State Health Care Reform: Key Questions and Answers

Studies | Health

No. 311
Monday, April 21, 2008
by Linda Gorman and R. Allan Jensen


Should Government Decide How Medicine Should Be Practiced?

The Colorado Commission also recommends establishing an Orwellian-sounding “Improving Value in Health Care Authority” to “fundamentally realign incentives” in the Colorado health care system by regulating provider payments and determining acceptable treatments.  The proposal recommends that the Authority study the “best scientific evidence to foster clinically, ethically, and culturally appropriate end-of-life care.”  However, based on what has happened in other cases when such recommendations have been put into practice, the Authority will likely end up transferring control over medical practice from individual citizens and their doctors to unaccountable, unelected regulatory authorities.

The potential for harm is made clear by a recommendation to “Pay providers based on quality, such as use of care guidelines, performance or quality measures, coordination of patient care, and use of health information technology.”  While the proposal never defines quality, it is confident that the Authority will know it when it sees it.  Physicians who do not do what the Authority demands will face financial penalties.  If what the Authority wants differs from what patients want, physicians will have an incentive not to act in the best interests of their patients.  The Commission did not explain why it believes that the Authority will do a better job of aligning incentives than a program of deregulation that puts smart shoppers using their own money in charge of their own health care decisions.

"'Pay for performance' allows government to tell doctors how to practice medicine."

The pay-for-quality recommendation means the Improving Value in Health Care Authority will end up using evidence-based measures to regulate physician behavior and, ultimately, medical practices.  At present, physicians are free to disregard evidence-based recommendations that conflict with their experience in clinical practice or with their patients’ wishes.  Physician freedom of action is crucial to good medical care because it protects physicians and patients from regulators with an agenda or conflicting values.

The U.S. National Heart, Lung and Blood Institute’s JNC 7 clinical guidelines for treating hypertension provide a recent example of how agenda-driven research can create seriously flawed evidence-based national guidelines. They have the potential to increase patient morbidity and mortality.  The guidelines recommend starting all patients with high blood pressure on thiazide-type diuretics.  In support of this, the guideline for primary care physicians states:

“Thiazide-type diuretics have been the basis of antihypertensive therapy in most outcome trials.  In these trials, including the recently published Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), diuretics have been virtually unsurpassed in preventing the cardiovascular complications of hypertension.”4

This statement is grossly misleading.  In fact, the ALLHAT study has been subjected to withering criticism and the JNC 7 guidelines are not widely accepted.  In Britain, the National Institute for Health and Clinical Excellence recommends ACE inhibitors as the first choice for initial therapy in patients younger than 55.  The guidelines also ignore evidence suggesting that diuretics may increase the risk of developing new-onset type 2 diabetes.  Newer antihypertensive drugs appear to have a beneficial or neutral effect on glucose and lipid metabolism.5

"‘Evidence-based medicine’ may create incentives to deny people care."

The Colorado Commission advocates combining evidence-based standards with the pay-for-performance rules.  If the Improving Value in Health Care Authority follows this recommendation, it might use the results from poorly designed clinical trials to pressure physicians to use less expensive, older and less effective therapies, regardless of their relatively poor side-effect profiles or of their effect on individual patients.  The Commission recommendations also set the stage for various methods of provider profiling, including hospital and physician report cards, two currently fashionable quality initiatives which have been shown to have serious technical problems.  They also give physicians an incentive to deny care to people who are very ill.  Seriously ill people pose higher risks of poor outcomes.6

When such power is concentrated in the hands of an unaccountable group that has no personal contact with those affected by its decisions, patients become mere costs.  Such groups tend to focus on costs and are highly susceptible to influence from narrowly focused interest groups with political agendas not in accord with what patients value.  The danger is that access to advanced therapies for “expensive patients,” including the disabled, the chronically ill and those with complex medical needs, will be severely restricted.  In the Netherlands, physician-caused deaths are increasingly commonplace.  The utilitarian ethic adopted by the Royal Dutch Medical Society has virtually eliminated any prosecution of physicians who kill the elderly, the mentally ill or the disabled.7


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