Progressives to be a bit enigmatic. He has found much of their behavior to be persistently, almost defiantly, illogical and counterproductive to the rights Americans hold dear, rights which Progressives themselves also insist they revere – in particular, our inalienable rights to life, liberty and the pursuit of happiness.

As long as 20 years ago, DrRich had developed a sneaking suspicion that Progressives, their protests to the contrary notwithstanding, never really bought into the “inalienable” thing. On this point, he concluded, they were prevaricators. Since by then it was beginning to look like the Progressives were going to be running things for a while, it occurred to DrRich that it would be a good idea to understand what they really think, and what their agenda really was. And so, after much time and study and contemplation, DrRich developed his theory of Progressive thought, which he is now pleased to share with his readers so that they, in turn, might better understand Obamacare.

The Roots of Progressivism

When DrRich began his study of Progressives he did not quite know where to begin. So he decided to proceed, like Descartes before him, from the simplest and most irreducible of truths. Namely, that Progressives are really, really smart – or think they are. We know this because all the professors in all the best Ivy League schools are Progressives.

From this simple truth we can deduce that, whatever it is that Progressives are actually up to, it must have its roots in the writings of The Philosopher.

And sure enough, it was not at all difficult to discover the roots of Progressivism within the teachings of Aristotle.

Aristotle tells us that man is innately a political animal, an animal with an inherent propensity to gather into increasingly complex communities. The essence of man, according to Aristotle, is society.

The formation of complex societies is what defines mankind; it is what differentiates man from the rest of the animal kingdom. Hence, because man is defined by society, society is inherently on a higher plane of importance than the individual. Individuals are entirely beholden to and dependent upon and subservient to the society to which they belong. Indeed, they are defined as individuals by their place within that society. Without society, a man is just an ape (with a persistently infantile face).

In this sense, “socialism” is reduced quite simply to a philosophy in which society – the collective – takes precedence over the individual. Furthermore, the precedence of the collective over the individual is not something we can simply choose to accept or reject; it is the very essence of mankind. It is nature. It is just the way it is.

So, as you can see, Aristotle nailed Progressivism.

Clearly, while the name “progressivism” has only been around for a century or so (and we will shortly see from whence the name came), its roots are a very old idea. This idea, in fact, was the normal way of looking at the relationship between individuals and society until just a few hundred years ago, when humanists began to cautiously explore the radical notion that individuals (rather than the collective) constitute the fundamental unit of humanity. The new humanist heresy – which declared the primacy of the individual – was for a long time called “liberalism” (a term whose meaning has, recently, drastically changed, and is now a synonym for what had always been its opposite). Classical liberalism reached its zenith, DrRich thinks, a mere two and a half centuries after its painful birth, with the Declaration of Independence and the Constitution of the United States.

But to Progressives, classical liberalism has always been an aberration. Despite what America’s founding documents might say, society takes precedence over the individual. It takes this precedence by way of the very essence of mankind, as was taught by The Philosopher, and so it cannot be otherwise.

The Progressive Program

The Progressive Program – the thing that makes Progressives progressive – is to develop the perfect society. This program is not optional; it is dictated by the nature of mankind.

Since society is what defines mankind, it follows, as the night follows the day, that the program of mankind, the purpose, the work, the essence of mankind, is to create the perfect society.

The perfect society has two basic requirements. First, it must meet all the basic needs of the individuals within that society (such as food, clothing, shelter, sanitation, and health), without which individuals will always be tempted to engage in the counterproductive behavior of striving for things. Second, the social order must be of such a nature that it can persist, theoretically forever, without fundamental change. Indeed, the very notion of perfection implies that any change, of any type, is bad, since it will necessarily constitute a movement away from perfection.

The perfect society therefore requires complete stability. This would include (at a minimum) a stable population size, the preservation of natural resources and the earth’s environment (indeed, when one hears the word “sustainability,” one is listening to Progressive gospel), the careful management of the economy, and the careful control – if not suppression – of unplanned innovations. This latter refers both to material (or scientific) innovations, and innovations of thought, either of which will always threaten hard-won societal stability.

The perfection of society is the paramount work of mankind, so any method which may help in achieving this perfection is to be embraced; none discounted out of hand. The only considerations one must make in choosing methods of action are: Is this method practicable? And: Is this method more likely to be successful, or counterproductive? These two questions fully define Progressive ethics.

So that’s DrRich’s theory of Progressivism and the Progressive Program. While it is only a theory, DrRich hereby asserts that his formulation is correct.

He makes this assertion for the purpose of advancing the debate and inviting argument. If any of his readers have a better explanation of Progressivism, one that more successfully fits the facts and explains the otherwise difficult-to-explain behaviors we’ve seen from Progressives in recent years, why, DrRich will be delighted to hear it. If it is convincing, DrRich will cheerfully abandon his own theory and adopt yours.

But to accomplish this feat, your theory of Progressivism will have to offer a more successful explanation of the following Progressive behavioral phenomena than DrRich’s theory does:

Individuals and Groups Within Progressivism

While Progressivism by definition places individuals in a subservient position to society, this is not to say that individuals are merely interchangeable cogs in a great machine, or entirely analogous to worker bees in a hive. DrRich’s prior sarcasms aside, Progressive society is not the Borg.

Indeed, individuals within a Progressive society are differentiatable, and can be publicly celebrated or castigated as individuals. But to a great extent the potential worth of an individual is pre-determined by the group to which the individual belongs. Group identity in Progressive society is critically important, as it provides the only feasible means by which the leadership of Progressive societies can attempt to control and direct individual behaviors.

(Group identity is so critically important to Progressive thought that it has been given a special name – “Diversity” – and has been designated as the Cardinal Virtue, from which all the other, subsidiary, virtues – faith, hope, charity and the like – must necessarily spring.)

And so, to stand out as individuals, individuals must stand out as a member of their group, and the manner in which they stand out must fundamentally reflect the assigned essence of their group. So, for instance, Al Sharpton and Jesse Jackson are celebrated individuals, whose accomplishments nicely reflect their assigned group identities. In contrast, Clarence Thomas and Thomas Sowell are not celebrated by Progressives, and indeed are castigated as abominations, because their individual accomplishments do not reflect their assigned group identities.

Therefore, while individuals within Progressive societies can achieve a certain level of importance, individual importance is merely of tertiary concern, rather than primary or even secondary concern. Individuals can become officially “important” only if their importance reflects the essence of their assigned group; and the importance of the assigned group (the secondary concern), in turn, is proportional to its ability to advance the Progressive Program in general (which, of course, is the primary concern).

While individuals have the potential of rising to a state of importance within Progressivism, the vast majority of individuals will never actually do so. The great masses of individuals will be regarded by society as featureless members of their group, and will be treated accordingly. And the status of a particular group is always subject to change, given the extant needs of the leadership class. Certain groups (e.g. labor unions) may be exulted by the leadership, while others (e.g. the elderly, the white males, or the fat) will be devalued. Yet other groups (e.g. illegal aliens) may be celebrated by the leadership at one point in time (when, for instance, it behooves Progressive leaders to acquire voting rights for them before 2012), but then may be dismissed at some other point in time (in 2013, for instance, after the critical votes have been gathered, and now the group just represents large volumes of mouths to feed and healthcare to consume).

Good and Evil In Progressivism

Many Progressive intellectuals are fond of saying there are no absolutes, and so there is no such thing as inherent good and inherent evil. These intellectuals are wrong, even from within the Progressive paradigm. Because the Progressive Program – which, again, is to achieve a perfect society – is the innate agenda for mankind, there indeed exists a standard by which one can determine good and evil.

“Good” is anything which advances the Progressive Program; and “evil” is anything which threatens it.

Anyone who doubts the existence of good and evil within the Progressive Program need only observe the scores of behaviors and figures of speech which are condemned as unrelentingly evil by Progressives, with all the certainty and fervor of a Jonathan Edwards.

Accordingly, individuals who hinder the Progressive Program are a danger to mankind’s very essence. They are evil, and must be rehabilitated or eliminated.

Progressivism and the Leadership Class

Despite its lip service to the contrary, Progressivism is not egalitarian, even in theory.

The duty of mankind is to strive for the perfect society. The chief tool by which mankind is to achieve this program is man’s intellect and logic. It is axiomatic that only a minority of people will have the intellect and logic necessary to direct the program of mankind. Therefore, Progressivism fundamentally relies on an elite corps of individuals to guide our progress toward a perfect society. The perfect society will not just happen, it must be engineered by those who are gifted enough to lead.

The lack of egalitarianism in Progressive thought is illustrated by the special treatment accorded to the elite corps. The leadership class must be nurtured and valued by society. Furthermore, it must be given special privileges which others in society do not have. Because their work is so critical to the essential program, the elite must be removed from worry over the mundane necessities of life. That is, providing the leadership class with certain luxuries and privileges, and even freedom from having to follow all the rules that apply to the masses, is therefore not hypocrisy, but is an essential good. It redounds to the benefit of the Program.

Anyone who has not noticed recent glaring examples of this “different standard” for the Progressive elite should consider activating their “durable power of attorney” forthwith, so that a more alert individual can manage their affairs.

Progressivism and the Unwashed Masses

It goes without saying that, if left to their own devices, the populace would devolve into some primitive societal arrangement (such as capitalism) in which individuals would spend all their time striving to improve their own individual situations, even at the expense of others.

This means that the great unwashed masses must be “managed.”

Ideally, the best way to manage the population is through education, and so all efforts must be made – through formal education and by controlling the public media – to indoctrinate the population to the great benefits of the Progressive agenda, to the natural duty and obligation of all men and women to work within society to realize the Progressive Program, and to the inherent evil of all the alternatives. Since education will never be sufficient, the unwashed masses may need to be controlled through pacification (i.e., attempting to meet all their basic needs, so as to eliminate their impulse to strive). If this fails, they must be controlled through coercion, intimidation, peer-pressure, or (as a last resort or to serve as an object lesson) violence.

Fundamentally, the Progressive Program relies on all members of the great unwashed to subsume their own individual needs to the needs of the collective. That is, the Progressive Program requires a fundamental change in human nature. This change will never be forthcoming, and so Progressives are apparently doomed to be frustrated in their efforts. (However, as we will see shortly, Progressives ultimately have the answer to this problem, as well.)

So, despite their frequent hymns of praise to the worthiness of the common man, Progressives invariably develop an underlying contempt toward the unwashed masses. It is not difficult to spot this contempt if one is alert to it.

Progressivism and Politics

Under the Progressive Program, just like Aristotle says, mankind is essentially a political animal. In fact, the Progressive Program can only be achieved by political action. This means that politics – and to be clearer, political control – is the fundamental work of Progressives. Without politics, without political control, there is nothing. To lose political power is oblivion.

This attitude toward politics is in stark contrast to the attitude of conservatives, for whom government (and therefore politics) is merely a necessary evil, with which one must occasionally contend, when it cannot be avoided, as a part of life. For most conservatives politics is an afterthought.

For Progressives, politics is everything, the essence of human behavior. And it is worth any cost, any desperate measure, to maintain political control. Indeed, to fail to lie, cheat and steal in order to keep political control would be unethical.

Progressivism and Religion

Progressives have a natural adversity to organized religion. For one thing, religions tend to give a higher priority to some supernatural entity (and worse, to an afterlife), than to mankind’s “true” imperative, which is to achieve a perfect society right here on earth. However, since religious leaders can be readily coerced to serve the needs of the state (and always have been), this is not an insurmountable problem.

The real difficulty with organized religion is that the major ones stress the importance of the individual (since individual salvation, or individual enlightenment, is the major theme of the big religions). Under progressivism the inherent importance of individuals is necessarily subsumed by the importance of the collective, so by focusing the ultimate meaning of life on the individual, traditional religions become a major threat to Progressivism.

Apparently realizing that abolishing religion is far too difficult a task, Progressives have adopted the long-term strategy of infiltrating and co-opting religious establishments, and by means of introducing new ideas – such as group salvation, and the concept of social justice as a religious imperative – rendering religion, this “opiate of the masses,” less incompatible with the Progressive Program.

Progressivism and Eugenics

Since World War II, the enthusiasm with which Progressives publicly embrace the idea of eugenics has become muted. But eugenics is, in fact, inherently bound to Progressivism. One way or another, a perfect society will require far more perfect citizens than we have today. Indeed, the seething contempt with which Progressives regard the current genetic pool that comprises the unwashed masses is often difficult for them to suppress.

To a large extent, modern Progressivism was born as an offshoot of Darwinism. The idea that society could be perfected, and the idea that mankind could be perfected, were two sides of the same notion. And early Progressives unabashedly embraced both of these ideas, such that the idea of “culling the herd” became extraordinarily attractive to them – and they said so. Theodore Roosevelt, Woodrow Wilson, Bertrand Russell, H. G. Wells, and Margaret Sanger (the founder, as it happens, of Planned Parenthood) are only the most well-known Progressives who extolled the idea of eugenics.

But public support of eugenics among Progressives has become quite subdued, ever since the Nazis committed their atrocities explicitly in the name of achieving societal perfection.

One can argue, of course, whether the recent Progressive support of such activities as late-term abortions, or creating human embryos for experimentation, are partially aimed at desensitizing the public for future efforts to “guide” a more favorable genetic makeup for the population. Either way, DrRich reminds his readers of the history of Progressivism in this regard, and of the inherent attractiveness of eugenics to the Progressive Program, and urges them to remain alert.

Progressivism and Environmentalism

Radical environmentalism and the Progressive Program are not perfectly compatible. But they are close.

Radical environmentalists believe that humanity is a plague upon Planet Earth. Everything man has done since the day he first learned to cultivate crops (and thus for the first time became a different kind of animal) has been bad. And anything which delays, halts or reverses the sins mankind has perpetrated upon sacred Gaia, since that day he first departed from Nature, is a good thing. So the radical environmentalists are in favor of strong central governments which will control the behaviors of individuals (and which might ultimately drastically reduce or eliminate the human population).

Progressives are certainly on board with controlling man’s effect on the environment, but (in most cases) they are not in favor of returning mankind to a hunter/gatherer condition (since most Progressives do not view this condition as the embodiment of a perfect society). Rather, they view the environmental movement – in particular, the Global Warming Theory – as a good way to get the populace to give them the power they need to carry out their Progressive Program. So Progressives have completely embraced the Global Warming Theory as a means to their own political end. Accordingly they have declared man-made global warming to be settled science, and they suppress any efforts to study it further.

DrRich is very sorry about this. He suspects that global warming is happening, and concedes that human behavior may be playing a role, and is saddened that this scientific question has been absorbed into the Progressive agenda in such a way that we are not allowed to find out what’s really going on.

Progressivism and the Great American Experiment

Unlike any other nation in the history of mankind, the United States was not founded because of geography, race, religion or ethnicity. It was founded on an idea. It was founded on the still-radical idea that individual autonomy – the individual’s God-given right to life, liberty, and the pursuit of happiness – is the chief Fact of humankind, and that the only legitimate role of government is to create an environment in which individuals can enjoy those rights to the fullest extent possible.

One can see immediately that the Great American Experiment – which awards primacy to individual autonomy – is fundamentally incompatible with Progressivism. But because a majority of Americans still like the ideas expressed in the Declaration of Independence, the Progressives need to play their cards close to their chests. They need to proceed carefully – but relentlessly.

By slowly re-interpreting the Constitution, and slowly addicting a critical mass of Americans to an array of government programs, Progressives are certain they will ultimately prevail. They have been at it for over 100 years, and have come a long way. DrRich cannot tell whether or not we have already passed the Event Horizon, the point beyond which restoring the Great American Experiment will become impossible. But we are at least very close.

In fact, one plausible theory for President Obama’s headlong pursuit of programs and policies which anger the majority of Americans, and which gravely and immanently threaten the political control which is the center of the Progressive universe, is that he sees America as being at the very cusp of that Event Horizon, and believes that one last, small push will gain it, and make the Progressive Program irreversible, whatever might happen in the next election or two.

Progressivism and Healthcare

DrRich does not need to say much about Progressivism and healthcare right now. Many of the posts in this blog have pertained to this very question, as, undoubtedly, will many more.

But to really understand the current American healthcare system, and to understand Obamacare (the future American healthcare system), it is necessary to understand Progressivism. DrRich sincerely hopes that this current post will help a few of his readers understand, if not Progressive thought itself, at least DrRich’s conceptualization of it.