The Right Prescription

Obamacare’s Medical Mercenaries

In "Choosing Wisely," they're replacing the Hippocratic Oath with the ethos of The Hunger Games.

By 4.13.12

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Those who fear Obamacare will be eliminated by an unelected Supreme Court can put down their Xanax: the un-elected American Board of Internal Medicine Foundation (ABIMF) and its un-elected proxies are working hard to get doctors to implement the health law by encouraging them not to diagnose their patients too often. You read that right.

The foundation's "Choosing Wisely" campaign is framed as a voluntary program to encourage doctors to cut down on "unnecessary medical tests."

In its "lists" the campaign offers 45 tests to avoid from 9 different medical groups. The selection process is portrayed as the product of deep thinking of leading experts in keeping with the medical edict of first do no harm. Each recommendation begins with the words -- much like the Ten Commandments -- "do not." But the definitive tone of denial repudiates the Hippocratic Oath and replaces it with spirit of The Hunger Games.

Indeed, Choosing Wisely is designed to sustain the rationale and ideology that shaped Obamacare. Ruling out any test prior to even seeing a patient is a political edict, not a scientific decision. As one of medicine's early innovators, William Osler, noted: "Variability is the law of life, and as no two faces are the same, so no two bodies are alike, and no two individuals react alike and behave alike under the abnormal conditions which we know as disease. Clinical judgment begins with uncertainty about the underlying causes of symptoms and ruling out conditions requiring even more tests and ineffective treatment."

Indeed, the "lists" are not the product of evidence-based review of practice and they come with a disclaimer inconsistent with the absolute certainty of their rightness that these statements are not medical claims. That's a caveat more commonly associated with weight loss informercials than with a physician's advice. But Choosing Wisely is not about patients exactly. It is part of the ABIMF and the American College of Physicians (ACP) charter designed to help make doctors "better stewards" in the "just and cost effective distribution of finite [medical] resources." If this rhetoric rings a bell it's because you have heard it before from environmentalists who justify government killing off oil production while spending billions on a failed solar energy business model as stewardship. It was also used by Garrett Hardin in The Tragedy of the Commons and Obama science adviser John Holdren to justify forced sterilization to save the planet from overconsumption. And, in The Hunger Games, by the Capitol to justify having tributes from each district kill the other until a sole victor remains.

The ABIMF campaign doesn't promote such measures (though we should be assured that the president's science adviser thinks such actions are, like Obamacare, constitutional). But it is designed to give the doctor's seal of approval to Obamacare's practice guidelines and rationing. And it's the blueprint for the campaign ABIMF is underwriting to get doctors to change how they practice medicine in order to bring about the Obamacare revolution.

Harold Sox, ACP's former president, noted: "I hope that we will look back upon [Choosing Wisely's] publication as a watershed event in medicine." Sadly it is. Choosing Wisely is the first collective effort on the part of professional medical societies to decide how to practice medicine on the basis of cost first and foremost. The list of thou shall nots is redundant and highly subjective. Out the 45 "don'ts" nearly six are the same (no pre-operative screenings ) and 16 pertain to cardiac imaging. Almost all are discouraged in patients at "low to moderate" chance of getting sicker or dying from a disease or treatment complication. And the list leaves no room for mixed or inaccurate measurements. Someone goes Code Blue because their doctor chose wisely? Oh well. As Katniss Everdeen observed: "It's easier destroying things than making them."

Moreover, it reflects political cravenness on the part of its creators who seek not only to promote Obamacare but cash in on it. Consumers Union, the group that puts out Consumer Reports and also supports a government-run health system, is part of this effort. In 2008 it pushed hard for a highly criticized and widely ridiculed system of rating health care quality in terms of how little care was delivered. By allying with ABIMF and ACP to promote Choosing Wisely, Consumers Union can relaunch its early failure with a medical seal of approval and use it to try to boost subscriptions to its newsletters and magazine. The ABIMF is giving cash to the National Physicians Alliance (NPA). Christine Cassell who heads up the ABIMF, is also on NPA's board along with Rachel DeGolia, director of the Soros-funded Universal Healthcare Action Network. The Bayview Healthcenter in Baltimore, which employs ABIMF board member David Hollander, also received Choosing Wisely dough. Cassell, along with former ACP president Harold Sox, were early advocates of comparative effectiveness research (CER). Sox appointed Cassell to the Institute of Medicine panel that decided how CER should be conducted.

The Choosing Wisely campaign is ultimately led by people who also stand to benefit from Obamacare contracts. Indeed, the closed cabal of docs and consultants who have received CER money in the past from the Agency for Healthcare Research and Quality (AHRQ) and have received most of the (taxpayer) money given out by the so-called Patient-Centered Outcomes Research Institute include ABIMF trustees such as Steven Pauker and Peter Basch (who is also a senior fellow at the virulently anti-Israel Center for American Progress). Richard Baron, an ABIMF trustee, is now a senior official at Health and Human Services, in charge of initiatives worth billions.

Together, CER and Obamacare innovation grants make up the biggest cesspool of single source contracts in government. These dwarf the crony capitalism of the Obama alternative energy program in dollar amount, political correctness, and sheer cronyism. ABIM and ACP are among the first groups to criticize doctors who receive support from drug and medical device companies for training and research. But they have no problem in campaigning for expansion of federal programs they have helped design and benefit from financially and politically.

Most important, Choosing Wisely looks backwards to ration older procedures that are rapidly being replaced by tests that, by identifying which patients respond best to what care, can avoid duplicative or ineffective treatments. Programs such as Horizon Healthcare Innovations' patient-centered medical homes give doctors more freedom to decide how to treat people and what to test for: the initiative has reduced hospitalization and emergency room use by keeping people healthy.

As Dr. Eric Topol notes in The Creative Destruction Of Medicine about the practice of medicine in general, Choosing Wisely "relies on the wrong concept that the median of patients is the message." Choosing Wisely is silent on getting doctors to use point of care and hand-held devices that can deliver individualized care frugally, if for no other reason than the insistence that CER be used to determine who has access to such advanced treatment and when. In order to maintain just distribution of medical resources, of course.

Topol notes: "[We] are right at the cusp of having new tools to affect that change -- the ability to define each individual in 'high definition' at the biological, physiological and anatomical levels. While we have long appreciated that each human being is unique, it is only now that we can leverage this information to improve medicine." That is truly choosing wisely, something Obamacare's medical mercenaries have failed to do in forsaking patients for a political agenda.

 

 

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About the Author
Robert M. Goldberg is vice president of the Center for Medicine in the Public Interest and founder of Hands Off My H ealth, a grass roots health care empowerment network. His is new book, Tabloid Medicine: How the Internet is Being Used To Hijack Medical Science For Fear and Profit, was published last month by Kaplan.