Priceless: Chapter 4

If you haven’t read the prior posts on John Goodman’s book Priceless, catch up using the Priceless tag. This post pertains to Chapter 4. I will warn you up front, to me this was the oddest chapter yet. Many arguments either didn’t relate to the main thrust of the book or didn’t make sense to me. Sometimes I felt like a punchline was left out. Examples follow.

The chapter begins with one of the strangest attacks on and rejection of science I’ve ever seen. I think what John might be trying to say is that a dogmatic imposition of how to use science in the exam room or operating theater is a threat to innovation. Putting aside whether I would agree with that, the fact is, he doesn’t clearly say this, and only this. He goes much, much further, and, in my view, unnecessarily and misguidedly so.

At heart, and by formal education, I’m a scientist. Evidence is very important to me. But I’m not a fool. I know there are all manner of problems in the process of gathering, reporting, and interpreting evidence. There is bias. There is corruption. There is lack of repeatability. There is lack of generalizability. There is bad science. There is non-science. There is motivated thinking. In the face of these, we should strive hard to improve the process and use of science, not reject it.

For, what is the alternative? Maybe, in time, John will tell us. While we wait, should we banish science and shun all evidence? Should we reject out-of-hand all the evidence he cites in his book? Should we discard evidence that the health system is as flawed as he (and I) think it is? Look, if neither doctor nor patient have access to evidence-based guidance in some form — not necessarily hard-and-fast rules, just something to light the way — they can only stumble in the dark on faith. Does your doctor talk to God? About your health? Are you sure? Do they teach that in medical school before or after the courses based on medical science?

Discussion of how to better acquire and use evidence are worthwhile. For instance, on the subject of heterogeneity with respect to comparative effectiveness research, see the recent Health Affairs post by Dana Goodman and colleagues. But John’s treatment of evidence didn’t invite that discussion. Why not?

Oddly, toward the end of his attack on science and evidence-based standards, John admits that

Evidence-based guidelines could be a boon to medical practice, helping doctors do their jobs. One place where standardization seems to be working remarkably well, for example, is at Geisinger Health Systems in central Pennsylvania.

If there is a doctor at Geisinger who thinks patient care would be better without evidence-based guidelines, I’d like to meet her. In all honesty, it is after reading this section that I was strongly tempted to read no further.

But I did. Next, John covered ways in which employers and insurers try to select healthier workers and consumers. I have no significant disagreements with him here. Along the way, he praises the bureaucrats in the Office of Personnel Management (OPM) for their ability to prevent the worst insurance company abuses in the Federal Employees Health Benefits Program (FEHBP), as well as those who run managed competition-like environments for state employees, universities, and large corporations. Why does he expect managers of state exchanges under Obamacare cannot do the same? I don’t know. Still, I agree with him that risk selection among competing plans is a valid concern.

John critiques the Medicare drug benefit’s donut hole and notes it will close under the ACA. Which is better policy? He doesn’t say. Was something cut from the book in the editing process?

The chapter closes with a brief section in which John notes that Medicaid providers receive relatively low reimbursements. To the extent that results in access or quality problems, no argument that this is problematic. But John didn’t go into this in the chapter. Again, it felt like something was missing.

The chapter is titled “What Being Trapped Means to You.” John never explained.

Expect my Chapter 5 post later this week.


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