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Tuesday, August 25, 2009

How American Health Care Killed My Father - The Atlantic (September 2009)

How American Health Care Killed My Father - The Atlantic (September 2009)

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This article really hits the nail on the head. It takes a sharp mind and an innovative thinker from OUTSIDE of medicine to have this perspective. This is a must read.

Saturday, August 22, 2009

Value based Medicine; Paradigm Shift or Marketing Ploy

Value is the buzz word in medicine this year. I must agree that it sounds great but I think we need to step back and make sure that everyone using the term has a common understanding of the term. Value can only really be understood within the terms of exchange and is commonly converted to monetary units because of the almost universal acceptance of these units. Value in the business world is relatively straight forward to define and understand because the architecture involved in exchanges. There is usually a buyer and a seller and the value of the product or service exchanged is defined by a voluntary exchange between the two parties. Each party ultimately receives value from the exchange or the exchange does not happen barring fraud or coercion.

Medical exchanges insert a whole new series of complications into the value equation. Because of insurance, at least one third party is injected into the equation which often results in the the purchaser of the service not being the recipient of the service. This aspect of value in medicine is virtually always glossed over. However, how can one begin to assess the value of any given transaction within the health care realm which has this exchange architecture?

The question becomes value to who? For transactions from which the patient incurs virtually no cost, almost any intervention which does not harm the patient is of value. Physicians as choice architects can generally sway patients to acquiesce to blatantly non-harmful interventions which may be financially beneficial to their practices. However, these transactions may not be of any value to the payer. In fact, virtually no transactions are of value to he payers.

In conventional two way exchanges, either party has veto power. In three way exchanges, it gets much more complex. What should be the rules? Who can and should have veto power? In reality, physicians always have veto power. They essentially cannot be compelled to treat a patient with a given treatment. In addition, patients should always have veto power. They may be ill suited to exercise this because of problems with information deficits. In an insured world where they are heavily insulated from costs, financial considerations are less likely to be a reason for saying no. Whether they decide to agree to a given intervention will be based upon whether they perceive they will be better off, independent of cost.

That ultimately leaves the payer with the most relevant veto. Should it be that majority rules and that the provider and patient can trump any payer veto? If the patient believes the intervention is of value to them, should the payer's vote count for anything?

Assuming the answer to this question is yes, the follow up question becomes on what basis should the payers be able to veto payment for services?

Presumably the answer to this question should be - if the intervention is of any real value, the third party should pay for it. The question then becomes value to who? Which value are we talking about? Is it value to a given patient, the average value to populations of patients, or the value to payers which is the determining factor?

It reminds me a hearing Ralph Nader speak many years ago about the deceptive practice of advertisers who would make all sorts of claims of the nature of "50% stronger" or "last 30% longer" but failed to define stronger or longer than what. The point is that value based medicine is a meaningless term unless it is defined within the context of value to who. This sort of ambiguity relegates the term of value based medicine to a marketing slogan as opposed to any real idea as a driver of health care reform.

Once we as physicians more into the realm of treating populations, as opposed to individual patients or become agents of third parties, we have gone down a dangerous path. I am not ready to face patients and tell them, although you have come to me for managing your health issues, I do not primarily represent your interests. I treat and represent the interests of individual patients. They should decide if there is value in what I offer. No third party who enters into the equation will ever be in a position to place a given patient's interest over their own financial interests.

Saturday, August 1, 2009

Why things thrive

One of my favorite books I have read in recent years is a book written by the economist Paul Omerod which is entitled "Why things fail". It is a fascinating study of failure of a variety of things ranging from fortune 500 companies, animal species, and civilizations. Its observations have implications in virtually all realms of human activity.

The take home message is that you can predict that things will fail but you cannot consistently predict what will fail, when it will fail, and what will trigger failure. Sometimes stressing an entity or system with a major stress will result in nothing while a small perturbation may result in cataclysmic effects.

The companion question which Omerod does not address directly is how do robust complex entities develop and persist? However, one can infer this from his observations, from the study of human history, and from study of biological systems. I maintain that complex systems, whether human systems or biological systems, have much in common and principles derived from one can be useful in understanding the other. This truism is not newly observed. Charles Darwin was heavily influenced by the preceding work of Adam Smith and David Ricardo in the realm of political economy when he conceived his work on the theory of evolution.

How do complex systems come to exist? There appears to be a tendency for humans to look for some sort of master designer, based upon the belief that complexi systems cannot come into being through self organization. Furthermore, it also appears that humans crave to be able to take on the master designer role, believing that is is possible for humans to take on God-like qualities.

Evolutionary theory and copious supporting observations point to complexity in biological systems developing in a bottum up fashion. Even the most complex systems can develop given sufficient time, feedback loops, and mechanisms supporting diversity. However, for every successful iteration there are likley many failures. Furthermore, the certainty of changing environments means that todays successful iteration will likley be tommorrow's failure.

While we humans desire to create and control complex social systems, I believe we delude ourselves if we think conceive the optimal structure of these systems. Best practices in social systems have developed in an ad hoc way in different places in different times. Many diverse human populations have tried many approaches to human organization and the extraordinary improvements in human existence over the past 400 years are the unintended products of legal and social constructs put in place for other reasons. Good tools do what they are designed to do. Great tools do much much more. Robust social systems adapt like biological systems. Over time adaptable and diverse social systems can respond to and thrive in changing and stressful environments.

What does this all mean? The only thing that never changes is that everything changes. For anything to thrive and survive long term, it must change and adapt and ultimately evolve into something else. The desire to plan and control works well as long as one realizes that for all the planning we do there is a limited realm where we have control.


I read a review of Paul Starr's 1982 book The Social Transformation of American Medicine and a retrospective of this work published in the Journal of Health Policy, Politics, and Law in 2004. The journal published a condensed version of the original work which has prompted me to order the book. Perhaps the work may be a bit dated given it was published almost 30 years ago, but I was struck by two things. First, present events can be viewed with greater insight given the historical background provided by Starr and in addition, Starr was remarkably prescient in predicting future events.

Starr's analysis of professionalism and power in medicine is enlightening and provided me with a better understanding of the role of claims of professionalism in various political positions of organized medicine. The series of events which occurred and allowed medicine to attain power, status, and money during the 20th century were unique and perhaps not sustainable.

A number of changes have occurred in the health care environment have eroded physician autonomy and status. At the same time concerns have been raised regarding the loss of professionalism among physicians and medical practice in general. My own experience in dealing trainees in general suggests that the elevation of medicine into a high income field has fundamentally changed the types of candidates who we attract to the field. Because medicine is so lucrative, we now attract smart people who place a higher priority on income generation. When medicine was not so lucrative, individuals with primary financial motivations steered clear.

An obvious solution to this problem is to decrease physician compensation to attract people with the right motivations to the profession. However, that might solve one problem and replace it with a less desirable state. What is the goal of providing any reward whatsoever? Ultimately what is the purpose of having physicians and what is the advantage of a professional class vs. someone who we employ or contract with to provide services?

Whether we like it or not in the modern world we must rely on other people to provide us with both things we want and things we need. The spectrum of virtues and faults displayed by those who provide our needs is extensive. You can be assured than none are perfect and it is a reasonable assumption that most operate with their self interest in mind. Even if the health care profession is not driven strictly by self-interest, it will be a rare exception who does not suffer from pressures from constituencies other than patients they serve (family, colleagues, employees).

What we want from our physicians is that they fix our problems. If they get rich honestly by doing so, so be it. Cultivating a virtuous but inept workforce creates more losers than winners.

More money less professionalism