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29
July
2013

Comments on the Affordable Care Act

The comments below were written by my brother Mark, who is a physician in Bar Harbor, Maine

Comments on the Affordable Care Act 
By: Mark A. Kandutsch, M.D.

The American Association of Orthopedic Medicine is not a typical conservative bunch; as I write this, I am returning to Maine from their annual meeting. The conference hall had a high ratio of (mostly graying) pony-tails and Birkenstocks vs. suits and ties... So why the cheers when one of the speakers announced a lawsuit against the FDA and President Obama's administration? After all, the President's health care reform program is often hailed as a triumph of progressive principles. I would like to explore some of the contradictions and sources of discomfort that I think led this free-thinking liberal audience to object to some concepts that are central to the President's version of health care reform.

The Affordable Care Act basically has two aims: accessibility and economy - equally important goals. I very much appreciate that the law will make health insurance available to many people who are not insured now, and will eliminate various unfair practices that plague self employed people and those who have 'pre-existing conditions'. However, some other components of the law are more objectionable, at least to me. Basically, the strategy for attaining lower cost and improved quality of care relies on a further industrialization of medicine. By "industrialization", I mean the application of business management theories to medical practice, so that health, or at least health care becomes a sort of "commodity". We are assured that, much in the same way that we have consented to certain improvements in education, that we will fix problems in the health care system by imitating the processes of big business. Manufacturers and banks are held up as our role models, and decision-making power is transferred ever further into the hands of corporations. Some of those who enthuse about these ideas like to explain that their program is one of "transformation," and shut down anyone who questions their theories as a Luddite, a dinosaur, or a throwback to "cottage industry medicine".

But wait! The Transformation of Medicine- its rebirth in the image of the big corporation, with an increased emphasis on top-down management -has been underway for decades.....and the results are no more spectacular for us than they are in the case of education under "No Child Left Behind" (which I think of in some ways as analogous "transformation".) We have, after 30 years of Managed Care, a system in which we spend a preposterous amount of money on medical care, yet achieve mediocre value at best; and we are facing, if you believe the scientific /epidemiological forecasts, a generation whose health will be worse than ours is, especially if you believe (as I do) the prediction that more than one third of Americans will have type II diabetes in less than a generation. The track record for public endeavors and services being forced into the corporate model is not one that inspires confidence in me, and I can't really understand its appeal for so many others. So I am skeptical when I hear that the solution to our national health crisis is MORE managed care, more top-down mandates, and more medical decisions being made by people other than the physician and patient. Fundamentally, despite the fact that we are promised by health care futurists that "reform" will empower primary care providers, we are asked to place our faith in the wisdom and the protocols that government and insurance companies present to us in the form of "best practices" and "standardized care" for many health conditions. We also, by endorsing the validity of the "Transformation", submit ourselves (and consent to) those same corporations and their proxies for evaluation and approval of our professional judgment and skills.

The goal, it seems to me, is more about consistency and predictability (which improve actuarial accuracy and thus profits for an insurance company) than about what a typical patient would consider to represent "quality". It is certainly NOT about innovation or individualized treatments, despite its advocates' touting of the notions of "personalized medicine", and "patient-centered care". There is less room for alternative modes of therapy, or for creative or even individualized thinking by doctors under the industrialized medicine approach. We are expected (and sometimes required) to basically follow plans developed by some anonymous industry group, mostly involving the use of products that are provided by Big Pharma.... and this is done under the trappings (but as I will explain, not the substance) of science. No wonder physicians in the AAOM are mostly unimpressed!

This brings me to problem of "evidence - based medicine". As with many other politically charged terms, (think of "best practices" and "standards of care") this term was presumably selected because it sounds so good. Who could question Evidence Based Medicine, after all? Would a skeptic, by definition have to endorse some form of "Evidence-Ignoring Medicine"?

No.

First, I need to say that I am a person who deeply appreciates and believes in science as a way of thinking and central motif in the advancement of the human understanding of nature. That's why I object to the way "evidence-based medicine" is being used by industry and certain arms of the government to manipulate healthcare providers and patients in ways that actually stymie scientific progress. To understand why I would make this claim, let's start by examining the power structures involved. Who, for instance, gets to decide what constitutes "evidence," and even more importantly, what are the questions to which the evidence is applied? It is, of course, corporations and to a lesser extent the CMS (government health care payer). And there is a great deal of bias in both. As an illustration, I want to explain that, at least in many cases, "evidence" is ranked in terms of validity based on various categories of study - methods on which it is based. The most valid studies are "randomized, placebo-controlled, double-blinded"... as indeed they may very well be. But to consider evidence to be suspect if it is NOT derived from one of these experimental treatment trials is itself biased. For example, the double-blinded placebo trial method itself is extremely difficult or impossible to apply to any treatment other than a drug, and therefore if it is considered the only true gold standard for evidence, it will (and does) bias the standard of care in favor of drugs and against other treatments (including dietary, injection-based, and physical medicine approaches. Second, such trials are extremely expensive, and since more and more medical research is funded by industry instead of by taxpayer's dollars (another mistake in my opinion), the power to label something as "evidence based" has become concentrated in the hands of corporations. One has only to look at the priorities seen in "best practice" therapies: mostly medications, applied very broadly to large groups of patients. Sometimes, too, the inferences that "expert groups" and medical authorities make on the basis of "evidence" reveal a twisting of logic which I have a hard time with. As a personal anecdote, I used to subscribe the American Academy of Family Practice's continuing education monograph series, but canceled my subscription after reading their issue on Evidence Based Medicine an few years ago. In this monograph, the authors recommended against giving patients advice about diet or exercise, since there was no conclusive evidence that doing so improved health outcomes! The bias I alluded to above, which exalts the placebo- controlled double-blinded study as the gold standard, also hides another scientific misunderstanding: one which in fact permeates and in my opinion tends to poison the water in this country when it comes to science. This is the bias in favor of experiment as opposed to observation as the basis for scientific knowledge. For the most part, experimental science (which would include the placebo-controlled trials) is thought of as being intrinsically better than other science. I think that both experiment and observation are valid, and would cite some of the greatest scientific advances in history, from da Vinci through Darwin and Einstein, none of whom were experimentalists; rather they were thoughtful, creative people who knew how to observe and infer truth from Nature.

The individual physician, or nurse, physical therapist, or medical assistant can contribute to science, at the "cottage industry" level, by thinking about each person's care and each person's symptoms with an open mind... something that might fly in the face of a protocol-driven standard care taken from industry... and will by so doing achieve a level of quality that means more, at least to me, than a computer-file full of "metrics". I hope it will always mean more to my patients as well. Will it save money? I have no proof it would, but the Industrialized Medicine approach has a terrible track record so far as well, so who knows. I tend to think that honest clinicians only ordering tests and treatments that are needed (as opposed to slavishly following protocols) might indeed be efficient. Big business and the government do not have a monopoly on concern for communities and their overall health.

We are practicing medicine in a wonderful time right now: the Nation is asking for a new vision for medical care, and although I think the Powers That Be are asking the wrong people (if you consider corporations to be people, and I guess the Supreme Court says we are supposed to do that), we still have some freedom to create Medical Homes that really are patient - centered, (to use the terminology,) rather than industrially standardized. I consider this one of the key tasks for me at this stage of my career. And while this Medical Home will not be exactly a "cottage," it is likely to look more like a home than it wills a factory.

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