• Priceless, Chapter 4 – ctd.

    I think I found this chapter as odd as Austin did. It’s entitled, “What Being Trapped Means to You.” I still don’t know the answer.

    John begins with an attack on third party payers for trying to have restrictions on care. I was pleased to note that he acknowledged that restrictions come from all types of payers, private and public. I’m not pleased to note, however, that he seems to oppose them en masse. What’s the counter-argument? Should insurance companies be required to pay for anything? Note, even if you just believe that there should only be catastrophic health insurance, you must accept that it has limits, no?

    But it’s the next section that was oddest. John really goes after guidelines. All of them. It’s a very strong attach against any types of guidelines. I found it wholly unpersuasive. The body of literature in support of standardizing care along an evidence base is enormous. In opposition stands the straw man of the patient who isn’t “average”. But there’s no one I know who doesn’t acknowledge that limitation. Guidelines are meant to be applied to a specific population. If you’re outside that population, the guideline doesn’t apply to you.

    He also notes that some guidelines are written by people with conflicts of interest. True. We need to do a better job of that. But you don’t throw out the baby with the bathwater.

    I do agree with him that wellness programs are often subtle ways to attract healthier employees.

    I was somewhat mystified by the last few themes. I totally get that John does not like central planning. But insurance inevitably involves some level of it. We pool money. We spend it on some more than others. That’s always how it goes. It makes sense that someone make decisions as to how that will be spent. If you want to get rid of insurance entirely, that will avoind anyone else making decisions for you, but I don’t think he’s advocating for that.

    As I worked through this, I had a thought. Are we “trapped” because many of us keep jobs we’d rather not because of health care? If that’s the case, and he’s advocating for uncoupling insurance from work, he’d be joined by many wonks on both sides of the political spectrum. I’d also point out that the ACA starts to take us in that direction by creating the exchanges. If that’s not what John meant by “trapped”, then I missed his point.


    • Do you know where I can find evidence demonstrating the relationship between the implementation of guidelines and health outcome improvements? I can find plenty of evidence of improved compliance, which would presumably lead to better outcomes, but I’d feel more comfortable if I didn’t have to presume.

    • “I totally get that John does not like central planning. But insurance inevitably involves some level of it. We pool money.” 

      Aaron, that takes us to the issue I had with Austin care vs compel. That also takes us to a second issue third party payer. I think we would have a lot more agreement if there was agreement that the individual has a right to choice and reasonable control over the dollars. Two party pooling of insurance money is not the problem.

      • Speaking for myself, we may agree a lot more than you think. We’re only on Chapter 4. John doesn’t really get to his proposals until much later. You might be surprised to find out how sensible I find many (not all) of them. Just wait.

        (This is why I think the first half of the book does his ideas a disservice. Many he might otherwise convince of the virtues of his ideas just can’t get through it. It’s too extreme, as I’ve been documenting. I would be very impressed if John understood this as valuable advice.)

        • Firstly, let me say I appreciate that you have an open dialogue. Thank you.

          I am sure we have a lot more agreement than might appear to exist, but in the end it all boils down to a very few basic principles and that is where the most significant differences seem to occur. Here are a few off the top of my head.

          Care vs. compel
          Incentives and how they are utilized
          Top down EHR vs bottom up
          Top down guidelines vs. bottom up and the impact on treatment and innovation

          We all care and recognize incentives. We would all prefer some type of EHR and guidelines, but even they get back to the care vs compel issue.

          • My basic principles are:

            Empirical evidence over theory
            Markets with reasonable safeguards and fallbacks
            Don’t forget political constraints

            With those, I barely need to decide anything. Take the whole private vs. public cost control question. Premium support with a public option, like Medicare, (again with the right safeguards) could provide the lowest cost without ever resolving the question some take as fundamental. It could be, likely is, that private is cheaper sometimes and in some places, public at other times and places. Who cares!? Just set up a market, safe for beneficiaries, set subsidies at the lowest bidder, and … well and nothing, except for the fact that politics will likely compromise this idea to the point that it may be worse than the status quo. It’s hard to know.

            If you’re not familiar with my pre-Goodman blogging, this has been a major theme. I linked to much of it earlier today in a post on the Kessler piece.

            • I understand your basic principles but it appears we are dealing with a political economic system so one has to be very aware of the incentives they are creating especially since your principles are not attached to parameters and therefore could vary person to person, issue to issue.  You could also add that the word reasonable (reasonable safeguards and fallback) covers an awful lot of territory and will be defined differently by every individual. Thus your parameters are a little too soft for me especially when you add ” I barely need to decide anything.”

              Let me deal with “empirical evidence over theory”. In many different disciplines there are a whole bunch of levels of evidence and evidence can easily contradict itself. I believe medicine is particularly difficult because one cannot measure success that easily and one can’t always do studies that can kill some people in the process. That is partly why the metrics used by government agencies observing physician performance have frequently been checklists, yes or no, done or not done. These types of metrics cannot possibly truly evaluate benefit to the patient. The evidence behind these metrics make physicians focus on these problems and stop focusing on others.

              Look at the problem Aaron and I were having in deciding which type of evidence to use, outcomes for a diagnosis or mortality. Nothing is clear. Everything is fuzzy and the one’s that know the least are in Washington. In fact frequently by the time they discover their evidence new studies have proven that evidence to be out of date. Look at how long it took for the government to realize that when based upon risk they paid the Medicare HMO’s far more than they should have. That should have been apparent based upon the rules before the first Medicare HMO opened up. 

              Incentives IMO control healthcare and one has to be very careful when one intervenes. Sometimes it is better to watch and wait targeting the problems rather than recreating the market.  This does not mean that we discard evidence. We shouldn’t, but we should be a bit more humble about interpreting what that evidence means.  

            • Here’s to being humble!

            • “Here’s to being humble!”

              Right you are Austin and that is why the policy makers in Washington should recognize that their knowledge of the market place that consists of hundreds of millions of people is limited and cannot be totally understood. Therefore, they should not be so complacent about the damage they do when persuing their ideas.

    • Should insurance companies be required to pay for anything? Note, even if you just believe that there should only be catastrophic health insurance, you must accept that it has limits, no?

      This is a pet peeve of mine. People will excoriate the insurance companies for not paying for some stuff but if you think about it for a minute you realize this is the way that it has to be.

      • Of course my above is a reason for supporting more direct payment for care. Perhaps if we could end the employer deduction people would migrate to high deductible health insurance for life where part of the premiums go into a savings account that can be used to increase the deductible to hundreds of thousand in the latter years.

    • In this chapter, guidelines are suspect. Yet in a later chapter, we hear of the marvelous efficiency of Minute Clinics where nurses follow algorithms of care. Distinction?

      • As best I can tell: Guidelines established by boards of experts with government affiliation — BAD. Guidelines established by providers in the market — GOOD. If my impression is wrong, I hope someone will correct me. Where the role of evidence is in all this is unclear. The approach seems to suggest that if people vote with their wallet for something, it’s judged superior, apart from what it might do to their health. Again, happy to be corrected.

    • Austin, why do you find it necessary to add government after: “boards of experts”?

      Guidelines created by boards, Good. Guidelines that are compelled, Bad on a federal governmental level.

      • I’m happy for a correction, but I still don’t know what John really thinks. When I find a guideline in the wild, what’s the litmus test to know how he thinks I should think about it?

        • Austin, John can speak for himself, but tell me what is wrong with the guidelines that were produced without government involvement?

          • If they followed a transparent process guided by evidence, with controls for conflicts of interest, involving public input and peer-review, and subject to re-examination as new evidence comes to light, they’re excellent. I have no problem, for example, with the USPSTF process. Not every body incorporates all this. Contrast: http://theincidentaleconomist.com/wordpress/call-this-eminence-based-medicine/

            My answer would not change if you’d asked me to comment on a government-associated guideline. Corruption and self-interest can occur outside as well as inside government. I think we agree that they should play no part in a scientific inquiry or the practice of medicine. Yet, sadly, they do, even without government involvement. See pharma: http://theincidentaleconomist.com/wordpress/all-about-big-pharma-faq/

            • Austin, I have no problem with official agencies creating their guidelines as long as the presumption is that all guidelines be tranparent and none of them be considered to be superior except by reputation based upon scientific study in the scientific community. With time some reputations would be destroyed and we would be better off. If you are complaining about pharma then your real gripe is with a government agency, the FDA, that becomes politicized. Just like we see our Congressmen go from Congress to the private sector we see our officials at the FDA go to the private sector as well or alternatively follow the dictums of politicians. Talk about bad incentives we have them all around government. With so many incentives misaligned I would like to see the individual with a lot more power.

              Unfortunately power is being removed from the individual and left to the government. It is that type of imbalance that causes so many dangerous incentives to exist.