Saturday, November 28, 2009

Health Refrom and Loss of Individual Liberties; The Road to Clinical Serfdom

There is no such thing as a little freedom. Either you are all free, or you are not free.

Walter Cronkite

If physicians continue to allow non-physicians and businesses such as hospitals and insurance companies to control them, they will lose their patientsand will be nothing more than over-eduated techniciana.

Donald Copeland, MD

This blog is about loss of individual liberties and the road to clinical serfdom under the best of intentions. In The Road to Serfdom, conservative economist and Nobel Prize winner Friedrich Hayek argued you cannot control or comprehend market transactions between individuals from the top-down through centralized planning or restrictive government rules and regulations.

Hayek's thesis was that one centrally directed intervention inevitably leads to another. The unintended consequences of each market intervention are economic distortions, which generate further interventions to correct them. Interventionist health care mindsets lead us down the road of individual and clinical serfdom subservient to government.

Centralized planning always fails because it lacks the flexibility, efficiencies,innovations, and freedoms of the marketplace. You simply cannot control marketplace transactions through central command and control rules and regulations.

The current reform bills portend to put the federal government in charge of individuals’ insurance choices and data privacy. This is all done, of course, in the name of covering the uninsured. It is also being done without the consent of the governed –only 35% to 40% of whom approve of what Obamacare proposes.

Buried, for example, in the Senate’s 2,074 page health bill are multiple provisions that undermine the patient’s health freedoms and privacy. The bill contains sections that mandate insurance for individuals, force them into those plans dictated by government, reveal financial data of patients to third parties, use personal data without consent of individuals, and requiring individuals to be seen by only those doctors using electronic medical records.

Not only are these government invasions into personal freedoms and privacy being done in the name of covering the uninsured but also in the names of reducing waste and overuse and, of course, in improving quality, safety, efficiency.

An organization called the National Priorities Partnership, convened by the National Quality Forum, proposes to help President Obama achieve his goals within 3 to 5 years by reforming payment, introducing a national interoperative medical records system, accrediting and certifying providers, measuring performance, implementing comparative effectiveness measures, and publicly reporting quality outcomes.

To reduce waste and overuse, the National Priorities Partnership recommends dtastically curtailing,

1. inappropriate medication use, such as antibiotics or multiple drugs

2. Unnecessary laboratory tests, such as panels of tests or special tests for Lyme disease

3. Unwarranted Cesarian sections

4. Unwarranted CT and MRI scans, bone or joint x-ray, endoscopies

5. End of life nonpalliative services

6. Unwarrated procedures – spine surgeries, knee-hip reppalcments, coronary artery bypasses, hysterectory, prostatectomies

7. Unnecessary consultations

8. Preventable ER visits and hospitlaization

9. Potential harmful preventive services, BRCA mutations to screen for breat and ovarian cancer, coronary artery screening, carotid artery screening, paper smears over 65, PSA tests over 75

As I read this list, I found it impractical, unenforcible, invasive, and restrictive of individual freedomes. To begin with, many of those who compose these lists have never practiced medicine and seem unaware of patient pressures and expectations, Two, patients rarely if ever complain of overtreatment. Three, the list assumes doctors are either self-serving or unaware of the consdquences of their actions, Four, patients have come to expect many of these tests to be done. Five, many of these tests, e.g, laboratory lipid panels, SMA panels, CT and MRI scans yield valuable diagnostic and treatment information. Six, who is to judge retrospectively if tests or procedures done prospectively at the point of care are inappropriate, unnecessary, unwarranted, harmful, or lead to preventable events, such as ER visits or hospitalizations.

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