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Wednesday, April 7, 2010

The power of saying No

David Leonhardt asks a very simple question in his column entitled "In Medicine, the power of No"  in the NYT today;
How can we learn to say no?
This seems like such a simple question but its complex answer underlies the apparently unsolvable quandary we find  ourselves in relating to allocation of resources to pay for health care. At the simplest level the question is ambiguous since it is not clear who we is. Each of us individually have no problem whatsoever saying no within a host of contexts. We say it every day, frequently more than once. We say no to our children, to our spouses, to our colleagues at work, to our friends at churches, synagogues, and mosques, and to ourselves. We recognize that our personal resources are not without limits, particularly time and we disappoint those around us by declining that dinner invitation, that opportunity to serve on the PTA board, the request to make an additional contribution to the police benevolence society. While some create problems in their personal domains by their inability to say no, for the most part people are individually pretty good at this. Ask any telemarketer and see what their hit rate is.

Something happens when we move from individuals making decisions about the allocation of their personal resources to groups of people allocating resources other than their own. Individuals have no trouble saying no because they are acutely aware of their many wants which virtually always outstrip the capacity of their personal resources to deliver. If individuals cannot husband their own resources, they quickly run out of resources. The bank takes their house. Their credit cards are no longer accepted at the local Target.

Once we move to groups and group resources, we run into the tragedy of the commons. What is owned by all is often protected and valued by none. What is the upside of saying no? Saying no in these circumstances cannot be leveraged to delay gratification for a payoff later. When it comes to common resources the use it or lose principle is basically always in play. Once potential future resources can be tapped via borrowing, the incentive to delay gratification becomes unthinkable. Where is the wisdom of saying no to anyone or anything?

Leonhardt's piece goes into great depth discussing various scenarios in the medical world where no one appears to have any incentive to say no to anyone else. From 20,000 feet, each of his arguments makes sense. Our inability or lack of incentives to say  no is part of the engine which drives crazy spending on activities from which patient likely derive little value, at least from the standpoint of examining what we believe they need.

However, the perspective taken is remarkably myopic. While undefined, much of the activity which falls under the definition of health care are services which are desired by but not necessarily needed by patients. While this distinction may be easy to sort out retrospectively in a non-pressured and contemplative environment, it is basically impossible where providers and patients meet.  In a world where both people's needs and wants will be paid for by common resources, who will be in the position to say no without appearing to be arbitrary and capricious? In fact, how can these decisions be anything but arbitrary and capricious when needs and wants morph so quickly as to be undefinable.

It is easy to see how it will play out. Common resources will be created through taxation and controlled by the state. State officials will be selected through the process used to select state officials, that is a political process. While state agencies may be guided by expert panels, the selection of the experts will be through a political process. Decisions of need and allocation of scarce resources will be done through politics. When do politicians say no? They say no when they can garner no additional resources. They say no when we are broke and their usual sources of credit are no longer available. They say no when they can no longer say yes. Saying no is not learned behavior, it is forced behavior.


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