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If I steal from you it’s theft, but what if I purchase lots of stuff on your credit card for which I expect you pay, is that any different? Oh I know, it’s for a good cause, still if I do not have your permission is it still OK? What if you give me money that you can deduct from your income tax, and later I arrange for you to receive money and it happens to be very much the same amount, does that sound right? This spending bill stinks.  Physicians need to begin asking themselves why they depend upon government “officials” like HHS Secretary Kathleen Sebelius for their wellbeing. Today there is yet another plea for government not to cut physician reimbursement beginning January 2, 2010. Surely you must be asking yourself if this is why you spent all that time in post undergraduate education. Just how much professional autonomy are you willing to surrender? Here is an objective worthy of adoption:
Write it down, paste it in front of your desk so that you see it each morning, and begin making it happen. Physicians must reduce the capricious effects of government in their practice by making the government less relevant to their future. Through Gapminder one can see an amazing view of the improvements in the health of countries over time in association with the wealth of those companies. On this site you’ll see an incredible view of progress and some failures over the past two centuries, one standout being China. The size of each dot represents the population size of the country, and because of this it is easy to point out China. Closely following China’s growth in terms of mean age of the population and their average wealth, it’s surprising to see such a dramatic change that occurred from 1958 through 1962. (This event is quick and deep on playback in the graphic, so you have to slow things down to see it) During this period the median age of the population fell precipitously from about 50 to below 30, while over 36 million people did of starvation. The Economist F. A. Hayek said that it’s “The curious task of Economics is to demonstrate to men how little they really know about what they imagine they can design.” The truth behind this statement is less often recognized by those who profess to be “smart”, while commonly appreciated among those who happened to be experienced. All the smart people in the late 1950′s China were convinced they knew best for all concerned. With enthusiasm (and a fair amount of coersion) an experiment in design forced already poor peasants to trade high valued resources (labor and food) and turn them into low value goods (metal), most of which was poor in quality and useless. Imagine starving to death because someone had an idea based in an ideology, not reality – tragically many did, and still do today in North Korea. Now, nearly 5 decades later a bunch of smart people think they can top-down design an infinitely more complex healthcare system to work more efficiently. These people know little about healthcare or medicine, but are absolutely confident that they know best simple because of who they are. They won’t be around when it fails, won’t see those who endure long waits for services or the damages that result, so does that make them smart or just shrewed? In a 1985 report for the Electronic Fronter Foundation, Dr. Curtiss Priest makes a compelling three step observation into the intrinsic relationship between information and freedom.
You cannot choose among things you do not know exists. A person in need of repairing a broken wrist, for example, can seek out specialized individuals in order to gain information on choices to be made, and get it fixed. Just 100 years ago, among those choices would have been amputation, rarely would this be considered now; today we have lots of choices.
Lacking external constraint by government on where one may go for help with a broken wrist, we have freedom to seek the best possible help we need for the best possible outcome. The freedom of acquiring proper information produces yet another freedom, the freedom that comes with a properly functioning wrist for the rest of one’s life; a nice freedom to have. But what if a person on whom we depend to know of all possible choices, are themselves deprived of information? When conditions are more complicated than a fractured wrist such a cancer or rare diseases, choices can find themselves limited arbitrarily by the person to whom one turns for help. If you’re sick, does it really matter to you how or from whom your physician learned of a potential cure? Does it matter if that information comes from a colleague, professor or even sales representative as long as it works?
So here we are, if “A” is correct, and “B” is correct than one must agree that “C” is correct. There is an intrinsic link between information and freedom that can not be denied. Information leads to greater freedom by exposing choices, and choices properly acted upon, improve outcomes. Conversely, freedom enhances the value of information in that without the ability to act upon choices (go where you wish to get help), information doesn’t much help, and this brings us to healthcare reform. The law recently struck down in Vermont, restricting the use of pharmaceutical prescription data, was passed in the name of “consumer protection”, also restrict choices and freedom. At an academic, legislative level such restrictions on information may seem perfectly harmless, but there can be no doubt that someone somewhere will be hurt. The notion that anyone has perfect knowledge into all the possible ramifications related to restricting information is naive, frightening and generally absurd. As government continues to meddle in healthcare, acts like that undertaken by Vermont will become more common and dangerous. A striking piece of news last week regarding the use of medical sales data. On November 23rd, US federal applet court ruled unconstitutional a Vermont law prohibiting the use of prescription drug information that identifies prescribers and patients for commercial marketing purposes. (Judgment Here) This is incredibly good news because had that law stood, or should this ruling be overturned at a higher level, we will all be poorer for it. Medicine is highly dependent upon unintended surprises which by definition are difficult to see, and impossible to predict. We need the ability to report on pharmaceutical sales data for commercial as well as clinical surveillance reasons, the challenge is that we don’t know when one will result in the other. Prenatal Folic Acid is a great example of a medical recommendation which resulted from meta-analysis of multiple studies, along with their clinical results. The impact this modest, and remarkably inexpensive addition to the prenatal diet has been simply astounding, resulting in an over 50% reduction of significant neurological birth defects. No drug company would have focused upon this research because it’s is nearly impossible to make money at it. Legislatures ought not play with things about which they do not understand. I’m losing my patients with half-witted interventions into a complicated healthcare system I will likely need in the future. T. A. Coss, RN |
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