• Reducing suffering vs. reducing costs

    Bill Gardner offers his customary wisdom:

    80% of Medicare dollars are spent on persons with five or more chronic conditions. In essence, there is a great concentration of illness and expense in a relatively small group of people. […] So let’s save costs by making them healthy, or at least getting them cared for more efficiently.

    I’m all for it.

    But I am skeptical whether this will save a lot of money in any short run. It is true that caring for these souls often costs more than it should, because they have avaoidable hospitalizations and emergency department visits. But the better alternatives — schemes for intensive outpatient care — cost money too. Moreover, if you decide to focus your attention on someone whom your records suggests has four chronic conditions — say, diabetes, hypertension, arthritis, and glaucoma — you will often find additional undiagnosed problems — say, depression, or periodontal disease. When these problems come to light they will generate health care costs. I’m not arguing that caring for these patients is futile. You can relieve suffering, and save some money. But most of these patients will remain ill, and expensive.

    So why is this the best way to cut health care costs? Let’s get our priorities straight. The reason that this is the most important way to cut health care costs is that this is where the suffering is! If we can relieve some of the suffering, and break even on cost, then this is the most important thing we can do. [Bold mine.]

    In all the debate over health reform and health costs, how many of those make this point loudly and unambiguously? If we spent a little more time exploring the physical and mental anguish that some of those with multiple chronic conditions deal with — those for whom we are spending the vast majority of our health care dollars — we might retain a better grip on what this is really all about. It’s a bit like spending a fortune on repairing and renovating one’s home and never stopping to notice one’s family members who receive shelter from it.

    I’m as guilty of this as the rest of the media and policy wonks, maybe more so. I might as well be throwing money at people, sick people, with disgust. It’s not really how I feel. But I don’t acknowledge them enough. If I’m going to spend the money (or, rather, if the tax revenue I contribute is going to be spent) on them anyway, I might as well deliver more dignity and recognition with the cash.

    It only takes a moment to honor someone’s humanity. Let this be such a moment. And let there be more of them.

    • A classmate of mine makes this point often. In the research and policy world, we often get so caught up in justifying policies on the basis of indirect economic consequences. “We should lower copays on effective generics because it offsets inpatient costs,” “We should pool sick and healthy folks to so selection doesn’t break down markets” “We should empower women in poorer countries because it helps development”. Yes, these are all good reasons for the policies.

      But, the most important reason is that these policies benefit the vulnerable. We shouldn’t be obsessed with the externalities.

    • Good to see that economists also have hearts and are aware of suffering.
      I wouldn’t be so quick to dismiss the economic benefits of improving the health care for those with multiple chronic diseases. This is, after all, where the money is and this is where there is a large potential savings. Numerous studies have shown that you can save lots of money in the short and long term by controlling blood sugar in diabetics, blood pressure in hypertensives, pulmonary flow rate in asthmatics and cholesterol in cardiac disease (as examples). The cost of these interventions is much less than the cost of hospitalizations and expensive procedures. A lot of these programs can also be implemented through patient education and frequent telephone/email contact through ancillary health workers.

    • — those for whom we are spending the vast majority of our health care dollars —

      If you were only spending your own money, then your compassion would be laudable. Unfortunately, when you speak of “our health care dollars” you are really speaking about other people’s money.

      Finding a way to improve the affordability and access to medical care is important—but this goal must be accomplished while staying true to the principles of voluntary association and rule of law, the essential underpinnings of civil society.

      Coercion is not compassionate. Not even when processed through the voting box.

      • No taxes then? Not a penny? For anything?

        • I liked your initial response better: “Huh? No taxes then? If you justify them for anything, why not to support health in some fashion? If you don’t think taxation is ever justified then you’ve got a consistent point of view, but you’re thinking of a very different society than one you know.”

          A major problem in the health care (or any social welfare) debate is that many who support government-enforced transfers of wealth tend to ignore or downplay the fact that what they are advocating tosses equality before the law right out the window–and all the problems which emanate from abandoning that principle.

          Relying on government for social engineering shifts the function of government from protecting individual rights and liberty to using force to benefit some at the expense of others. This changes the character of social relations from one of primarily voluntary association to greater and greater amounts of coercion. Is this really the direction we want to keep heading? In any cost-benefit analysis of a proposed system of health care delivery, these effects need to be included.

          I would argue that a better direction to head is one which attempts to solve the affordability/access/quality problem while emphasizing persuasion and voluntary social relations, keeping the use of government coercion to an absolute minimum–ideally eliminating it altogether.

          It’s important to look at the evidence of what is cost effective, at what “works”—but there is more to the problem than that. I can not believe that if someone devised a health care delivery system and proved that it could achieve universal access, superior health outcomes at a lower cost—but it required the resurrection of chattel slavery–that you would find the “solution” acceptable. Some “solutions” are wrong enough on the face of things that they lie outside the acceptable tool box. I just think that using majority rule to justify government coercion is a tool that must be used sparingly (if at all) and the down-sides of its use must be addressed.

          The use of force has consequences. So does deviation from equality before the law –which cannot coexist with the welfare state. The more regulatory control you delegate to government, the more rule by law is replaced by rule by men. It is a mistake to ignore or discount the importance of these issues and the kind of society you create based on where you draw the lines.

          When I read your posts, it is clear that you care greatly about people and the kind of world we live in. We have that in common. I’m interested in understanding what you think about these wider ramifications of policies which require a heavy dose of government control over the decisions and lives of private individuals..


    • Thank you for the links. It will take a while for me to digest and understand these posts. Okun’s book sounds very interesting and helpful.
      I greatly appreciate the work you are doing to clarify the issues and keep the data honest.