The Key To the Obama-Ryan Kerfuffle

DrRich | May 2nd, 2011 - 6:05 am


When Congressman Ryan released the House Republican budget plan a few weeks ago, he made it clear that he believed his proposal would engender a vigorous reaction from the Progressive leadership of our government. He further expressed the hope that such a reaction would at last engage both sides in a real debate about how to reduce our crushing federal deficit, which is growing fast enough to promise societal disintegration within a generation or two.

So when President Obama subsequently announced that he was giving a speech that would articulate a meaningful response to the Ryan proposal, and invited Congressman Ryan and some of his Republican confederates to attend, the Republicans respectfully showed up and sat in their designated front row seats, expecting, they said, to hear the President lay out some common ground for tough but necessary negotiations on reducing our debt.

Of course, that is not what happened. The President’s tone was righteous, accusatory, uncompromising. He ripped Ryan and colleagues each a new one, accusing them of attempting to “end Medicare as we know it,” and of trying to balance the federal budget by throwing old people under the bus, and depriving them of their God-given right to healthcare. While I am President, he indicated, the Republicans will never succeed in their efforts to break the social compact we have made with our elderly citizens. Never! (And through the whole speech, there the hapless Republicans sat, fidgeting with increasing discomfort and dismay – the self-satisfied perpetrators of this dastardly plan, the unfeeling tools of the wealthy and special interests – right there in the front row.)

After the speech, Congressman Ryan described himself as supremely disappointed by the President’s words and his tone. Ryan clearly felt he and his Republican friends had been set up by the President’s invitation, and had been maneuvered into attending their own lynching.

DrRich is disappointed, too – not by the President’s speech (which DrRich could easily have written for him) – but by Ryan’s apparent surprise. It occurs to DrRich that members of the President’s opposition simply do not understand where he is coming from, or how to deal with him. This is a very scary thought.

President Obama’s response to Ryan’s budget plan was not offered as an opening position for negotiations. It was, instead, an impassioned statement of First Principles, principles that define the difference between good and evil. There will be no compromise on first principles, no compromise with evil, no negotiations, no taking of prisoners.

This firm, uncompromising and immediate response (with the evil-doers sitting just a few feet away) came from the same President who deliberated for months after commanders in the field begged for an immediate infusion of more troops in Afghanistan, who equivocated for two years over the closing of Guantanamo, who waffled, also for years, on where to try captured terrorists and who should try them, and who allowed the tax rates for 2011 to remain unresolved until the last days of 2010. But this time he was sure of his position, and he was sure of it instantaneously and instinctively, as a matter of principle. His position on this matter is a reflection of his very core.

And what was it about Ryan’s plan that suddenly turned President Obama’s spine to titanium? It was this: Ryan’s plan would require at least some of the elderly to pay for some of their own healthcare.

The Ryan plan, in outline, is to convert the Medicare program to a voucher system, and allow the elderly to purchase their own health insurance from a pool of choices. Ryan has specified that the poor and the sick would receive full healthcare coverage – better coverage (he insists) than they are getting today. But well-to-do elderly Americans would have to carry at least some of their own weight, and to get the coverage they need would have to add their own funds to their federal vouchers. (An oft-ignored point is that anybody currently 55 or over would never be subject to Ryan’s new system, but would continue to receive Medicare as it is today.)

DrRich chooses to ignore for now the fact that the health insurance industry will never go for such a plan, since it requires them to operate under their current, utterly broken business model, and that therefore Ryan’s plan is a non-starter.  It is still an honest and principled attempt at a solution.

Ryan’s plan has the virtue of recognizing the fact that we cannot afford to purchase with public funds all healthcare for all individuals. That’s what is causing our federal debt to skyrocket to catastrophic proportions. And, recognizing that fact, his plan would require some elderly Americans, the ones who can afford it, to contribute their own funds to their healthcare coverage.

Require the rich to pay more. Isn’t this what President Obama has been saying all along?

So why is the President so adamantly opposed to such a thing?

This whole Obama-Ryan kerfuffle is simply a graphic illustration of a point DrRich has made many, many times before. Any Progressive healthcare system, at the end of the day, must attempt to centralize all healthcare decisions, and thus to direct ALL healthcare spending, and therefore, will have to restrict individuals from spending their own money (and making important decisions) on their own healthcare. DrRich has explained why this kind of restriction will be fundamental to Progressive healthcare reform, and he has described some of the steps our government has already taken to implement such restrictions. It is likely true that Progressives will have to make a few minor compromises here and there in order to advance the program as a whole (perhaps, for instance, allowing people to buy their own “alternative medicine” products). But they can never compromise to the extent that the Ryan plan would require.

Obama’s impassioned speech neatly reflects this fundamental precept. For the Ryan plan, or any plan, to not only allow but also require people to contribute to their own healthcare is a mortal sin under the Progressive program. And anyone who advances such a plan is anathema, and must be dealt with harshly. Just as Obama dealt with Ryan.

We are only a tiny step away from having any proposal such as Ryan’s being labeled as hate speech. Heck, after the President’s performance, we may be there already.

On Killing The Elderly

DrRich | April 11th, 2011 - 10:09 am


For some time now, numerous loved ones and dear friends have been advising and occasionally urging DrRich that, perhaps, it has become a bit inappropriate, and even unseemly, for him to continue in his longtime position as President and sole member of Future Old Farts of America (FOFA). For a not unsubstantial interval DrRich ignored this advice, feigning incipient deafness. But finally, after some focused study of that which these days returns his gaze in the mirror, and reluctantly concluding that maybe his loved ones have a point (and not wishing to seem Cranky), DrRich has reluctantly decided to resign from (and therefore disband) FOFA.

DrRich is pleased to announce that he has accepted a new position as President and sole member of Glorious Old Farts of America (GOFA).

And it is in this new capacity that DrRich has become alarmed at some of the dire warnings now being sounded by respected leaders of the Democratic Party, to the effect that the Republicans’ proposed federal budget for fiscal year 2012, released last week by Congressman Paul Ryan (who serves, DrRich believes, as Deputy Whippersnapper of the House Republican caucus), proves that Republicans are trying to kill old people.

Article 3, Subsection 4(D) of the GOFA charter clearly states: “All things being equal, we would prefer that Old Farts not be killed.”

Therefore, as President of GOFA, DrRich feels obligated to make some sort of public response to the Ryan budget, and to our ever-vigilant Democrat friends’ assertion that it is aimed at producing lethal harm to old people. DrRich’s important position in GOFA, of course, means that his opinion on this matter ought to carry serious weight in any high level discussions about this proposed budget.

By carefully studying the thoughtful commentary being offered by GOFA’s Democrat friends, DrRich has ascertained that Ryan’s proposed budget apparently will kill old people by “ending Medicare as we know it.”  DrRich does not find this a compelling argument, since Medicare as we know it is already being ended, by Obamacare, which is now the law of the land. Strangely, Democrat leaders are not claiming that Obamacare also kills old people.

So, as is all too often the case, the logic being offered up for public consumption by our political leaders does not hold up to simple analysis, which places DrRich into the position of having himself to provide the logical analysis of the question at hand.

DrRich, to be clear, frames that question thusly: Which plan for Medicare most threatens to kill old people? And he finds abroad in the land three distinct plans for Medicare: Medicare “as we know it,” Medicare under Obamacare, and Medicare under the Ryan budget. Let us analyze dispassionately how each proposes to kill the elderly.

Medicare As We Know It. Medicare as it is being operated today is generally popular with GOFA’s constituency, and most old people would like to continue things just as they are. And if you are one of those elderly Americans who is above, say, 75 years of age, chances are you would do just fine under Medicare as we know it. That is, odds are that you would live out your allotted years, and finally die from your heart disease or cancer only after enjoying every modern contrivance our healthcare system has devised.

However, if you are substantially younger than that, there is a real chance that your demise will be related to more systematic causes. This is because Medicare, if it were to continue just as it is today, would drive the U.S. into insolvency within a couple of decades, leading to cultural collapse, societal upheaval, &c. Our modern healthcare system (any modern healthcare system), being totally dependent upon a robust, complex, reasonably stable and technologically advanced society, would cease to exist. All of today’s life-prolonging therapies would either become very scarce, or would disappear altogether. And unless there arises out of the ashes a new culture which is centered upon ancestor worship, odds are that what little healthcare is available would not be disproportionally offered to the very old.

As DrRich sees it, continuing Medicare as we know it would ultimately result in most of our elderly dying much earlier than they do today.

Medicare Under Obamacare. Obamacare promises to prevent a Medicare-induced societal collapse by centralizing virtually all healthcare decisions, thus controlling expenditures. Government-appointed “experts” will decide which medical services ought to be offered to which patients, and will publish those decisions as “guidelines” (a euphemism for “directives”), which will be followed to the letter by doctors who wish to continue their careers and stay out of jail.

DrRich has argued herein that such a system will do great harm to many individuals in all age groups, and will effectively end the Great American Experiment. (Unlike some, DrRich would consider this latter result to be a bad thing.) But our question at the moment is more focused: Will old people be killed disproportionally under Obamacare?

DrRich thinks the answer is yes. First, “guidelines” have the most merit when they are applied to patients whose only (or main) disease is the one to which the guideline applies. For patients with multiple serious ailments, or who are beginning to suffer from various motor and sensory disabilities related to aging, the response to (or ability to follow) standardized treatment directives may be far less than supposed. The reduced ability of doctors to tailor therapy to individual needs (without incurring the undifferentiated wrath of the Central Authority) may thus prove particularly harmful to the elderly.

Second, our leadership class has already anticipated that merely centralizing all healthcare decisions will be insufficient to avert a fiscal disaster, and that more stringent controls will have to be employed. While they do not like to discuss such contingencies publicly, when they do, they make it clear that the elderly will have a reduced priority for healthcare services. That is, there will be age-based rationing.

Third, it is plain that Obamacare will attempt to make it illegal for elderly Americans (or any Americans) to go outside the system to purchase their own healthcare. Old farts will get what the Central Authority says they will get, and nothing more.

DrRich believes Obamacare would end up being pretty tough on the elderly, and that many old people will die earlier than they would die today.

Medicare Under The Ryan Plan. The Ryan plan offers to allow anyone who is 55 or older to remain on Medicare as we know it today. For those currently younger than 55, when they reach the age of Medicare they will be given a suite of health insurance plans to choose from, and will be given a certain amount of money by the government to use to support their premiums. This system is quite similar to that currently offered to many federal employees.

The amount of premium support will be based on the wealth of the individual. The poor and the sick, Ryan insists, will get full premium support, and indeed will end up with “better” health insurance than they would get today under Medicare. Wealthier individuals will have to pay a much higher proportion of their own insurance premiums.

The Ryan plan in its current form is little more than an outline, and DrRich would need to see details before feeling warm and fuzzy about it. But fundamentally it takes medical decisions away from a Central Authority and places those decisions back into the hands of patients. Further, it not only allows but insists that people (who can afford it) spend at least some of their own money on their own healthcare. Also, patients under the Ryan plan will be legally permitted – even encouraged – to purchase any additional healthcare they want, any time they choose. This plan restores individual autonomy (and its twin, individual responsibility) to American healthcare.

Undoubtedly, the insurance companies under the Ryan plan would be no less evil than they are today, and would do harm to patients every chance they get. But (as DrRich has amply demonstrated) so will the Feds, and it is far easier and far less dangerous for doctors and patients to fight insurance companies than the Central Authority.*

*DrRich hastens to remind his readers that health insurance companies will want no part of a plan such as Ryan’s. Ryan’s plan would require these companies to continue operating under their current, broken business model. After fighting so hard for Obamacare (which converts insurance companies essentially to public utilities), the insurance industry will not give up its victory without a fight – especially if doctors keep insisting on publishing articles showing that old farts can do just fine after receiving intensive medical care. DrRich thinks the health insurance industry will watch the progress of the Republicans’ budget proposal carefully, and if they perceive it has any chance of success, will do whatever they need to do to stifle it.

Would elderly people die earlier under the Ryan plan? Those who are deemed wealthy enough to contribute to their own health insurance premiums, and who as a result choose to become under-insured, may certainly die earlier. DrRich supposes this is what the Democrats mean by “killing old people,” since he can find no other rationale to support such a statement.

The Bottom Line. Ultimately, the worst thing that could happen to us old farts would be for the current Medicare system to continue as it is, without any meaningful fiscal reforms. The two other plans for Medicare both promise to control government expenditures on healthcare, and thus promise to avoid the societal collapse (and mass elderly casualties) that likely would be produced by doing nothing.

Obamacare accomplishes this by placing healthcare decisions into the hands of government-chosen “experts” who will determine the management of individuals from a great distance, and by giving the elderly a lower priority in unavoidable rationing schemes.

In contrast, the Ryan plan proposes to avert catastrophe by placing elderly individuals in the position of having to choose (and in many cases partially pay for) their own health insurance product, and then live with those choices.

Speaking on behalf of the entire GOFA organization, DrRich would rather his fellow old farts die as a result of their own personal choices in a plan like Ryan’s, than die as the first victims of the societal upheaval, or through the tyranny, promised by the other two options.

DrRich trusts that his position as President of such an august organization will render his opinion in this matter dispositive.

Overhauling America’s Healthcare Machine – A Review

DrRich | February 15th, 2011 - 6:08 am

Some might wonder why America needs a new book on fixing our healthcare system, now that the the Patient Protection and Affordable Care Act (i.e., Obamacare) has already done that for us. Well, there are several reasons, so take your pick:

1) Obamacare might be repealed.
2) Obamacare might be found unconstitutional.
3) If Obamacare is permitted to proceed into its full glory, it shouldn’t be long before it leads to social upheaval either by: a) exploding the federal deficit far beyond even what we’re seeing today; or b) alarming a critical mass of Americans regarding the new, oppressive powers which the new law grants to the federal government.

If 1 or 2, the process by which our nation will re-address healthcare reform may look much like the contentious, but deliberative, processes we have used in the past to reform certain aspects of our society. If 3, the process may look a lot more like Egypt.

In any case I think there is a reasonable chance that, in the next few years, we may be looking for a completely new way to reform our healthcare system, one that resembles neither Obamcare, nor the alternate and rather tepid “solutions” that have been proposed by the Republican leadership.

When that day comes, you will be very glad you took the time to read Douglas Perednia’s new book, Overhauling America’s Healthcare Machine – Stop the Bleeding and Save Trillions.

Perednia, something of a polymath, is an internal medicine specialist as well as a dermatologist, an NIH researcher, a writer, and an expert in telemedicine and medical informatics (he is a professor of this latter discipline). While he has founded and directed non-profit organizations, he is also an entrepreneur (which explains how he has become “New Zealand’s sole domestic source of boiler cleaner and glue for beer bottle labels”). He admits also to being a tap dancer (not that there’s anything wrong with that). And, as anyone will know who reads his excellent blog, Road To Hellth, he also knows a lot about the healthcare system.

Perednia’s book is a true tour de force – but don’t let that frighten you away. The author’s writing style is clear and conversational, easy to follow and entertaining to read.

In this style, he tells you everything.

Perednia does not pretend that American healthcare isn’t in dire need of the very kind of fundamental change that President Obama says he wants, nor does he pretend that a little insurance reform will do the trick. The healthcare system, he suggests, is on its last legs. It is a machine that is wearing out and bogging down, and it needs to be completely overhauled.

The healthcare machine is far more complex than it ought or needs to be. It is burdened by all manner of extraneous flywheels, gears, and gewgaws that were glommed on during its long history to please one long-forgotten constituency or another, that do nothing useful, but that consume a lot of fuel and deposit a lot of grime. The healthcare machine’s great creaking clockwork grinds away against all this unnecessary friction and accumulated grunge, and for all its strenuous efforts produces an ever-smaller amount of useful work. What this machine needs is more than some bright new attachments and smarter operators to oversee its churnings. It needs to be torn down and rebuilt.

Perednia does not pull his punches. He starts by showing that the American healthcare system, when its output is analyzed objectively and soberly, does not produce nearly as much good as its present apologists suggest. It certainly does not produce very much good in relation to all the money we spend on it. He then moves on to analyze the roles all the big players have within the healthcare system in producing all this waste. He amply demonstrates how the doctors, the hospitals, the insurers, the government (and, yes, the patients), behaving in a manner that is entirely consistent with the incentives the system has provided for them, with no especial evil in their hearts, and with no more than the natural, baseline amount of greed and self-interest that accompanies any human enterprise, operate in a grotesque ballet of waste and excess. He shows how the healthcare machine has reached the point where it simply cannot go much further, and that, like it or not, we’re going to have to do something about it. (Along the way, Perednia clearly demonstrates how Obamacare, far from representing any kind of fundamental departure, simply exaggerates the pathology.)

The strongest part of this book, however, deals with how to fix all this. Perednia begins by establishing what almost anyone would agree ought to be the goals of the American healthcare system – it must deliver effective and efficient healthcare services in a manner whose fairness to all Americans is commensurate with the contributions all American make to it, and it must be financially sustainable – at least to the point that its cost does not drive us to societal collapse. He then outlines a scheme that can achieve these goals.

I would be less than forthcoming if I did not mention that the broad outline of Perednia’s solution, as he graciously acknowledges, derives from my own book. That outline looks like this:

He proposes a 3-tiered healthcare system. The bottom tier, Tier 1, consists of self-pay healthcare. All individuals would be expected to pay a certain amount each year toward their own healthcare, say $2000 per individual, or $4000 per family. The funds for Tier 1 could reside in a Health Savings Account, which the individual would own. People with low incomes would have HSAs funded by the government. But everyone has the opportunity to own an HSA, and everyone controls the first $2000 of spending on their own healthcare (and keeps what money is not spent).

Once the individual exhausts their annual $2000 limit, their healthcare would default to a publicly-funded Universal Health Insurance Plan (Tier 2). The universal health plan – which would cover every American, even members of Congress – would operate under a system of open healthcare rationing, for the purpose of keeping public spending on healthcare on a reasonable budget. Perednia spells out the details on how such open rationing could be accomplished. Obviously, establishing any system for openly rationing healthcare would be a very difficult and exceedingly painful process. It seems very likely that only after experiencing great gouts of pain from our current healthcare system could we Americans be enticed to tackle such a thing. But Perednia (and I) postulate that such a circumstance may become manifest in the very foreseeable future.

Tier 3 is a completely voluntary, self-funded insurance product. Here, the health insurance industry would offer various levels of additional health insurance to people who want it, which will pay for services not covered under the open rationing in Tier 2. Health insurance in Tier 3 would begin to look like an actual insurance product (i.e., one that protects individuals against unforeseen, potentially catastrophic expenses), instead of the soup-to-nuts coverage of everyone’s heart’s desire that now passes for health “insurance.”

Again, this is just an outline. While my book did not take it much farther than this, Perednia takes his solution to the healthcare problem several steps beyond, and provides a very comprehensive plan. He discusses specifics of insurance reform, physician reimbursement, paying for goods and services, physician credentialing, government regulation, malpractice reform, addressing fraud and abuse, implementing electronic medical records that actually help efficient patient care (a particularly strong section of the book), and assuring that innovations in healthcare are encouraged. If you really want to know how to fix American healthcare, it’s all here.

Once Omamacare is repealed or declared unconstitutional, or once it goes forward in tact to accelerate the final implosion of our already-near-terminal healthcare system, smart people will find themselves looking for new ideas upon which to re-build American healthcare. Amidst all the cacophony about healthcare reform, however, there are really only very a few voices that are offering truly novel solutions. Doug Perednia has thrust himself to the front of that short list of visionaries with Overhauling America’s Healthcare Machine.

Please read this book, so that when the time comes you can tell your Congressperson (or perhaps by that point, your local Commissar) about it.


Overhauling America’s Healthcare Machine is available in all bookstores, and at Amazon.

Get Perednia’s New Book For Free On Kindle, Through Feb. 12

DrRich | February 10th, 2011 - 9:31 am

You can get a free Kindle edition of Douglas Perednia’s excellent new book, Overhauling America’s Healthcare Machine from now through February 12, at this link. This is an offer you should not pass up.

Perednia writes the very fine Road to Hellth blog, and is a well-known author, researcher, medical practitioner, and entrepreneur.  His new book is a post-Obamacare view on what we really ought to do to reform our healthcare system in a way that will actually work, and will actually reduce costs.

DrRich will be posting full a review of Overhauling America’s Healthcare Machine here next week, but he can assure you right now that it would be well worth your time to read it. (And if you’re going to read it, why not get it while it’s free?) It is comprehensive, extremely readable, and convincing.

Again, through February 12, get the free Kindle edition here.

The Constitutionality Briar Patch

DrRich | January 7th, 2011 - 7:17 am


“Drown me! Roast me! Skin me alive! Do whatever you please!” cried Br’er Rabbit. “Only please, Br’er Fox, please – whatever you do, just don’t throw me into that briar patch!”
- Joel Chandler Harris

Quite a lot has happened on the healthcare front over the holidays, even in addition to the Telltale Pacemaker story, and DrRich suspects that more than a few of his readers – busily eating, drinking and being merry – may have missed some of it. But fear not. DrRich is committed to catching you all up.

One story even the most dedicated of you revelers might have heard something about is that a U.S. District Judge, Henry E. Hudson, has declared the Obamacare individual mandate to be unconstitutional.

This ruling has no immediate practical result, since the individual mandate is not scheduled to go into effect until 2014. But Hudson’s ruling has given a great boost to Tea Partiers, certain Republicans, constitutional fundamentalists, and other recalcitrants who keep trying to disrupt the modern Progressive program by invoking the Constitution, and other old-timey scripture, written by slave-holding, wig-wearing, pompous old white men who didn’t even like each other very much, let alone Diversity, and who had never even heard of Twitter or Facebook or 4G networks, and whose scribblings therefore cannot possibly have anything important to say to modern-day people like us. In any case, Hudson’s ruling is not dispositive, and the matter of the constitutionality of the individual mandate will finally be decided in the U.S. Supreme Court.

In a related matter, also over the holidays, President Obama phoned the president of the Philadelphia Eagles to praise him for giving Michael Vick a second chance.

Some readers will not immediately see how President Obama’s phone call to the Eagles is relevant to Hudson’s ruling on the individual mandate, but that’s what DrRich is here for. You see, Dear Readers, Mr. Obama is a very brilliant and subtle man, whose actions and words can never be taken at face value, but which (like, as it happens, the actions and words of Christ) must be interpreted in the context of the entirety of his life’s work. Accordingly, his phone call to the Eagles can only be properly interpreted if one understands (as the President undoubtedly does) that Judge Hudson is the selfsame judge who sentenced Mr. Vick to the federal penitentiary for engaging in unsavory sporting activities involving dogs.

It should be clear then that President Obama’s real message, for those few of us who are perceptive enough to understand it, is: “Judge Hudson has a history of making rulings whose ultimate result is the precise opposite of what one might originally think. His Vick ruling was seen by everybody as an action that would ruin Mr. Vick’s career forever. But, as a result of that action, Mr. Vick dedicated himself as never before to becoming a great quarterback, and has already achieved heights he might never have reached if Hudson had been more lenient. So when Hudson says the individual mandate is unconstitutional, take heart! The final effect of his ruling will be – as in the case of Michael Vick – the opposite of what everybody thinks.”

The loud protests you hear from Mr. Obama’s side regarding the challenge to the constitutionality of the individual mandate, for the most part, are genuine. Most Progressives, lacking Obama’s subtlety, are outraged that something as important and as groundbreaking as Obamacare is threatened by mere scratchings made by old men in ancient days on a piece of cracked parchment. The official defense of the individual mandate made shortly after Hudson’s ruling, by none other than Kathleen Sebelius and Eric Holder, stresses this point. These eminences (one of whom is the Attorney General of the United States for goodness sake!) were utterly unable to come up with a legal or constitutional justification for the individual mandate, and based their defense entirely on the proposition that Obamacare is really, really important, and that the individual mandate is vital to Obamacare. The notion that if something is important enough the Constitution must be pushed aside (or, more accurately, “re-interpreted” in light of modern-day exigencies) is a given for Progressives, and they just don’t understand how any reasonable person could think otherwise.

Mr. Obama, DrRich believes, looks at it differently. Let us review some basic facts:

1) President Obama favors, and is working toward, a single-payer healthcare system. He has said so publicly many times. (Here’s one example.)
2) Obamacare places us on the road to a single-payer system – either a direct single-payer system run entirely by the government, or a single-payer system which is administered by minutely-regulated “health insurance utilities.”
3) The health insurance industry is currently running out the string on its fundamentally broken business model, and desperately needs Obamacare as a pathway to a graceful exit strategy.
4) The sole reason for the individual mandate was to get the health insurance companies on board with Obamacare, that is, the individual mandate buys the insurance industry a few more years of life – one last windfall – in return for which they will become heavily regulated utilities,  and likely avoid the ignominious and catastrophic failure their current trajectory suggests.
5) On the other hand, if we instead went to single-payer healthcare like the President and his Progressive friends want – such as Medicare for all – then the constitutionality of the individual mandate would immediately become moot.

If these facts – particularly the ones about the state of the health insurance industry – are correct (and DrRich believes he has amply demonstrated that they are), then declaring the individual mandate to be unconstitutional will actually play into Mr. Obama’s hands quite nicely.

If the individual mandate is declared unconstitutional and Obamacare becomes entirely defunct, the insurance industry will remain on their path to imminent disaster. They will be forced to price nearly everyone out of the insurance market, and themselves out of business, and we Americans will be left with no obvious choice but single-payer, Medicare-for-all healthcare by default, as the only obvious constitutional option. (There are, of course, other options – such as the one DrRich has proposed – but these likely will continue to be ignored.)

Mr. Obama will go on TV and say:

“We tried! Nobody can say we didn’t. We presented our nation with a healthcare plan that would cover almost everybody, and which would save the private insurance industry. But now, the actions of the Republican naysayers have destroyed the only mechanism that would have allowed the insurance industry to continue to function.  And now the insurance companies are falling like dominoes, and uninsured Americans will soon number over 100 million.  You and your loved ones and your neighbors face imminent death or disability from Republican neglect.  We must act, and we must act now.

“I and my Democratic colleagues did not want it this way. We fought hard for our centrist, market-based plan.  But our Republican opponents and their allies in the reactionary Court leave us no choice.  My fellow Americans, as a matter of national security, and of national survival, we must pass into law, within the next 30 days, my new program to expand Medicare to cover all Americans. All other paths have been closed to us. And if you don’t like it, as I myself do not, you know who to hold responsible at the polls.”

On the other hand, of course, the individual mandate may be declared constitutional by the Supreme Court. (DrRich does not understand how this could happen under the Constitution as written, and neither, apparently, does Mr. Holder. But given the “living document” proclivities of many justices these days, one must admit it is reasonably likely to happen.) And if the individual mandate is declared constitutional, then the federal government will have been granted the authority to dictate any behavior it wishes upon individual Americans, as long as those behaviors are deemed to be important enough by the government to the collective interest.

Either outcome to the constitutional challenge to the individual mandate, therefore, will be more than convenient to the ends of President Obama. He understands this very well as he stands there, entirely serene and above the fray, watching Sebelius and Holder, and his other minions, caterwauling over the constitutional challenge to the individual mandate.

“Please, Br’er Elephant,  whatever you do, please don’t throw my individual mandate into that briar patch!”

The Inevitability of Bias in Clinical Research

DrRich | September 23rd, 2010 - 6:47 pm

DrRich has said many times that clinical science is among the least exact of the sciences, and therefore, the results of clinical research are particularly susceptible to “spinning” by various interested parties, in order to yield the kind of results they would prefer to see.

Until recent times in American medicine, the parties who have been most interested in spinning clinical research have been the people who run drug companies and medical device companies (who need clinical research which supports the use of their products), and the medical specialists (who are more likely to be paid for performing medical procedures that are supported by clinical research). In writing about such data-spinning abuses, DrRich has particularly targeted his own Cardiology Guild, but only because he knows and loves cardiologists the best. He suspects that other specialists are doing exactly the same thing.

While DrRich has used reasonably gentle humor (laced, to be sure, with sarcasm and irony) to criticize doctors and their industry collaborators for twisting clinical data to their own ends, others have expressed the same concerns in much more indignant terms, and have threatened to employ professional sanctions, civil and criminal penalties, and everlasting perdition, to curtail such behaviors.

(Indeed, DrRich has always suspected that the real reason President Obama has not closed Guantanamo is so he has someplace to send recalcitrant American physicians who persist in accepting logo-ed plastic pens from drug reps, or who refuse to accept reduced Medicare/Medicaid reimbursement schedules, or who engage in the black market healthcare activities the President surely understands he is provoking. The one thing that can torpedo Obamacare completely is if American doctors refuse to go along, and any physician who shows signs of doing so will have to be dealt with harshly – if not by detention in exile, then by some other method.)

There is nothing wrong with a little old-fashioned American Puritanism, of course, and physicians and companies who behave badly ought to be punished. But DrRich begs his readers to understand that the inevitable bias in clinical research is not one-sided; it cuts both ways. And clearing the field, so that the only entities which are left to spin clinical research data will be the government-controlled expert panels, is a very bad idea.

DrRich must remind his readers that Obamacare provides for several distinguished expert panels, to be appointed by the executive branch of the federal government, to direct the studies, interpret the results, and apply the results to official reimbursement policies, of a species of clinical research which is called “comparative effectiveness research.”

Comparative effectiveness research comes in two flavors. First, there is the comparative effectiveness research whose unambiguous goal is to compare the clinical effectiveness among different treatment options, so as to offer physicians objective guidance in making the clinical decisions whose results are more likely to be clinically favorable to their patients. This kind of comparative effectiveness research is an unalloyed good, and it is as unassailable as babies and bunnies. Then there is Comparative Effectiveness Research (CER), which is to be operated by new government bureaucracies, whose agenda regarding what kind of effectiveness is actually to be compared is intentionally ambiguous, but which at the end of the day will be comparing cost effectiveness, as opposed to clinical effectiveness, so that doctors will make the clinical decisions whose results will be more favorable to healthcare cost containment.

Our policymakers have been studiously ambiguous about what they mean by  Comparative Effectiveness Research.

This ambiguity was made clear during the Obamacare debates when Peter Orszag testified on behalf of the administration before the Senate Finance Committee. When queried by skeptical Republicans on the ultimate goal of the proposed CER boards, Mr. Orszag was evasive. Specifically, when asked by Senator Kyle (R-Arizona) whether the CER board would be empowered to make decisions regarding which medical services will be reimbursed, Mr. Orszag finally replied, “Not at this point,” a reply which did not alleviate the suspicions of the minority party.

To state the ambiguity more plainly, it is clear that while the government’s CER panels will mainly be concerned about comparing cost effectiveness, the only kind of effectiveness they are willing to discuss publicly is clinical effectiveness. This studied ambiguity allows proponents of Obamacare to paint opponents of the CER panels as being against the “babies and bunnies” form of comparative effectiveness research, and thus reveal those nay-sayers as being beneath contempt, and unworthy of anyone’s attention. Meanwhile they will be free to advance their real “cost effectiveness” agenda.

Therein, of course, lies the government’s bias regarding clinical research. Since clinical research is the primary mechanism by which Obamacare proposes to cut the cost of healthcare, and since the new government panels provide the chief mechanism for controlling and applying the results of that clinical research, the government will be strongly biased toward research results that point toward the less expensive of the two treatments that are being compared.

The idea that government-controlled expert panels will be unbiased, of course, is so absurd that nobody can plausibly believe it. Where you go wrong, dear reader, is in believing that their bias can only take them so far; that clinical research, being science, will more or less yield the Truth; that while a biased party might shade things a bit in this direction or that, at the end of the day the answer which is reached will approximate the Answer.

In fact, clinical research is inherently biased, from the moment a research study is conceived. And those who conceive of, plan, conduct, and analyze the clinical study have every advantage. (This, indeed, is the very reason why everyone is so indignant about the studies conducted by medical industry and their minions in the medical academy.) That advantage is now, under law, defaulting to the government panels.

To be sure, many clinical researchers believe in their hearts and souls that bias can be eliminated through the use of randomized clinical trials (RCTs). In such trials, “like” groups of research subjects are divided randomly into two or more groups, and each group receives (for instance) a different therapy, whereupon differences in outcomes among the groups are attributed to the different therapies to which they were randomized. Indeed, the widespread belief that RCTs are the necessary and sufficient means to achieve “clinical truth” has become so deeply ingrained within the medical establishment that when anyone (such as DrRich) says otherwise, he immediately reveal himself as a scientific Neanderthal.

DrRich has previously observed that the widespread belief in RCTs has become like a Cult, whose creed can be reduced to three main tenets:

1) Data derived from randomized clinical trials represents Truth.
2) Data derived from non-randomized trials represents Falsity.
3) If you don’t believe this, you are a heathen.

Objective observers will find it at least a little ironic that an attempt to claim the scientific high ground has so obviously resulted in a new religion, replete with its own dogma.

The sad truth is that the results of RCTs are invariably dependent on the bias built into their design, and even if internally they are statistically legitimate, they can often send us down the wrong path.

Those who design RCTs (the smart ones, at least) know this. Like smart trial attorneys, they know the answer before they ever dare to ask the question. So they tailor their “question” in such a way as to yield the answer they want to get. Indeed, if a lawyer should end up asking a question in court that produces an unexpected answer, he or she is completely incompetent and ought to be sued for legal malpractice. In more cases than one might think, the same is true for those who design RCTs.

So, for instance, if you are a payer and want to limit the use of an expensive therapy, you design your RCT so that enrolled patients likely to respond to the therapy are diluted with a broad population of enrolled patients, many of whom are less likely to respond to the therapy, to assure that the average response of the whole population will be quite small. (In many instances the clinical characteristics of the likely responders and the likely non-responders will be reasonably apparent.)

On the other hand, if you are a company that wants to encourage the use of your expensive new product, you design an RCT that preferentially enrolls the relatively small subset of patients who are very likely to respond favorably, and then trust the marketplace (with a tweak from your DTC advertisements) to “extrapolate” the results to broader categories of individuals.

So RCTs do not eliminate statistical bias, as the dogma suggests. Rather, they simply offer an opportunity to control the statistical bias in your favor. Since most doctors (and most regulators, guideline writers, and reporters) don’t seem to get this, it becomes relatively easy to fool them.

What DrRich is saying, with regard to the government panels that will direct and interpret the CER (panels that will determine who gets what, when and how, and who gets paid for it and who doesn’t), is that even if those CER panels were not overtly biased against high-cost medical care, eliminating bias from their clinical research would be impossible. And given that the CER panels are being created expressly for the purpose of reducing high-cost medical care, the bias will likely become extravagant. But since that extravagant bias will be couched within the results of various RCTs, the Cult of Randomization will be invoked as “proof” that this expensive medical treatment is no better than that cheaper one.

DrRich has illustrated numerous times how the results of RCTs can be twisted and spun by interested parties, whether by private or government interests, to achieve the results one wants. The CER panels will (it seems obvious) become masterful at doing this.

The apparently widespread notion that industry-sponsored research is invariably biased, while government-sponsored research is entirely objective – and that therefore, the only thing we need to assure accurate clinical research is to have it all controlled by the government – is astoundingly naive.

DrRich believes that, since we cannot possibly eliminate bias from clinical research, we are more likely to approach the actual Truth if we: a) encourage clinical research by all parties – the government and private entities – so that, at least, we may be more likely to engender a “balance” of results; and b) insist that all clinical research be conducted with complete transparency, so that not only are the results made available to anyone who wants them, but also a complete accounting of all the other aspects of the research – including the study design, conduct of the study, and the analysis of the data.

Since bias cannot be eliminated from CER even if the federal CER panels wanted to (and they decidedly will not want to), then insisting on complete and total transparency (ideally, even to the point of making the raw data itself accessible), will be our chief defense. DrRich assumes, since covert rationing will undoubtedly be the CER board’s main, though unspoken, agenda, that such transparency will not be forthcoming without a fight.

Transparency will be worth fighting for, however. At least some bias in clinical research is unavoidable, so complete transparency is our best defense against the biased application of the results of clinical research, whether it is conducted by companies or CER panels.

How Cardiologists Will Manage the GOD Panelists

DrRich | September 14th, 2010 - 8:50 am


In quainter times, medical “guidelines” merely meant a set of general principles which doctors ought to keep in mind when deciding on the most appropriate medical care for their patients. But in recent years guidelines have come to represent reasonably firm expectations for medical practitioners. And doctors who fail to closely follow guidelines may not be looked upon favorably any more by insurance companies or Medicare.

Obviously, then, since the guidelines finally determine who gets what, when and how, controlling the guidelines (i.e., making sure the guidelines say what you want them to say) has become important to any interest group within the healthcare system. And nobody understands the critical importance of guidelines better than cardiologists, a group of which DrRich is a proud member.

In a valiant attempt to carve out as much turf for themselves as possible within a healthcare system driven by guidelines, cardiologists, through their powerful professional societies, have been vigorously fighting the Guideline Wars for two decades – well before most other medical specialties even recognized that a war was being fought. This long struggle has lent to the cardiology profession a certain level of experience and sophistication that may help them to preserve some of their hard-won turf, even as we move into a far more dangerous phase of the Guideline Wars, in which less robust specialties risk debilitation, and even extinction.

For, under Obamacare, guidelines are now to become far more than mere guideposts, or principles, or even strong expectations. They are to become handed-down and inviolable rules which will dictate the details of proper patient care, and which doctors must follow to the letter. Following this new species of guidelines as closely as scripture will be necessary for any doctor who wants to be officially tabulated as a “physician of quality,” who desires to be paid the going rates, and who would prefer to avoid fines or imprisonment for fraud (fraud being, of course, the failure to practice medicine according to the guidelines).

Whereas until now the Guideline Wars have been largely fought among various medical specialties competing for turf, from now on the major combatant in these wars will be the federal government. Under Obamacare, the official medical guidelines will no longer be determined by conflicted medical specialty organizations (which will always try to establish guidelines that cause the healthcare system to spend lots of money on their specialists), but instead by government panels, which will have their own obvious conflicts of interest.

Most observers of the healthcare system seem congenitally unable to recognize that a government bent on controlling the behavior of its citizens (in order to create the perfect healthcare system, which, in turn, is a necessary component of a perfect society) will be working under, if anything, more conflicts of interest than any other healthcare entity.  In particular, the government, and by extension its appointed panels, will be desperate to the point of apoplexy to avoid spending any money, at any time, for any medical services, any time they can get away with it. So ultimately, the widespread proposition that the government panels will be entirely free of any particular agendas, or conflicts, or prejudices, as they hand down the rules of medical engagement to physicians, is balderdash.

The abiding conceit of the government panelists, of course, is that they will behave in an entirely objective manner in rendering the guidelines of medical practice, and will simply follow the science wherever it may lead, without any prejudice whatsoever. That is, they will not actually create the guidelines, but will simply “discover” them, through the objective application of clinical science. In other words, under Obamacare, the “true” medical guidelines will be handed down not by flawed men saddled with conflicts of interest, but by the inherent properties of nature. The government panels will simply be interpreting nature, and will do so, unlike those conflicted physicians, without prejudice.

Indeed, DrRich will go so far at to point out that the Obamacare guidelines will come from GOD – Government Operatives Deliberating. Readers who think it is in poor taste to refer to these individuals – who will invent the guidelines which will determine life and death for so many of us – as GOD panelists should be reminded that other, less sensitive individuals have tried to label them “death panelists.” DrRich’s nomenclature is not only more descriptive, but is much kinder.

In any case, this is where cardiologists have a tactical advantage over most medical specialists as we enter the Obamacare phase of the Guideline Wars. For, in their decades-long struggle in those wars, cardiologists have discovered something that more naive and inexperienced medical specialists, as well as academics, and even most government advisers, are only dimly aware of. Namely, that there is no such thing as the objective application of clinical science. Inevitably, interpreting clinical science – which is among the most inexact of the sciences – incorporates inherent bias.

That bias can be applied either subconsciously or consciously, but one way or another it is applied. And the advantage the cardiologists have over other medical specialists is that they understand that, to have a better chance of getting what they want, they need to direct the application of bias in interpreting critical clinical trials, and they must do it aggressively.

At the highest levels, of course, the agents of the government understand the very same thing. This is why they are setting up their own panels to control the guidelines in the first place. And you can be sure they will choose their panelists carefully.

But DrRich (and his cardiologist friends) know that when the government panelists are being sworn in, they will not be told their true mission in stark terms. They will not be told, “Your job is to twist the eminently-twistable clinical data in any way you must in order to reduce spending on healthcare, no matter who is hurt by it.” This charge would be unacceptable to most of the individuals the government would prefer to choose as panelists, namely, proud and accomplished individuals with valued professional reputations to uphold (though, to be sure, with a proven track record of thinking about clinical science with the kind of bias the government appreciates).

Rather, the panelists will be told:

“Panelists! You have perhaps the most critically important job in all of healthcare, namely, reining in the counterproductive, harmful, wasteful activities of the self-serving medical profession, which is married to greed, and beholden to its evil partners in medical industry. Your job is to lead doctors (most of whom would do the right thing if they can be shown the way in a sufficiently forceful manner) out of the wilderness, and bring them to the path of righteousness. For we hold these truths to be self-evident: that good medical care is efficient medical care; indeed, it is parsimonious medical care; and this being the case, the proper interpretation of clinical science will virtually always show us that less is more. It is your job to interpret clinical science in that proper way, to show American physicians how to fulfill their primary moral obligation to the greater health of the collective.”

DrRich has already demonstrated that there are plenty of physician-ethicists in very high positions who completely buy this stuff. It will be no problem for the Feds to find as many of them as they want to populate the GOD panels, and indeed candidates are virtually tripping over each other to audition.

In any case, their government handlers will reassure all the panelists that they simply are to follow the science, while establishing very strong expectations as to where properly-applied science will inevitably lead. This procedure will be aimed at allowing panelists to maintain the soothing and necessary fiction that they are, in fact, functioning as unbiased agents of reason and logic, and are well-deserving of public adoration, and perhaps even of self-respect.

Cardiologists, battle-hardened Guideline Warriors that they are, understand the position in which the new GOD panelists will find themselves, and as a result they understand that the clinical science these panelists will use to fashion medical guidelines must not reach them in anything like a pristine condition. Rather, that clinical science must reach them “pre-spun,” with the “right” interpretations already spelled out for them by respected academic figures, and, to the fullest extent possible, already permeated into the public consciousness. Cardiologists hope that panelists will be relatively reluctant to make guidelines which are starkly opposed to such predisposed interpretations, for fear they will be found grating to professionals outside of government whose opinions they might value.

With such a strategy the cardiologists are perhaps clinging to a thin thread. It is, in fact, not much of a plan. But it beats whatever it is you gastroenterologists are doing.

In his next post DrRich will illustrate cardiologists’ new strategy of “pre-spinning” clinical trial data, in order to make it more difficult for GOD panelists to do them grave harm.

PCPs: We Are The Borg. Prepare To Be Assimilated.

DrRich | September 3rd, 2010 - 10:33 am


In a remarkable article that somehow* was accepted for publication in the Annals of Internal Medicine, the White House offered some friendly advice to American PCPs who may be wondering how Obamacare will affect them. That advice, to summarize, is: “We are the Borg. Prepare to be assimilated.”
* DrRich is forced to wonder whether yet another group of medical editors is auditioning for the death panels.

The article was written by Ezekiel Emanuel from the White House’s Office of Management and Budget, and Nancy-Ann M. De Parle, who is Mr. Obama’s Czar of Healthcare Reform. (A third author was from the McKinsey Group.) After reminding physicians of their moral obligation to the collective, the White House authors rhapsodized about all of the wonderful changes inherent in Obamacare that will help physicians to realize this obligation.

There’s actually no need to read the entire article, assuming you heard any of the 400 speeches President Obama delivered in his unsuccessful attempt to convince the public that his healthcare reforms ought to displace the holy writ as The Good News. The meat of the article, if you’re a physician, appears at the end:

These reforms will unleash forces that favor integration across the continuum of care. Some organizing function will need to be developed to track quality measures, account for and manage shared financial incentives, and oversee care coordination….These coordinating functions, to the extent that they currently exist, traditionally have been managed by hospitals or health plans….As physicians organize themselves into increasing larger groups — patient-centered medical home practices and accountable care organizations — they are, out of necessity, investing in information technology tools that are becoming both cheaper and more capable and investing in the acquisition or development of management skills that could provide these organizing functions efficiently for physicians groups….For physicians, this means a profession that is more rewarding, more productive, and better able to realize its moral ideal.

DrRich translates this message thusly: “Physicians! You have been neglecting your moral obligation to the collective, in favor of your archaic devotion to the individual patient. Under Obamacare you will need to join organizations which are devoted to the collective goals of Obamacare, and which therefore will guarantee the proper moral ideals. You must function not as individual decisionmakers, but as integrated cogs in a vast healthcare continuum, which will stretch from the centralized bastion of gleaming moral authority (from which we pen this message) all the way down to the humble tip of your stethoscope. You will be rewarded for your cooperation, or suffer for your resistance (resistance, of course, being futile).  So rejoice for the health of the collective, and for your own well-being, and prepare to be assimilated.”

Ostensibly this message is for all American physicians, but it was submitted to the Annals of Internal Medicine for a reason. The Annals is the journal of record for doctors who practice internal medicine, and who comprise the largest group of PCPs. The White House in this article is speaking directly to American PCPs.

This is because PCPs pose the greatest short-term threat to Obamacare.

Most medical specialists have already been “assimilated.” Because they require lots of expensive stuff to practice their specialties – things like gamma cameras, operating suites, catheterization laboratories, hordes of highly trained medical technicians, &c. – it is very difficult for most specialists to function as independent operators. If you want medical specialists to follow the rules, all you have to do is make following the rules a requirement for keeping their access to all the technology and the complex infrastructure they need to practice their specialties.

Only PCPs can fairly readily make themselves independent from the collective.  And more and more PCPs are choosing to do so.

The White House does not like this.  The Annals article, DrRich thinks, is the administration’s first official attempt to curtail the PCPs’ fledgling independence movement. The threat is veiled – the article instead appeals to the PCPs purported moral obligation to the collective, and emphasizes the rewards that will follow when PCPs allow themselves to be assimilated into the Borg.

So this first attempt, for the most part, is merely creepy. The next step will not be as benign.

DrRich urges his PCP friends to take heed. If you have any thought of striking out on your own, and starting a direct pay practice – thus reasserting your profession’s real moral obligation, which is to your patients – you had better act now, before it becomes a federal crime to do so.

An Ounce of Prevention Costs A Pound of Cure

DrRich | April 6th, 2010 - 9:37 am


As DrRich has noted many times over the years, “preventive healthcare services” cost the healthcare system far more money than they can ever save, and for this reason, any healthcare system engaged in covert rationing is going to have to find a way to stifle these preventive services.

Now, dear reader, before you go away angry, DrRich understands that some preventive measures are indeed very cost-effective. In fact, DrRich will now engage in a bit of cost-effective preventive healthcare: Don’t smoke. Don’t eat so damned much. And get some exercise.

There. DrRich has just successfully administered pretty much all of the truly cost-effective preventive measures known to modern medicine. (And it’s only cost-effective because the advice was free.)

All the other preventive stuff we do in medicine tends to bend the cost curve in the wrong direction.

Reasons that preventive healthcare services increase the cost of healthcare include: a) The preventive measure itself costs money. b) The preventive measure may not be effective. c) Many “preventive healthcare services” consist of some kind of screening test for “early detection,” and these screening tests almost always produce more false positive results than true positive results – leading to the need for more definitive, more expensive, and often invasive confirmatory tests. d) “Early detection” of any medical condition often detects “occult” disease, that may or may not have become manifest if it had remained undetected. e) Treating the diagnosed – and often occult – medical condition is often very expensive, produces complications, and/or is ineffective. f) Successfully preventing the target medical condition may give patients more time to consume healthcare resources for all their other medical conditions.

Please note that DrRich is not arguing here that preventive services are useless or undesirable. Often they are quite useful and very desirable. Rather, he is arguing that the healthcare system will spend more money by offering these preventive services than if it did not offer them.

This fact ought to prove embarrassing to our leaders, who have spent the last few years assuring us otherwise. Indeed, they have doggedly insisted, not only are preventive healthcare services cost-effective, but also it is precisely because of such preventive services (delivered in the remarkably efficient manner which will be achieved by our new healthcare system) that we will enjoy tremendous cost savings over the next decades.

Like Nancy Pelosi says, it’s all about “prevention, prevention, prevention.”

And having taken this bold and very public stance on prevention, our leaders are going to have to walk very gingerly (now that they have finally been successful in giving us the gift of healthcare reform), as they seek ways of cutting back on those selfsame preventive services.

They know this, of course, and have taken steps to provide themselves with the tools they will need to accomplish this feat. Their chief tool, based on what DrRich can find in the new healthcare law, is our old friend, the United States Preventive Services Task Force (USPSTF).

Readers may remember that it was the USPSTF that released the controversial new “recommendations” on breast cancer screening last fall. Readers will also recall that the USPSTF’s new recommendation, that women under 50 no longer need screening mammograms, proved quite shocking to many women – women who had been urged for over a decade by various cancer societies, by the government, and by their doctors to get regular mammograms beginning at age 40, because the early detection of breast cancer was the best way not to die from breast cancer. Indeed (readers will again recall), the outcry was so great that Secretary Sebelius quickly issued a statement reminding us that the recommendations of the USPSTF were merely that – non-binding recommendations – and that women should continue getting their screening mammograms as they and their doctors thought best.

DrRich wondered at that time whether Secretary Sebelius (who was simultaneously urging all of us to support the healthcare reform bills which were then making their way through the House and Senate) actually knew that both of those bills contained language making the recommendations of the USPSTF legally (and retrospectively) binding.

In any case, DrRich wishes to take this opportunity to remind his readers that the healthcare reform which is now the law of the land indeed makes the USPSTF the arbiter of which preventive services are to be covered by private insurers (Section 2713), by Medicare (Section 4105), and by Medicaid (Section 4106). To be sure, presumably to bail out Ms. Sebelius, new language was added (Section 2713) to say that the recent recommendations on mammography do not apply, at least not for private insurance plans. (Similar language, however, does not appear in the Medicare or Medicaid sections [4105 and 4106], so patients covered by these programs may indeed be subject to the new mammography recommendations .) New mammography recommendations aside, for the rest of the preventive healthcare services that exist in the universe, only those that have achieved a grade of A or B by the USPSTF will be covered.

Now that the USPSTF has been officially converted from a panel that simply makes recommendations which doctors and insurance companies can take or leave alone, into a panel that determines definitively what is covered and what is not – and indeed, into the chief tool by which our leaders will seek ways to withhold expensive preventive services – DrRich would like to very briefly restate his objections to the USPSTF’s recent mammography rulings.

In a word, DrRich’s problem with the USPSTF’s revised mammogram recommendations has nothing whatever to do with whether mammography is really useful or not, but rather, with the methodologies the panel used to make those recommendations. For, if those methodologies are deemed legitimate, unfortunate precedents will have been set. Specifically, by analyzing the USPSTF’s own justifications for making its new mammogram recommendations, it is possible to derive at least four new “rules” under which the panel can operate in the future.

1) The USPSTF now recommends that breast cancer screening no longer be done for women under age 50. But by the panel’s own words, screening mammography in women in the 40 – 49 age group appears as effective at reducing mortality as it is in women 50 and older, and the panel indicates this fact several times within its own document. And as nearly as DrRich can tell, the panel’s only concrete rationale for dropping mammography for women under 50 is that it has found “a new systematic review, which incorporates a new randomized, controlled trial that estimates the ‘number needed to invite for screening to extend one woman’s life’ as 1904 for women aged 40 to 49 years and 1339 for women aged 50 to 59 years.”

This rationale implies the following rule, Rule 1: If you have a preventive measure which is equally effective across a large population of patients, you can withhold that preventive measure from any arbitrary subgroup within that large population, as long as performing the effective measure in that arbitrary subgroup is more costly than it is for some other arbitrary subgroup.

2) In its public justification for withholding mammogram screening for women aged 40 – 49, the USPSTF did not emphasize cost savings, but rather, emphasized the fact that screening in this age group results in more false positive tests than for older age groups, and thus in more unnecessary biopsies, and the potential for more unnecessary emotional trauma. While this is true, the traditional response to such a circumstance would be for doctors to carefully review the pros and cons of screening with each woman, so as to allow the individual to decide whether the possibility of needing an unnecessary biopsy outweighs the possibility of diagnosing breast cancer while it is still curable.

But instead, the panel established Rule 2: Rather than allowing individuals to apply their own values when weighing healthcare decisions which reasonable people could decide either way, it is legitimate for the panel to make those decisions from on high for all patients; and furthermore, it is legitimate for the panel to make different decisions for different and arbitrary subgroups of patients (e.g., one decision for women 40 – 49 years of age, another decision for women over 50).

3) The USPSTF now recommends that women not be taught breast self examination (BSE). In point of fact, since most doctors stopped teaching BSE a long time ago, this recommendation will probably have little actual impact. But the panel came to this recommendation based on clinical trials conducted in backward, 3rd world healthcare systems (Russia and China), where outcomes with breast cancer have little to do with outcomes in the U.S.

Perhaps more to the point, a similar tactic was used in deciding to withhold mammogram screening for women under 50. That is, the “new randomized controlled trial” the panel invoked to justify this decision was conducted in England, where outcomes for the treatment of breast cancer are substantially – and famously – worse than they are in the U.S.

So Rule 3 is established: It is legitimate to take the results of clinical outcomes trials conducted in backward countries with poor healthcare systems, or in less backward countries which nonetheless have demonstrably inferior outcomes, and directly apply those results to coverage decisions affecting American patients who are being treated in the American healthcare system. This is like performing a careful statistical analysis of outcomes from a Pee Wee football league, then telling the New England Patriots to abandon the forward pass, because the percentages just aren’t there.

4) The USPSTF now recommends that women 75 and older not get breast cancer screening, despite the fact that (from the panel’s own words) breast cancer is the leading cause of death in this age group. The panel justifies this recommendation by noting that there are insufficient data from randomized trials in these patients, and further, that “women of this age are at much greater risk for dying of other conditions that would not be affected by breast cancer screening.”

It is, perhaps, convenient that very few randomized clinical trials assessing preventive measures have ever been conducted in elderly populations, and further, that if such trials were conducted, any actual benefit that might accrue to the subset of relatively healthy older people would be diluted by the inclusion of large numbers of less healthy elderly patients. And, while doctors usually have little problem identifying those healthy 75-year-olds who are likely to survive another 10 – 15 years, and in whom detecting early breast cancer would likely be beneficial, the large, long-term, randomized clinical trials “proving” to the satisfaction of the USPSTF that these women deserve screening will, for all practical purposes, never be done.

So, Rule #4: Preventive measures should not be offered to old people, because they’re probably going to die soon anyway.

Those who want to criticize DrRich  because they feel the USPSTF’s actual recommendations on breast cancer screening are appropriate may, of course, do so. But you will be revealing yourself as a dunderhead. For, as DrRich has just made quite plain, he is not necessarily criticizing the substance of the new recommendations, but rather, the dangerous methodologies the panel used to reach those recommendations, and the four new rules those methodologies have established. These precedents are very troublesome indeed – especially now that we’re no longer dealing with the quaint USPSTF of old. The new USPSTF has acquired broad new powers, and is no longer making mere “recommendations,” but rather, definitive coverage decisions which will directly affect all of us.

And this, it appears, will be the primary means by which our leaders will get out of providing us with all those robust preventive healthcare services they always insisted they were dying to implement.

Some Powers of the Immutables

DrRich | April 5th, 2010 - 7:34 pm


As DrRich helpfully pointed out in his last post, our new healthcare law (Section 3403) creates a new and apparently immutable entity called the “Independent Medicare Advisory Board,” whose job is “to reduce the per capita rate of growth in Medicare spending.” This, in fact, is the right goal. For it is the rate of growth in healthcare spending (and not the absolute amount being spent) that threatens us with societal disintegration within the next couple of decades.

But it is mathematically impossible to attribute this explosive growth rate in healthcare spending to waste and inefficiency. Most of that growth must necessarily be caused by healthcare expenditures that are actually producing some benefit (though, to be sure, some of that benefit is marginal). And this means that in order to reduce the rate of growth, we have to ration healthcare (i.e., to withhold at least some beneficial healthcare from at least some of the people who would benefit from it).

We can only conclude that, in order for the new IMAB to do its designated job, it must ration healthcare. But since the same law that creates the IMAB also stipulates that it must not ration care, the IMAB must necessarily perform that unavoidable rationing covertly. This is a very difficult job, as demonstrated by the fact that the private health insurers (even with the wonderful incentive of profits, and with the full support of Congress) have utterly failed to develop a sustainable business model based on the covert rationing of healthcare.

But still, this is the job that our leaders have now assigned to the IMAB. And so, DrRich has attempted to tease out some of the options which remain available to the Immutables as they embark on their difficult but necessary assignment of covertly rationing our healthcare. (As DrRich will shortly explain, the legal nomenclature for the IMAB is actually a bit confusing and misleading. So for clarity’s sake, DrRich will hereafter refer to this Board as the Immutables.)

DrRich has found, so far, at least three powers which our new healthcare law grants to the Immutables, that will give them at least a fighting chance at success.

1. The most fruitful pathway to covert rationing remains open to them.

The new healthcare law specifically does not allow the Immutables “to ration health care, raise revenues or Medicare beneficiary premiums. . ., increase Medicare beneficiary cost-sharing (including deductibles, coinsurance, and copayments), or otherwise restrict benefits or modify eligibility criteria.” While these prohibitions might appear on the surface to greatly limit the options available to the Immutables, in fact all this language does is to formalize their directive to ration covertly instead of openly. Since covert rationing has long been our society’s policy regarding healthcare, these prohibitions actually change nothing.

What is left to the Immutables, of course, is the most time-honored pathway to covert rationing – coercing the healthcare providers to place the needs of the payers ahead of the needs of their patients. DrRich has posted innumerable examples over the years showing how payers do this. He is confident that the Immutables will employ all the methodologies which have been devised to date for coercing providers, and (with the awful power of the sovereign authority behind them) they will invent some really useful new ones.

2. The Immutables have been granted near-dictatorial authority.

On the surface, one might think of the Immutables as a sort of Mr. Rogers of healthcare – a mild-mannered, friendly, always-helpful, but ultimately undemanding agent for good. One might get this impression by reading the first few paragraphs of Section 3403, which paint the new entity as an “advisory” board, whose main task is to develop “proposals” and “advisory reports,” and these “proposals” and “advisory reports” would solely consist of various “recommendations,” that ought to be “considered” for the purpose of cost reduction.

Indeed, one might get the impression that the main difference between the Immutables and this blog is that the former is appointed by the President, and has a travel budget.

Nothing could be further from the truth. Once the Chief Actuary of CMS determines that the projected per capita growth rate for Medicare exceeds the target growth rate, the Immutables are required to submit a “proposal” which will cut costs sufficiently to bring the growth rate back in line. Then, the Secretary of HHS is required to implement that “proposal” in its entirety, unless Congress acts to block implementation. However, Congress is forbidden from taking any action “that would repeal or otherwise change the recommendations of the Board,” unless it replaces those “recommendations” with its own legislation that would cut Medicare spending to the same target level.

For all practical purposes, then, the cost-cutting “recommendations” which the Immutables would “propose” for “consideration” will be implemented nearly automatically, with the full authority of the Federal government.

And, for all practical purposes, the Immutables will become a new agency of the executive branch, with near-dictatorial authority to cut Medicare spending as it sees fit.

3. The Immutables have been granted the authority to limit private health-care expenditures.

Those who paid attention to the process that brought us our new and transformational healthcare system might recall that the Senate bill, which ultimately became law of the land, was never designed to be actually implemented. It was designed solely to assure 60 votes in the Senate, after which the Joint Conference with the House was to meld the House Bill and the Senate Bill into a workable law.

As part of the negotiations to gain those original 60 votes in the Senate, five or six Democrat Senators cobbled together a list of amendments to the original Senate Bill – the so-called Manager’s Amendments. It is in the Manager’s Amendments that one can find such famous niceties as the bribes paid to Nebraska. But the Manager’s Amendments (which, contrary to the expectations of the actual Managers, are now part of our new healthcare law) contained lots of other stuff as well.

One of the more interesting parts of the Manager’s Amendments (Section 10320) is entitled, “Expansion Of The Scope Of, And Additional Improvements To, The Independent Medicare Advisory Board.”

Section 10320 (which can be found way down on page 2210 of the new law) grants the Immutables (beginning in 2015) the authority to limit all healthcare expenditures, and not just expenditures by Medicare or government-run programs.

To emphasize this expanded authority, Section 10320 changes the name of the Immutables from the Independent Medicare Advisory Board to the Independent Payment Advisory Board. It directs the Immutables (and now readers will understand why DrRich has resorted to this more descriptive name), at least every two years, to “submit to Congress and the President recommendations to slow the growth in national health expenditures” for private (non-Federal) healthcare programs. Furthermore, it allows that these “recommendations” may be implemented by the Secretary of HHS or other Federal agencies administratively.

Ostensibly, the justification for this expansion of the Immutables’ authority is that controlling private healthcare expenditures will directly impact Medicare, since the “target” Medicare growth rate which the Immutables are charged with achieving will be determined by overall healthcare expenditures. More practically, if Medicare patients (who are subjected to arbitrary cost-cutting measures) see their younger counterparts enjoying less restricted healthcare, the old farts are likely to become rowdy. But DrRich suspects there was an even stronger reason to give the Immutables this authority over private healthcare expenditures.

DrRich has often speculated that the real fight regarding healthcare reform will come when the government attempts to limit the ability of American citizens to spend their own money on their own healthcare. This limitation is absolutely necessary if we’re to have a single-payer healthcare system, since if you can spend your own money on your own healthcare, that would be at least two payers. (It would also be “unfair.”)

Many of DrRich’s readers think it’s absurd to think we’re headed toward a single-payer system. DrRich hopes these readers are correct. But he also thinks there’s plenty of evidence that some of our leaders are intentionally taking us there. The new healthcare law, at least arguably, is entirely consistent with such an ultimate goal. And if we are ever to have a single-payer system, the government ultimately will need the authority to limit private expenditures.

DrRich does not believe that the Immutables will act immediately to limit the ability of private citizens to spend their own money on their own medical well-being. Such an action would create a great uproar today, and likely for several years to come, at least until those of us who still cling to the quaint notion of individual autonomy are finally worn down, or re-educated, or otherwise made to see the light.

But whenever that time comes, Section 10320 of the new healthcare law appears to give the Immutables all the authority they will need.

(At the same time, those who castigate DrRich for paranoia might consider reading just how far our healthcare system has already come in limiting the prerogatives of individuals.)