President Obama pulled a fast one last week. While the public was entranced by trivial stories on Hollywood celebrities gone mad, or repeated laments about the oil spill, the President appointed Dr. Donald Berwick as head of Administrator of the Centers for Medicare & Medicaid Services (CMS).

His appointment is a triumph for “scientific medicine”, because Berwick has spent his career trying to implement studies showing physicians the most cost effective way to treat our patient.

Presumably I should be pleased, except that I am old enough to know that caring for patients is an art, not a science, and that the cold world of scientific tests, impersonal medicine dispensed at 15 minute office visits, where cost effective treatment is part of our decision making, is one reason our patients prefer to use unproven, but more human, “alternative medicine” approach for their illnesses.

Berwick’s appointment was a “recess appointment”, made necessary, the administration claimed, because those nasty Republicans would block his appointment.

The dirty little secret is that some Republicans would score political points by daring to point out Berwick’s support of medical rationing. But their opposition would be a sham.

The Republicans don’t oppose medical rationing (they only pretend to, so they get votes from the powerful prolife lobby). Their business and profit oriented leaders would agree with “efficient” health care, and with guidelines that would eliminate waste by using the cheapest medicines and treatments, or not giving treatment to those it won’t benefit.

And, ironically, his appointment was cheered on by the AMA and the AAFP, both of whom worked with the Obama administration to implement health care reform against the express wishes of most of their dues paying members.

Now, Dr. Berwick has written many articles in journals, but one should note that he is part of a medical establishment that wants to “modernize” medicine from the idea of a warm and fuzzy doc caring for you and your family into a scientific and logical system.

Although other industries have transformed themselves using tools such as standardization of value-generating processes, performance measurement, and transparent reporting of quality, the application of these tools to health care is controversial, evoking fears of “cookbook medicine,” loss of professional autonomy, a misinformed focus on the wrong care, or a loss of individual attention and the personal touch in care delivery. We believe that public reporting of performance with regard to appropriately designed clinical standards can overcome these concerns.

So now, according to the AAFP, his job will be:

As CMS administrator, Berwick will serve as a key player in overhauling the nation’s health care system by overseeing a variety of major tasks associated with the new health care reform law. Those tasks include expanding Medicaid coverage, writing new rules and regulations and establishing pilot projects to test different models of care and payment policies.

All of which will be implemented on physicians whether they like it or not.

After all, writes Dr. Berwick: It’s scientific.

The benefits of evidence-based medicine, thus defined, have been immense. Patients today can count on a growing proportion of the tests, diagnostic processes, surgical procedures, and other costs and risks in care to have been subjected to proper systematic evaluation. The very definition of “quality” in health care has now come to incorporate the use of scientific evidence in practice; that is what the Institute of Medicine meant in its call for improvement of “effectiveness” as a key aim for improving care.15 Gaps between science and practice remain wide, but we seem increasingly committed to closing them. That is good.

Yet even he admits in this paper that this philosophy essentially allows a small elite who are the gatekeepers for published studies to make the decisions on what care should be given, and what care works.

The problem is this efficiency ethic. The LATimes editorial that backed Berwick writes:

Berwick is just a warm-up to the real battle over reining in Medicaid and Medicare costs. The growth in those programs isn’t sustainable, and lawmakers will soon have to make even tougher choices about how to save the Medicare hospital trust fund from insolvency. In the meantime, we need to maximize the value we get for our healthcare dollars by cutting back on services that are duplicative or ineffectual. That’s Berwick’s cause.

Benign sounding editorial, isn’t it? Unless you go to their LINK at the New England Journal of Medicine.

Big discussion on how to divide the pie. Should we spend a lot of money to pay for big expensive treatment or low cost treatment for all?

Guess what is their answer. And the decision is made with that lovely formula “QALY”…quality of adjusted life years.

The problem: That “quality” part. A Down’s baby given open heart surgery might live 50 more years, but because some bureaucrat decides his “quality” is low, it only measures 20 or 25 QALY’s.

To get the idea of the ruthless nature of this “scientific” approach:

The Quality Adjusted Life Year (QALY) has been created to combine the quantity and quality of life. The basic idea of a QALY is straightforward. It takes one year of perfect health-life expectancy to be worth 1, but regards one year of less than perfect life expectancy as less than 1.

Second problem: They, not you or your family, are the ones who make this formula and decide your treatment. And the dirty little secret is that elites tend to look down on poor quality life.

Watch the news. You will read over and over stories like the one that a certain blood pressure medicine, one that is more expensive but has fewer side effects, causes cancer (it doesn’t: the study was flawed, and notice that only the expensive medicine was chosen to be investigated).

Expect more studies about expensive treatment that dosen’t work (except it does, or maybe it doesn’t work as well, but would be a better answer for your patient). Or you will read stories of “over-treatment” of the dying, leaving out the part where the over-treatment was started because their chance of living was significant.

One hopes that Berwick will be sensitive to the public’s and physician’s concerns about the imposition of medical decisions from above.

But the dirty little secret is that President Obama made this appointment without public scruntiny, not because the Republican elites would block his nomination (they don’t have the votes to do that, and as I noted, many would welcome medical ratioining as a good business decision).

No, the appointment was made because it is grass roots Democrats, who risk losing their reputation for the advocate of the poor, who would lose if a discussion of what is going on was allowed.

Too many “Reagan Democrats” want government health care but not some bureaucrat telling them what to do; and a discussion about “hard choices” will assure us that it is scientific and humane to use “QALY” criteria to decide who gets care.

From Nat Hentoff’s column:

Unlike Obama, Berwick is enthusiastically, openly candid in his support of Britain’s socialistic National Health Service. In a 2008 speech to British physicians, our new health czar said: “I am romantic about National Health Service. I love it (because it is) ‘generous, hopeful, confident, joyous and just.'”
That “just” National Health Care Service decides which care can be too costly for the government to pay. Its real-time decider of life-or-death outcomes is the National Institute for Health and Clinical Excellence (NICE)

So expect all the experts to laud Berwick’s appointment. Expect a constant drum of news stories that are published to change our mind: repeat after me: Rationing is good for you, grandmom would die anyhow, don’t use an expensive pill if a cheap one that makes you impotent works just as well…and, alas for Progressives, the dirty little secret is except for Nat Hentoff, they will continue to close their eyes and toe the line…

Which leaves an opening for that bimbo from Wailla to write editorials on Facebook. Without naysayers in the Progressive community, only Sarah will to be the one who will keep this vitally important question about our health care alive.

“Scientific” Death panels anyone?


Nancy Reyes is a retired physician living in rural Philippines. She blogs at Finestkind Clinic and Fishmarket.

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