Such as? I assume from what you say that these are not first line optimal procedures, so I’m not sure what point you’re making. But if they are procedures you should be doing on the basis of clinical need then a public insurance system must be configured to offer them cost-effectively and there does not appear to be any reason why this cannot be afforded easily given the more than double the US spends per head on healthcare than most other western nations.

Your conclusions are wrong. Surely I am practicing good medicine, and just as surely you have absolutely no basis to conclude otherwise. That I decline to offer certain costly and under-compensated procedures does not mean I am not willing to tell my patients about them or to suggest that if they want them that going to a non-profit institution, like a university surgical service, might be one way to obtain them. There is nothing substandard at all about that. I also offer patients the option of charging only for the administration fee and providing a prescription to obtain necessary materials–like Botox–on their prescription drug coverage plan.

This discussion has nothing to do with “evidence-based medicine”, and please understand that “evidence based medicine” is no sort of shibboleth for passing by the unresolved problems that Medicare and other third-party entities visit on medical care delivery in our country.

If you are thinking huge practices are the road to costs efficiency, you are mistaken. Small group practices have been shown to maximize cost efficiency. Big care organizations are larded with too many layers of management to enjoy the same operating efficiencies. And they more than any other entity are the ones with giant executive salaries.

But what do I know? I just do this every day, for a living. What about you, or are you just an “observer”?

If these are therapies that are the best based on clinical evidence then surely you are not practising good medicine. And surely the whole point of evidence based reform is to provide the gold standard to everyone – and after all, with the amount spent per head in the US on healthcare then this should be easily affordable, although you’ll have to get rid of inefficient small practises and all that money spent on profit and executive salaries.

Kevin, tarring these efforts with the brush of national socialism is being lazy and dishonest. It is name-calling. No one I can see is suggesting the actions of a commission need to be opaque or above public scrutiny.

We really don’t have a choice about rationing care. It is already happening by virtue of underpayment. There are therapies I will not offer from my practice because I cannot even cover my cost by the amounts paid by Medicare, even if I stopped taking assignment. No one is preventing me from providing these services, but the end result is the same: rationing by making services so economically unfeasible that they are restricted to only those practices willing to eat losses. That is fundamentally not reasonable.