Healthcare policy Archives - Page 3 of 6

Practicing medicine for the common good

Michel AccadMay 26, 2016October 28, 2017Ethics, Healthcare economics, Healthcare policy4 Comments

In a recent New England of Medicine article titled “Considering the Common Good—The View from Seven Miles Up,” Dr. Martin Shapiro tells a story that serves as a parable for a more general point: Instead of only considering the best interests of individual patients, American physicians should adopt “a more communitarian approach to decision making” and consider “the implications of individual clinical decisions for other patients and society as a whole.”

The parable is as follows: two sick patients are aboard an airplane, each with his own physician. The first one is terminally ill and on his way home; the second one has a grave illness but stands a small chance of surviving. A decision to land midway must be made in flight, and it pits the interests of the one against those of the other.Continue reading “Practicing medicine for the common good”

Against surgical excellence

Michel AccadMay 19, 2016December 13, 2016Healthcare policy, Medical sciencemedical decision-making2 Comments

A Vox.com piece about decision-making caught my attention this morning.

The story was compelling. A 12-year-old boy had intractable seizures from a leaking vascular malformation in the brain. A first neurosurgeon would not operate and recommended radiation therapy instead. The patient’s mother sought another opinion from a Mayo Clinic neurosurgeon who was adamant that an operation should be undertaken. The second surgeon surgeon was undeniably right. The patient is now a bright, fully-functional researcher at the University of California San Francisco.

So far, so good? Not so, according to Vox. That there should be a smart mom making a smart decision, and a smart doctor carrying out a successful surgery is apparently a problem.

Why? Because the more cautious surgeon had a different opinion and, had the mom compliantly accepted his recommendation, the child could have been worse off. Variability in judgment, as always, is the enemy.Continue reading “Against surgical excellence”

A free market repudiation of evidence-based medicine

Michel AccadMay 13, 2016December 13, 2016Healthcare economics, Healthcare policy, Medical scienceevidence-based medicine6 Comments

In a recent article entitled “A Hayekian Defense of Evidence-Based Medicine” Andrew Foy makes a thoughtful attempt to rebut my article on “The Devolution of Evidence-Based Medicine.” I am grateful for his interest in my work and for the the kind compliment that he extended in his article. Having also become familiar with his fine writing, I return it with all sincerity. I am also grateful to the THCB staff for allowing me to respond to Andrew’s article.

Andrew views EBM as a positive development away from the era of anecdotal, and often misleading medical practices: “Arguing for a return to small data and physician judgment based on personal experience is, in my opinion, the worst thing we could be promoting.” Andrew’s main concern is that my views may amount to “throwing the baby with the bath water.”

On those counts, I must plead guilty as charged.Continue reading “A free market repudiation of evidence-based medicine”

The war on the NEJM

Michel AccadApril 30, 2016December 13, 2016Healthcare policy, Medical scienceconflict of interest1 Comment

The war against the New England Journal of Medicine has gained visibility after Charles Ornstein traced its developments in the pages of the Boston Globe. The story was amplified in a number of trade publications, and was even picked up by a NPR-affiliated show.

This has emboldened the attackers to open fire on Twitter with calls for “transparency,” “open science,” and a “unified research community.” Their ideological alliance is with the BMJ.

A users guide to key differences between @bmj_latest and @NEJM pic.twitter.com/vXZElda4wD

— Vinay Prasad (@VinayPrasad82) April 21, 2016

Those who refuse to partake in the cause of transparency live in a world of “silos,” “conflicts of interest,” and “industry ties.”

Bottom line: lots of trialists don’t want to share their data. Not really a surprise. But a shame IMHO. https://t.co/9PcScwpLur #openscience

— Harlan Krumholz (@hmkyale) April 29, 2016

The NEJM‘s lukewarm attitude towards the movement is “an oppression,” says Eric Topol, as quoted by Ornstein. Did he intend to use a term with Marxist connotation? The loose coalition of scientists, healthcare journalists, and muckrakers ready to overthrow the established order might as well be known as the Data Liberation Front!Continue reading “The war on the NEJM”

Flexner versus Osler

Michel AccadApril 26, 2016December 13, 2016Healthcare policy, Medical science, Philosophymedical education5 Comments

In the introduction to a talk I gave at the Mises Institute this year, I noted how, in the early part of the twentieth century, a convergence of interests between social progressivists and ideological empiricists led to the publication of the Flexner report and the subsequent enactment of licensing laws.

That historical context is further treated in an outstanding article by Alfred Tauber, who was professor of medicine and philosophy at Boston University School of Medicine.

In “The two faces of medical education: Flexner and Osler revisited,” Tauber contrasts the radically different views these two men held about the ethos of medicine and the proper approach to medical education. It is ironic that the victorious position would be the one pushed by Flexner who, as Murray Rothbard put it, was “an unemployed former owner of a prep school in Kentucky…sporting neither a medical degree nor any other advanced degree.”Continue reading “Flexner versus Osler”

Good news about quality measures?

Michel AccadFebruary 26, 2016December 13, 2016Healthcare policy, Philosophy7 Comments

A few days ago, the medical community received unexpected good news from the government about a “simplification of quality measures:”

Impactful news today: Physicians, CMS and major commercial plans, announce simplification of quality measures. “Huge step forward” #aafp

— Andy Slavitt (@ASlavitt) February 16, 2016

Strictly speaking, and contrary to what Mr. Slavitt’s tweet would lead us to believe, the agreement to the new rules was primarily between commercial insurers and CMS, the Center for Medicare and Medicaid Services. Physicians were not actually party to the deal.

Nevertheless, doctors were expected to greet the news with cheers.Continue reading “Good news about quality measures?”

The Swiss healthcare system

Marc FouradoulasFebruary 19, 2016September 10, 2021Healthcare economics, Healthcare policy10 Comments

[This week’s post is by Dr. Marc Fouradoulas who is a board-certified internist with a subspecialty in psychosomatic medicine. Marc’s ten years of clinical experience include psychiatry and primary care, and he currently works at the University Clinic in Bern, Switzerland. For the past 3 years, Marc has been studying towards a Master’s degree of advanced studies in managed healthcare and health economics at the Winterthur Institute of Health Economics, School of Management and Law, in Zurich, Switzerland. You can send him email.]

An alternative take on the Swiss health care system

In a recent New England Journal of Medicine editorial, Nikola Biller-Adorno, a German ethicist now based in Switzerland, and Thomas Zeltner, a physician and former Secretary Director of the Swiss National Health Authority, painted a rosy picture of the Swiss health care system, which they qualified as a potential role model for the US.

Given the author’s backgrounds and positions, their viewpoint may not be the most objective. Here, I wish to give readers a more realistic glimpse into this highly complex system from the perspective of a practicing physician.Continue reading “The Swiss healthcare system”

Maintenance of board certification

Michel AccadFebruary 5, 2016September 10, 2021Healthcare policy, Medical practicemaintenance of certification7 Comments

[This article first appeared in the November/December issue of San Francisco Medicine, the magazine of the San Francisco Medical Society. That issue was dedicated to the theme of ‘Thriving in Medicine.’ For other blog posts on the topic of MOC, see here.]

Up until recently, obtaining and maintaining a specialty board certificate seemed essential for a physician intent on having a thriving medical career. Doctors and the public alike widely viewed board certification as a proof of proficiency that distinguished those with advanced training and expertise.

To maintain board-certified status, certificate holders were quite willing to be subjected to a decennial examination, and some doctors even looked forward to preparing for the test and to an opportunity to systematically review their field of expertise.

In a few short years, however, any positive sentiment regarding maintenance of certification (MOC) exercises seems to have all but evaporated.Continue reading “Maintenance of board certification”

How doctors became subcontractors

Michel AccadOctober 27, 2015December 13, 2016Healthcare economics, Healthcare policy, Medical practicedoctor-patient relationship2 Comments

During my recent podcast interview with Jeff Deist, president of the Ludwig von Mises Institute, I remarked that third-party payers are not, in fact, intermediaries between doctors and patients. In reality, it is the physician who has become a “middleman” in the healthcare transaction or, as I argued, a subcontractor to the insurer.

Important as it is, this reality is not well recognized—not even by physicians—because when doctors took on this “role” in the late 1980s, the process by which healthcare business was conducted did not seem to change in any visible way.Continue reading “How doctors became subcontractors”

Neither expert nor businessman: the physician as friend.

Michel AccadOctober 15, 2015December 13, 2016Ethics, Healthcare policy, Medical practice, Philosophydoctor-patient relationship, friendship, outcomes2 Comments

In a recent Harvard Business Review article, authors Erin Sullivan and Andy Ellner take a stand against the “outcomes theory of value,” advanced by such economists as Michael Porter and Robert Kaplan who believe that in order to “properly manage value, both outcomes and cost must be measured at the patient level.”

In contrast, Sullivan and Ellner point out that medical care is first of all a matter of relationships:

With over 50% of primary care providers believing that efforts to measure quality-related outcomes actually make quality worse, it seems there may be something missing from the equation. Relationships may be the key…Kurt Stange, an expert in family medicine and health systems, calls relationships “the antidote to an increasingly fragmented and depersonalized health care system.”

In their article, Sullivan and Ellner describe three success stories of practice models where an emphasis on relationships led to better care.

But in describing these successes, do the authors undermine their own argument? For in order to identify the quality of the care provided, they point to improvements in patient satisfaction surveys in one case, decreased rates of readmission in another, and fewer ER visits and hospitalizations in the third. In other words…outcomes!Continue reading “Neither expert nor businessman: the physician as friend.”