• Wait! Defenders of Medicare have a point – ctd.

    Austin gets to the office earlier than I do, so he beat me to this post. He also did a great job, so I won’t take my toys and go home.

    I’ll add one small point. If we accept Miller’s critique that both (1) and (2) are true, then we accept that we spend way too much on (a) care that doesn’t work. Mixed in with that is (b) care that does work. How do we reduce (a) without reducing – or maybe increasing – (b)?

    Some people say that consumers are the best vehicles for doing that. Give them the money and purchasing power and let them decide for themselves. Others say that we should use experts and work in the system to identify (a) versus (b) and then work to decrease (a).

    I favor the latter, and I think the former may result in harm. Miller is forgetting there are other ways to cut Medicare spending than cost-shifting.

    If you think Austin already made this point, I apologize for the duplication. But it’s critical, and so often missed.

    • You mean consumers aren’t skilled scientists, able to judge the efficacy of various medical procedures and insurance plans? That they hire experts (aka physicians) because those experts are better judges than they are?

      Or perhaps you mean large scale purchasers, such as big employers, exchanges or the government, can negotiate lower prices than individuals, as if there were such a thing as bargaining power or bulk purchases?

      You clearly have no faith in the sovereign consumer acting in the free market 🙂

    • Having experts determine what works or doesn’t might work if all patients were substantially the same. But as a physician, you know that there is a wide dispersion in patients’ presentation, examination results, and response to treatments. Throw in differing expectations and values (e.g., patients value pain/pain relief very differently) and you have a situation where any ‘optimum’ solution is optimum only for a segment of the population.

      The advantage to a ‘consumer’ focused solution is not that a consumer is better able to judge the absolute efficacy of a particular course, it is that he/she can better adjust their choices based on ‘local’ variations that a centralized expert panel sees only as another point on a broad bell curve.

      • About 90% of my patients say “whatever you think doc.” Most clearly do not understand the options I give them. If we want to have consumers make more of these decisions, it will take a major cultural change with patients learning a lot more about their options. Since a lot of decisions are made at night by patients stressed over a new, and scary diagnosis, I am not sure this possible for most big ticket spending.


      • Sorry, but patients are substantially the same. I’m a unique snowflake just like all the other snowflakes. In other words, uncommon presentations of common conditions are more likely than commom presentations of uncommon conditions. Thinking otherwise makes care expensive.

        If there is a generic available, prescribe it. Follow guidelines for common diseases (which allow for outliers anyway). We can’t even do those two things in our system.

        As someone who has been an outlier at times, I still have had doctors waste resources because they couldn’t be bothered to follow basic best practice guidelines. Not to mention my time and money. Couple that with other practices that are a waste (yearly visists to doctors for long term prescriptions for instance), there are probably many ways to reduce cost. But that is another way of saying that someone is going to take a pay cut.

        • @MV
          Are you a clinician, i.e., do you see patients in any professional capacity? Yes, we are all ‘snowflakes’ in that we have two legs, two arms, etc. (most of us, at least), but the differences are important in medical care. If you walk through the mall and look at the wide variety of body habitus, and consider that the people also differ in what they eat, what work they do, who their parents were, etc., all of which change what diseases they get, how the diseases progress, how they respond, etc. Pigeonhole medicine will work for some of the people some of the time, but a lot will be left outside the guidelines.

          • As a clinician, I am fortunate that although each patient is unique, the overwhelming majority tend to respond in ways that are predictible. If that were not true, my medical training would have been wasted, since without a scientific basis and scientific measurement of results, we would all be trapped in the “Aleric, Barber of York,” era of health care and everything would be random grouping in the dark. So although it is always necessary to be vigilant for outliers — people who react to drugs with allergies or with abnormal metabolism, surgical patients with anatomic varients, and so on — it is predictable that most patients will benefit from appropriate antibiotics, will have laboratory findings that have stable meanings, will have surgical responses that allow surgery to be useful if used appropriately, will respond to proven treatments, and so on.

            Even though each snowflake is different, they all tend to start to melt when they reach about 32 degrees.

            Medical care is an art as well as a science, but fortunately for us and our patients, the science is in fact the dominant feature of medicine in the 21st century, and it is appropriate for our patients, our payers, and our government to ask us to adhere to proven scientific standards, all the while, of course, watching carefully for the rare exceptions.

    • @SteveSC

      1) a substantial portion of our healthcare system is consumer focused (including employer provided insurance) and costs have risen very rapidly, much more than government provided insurance.

      2) Are you suggesting abolishing insurance? Otherwise, if you’re aggregating large groups of people and hope to contain costs, how will this supposed local variation work in practice?

      • @foosian
        Government provided insurance payments may have risen more slowly than private insurance, but is through fiat and has resulted in less supply and access. Where is the data that costs of care (not payments, but actual cost) is lower? In areas that are truly private pay (such as cosmetic surgery, etc., ) costs actually have come down. Most private insurance is still highly regulated by government, and therefore innovation is limited.

        It is interesting that you equate addressing local variation with abolishing insurance. As insurance has become more and more involved with controlling care, it has increasingly constrained the options for individualized care. There is a fundamental difference between treating the health of a group (where success is decreasing cholesterol by 10 points and equivalent exercises) and treating an individual sitting in front of you. Individuals do not have death rates of 10% or somesuch, they either die or live.

        • “(such as cosmetic surgery”

          Cosmetic surgery (and Lasik, you forgot that one) is really much more like getting a tattoo. There really is no comparison. They also meet the most basic conditions for a market to work, ie, both parties are free to walk away since they are totally not necessary. The large majority of medical care does not meet this condition. Cancer care, cardiac care, etc. are seldom totally elective. Even total joint replacements usually happen because there are limitations in movement or there is pain. Not so for Lasik or cosmetic surgery. Anesthesia care is seldom optional.

          “. Most private insurance is still highly regulated by government, and therefore innovation is limited.”

          What innovation? Insurance companies are required to cover certain conditions decided at the state level. They are usually required to carry a defined amount of reserves. Beyond that, insurers usually innovate by trying to not cover things, or not pay. Real innovations like VBID are not being adopted by any private insurer I know.


          • “They also meet the most basic conditions for a market to work, ie, both parties are free to walk away since they are totally not necessary.”

            So we should not have a market in food? If the market only worked for “totally not necessary” items we would still be hunters and gatherers. You throw up a straw man when you say most medical care is either totally elective or absolutely necessary–what is done and how much it costs is a much more continuous function (except when government mandates only one option, of course).

            “What innovation?”

            Totally agree.

    • This Forum here


      seems to have a rather objective view on how to judge whether or not private insurance as proposed by Repubicans lives up to what the Republicans are saying about it.