Evidence Based Medicine
Freedom’s fundamental principles are choice and the lack of coercion. When you are free you make the choices in your life and you’re responsible for the consequences of your choice. In an authoritarian regime, someone else makes the choice for you and you’re left to obey or be punished. In some cases, you don’t even have the choice to obey – you are forced to comply.
And it is the latter of which this reminds me:
Public health officials are considering promoting routine circumcision for all baby boys born in the United States to reduce the spread of H.I.V., the virus that causes AIDS.
No. Huh uh. No way.
“Public health officials” don’t get to make those decisions if a free country. There they’d be limited to offering the surgery as an option for the reasons stated, but no more. But “routine circumcision” doesn’t mean it will be offered as an option – routine means it will be done as a part of the birth procedure with or without the parent’s permission.
But Dr. Peter Kilmarx, chief of epidemiology for the division of H.I.V./AIDS prevention at the C.D.C., said that any step that could thwart the spread of H.I.V. must be given serious consideration.
“We have a significant H.I.V. epidemic in this country, and we really need to look carefully at any potential intervention that could be another tool in the toolbox we use to address the epidemic,” Dr. Kilmarx said. “What we’ve heard from our consultants is that there would be a benefit for infants from infant circumcision, and that the benefits outweigh the risks.”
Now, let’s take a broader view of what is being said here by Dr. Kimarx in relation to the health care insurance reform now being considered.
Remember, we’re told, almost daily by proponents of this reform that decisions on care will be left to you and your doctor – correct?
So whose advice is Dr. Kilmarx basing his treatment recommendation on? That’s right his “consultants”. Where are you and your doctor in this decision making process?
Left out. Despite all the rhetoric to the contrary, Kilmarx is talking about keeping both you and your doctor completely out of the loop.
What Dr. Kilmarx is saying is the recommendations of the “consultants” outweighs your concerns and puts you out of that decision making cycle. Or, said more succinctly – they don’t care what you or your doctor want, they’re going to direct that “routine circumcisions” be a part of the birth procedure and they invoke an “epidemic” as the reason for this “intervention”.
So, given this is just the CDC, imagine what those government officials charged with providing “evidence-based medicine” for everyone will be putting out as directives that get between you and your doctor. And don’t forget, Obama is a great fan of “evidence-based care” as he noted at one of his pep-rallies townhalls on health care insurance reform.
What you’re seeing from the CDC is only the very tiniest of tips of the iceberg if government is put in charge of health care. Allowing the government to dictate forced circumcision would only set the precedent for what we all fear government run health care would bring. It may not seem to be that important of an issue, but it is.
This isn’t the government’s choice to make or direct. And it never should be.
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While I’m sure the specials last night on the deaths of Farrah Fawcett and Michael Jackson vastly outdrew the ABC’s Obama healthcare special the other night (no I didn’t watch it – I was being disappointed by the Yankees/Braves game), there were some very telling moments apparently. And, being the curious type, I found the transcript and read the whole thing.
Let’s say Mr. Eloquent was less than convincing. But he did shed some light on what he’d like to see the final product look like.
Naturally there were some moments that were instantly reported by the media and other bloggers. For instance when he essentially said that if that he’d use his wealth if necessary to go outside any system that denied his family the healthcare he thought they needed. The obvious point is he concedes that his system will do so – i.e. ration care through denial. Of course that’s one of the big complaints he’s had about private healthcare – rationing through denial.
But there were some other things said which only a careful reading of the transcript reveal. Let’s start with this question:
DR. JOHN CORBOY, NEUROLOGIST & MEDICAL PROFESSOR: Well, I think you still have to provide the appropriate care. And I think we all know that there is a significant amount of care that actually is inappropriate and unnecessary.
And the question then is — for you, Mr. President, is, what can you convince — what can you do to convince the American public that there actually are limits to what we can pay for with our American health care system?
And if there are going to be limits, who is going to design the system and who is going to enforce the rules for a system like that?
This question is loaded with key words and phrases. The first is “appropriate”, as in “appropriate care”. Who gets to decide? If you listen to a glib Obama, he constantly says medical decisions should be left to doctors. But this question isn’t being addressed to that point, is it? If there is an “appropriate care” standard, someone is going to have to define it.
And that is precisely what Corboy asks – “who is going to design the system and who is going to enforce the rules?” In fact, who gets to decide what the rules are?
I think you know the answer, but let’s look at the President’s answer:
OBAMA: Well, you’re asking the right question. And let me say, first of all, this is not an easy problem. If it was easy, it would have been solved a long time ago, because we’ve talking about this for decades, since Harry Truman.
We’ve been talking about how do we provide care that is high-quality, gives people choices, and how can we come up with a uniquely American plan? Because one of the ideological debates that I think has prevented us from making progress is some people say this is socialized medicine, others say we need a completely free market system.
We need to come up with something that is uniquely American. Now what I’ve said is that if we are smart, we should be able to design a system in which people still have choices of doctors and choices of plans that makes sure that the necessary treatment is provided but we don’t have a huge amount of waste in the system. That we are providing adequate coverage for all people, and that we are driving down costs over the long term.
OK, let’s stop for the moment right there. We begin with Obama in stump-speech mode. That’s a time buyer. He’s fumbling for an answer and is filling time. By the third paragraph he’s beginning to formulate an answer. Of course, I had to laugh because a uniquely American solution would be to have government back off and let the market take the ball and run with it. But obviously that’s not his plan. I think what he’s saying here is he hopes for a Euro-socialist plan with an American twist.
Anyway, in the third paragraph we’re again into some key words – this time “necessary” and “adequate”. Again, who will decide what is “necessary” and what form of coverage is “adequate”? Well, trust me, it won’t be you or your doctor, because his priority is what? That’s right – “driving down costs over the long term”. So “necessary” treatment will be considered in the context of “driving down costs”. I’m sure you figure out what that means.
Then there’s the “we should be able to design a system”. He’s not talking about you or the market here. He’s talking about government. He’s a part of the ‘we’ – you’re not.
Last, of course, is the overriding priority – drive costs down. He claims health care is the reason for the current deficit. So the obvious first priority for this so-called reform is to cut costs.
But let’s add 47 million new insured while driving costs down. Make sense to you? And if it does, then you have to admit that lesser cost, if possible, will have to come from some part of the current health care system. He has his ideas, and we’ll cover that in a different post.
Moving on with the answer:
If we don’t drive down costs, then we’re not going to be able to achieve all of those other things. And I think that on the issue that has already been raised by the two doctors, the issue of evidence-based care, I have great confidence that doctors are going to always want to do the right thing for their patients, if they’ve got good information, and if their payment incentives are not such that it actually costs them money to provide the appropriate care.
Here we find a very critical clue to the plan for your health care – the term “evidence-based care”. This is the new way of saying “we’ll decide for you”. Evidence based medicine claims to use the scientific method to determine optimum treatment decisions. The Centre for Evidence Based Medicine says it is “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.”
Said another way, a group somewhere doing research decides that certain diseases or conditions should be treated in certain ways. Those treatments are then applied to individual cases without any caveat for unique situations. The cost savings comes with uniform procedures and uniform care – no deviations. In other words, for the most part, decisions on how to treat individual cases will most likely have to conform to EBM guidelines or be considered outside the system. So what Obama said with that simple term is “we’ll decide how you will be treated, not your doctor”.
Of course critics of EBM are many and claim that it has some utility in outlining suggested treatment for populations as a whole, but has limited utility when taken down to the individual situation since each is unique.
And then there’s the inference that medicine to this point hasn’t been based on science. As Abraham Verghese said:
“Evidence Based Medicine” is a term which makes about as much sense as “Sex-based intercourse”–Were we practicing based on zodiac signs before EBM came along?
That brings us to the bit about “doctors always want to do the right thing for their patients”. Yes, of course. But what he says next hints that “the right thing” may be what the technocrats think is right, not necessarily what the doctors might think is right. He says doctors will do that “if they’ve got good information, and if their payment incentives are not such that it actually costs them money to provide the appropriate care.”
Anyone know right now instances when “appropriate care” costs a doctor “money to provide”? Yup, Medicare and Medicaid. It’s the reason so many opt out of treating Medi patients.
How then does he plan on changing their payment incentives so it doesn’t cost them money? Well to do that you either change the reimbursement rate or you change what is “appropriate”, don’t you? EBM promises the latter.
That brings us to the final part of his answer:
And right now, what we have is a situation, because doctors are paid fee-for-service, and there are all sorts of rules governing how they operate, as a consequence often times it is harder for them, more expensive for them, to do what is appropriate.
And we should change those incentive structures.
Now this is simply a load of road apples.
Litigation is part of the problem. Obama refuses to address that as a basic health care cost problem. It drives up costs and it also induces doctors to use unnecessary tests in a CYA gambit. Want to “change incentives?” Here’s a great place to start.
The second problem is chronic underpayment by the government through Medicare and Medicaid – something Obama and Congress want to again reduce by up to 20%. That causes cost shifting to the private side of things. But insurance companies have gotten smart and now refuse, in many cases, to pay more than the Medis. That is an artificial distortion of the market introduced by government arbitrarily deciding what a medical procedure is worth.
And the rules under which doctors operate are no less stringent under the Medis than under any private insurance plan.
That’s one question from the staged ABC “town hall meeting”. There was an amazing amount of info in that one question and answer. Enough information that you should be absolutely shaking in your boots, because what he said is he plans on doing precisely what he has been telling you he wouldn’t do – design a system which will decide how your doctor will treat you. It is all there, and no one has even bothered to take the close look it deserves.
I’ll parse a few more questions from the interview as I have the time, but suffice it to say, if you look hard enough you can figure out exactly where this guy wants to take us.