Wednesday, November 26, 2014

Hsieh Forbes Column: How Mandatory Calorie Labeling Hurts Consumers

My pre-Thanksgiving Forbes column is up, "How Mandatory Calorie Labeling Hurts Consumers".

I discuss the strict new FDA rules mandating calorie counts on all manner of foods sold in restaurants, stores, etc.

These new rules will be unprecedented in scope, as the Washington Post describes:
Chain restaurants, vending machines, grocery stores, coffee shops and pizza joints will soon have to display detailed calorie information on their menus under long-awaited rules to be issued Tuesday by the Food and Drug Administration. The calorie-posting requirements extend to an array of foods that Americans consume in their daily lives: popcorn at the movie theater, muffins at a bakery, a deli sandwich, a milkshake at an ice cream shop, a drive-through cheeseburger, a hot dog at Costco or Target.
In particular, I discuss three problems with the new regulations:
1) It’s doubtful they will significantly change consumer behavior.
2) They create a significant economic burden on grocers.
3) They tilt the playing field away from fresher foods towards pre-packaged foods.
Given the federal government's poor track record in dispensing nutritional advice (e.g., promoting carbohydrates and demonizing fat), this merely reinforces a bad mindset towards food.

For more details, see the full text of "How Mandatory Calorie Labeling Hurts Consumers".

If the federal government wants a War On Bacon, I know what side I'm on.  And it's not the FDA's.

Tuesday, November 25, 2014

NYT: How Medical Care Is Being Corrupted

I was pleasantly surprised to see this OpEd in the 11/18/2014 New York Times by Hartzband and Groopman, "How Medical Care Is Being Corrupted".

In particular, they describe perverse incentives being imposed upon physicians to practice "cookbook medicine", often at the expense of actual patient care.

An excerpt:
Contracts for medical care that incorporate “pay for performance” direct physicians to meet strict metrics for testing and treatment. These metrics are population-based and generic, and do not take into account the individual characteristics and preferences of the patient or differing expert opinions on optimal practice.

For example, doctors are rewarded for keeping their patients’ cholesterol and blood pressure below certain target levels. For some patients, this is good medicine, but for others the benefits may not outweigh the risks. Treatment with drugs such as statins can cause significant side effects, including muscle pain and increased risk of diabetes. Blood-pressure therapy to meet an imposed target may lead to increased falls and fractures in older patients...

When a patient asks “Is this treatment right for me?” the doctor faces a potential moral dilemma. How should he answer if the response is to his personal detriment? Some health policy experts suggest that there is no moral dilemma. They argue that it is obsolete for the doctor to approach each patient strictly as an individual; medical decisions should be made on the basis of what is best for the population as a whole.
We fear this approach can dangerously lead to “moral licensing” — the physician is able to rationalize forcing or withholding treatment, regardless of clinical judgment or patient preference, as acceptable for the good of the population.
As always, a key principle is, "follow the money".  When the government (or insurers acting as proxies for the government) control the medical pursestrings, they'll also control medical care.  Which may or may not be the care that's right for you as a patient.

Tuesday, November 18, 2014

Quality Reporting Problems

Meeting "quality metrics" is not the same as providing actual quality medical care. From Dr. Arvid Cavale at Rebel MD: "The Physician Quality Reporting game hurts patients, physicians alike".

One money quote from Anders Gilberg of Medical Group Management Association (MGMA):
Medicare has lost focus with its physician quality reporting programs. Instead of providing timely, meaningful, and actionable information to help physicians treat patients, this has become a massive bureaucratic reporting exercise. Each program has its own set of arcane and duplicative rules which force physician practices to divert resources away from patient care .
In many ways, the various quality metrics are like the push for aggressive standardized testing in public schools.  The standardized tests may not reliably capture whether or not a school provides actual good education. And school districts can be tempted to "teach for the test" at the expense of doing what's best for their students.

Dr. Cavale's bottom line:
Medicine is a highly personal and individual profession, with incredible variation across specialities, regions and populations in our diverse country. All centrally planned and dictated methods, do not and cannot, provide evidence of quality of care. It is obvious to any observer that these attempts are simply methods to collect data, gain control over physicians and provide rationale for payment reductions...

Monday, November 17, 2014

Should Doctors Become Proxy Data Collectors For the Government?

The Institute of Medicine (a branch of the National Academy of Sciences) is recommending that doctors use electronic medical records "to capture patients' census tract information (to estimate their median income and for geo-coded mapping), as well as information about their financial resource strain and levels of physical activity and stress."

Furthermore, the IOM is recommending to the federal government that regulators and Medicare link such collection to financial incentives to physicians -- essentially turning them into proxy data collectors for the government:
The widespread capture of data in these eight categories, or “domains,” could be achieved by adding them to the requirements of the federal government's EHR incentive payment program, the IOM committee recommended.

The recommendations will be submitted to the CMS and the Office of the National Coordinator for Health Information Technology at HHS for their consideration as they develop requirements for Stage 3 of the EHR incentive program, according to Dr. William Stead, co-chairman of the 13-member IOM subcommittee that released the report. Stead is a professor of medicine and biomedical informatics at Vanderbilt University.

The CMS writes the rules on what providers must do to become “meaningful users” of EHRs, qualify for incentive payments and avoid Medicare penalties under the program created by the American Recovery and Reinvestment Act of 2009. The ONC sets the EHR testing and certification requirements vendors must meet so providers using their systems can meet their meaningful-use requirements.
Additional data that might be collected:
The IOM panel also recommended that EHRs and their users gather information about patients' educational status; whether they are experiencing depression; their social connections and sense of social isolation; and whether or not they're subjected to violence by a partner in an intimate relationship.
It's still unclear when and how such data might be released from patient medical records to which government agencies.

(Link via Dr. Kathleen Brown.)

Thursday, November 13, 2014

AZ Approves "Right to Try"

I just learned of this bit of good election news, in the Washington Post (11/5/2014):"Voters in Arizona just overwhelmingly backed a 'Dallas Buyers Club' law":
Arizona voters on Tuesday became the latest state to approve a law providing terminally ill patients with greater access to unproven medical treatments, following in the footsteps of four states enacting similar measures this year.

Arizona's new law marks the first time a so-called "Right to Try" measure was approved by ballot initiative — and did so convincingly — after Colorado, Louisiana, Missouri and Michigan all passed laws in the past six months.
USA Today supported similar laws in its 8/17/2014 piece, "FDA vs. right to try: Our view".

For those who want to read an opposing view, see "USA TODAY flubs it big time over right-to-try laws".

Wednesday, November 12, 2014

WaPo On Gruber

Washington Post: "Obamacare consultant under fire for 'stupidity of the American voter' comment".

This issue has been making the rounds on social media, but finally hit the mainstream media yesterday.

The relevant quotes from ObamaCare advisor Jonathan Gruber include:
This bill was written in a tortured way to make sure CBO did not score the mandate as taxes... Lack of transparency is a huge political advantage. And basically, call it the 'stupidity of the American voter' or whatever, but basically that was really, really critical to getting the thing to pass...  In terms of risk-rated subsidies, if you had a law which explicitly said that healthy people pay in and sick people get money, it would not have passed...  You can't do it politically, you just literally cannot do it. It's not only transparent financing but also transparent spending.
Gruber subsequently apologized on MSNBC, saying that he "spoke inappropriately".

To me, it sounds an awful lot like, "I wish I hadn't said those things now that everyone knows I said them."

Tuesday, November 11, 2014

Armstrong on Direct Primary Care

Dr. Richard Armstrong has published a nice piece, "How Direct Primary Care Is Serving as a Health Care Solution".

An excerpt:
Combined with other straightforward alternatives to the Affordable Care Act, such as Health Savings Accounts and High-Deductible Health Insurance plans, Direct Primary Care practices could fill a glaring hole in America’s health care system by allowing patients direct access to their personal physicians for a fee comparable to what they pay for their cell phones each month.

But one potential barrier to the growth of Direct Primary Care is the question of whether these practices can be regulated as “insurers.” Direct Primary Care providers have been concerned they could be labeled by states as “risk-bearing entities” when they provide health care in exchange for a monthly fee, and thus be forced to be licensed and regulated as insurers...
Fortunately, some states (like Michigan) appear poised to recognize that these practices are not "insurance companies".  Let's hope other states (and the federal government) follow suit.

For more details on one promising alternative to ObamaCare, see the Docs4PatientCare Foundation "Physician's Prescription for Health Care Reform".

Monday, November 10, 2014

Medical IT Failures

A couple of quick links on the electronic medical records issues:

"Doctors, hospitals rethinking electronic medical records mandated by 2009 law" (10/10/2014).
The complaints focus on poorer quality care for patients and fewer medical reports while immense new financial burdens are imposed on medical providers. In addition, the new digitized system leaves millions of people vulnerable to hacker attacks.

Many of the responding physicians said they spend too much time looking at computer screens instead of the patients they are examining... [Dr. Kevin] Pho cited a study published earlier this year by the American Journal of Emergency Medicine that found doctors in community hospitals average spending 44 percent of their time in front of a computer and only 28 percent in direct patient care. 
"Why is medical IT so bad?" (11/1/2014)

Critical quote: "EMRs often hinder, not assist, the giving of medical care."

(First link via Dr. Matthew Bowdish.)