• Priceless: Chapters 6-7

    Reading chapters 3, 4, and 5 of John Goodman’s book Priceless left me exhausted and disappointed. As I’ve already expressed in my reviews of them (all under the Priceless tag), the book’s style doesn’t suit me, I’m finding a lot of selective reading of the literature, and seeing arguments that strike me as wrong, sometimes strangely so since they seem unnecessary to John’s focus. After writing my Chapter 5 review, I told Aaron I wasn’t sure I should continue, especially if doing so caused me to feel the need to respond at length to every chapter. By now, you know I kept going.

    Fortunately, Chapter 6, about how price competition could also improve quality didn’t upset me. I have no major problems with it. I concur with John that, all other things being equal, more price competition is a good thing for the health care market. What I want to see more of is consideration of the consequences beyond price and consumer satisfaction. Here’s a key question: would providers sell and would people buy more or less care that is beneficial vs. harmful or useless?

    With that, I moved on to Chapter 7. It begins with a typical Goodmanian assertion, the form of which is: Conventional health policy wisdom is X. Everyone (but me) is wrong. In truth it’s not X, it’s Y. In Chapter 7, X is that price is a barrier to health care access to the poor. John says that’s not right, that non-price barriers, in particular waiting times, are the main culprit.

    Even if John is right, this set-up still bothers me. What’s wrong with acknowledging that both price and non-price barriers exist? Why does it have to be John against the world? Beats me. But boy is it tiresome.

    By the way, here’s a study that shows that financial and non-financial barriers to care are nearly on the same footing, even for the poor. According to this study, waiting times are not the major issue, even among non-financial barriers. But, yes, non-financial barriers deserve more consideration than they are afforded in policy debates. In light of this, can we really say, as John does, that “everything we have been doing in health policy to make healthcare accessible for low-income patients for the past 60 years is completely misguided”? That’s a little extreme, don’t you think? Extreme views are typically wrong. To accept one, demand the most thorough consideration of the evidence. John didn’t provide that. (Nor, by the way, have I. But I’m not taking an extreme view. I’m not suggesting that nearly everyone else on the planet is wrong. Nor do I need to.)

    Anyway, I reiterate, what I’d like to know is whether the marginal person able to access care — whether due to decreased financial or non-financial barriers or both — is getting beneficial or non-beneficial care. Isn’t that relevant? I would love to know if I’m spending an unpleasant hour in my doctor’s waiting room for something that is worth my time, if not my money.

    John raises the issue of whether health insurance affects mortality, winding up with a citation of Richard Kronick’s study. Stan Dorn, for one, is not as impressed with that study as John is. You can read a lot more about insurance and mortality by Michael McWilliams and Harold Pollack. Citing Michael Cannon, John suggests that the health care additional insurance might facilitate wouldn’t have a large impact on health. I think we need to keep in mind the fact that half of longevity gains in the last half-century or so are due to health care. John sets up the straw-man of decreased mortality being the sole goal of health care. Is that why you usually see the doctor? To prevent imminent death? Me neither.

    There are many studies that show health insurance matters for health, even Medicaid. Does John disbelieve the results of the Oregon Health Study? For all that, you will get no argument from me that Medicaid could be improved.

    John lauds the systems of the Parkland Memorial Hospital in Dallas.

    Clearly the Parkland system should be continued and its replication encouraged in other cities […] with nurses following computerized protocols.

    But, remember, John also doesn’t believe replication of what works is possible. John doesn’t believe that adhering to protocols is a good idea.* His book is very confusing.

    I read the rest of the chapter less carefully. I noticed it returned to a topic I’ve already addressed: waiting times in Massachusetts. I’ll leave whatever John wrote about Canada and the NHS to those of you who wish to discuss it in the comments.

    On Monday I will post about Chapters 8 and 9.

    * I’m being flip. I think it is likely John could articulate when protocols are good and when they’re not. But, as far as I can tell, he hasn’t, or not in a way that I can understand.


    • I found the waiting times part interesting. Like you, I dont find it convincing that they are the only factor. I think the time factor is something that should be remembered as John advocates for people traveling for their health care. Lots of my older patients (younger ones too) are very restricted in where they can or want to go. They need to be close to home so that family can get back and forth to them and still make it home to take care of the dog or other family members. I think these non-financial factors need more investigation and emphasis.

      I hope John can clarify when and how we should learn from other models and experiences. As a doctor, I do suffer from thinking like a physician. We tend to look at data and models. We then try to use those in our own practices. Should we be doing that or not? What would be better? Is there some reason why I should not follow that central line protocol?


    • I was traveling when the sparks were flying over Chapter 4. Since that segues nicely into the issues of quality in Chapter 6, let me recap my views:

      1. Evidence based medicine is cookbook medicine.

      2. I am not opposed to cookbook medicine. It’s why MinuteClinics are so successful.

      3. However, a cookbook can be a master or a servant. If it is a servant, patients will gain. If it is a master, they will lose.

      4. If chosen voluntarily by doctors, protocols will be a servant.

      5. If imposed by a third-party payer bureaucracy, they will become a master.

      6. I suspect that 90% of all doctors will agree with this and not find anything “odd” about my discussion of protocols in Chapter 4 — as Austin and Aaron did.

      7. Price competition will lead to quality competition (now we are in chapter 7) and encourage the appropirate use of protocols.

      8. Ham fisted third-party payer meddling in the practice of medicine will not.

      • 1) Evidence based medicine is most definitely not cookbook. You need to know the evidence behind your choice of tests and interventions. W/o evidence, we would all just make it up. Are you advocating that we stop reading our journals?

        3) Ok. This is better. In order to practice, you need to know the current state of medicine, evidence, and you need to know your patient.

        5) I am sympathetic to this idea, but I cannot really think of an example where this has occurred. During the 90s we had HMOs setting pretty strict limits on pre-approval, but I dont remember them dictating treatment protocols. Maybe in the PCP arena which I dont know as well? On the inpatient side, once they got to us we were not affected at all.

        What I do remember are many instances where there have been proven clinical interventions that were followed by smallish percentages of providers until they became mandatory. OR checklists, anticoagulants for Afib patients, ASA for post-MI patients, central line protocol, antibiotics pre-op, maintaining people on beta-blocker, etc.

        7) I would think of this as price competition will probably lead to the enlightened use of protocols. This should lead to pretty uniform quality.

        8) Ham-fisted anything is bad.


    • We need to distinguish between two things: (1) protocols that should be followed, but are not and (2) protocols that are followed, but shouldn’t be. In Chapter 6, I argue that (1) is most likely to happen if we have price competition. In Chapter 4, I argue that (2) is likely to happen with top down bureaucracy telling doctors what to do.

      Every doctor I talk to knows of instances where (2) has harmed patients. I also hear a lot about this from doctors who post at my blog. Is my sample that much different from everyone else’s?

      All this is about to become more important because of the development of personalized medicine. It’s where the science is going. It’s where the technology is going. But Zeke Emanuel, former White House health advisor who masterminded Obama care, calls personalized medicine a “myth.” Why? Because it conflicts with the standardized care he wants to impose on all doctors and patients. See my discussion in these articles:



    • John
      I appreciate you engaging.

      In your view, which way does value-based insurance design tilt: server or master?


    • Brad:

      Value based purchasing could go either way. It could be used as a tool to deny people high quality care or it could be a tool to reward them for making good choices. That’s why we need competition. At a minimum, we don’t want to give plans perverse incentives to under porvide — which is what the employer-based system is now doing and which will get much worse under Obama Care.

      • VBP may place, say a total knee replacement out of reach for the average enrollee. Evidence, and its correctness or not, will drive the decision to tier the service.

        Do you mean company #1 does not tier and offers surgery at covered rate–minimal OOP, and company #2 tiers with higher OOP (and chooses to abide buy “errant” guideline)–and due to competition, patients go to #1. The presence of both companies offering different options fulfill goals and provides the milieu you prefer? Is this the competition you mean?

        I am not clear if you object to evidence applied to pricing.


    • “Every doctor I talk to knows of instances where (2) has harmed patients. I also hear a lot about this from doctors who post at my blog.”

      I read your blog everyday, but maybe I missed those. What I think we see is problems with service line managers and new dept. chairs imposing protocols that cause problems. To the best of my knowledge, the current guidelines like SCIP measures have not been causing problems.

      We older docs have heard about the coming of personalized medicine, the cure for cancer and the cure for sepsis for years. Most of us are pretty skeptical.


    • “John says he doesn’t have any issues with what I wrote here. What’s most important to him is that private entities work out the risk-sharing arrangements among themselves, rather than a government-imposed solution.”

      Sounds utopian. Does anybody have confidence that insurers will put the patient’s interest first? Sort of like letting bankers set the LIBOR.