04 February 2012

Obfuscating Authority in Obamacare

Sen. Rick Santorum campaigning in Missouri  (photo Seth Perleman/AP)

While campaigning at a Missouri church for the GOP Presidential nomination, former Senator Rick Santorum (R-PA) repeated the claim that under Obamacare  stroke victims over the age of 70 will not generally be offered advanced neurological treatment and will be offered comfort care.  The Lamestream Media was quick to link Santorum’s remark with conservative evangelical leader Dr. James Dobson, who echoed former Governor Sarah Palin’s  (R-AK) characterization of “death panels”.

Last November,  a caller to the Mark Levin Show claiming to be a neurosurgeon from Chicago had participated in professional discussions among neurosurgeons which anticipated new evaluations being needed for superannuated stroke victims.  The policy was said to defer judgment for such cases to an ethics panel on an individual basis.  But common sense indicates that such ethics panels would not often convene at all hours to bless extraordinary treatment for stroke patients.  Levin pressed “Jeff”  if these procedures had been published but the anonymous caller ”said that these policies had not yet gone to the press.

There have been two waves of effort to quash  this stroke “death panel” story.  Several weeks ago, Rick Unger contributed a piece to Forbes which supposedly discredits “Jeff” by revealing that the American Association of Neurosurgeons and the Congress of American Neurosurgeons know who “Jeff” is (but won’t say for fear of litigation). The AAN and CAN can positively assert that he was not a neurosurgeon (but that “Jeff”  may be a physician) and that he was not registered for the conferences in Washington.  This sounds as dubious as when Senate Majority Leader Harry Reid (D-NV) kept referring to an imaginary friend “Tommy” while making floor speeches over major  legislation. Thus is was prudent to spike stroke treatment changes with another angle.

Since that the stoke comfort care story reappeared in public, the AANC/CAN story has changed somewhat from the ad hominem attack. Now the groups' joint statement indicates that they were  "unaware of any federal government document directing that advanced neurosurgery for patients over 70 years of age will not be indicated and only supportive care treatment will be provided."  So the emphasis has switched from demonizing the messenger to obfuscating if there is an official policy.

Having lived through the Monica Lewinsky affair, one becomes accustomed to understanding context and parsing words in denials.   The original vilification of “Jeff” reveals that the AANC/CAN did meet and discuss such issues, but the professional societies claim that he did not participate in the neurosurgeons groups’ policy discussions as “Jeff” was not a neurosurgeon. But it does not take a brain surgeon to conclude that  neurosurgeons gathered and debated such a policy.  The later AANC/CAN denial was carefully worded to concentrate on “no federal government document” directing changes in care.  Interesting.

The Federal government need not directly dictate how medicine is practiced to control it as they can rely upon task forces made up of health care experts to do the dirty work.  For example, take medical recommendations for mammographies.  For years, the prevailing wisdom has been that women over 40 should get yearly breast exams.  But in 2009, the U.S. Preventative Services Task Force issued “guidelines” which resolved that women should only get mammography exams every two years after age 50 and that they should not do self breast exams.  The rationale cited a harm benefit analysis that suggested that women might have false positives which leads to anxiety and distress, and unnecessary biopsies.  The USPSTF is a government appointed "independent" panel made up of ten distinguished medical professionals at the behest of the US Department of Health and Human Services, headed by Kathleen Sebilius.

While the Mayo Clinic still recommends the American Cancer Society’s recommendations for yearly mammographies for women over 40.  But once Obamacare kicks in, the HHS Secretary will have wide discretion as part of the Administrative State to apply the recommendations of its physician panel. This would not require a bureaucratic edict declaring eligibility but merely an HHS acquisition to health experts’ prevailing recommendations.

It would seem that the USPSTF recommendation certainly saves health plans money and is not a federal government document per se.  Is this type of decision made for good medical reasons or mindful of the bottom line?   Perhaps this will cut down on Planned Parenthood referrals for mammographies so they can concentrate on their core business.

The same bureaucratic sleight of hand is echoed in the Obama Administration’s  rescinding the respect of religious conscience regarding employers offering qualifying health plans.  Simple minded liberal sycophants will slavishly insist that now everyone can get “free” contraception and if individuals have an ethical problem, they need not use the reproductive rights services.  But the religiously affiliated employers, which  are legal persons, have no choice as health insurance companies can only offer qualified plans. These HHS final guidelines insist that all plans cover the gambit of contraceptives, including IUDs, the “morning after pill” and sterilizations. This diffuse decision-making blurs the responsibility chain of responsibility from the federal government and can be cast as a net positive for community standards.

If the Lamestream Media outlets had journalists rather than acting as servile stenographer for favored  policy makers, they would ask salient questions which impeached their sources credibility.  Instead of accepting the blanket assertion that there was no federal government document, enquiring minds would  want to know the current protocols for neurosurgeons in discerning the appropriate application of advanced neurological treatment for elderly patients.  Another probing question is “What is the procedure for decision making for advanced neurological care?”  In addition, it would be enlightening to know “What criteria influences changes to these guidelines?”.  If an ethical journalist really wanted to wander into the tall grass, pose a questions to  neurosurgeon policy makers thoughts on the “Complete Lives System” as applied to their practices. So this is not shrugged away as bogus “death panels”, refer to the Lancet medical journal article  "Principles for Allocation of Scarce Medical Interventions", which was incidentally co-authored by Dr. Ezekiel Emanuel (special health issues adviser to the Obama OMB and brother of former Obama Chief of Staff Ron Emanuel).

What about the views of  Dr. Donald Berwick, the twice recess appointed Administrator of the Centers for Medicare & Medicaid Services?  Berwick never received Senate confirmation after making comments endorsing the British National Health System and that he favored “rationing with our eyes open”?  Surely two years with  “Rationer in Chief” Berwick might have some sway with health care experts issuing “guidelines” that will become de-facto law as HHS becomes responsible for approving all health plans.

Another unsightly reason to revise health procedures is the cut in Medicare reimbursement. To get Obamacare passed with a CBO number under $1 trillion, it necessitated “cutting” $500 billion from Medicare.  What this means in all reality is that the government will reimburse health providers less for services.  Certainly advanced neurological treatment does not come cheap and is predominately needed by the elderly.  All of the elderly must belong to Medicare, so would it not be convenient to make approval procedures more cumbersome to limit exposure for treatments that would not be fully reimbursed by the government?

It took five reams of paper to print out the original Patient Protection and Affordable Care Act (a.k.a. Obamacare).  It sounds contrived and sketchy for neurosurgeons groups to claim that they were not aware about such federal government documents.  Then again, try reading Public Law 111 - 148 and divining anything.  It makes one sympathize with Representative John Conyers (D-MI 14th) consternation about calls to read the healthcare bill.

 There may not be a federal government document dictating procedure, but the law gives the HHS Secretary extreme discretion in implementing policies, so the health care experts guidelines become de facto law without being a federal government document per se. But there is all of the financial incentive for speciality physicians to cut costs.  The governmental powers that be seem disposed to redirect funds away from elderly “extraordinary” care.

While Santorum may not be able to point to a smoking gun document on changes in stroke protocol written by an officious Obama Administration official, the charge ought not to be summarily dismissed.  The  pattern of obfuscation in setting health policy may reflect the  axiom epitomized in the film Absence of Malace (1981) “It’s the truth, it’s just not accurate.”

ht: Associated Press

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