Doctors are part of the capitalist economy as well — February 19, 2014

Doctors are part of the capitalist economy as well

That would be my takeaway from any number of Atul Gawande’s works, maybe taking canonical form in [book: The Checklist Manifesto]. If you’re looking for a short intro to the idea, how about Gawande’s piece on the Apgar score? According to Gawande, there’s a more or less straight line between the Apgar score and the rise of C-sections. C-sections may be industrial and clinical, but they seem to lead to higher Apgar scores. You optimize for what you can measure.

Boy, did that Apgar-score essay ever irritate an ex-girlfriend of mine, who had had experience with the hospital system and absolutely hated the idea of birth being mechanized, and mothers being routinely subjected to surgery for something that should be natural and beautiful. I’ll even set aside for the moment the whole question of whether the C-section is better for mothers and babies; a lot of people just hate the idea of medical care being turned into this cold, mechanical, capitalist process.

Doctors seemingly hate the idea of being treated as mere cogs in the capitalist machine, churning out the same medical procedure over and over again. They’d probably hate to be penalized for deviations from accepted practice. That would explain the resistance that Gawande encountered among doctors to their merely washing their hands more often. They might like to believe that each patient is a separate entity with his or her own feelings and needs, and that the main thing the doctor brings to the relationship is empathy — deeply personalized empathy.

I want to believe that too. I also want to believe that the data would bear it out: the more empathetic the doctor, the better the care and the better the health outcomes. And maybe that’s true. But it’s just as easy for me to believe that we want to be measuring rates of central-line infection and hand-washing, and that the way to measure these things is to get doctors to spend a lot more time feeding data into the system that confirm they’re running procedures exactly the same way every time. Hospitals become Taylorist factories. Sorry.

That’d be my response to Bill Gardner’s thought-provoking latest piece at The Incidental Economist. Maybe measuring everything is at odds with understanding the patient as a human being. But given that conflict, which do you think will win? Capitalism always wins. The bet isn’t remotely fair.

Sounds like “ObamaCare kills jobs” in the same way that “stopping people from smoking increases health-care costs” — February 4, 2014

Sounds like “ObamaCare kills jobs” in the same way that “stopping people from smoking increases health-care costs”

I.e., this may be another “tyranny of accounting” problem. See Matt Yglesias for an example.

The usual story with how ending smoking could increase health-care costs is that people live longer, so the medical system has to take care of them when they’re older. (Though without looking at the numbers, I don’t know if this is true. It could be that smokers have to go through long, agonizing cancer treatments that end up costing the same.) By this measure, the best thing for the medical system would be if everyone died in infancy.

Likewise, ObamaCare might make it possible for more people to take part-time jobs now that they don’t need a full-time job to secure insurance; and it might allow people to retire earlier without fear of losing their insurance. I rejoiced almost four years ago that this might happen, and now the CBO thinks that it might.

If we think that people dropping out of the workforce because they can is a bad thing, that is equivalent to saying that it’s bad for people to have more choices. Likewise, if we think that it’s bad for people to live longer and cost society more for their health care, I submit that we’re measuring the wrong things.

Telling Massachusetts patients how much their health care will cost — January 23, 2014

Telling Massachusetts patients how much their health care will cost

This is fine, but … isn’t this what insurers are for? If one hospital on one side of Boston charges much less than another hospital on the other side of Boston, then shouldn’t my insurer be willing to pay me to use the cheaper hospital?

Similarly: shouldn’t my insurer be willing to fly me to another state or even another country, if the cost of airfare plus the cost of the foreign medical care is less than the cost of the local medical care? And if I refuse to fly to India for dental surgery, shouldn’t my insurer say to me, “Fine, but you need to pay us a fee for not having taken the cheapest equivalent medical care”?

I’m not saying this is necessarily desirable. But it’s puzzling that the brave new world of medical care involves my sitting on the phone for hours, rather than letting my insurer take care of it. Paging Corey Robin

The war on the bros — January 18, 2014

The war on the bros

What Uwe Reinhardt said. In short: if you think that it’s an outrage that you have to pay more for your health insurance so that everyone can pay the same premium, including women and the elderly and the sick, then you should have been upset at the existing system of employer-based health insurance. Women and the old and the sick *at your company* are also paying the same premium as you, even though they likely go to the doctor more.

Reinhardt doesn’t even touch on the other obvious fact: one of these days you will be sick. One of these days you and your spouse may want to have a child. One of these days you will be old. When that happens, you’ll benefit from the same community rating that supposedly harms the “bros” today.

Did this country at some point lose the notions that we’re all in this together, that we’re sharing burdens, and that we’re all only one accident away from catastrophe? The phrase is “there but for the grace of god go I”; a just society protects everyone from unexpected, uncontrollable disaster. I hope we can relearn this.

Corey Robin gets at what’s so annoying about Obamacare — December 10, 2013

Corey Robin gets at what’s so annoying about Obamacare

Excellent post. Just one sample:

> A version of this notion came home to me not long ago when my wifes employer announced that they were changing their healthcare coverage. It used to be that our entire familymy wife, daughter, and Iwere covered under her plan, which provided great insurance for fairly low cost. Very old school. Then the employer announced that from now on any member of the familyi.e., mewho was eligible for coverage from their employer would have to use that insurance first. But, and heres the kicker, if that insurance didnt cover some particular procedure or doctors visit, then my wifes insurance would cover it. So now, on certain procedures or visits, I have to submit two claims: one to my insurance, and then, once they refuse to provide coverage, one to my wifes insurance. And then, because we have one of those health care accounts that makes the right so giddy, I can submit a third claim to that company (in the event that my wifes insurance does not provide full coverage).
> One procedure, three claims, all to get what, in more mature democracies, would be mine by right. Thats some freedom.

That comes by way of Robin’s post at Crooked Timber. Like Robin, “Im not interested in arguing here over what was possible with health care reform and what wasnt; weve had that debate a thousand times.” I too would like single-payer. I too think it would just be radically simpler. You pay your taxes, you get your services. Done.

I’m feeling this lately in particular. Our insurance has decided to emphasize “consumer-directed health care,” which means “making the user of health insurance pay more attention to how much things cost.” (We’ve also been offered a new, low-premium, higher-deductible health-insurance plan, paired with a health savings account. An HSA is like a 401(k) for your medical expenses. I hate 401(k)s and love Social Security for the same reason that I hate HSAs and love Medicare.) Two things to note about this:

1. Most of us are not responsible for most of this country’s health-care costs. Getting me to buy a generic medication rather than a name-brand one is just not going to solve any problems. So when a health-insurance company tells me that it’s “consumer-directed,” that’s when I reach for my revolver.
2. There are numerous points of negotiation in the health-care system. There’s the insurer negotiating with the provider (refusing to pay for certain services, say). There’s the insurer negotiating with the health-services consumer (refusing to cover certain procedures). There’s the health-services consumer negotiating with the provider (insisting on generics, or opting for a CAT scan at a scan center rather than at a hospital). And then there’s the government interacting with all the other parties. “Consumer-directed health care,” as I understand it, only works on the provider-consumer side. I’m not convinced that there’s very much negotiation to be had there.

Health care in this country costs more because it’s more expensive. This is not a tautology. For a given unit of care, we pay more for it. You can break down costs in various ways, but basically (total health care cost) = (cost per unit) times (number of units consumed). We don’t consume more units of care; we use hospitals less, in fact. We just spend more for a given unit of care than other countries do. One very obvious way to pay less for a given service is to change the balance of power between the provider (the doctor) and the insurer. If there were only one insurer out there that paid for all of your medical services, it could strong-arm the doctors. This is not rocket science; it’s how Wal-Mart offers low prices. It’s how Medicare offers low prices.

So whose problems is the insurance company solving when it makes me negotiate more with my doctor? It’s not solving the health system’s problem as a whole. It’s not likely to lower my prices. [foreign: A priori], my assumption is just that this is a disguised way for the insurer to make more money, by covering a smaller fraction of my costs with Obamacare’s blessing and with a friendly pat on the back while they tell me I’m on my own. If we had perfect price transparency, then maybe our negotiating power would have some teeth. And maybe Obamacare has some innovations to push in that direction; it certainly is filled with experiments that may really pay off. And Medicare is putting price data for individual providers up on the web. It’s not consumer-friendly at the moment, but it’s a start. With that sort of transparency, maybe we could actually make some use of “consumer-directed health care.” Even then, I’d still prefer that someone else — someone who spends all his or her time working to get good deals on health care — do this for me. Someone like my employer, say. But then, why would my employer want to do this? My employer is good at building software; there’s no reason to expect that it’s any good at judging which tests the doctor should give me. Let’s centralize the bargaining.

Incidentally, I’m also convinced that, within my employer, everyone is going to end up on bronze plans, or what would be called bronze plans if we were buying them through the exchanges rather than through our employers. Imagine that you have a choice between a high-deductible, low-premium plan and a low-deductible, high-premium plan. People who believe that they’re not going to need much health care (the young, the healthy) will opt for the high-deductible plan. Those who are more worried about their health will opt for the low-deductible one. This will lead to something that looks a lot like the classic adverse-selection death spiral: since the high-deductible plan is getting the healthy people, the low-deductible plan will have higher costs this time next year, which means it’ll have to raise its premiums. But then more people (now a somewhat sicker group) will rationally decide that the low-deductible plan doesn’t make financial sense for them, and will opt for the high-deductible plan. And so on.

I don’t know how much of this was planned ahead of time, but it seems perfectly obvious now. The cynical but, I’m afraid, probably correct take on it is that we now have two choices:

> to be ground down a bit at a time by technocrats who either wont admit to or do not understand the ultimate consequences of the policy infrastructures they so busily construct or to be demolished by fundamentalists who want to dissolve the modern nation-state into a panoptic enforcer of their privileged morality, a massive security and military colossus and an enfeebled social actor that occasionally says nice things about how it would be nice if no one died from tainted food and everyone had a chance to get an education but hey, thats why you have lawyers and businesses.

“Conservative” health reform — November 23, 2013

“Conservative” health reform

You should go read Uwe Reinhardt. That’s true 100% of the time, but it’s especially true here. Reinhardt writes about “conservative” health reform, where “conservative” somehow means “involving a great deal of intrusion into everyone’s life.” Remember how one of the big problems with is that it’s required to connect to so many other systems to confirm details of the beneficiary’s life? It needs to confirm that you’re not in the U.S. illegally; needs to confirm that your income is low enough to qualify for subsidies; needs to connect to private insurers’ websites; etc. How is that conservative? It’s likely to make an already inefficient system even less efficient.

Why is this so hard? I don’t need to sign up for bronze, silver, and gold national defense. I pay my taxes, and I get a service in response. Let’s just expand Medicare to everyone and call it a day. Or extend the VA hospital system to everyone and call it a day. Inasmuch as ‘conservative’ should mean ‘delivering a given level of service as cheaply efficiently as possible’, those approaches would be highly conservative. Instead we get systems that are more and more jerry-rigged over time, with more and more obvious flaws. Enough already.

LazyWeb request: Uwe Reinhardt, “The Disruptive Innovation of Price Transparency in Health Care” — November 13, 2013