A Must Read

I will not say much, but this piece in the Sunday’s New York Times editorial page is a must read if you want a synopsis of why health care costs so much in the U.S. It weeds through the inaccurate information used by politicians and pundits and begins to look at what can be done. Again, it is a must read.


2 responses to “A Must Read

  1. First off, hats off to you for a very thoughtful and comprehensive effort to address an issue that is at least in the top two or three of our time. It will take some time to read through your comments, but I started with your praise of the NYT editorial of 11/25/07. I agree with much of the comments, but I think one point is worth more emphasis is given. Please see the paragraph starting “There would most likely be some savings. A classic experiment by Rand…” and ending with two key sentences, “The one exception was low-income people in poor health, who went without care they needed. Any cost-sharing scheme would have to protect those unable to bear the burden.”

    I tend to be a wordsmith and believe the crux of the problem is in this sentence in the words, “they needed”. As the editorial makes clear, one of the largest factors driving up healthcare costs is the rising expectations of physicians and, by extension, patients. We do expect that follow-up MRI for a knee problem when the original (far, far cheaper) X-rays produced the very likely proper diagnosis. The NYT editorial comes off fairly critical of physicians for their practices, but I believe physicians are just one link in a chain of overly high expectations. This chain runs from companies (and their shareholders) appropriately seeking the next big blockbuster drug – to the physicians compassionately seeking to solve their patient’s refractory symptoms – to the suffering patients who expect to feel better NOW – and the advocates who are deeply moved by suffering feel someone is being shortchanged. We all expect the best of the best for everyone. In any other industry, this would be laughable, but in healthcare, this fantasy is allowed to go on.

    I believe our problem is the way we think about the problem. As legislators, public health administrators, researchers, and observers of the system, we consider issues from a nomothetic point of view. That is, we look at systems overall – trends, total and average costs, and epiemiological factors that characterize a whole group. This is similar to a clinical trial of a medication where the goal is to determine whether the condition of a group of people who received a medication improved more than the condition of a group who received placebo.

    But doctors, advocates, and patients themselves are fundamentally idiographic in their thinking. That is, they deal with specific individuals who have a particular problem. To extend the analogy to a clinical trial, consider that the average depression score for patients receiving an effective antidepressant will have dropped – but not everyone in the treatment group will have improved. Some will improve more than the average – others less. Some might not improve at all or even worsen. So the physician assessing an individual with depression is only able to conclude that the medication “is likely” to work. The information a physician receives is group-based while the essence of a medical prescription is individual-based.

    Back to policy, it’s one thing to make a policy that expensive MRI’s will be reimbursed only under certain situations. It’s completely another to enforce that policy by telling Dr. A that he/she’ll have to determine the appropriateness of knee surgery for Ms. B without a (more precise) MRI. Dr. A will be outraged. Ms. B will be outraged. Care is being restricted!

    So I believe our knowledge and technology for determining how much care a particular person SHOULD have is woefully behind our own expectations. Some would say that people SHOULD have whatever care ‘they need’! And how much healthcare do “low-income people in poor health” need? How on earth do we answer that question? And once we do, how can we apply that to an individual patient sitting in front of us who needs help?

  2. Dan,

    I appreciate your insights and I agree. The step from the group policy to the individual enforcement is a huge problem that I don’t believe anyone has solved yet. And the need issue is also huge? We definitely don’t provide needed care and we definitely do provide care that is not needed. Look at the variance in care between geographical areas (small area variance). It’s remarkable that the amount and type of care can differ so much between two similar areas. A common study is one that compared the care between New Haven, CT and Boston, MA where much more care and expensive care is given out in Boston without measurable health benefits. We realize the problem, but don’t yet have the solution.

    I think a closely related idea is the step from the person who is buying the insurance policy to the same person down the road who is receiving the care. The heathy person buying the insurance wants the low cost coverage (even if they know that the coverage might be less), but as soon as that person gets sick they want the high quality care – moral hazard. As a purchaser they look at the trends and their bank account. As a patient they are only focussed on increasing the effectiveness of their care. I’ll leave it at that for now, but will have to dive into both of these topics – small area variance and moral hazard – at a later date.

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