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Wednesday, February 24, 2010

"Bending the Curve" without wishful thinking

This is a great piece on the variables which are drivers of health care inflation.

It all about how complex this issues are and our limited ability to tease out all the drivers. I tend to think about problems like this in terms of complex clinical problems.  I deal mostly with symptomatic but not necessarily life threatening disease, frequently long standing. I am often put in the situation where the patient wants both an explanation for why things have gone wrong and also wants to be relieved of their symptoms. Many times I simply cannot sort out all the drivers of a specific clinical problem. However, I can use some basic therapeutic principles to alleviate their suffering, dependent upon a broad understanding of pathophysiologic processes but short of a complete or even near complete picture. As long as I am in the neighborhood (am I dealing with animal, vegetable, or mineral?), I can make an impact.

Looking at the health care reform debate I feel no particular obligation to understand every small detail of pathology in order to feel comfortable with an approach to improve outcomes. While the health care debate has moral implications, the spiraling costs are primarily an economic problem. Looking at the runaway cost issue in health care economics, one can make a similar assessment using observations of the present state and looking at similar economic scenarios. Based upon history one can be pretty confident the spiraling upward costs happen when t0o much money is chasing after something and/or those spending are spending someone else's money.  In the case of health care it is both. No amount of regulatory complexity or moral posturing will  change how this turns out. Markedly skewed financial incentives will trump everything and appealing to the best in humanity will not succeed when we financially reward our worst impulses.

Moral indignation may drive some to use the blunt force of the state to try to control costs. While the impulse is understandable, even the most modest appreciation of previous attempts to use such an approach (and there have been many) will have to lead even the most ardent proponent of legal cost controls to be a bit leery of pushing this agenda. Perhaps this time is different. Where have I heard that said before?


  1. As you point out, financial incentives conflict with the greater good. Which of the stakeholders, including physicians, will surrender income and control to pursue true health care reform? This is the Gordian knot. Even the physician community - one player among dozens - isn't unified. We wouldn't design the current system if we were just starting out, but we can't scrap what we have. I'm prepared for incrementalism.

  2. I could not agree with you more. The incremental approach will involve placing many small bets with the hope that at least some of them will pay off. We must understand that many of the bets will simply be losers.