I am incedulous that this activity has not received more attention!

From the Washington Post today(Link). This is an op-ed piece from Nicholas Quinn Rosencranz regarding the Justice Department's settlement with various large banks which included the requirement for donations to various community development groups.

What is less well known is that some of this money — amounting to hundreds of millions of dollars — is designated for “donation” to various “community development” organizations that were neither parties to the case nor victims of the alleged wrongdoing. Investor’s Business Daily has characterized these payments as “political payoffs to Obama constituency groups,” and Congress is now considering banning this practice with the Stop Settlement Slush Funds Act of 2016.

How bizarre!  The constitutional issue is obvious. The settlement represents money paid to the Federal government which is then appropriated to pay another party, without any Congressional approval. What we are seeing as the discretionary portion of the Federal budget essentially disappears is the use of DOJ shakedowns of private entities for cash then used to repay politically connected.

How can we better the world?

Deirdre N. McCloskey published what I consider a spot-on piece today in the WSJ. (Link) It is titled "How the West (and the rest) got rich". It is well worth reading in its entirety and I will almost certainly pick up a copy of her new book, “Bourgeois Equality: How Ideas, Not Capital or Institutions, Enriched the World,” .


I am fascinated by why certain systems work well while other systems do not and I have come to believe that functional complex systems develop not because of intelligent design, but because of innumerable trials resulting in many failures and few successes. Thus the great enrichment is described by Dr. McCloskey. The essay is eloquently written and I thought it useful to highlight some of the most pithy parts.

Nothing like the Great Enrichment of the past two centuries had ever happened before. Doublings of income—mere 100% betterments in the human condition—had happened often, during the glory of Greece and the grandeur of Rome, in Song China and Mughal India. But people soon fell back to the miserable routine of Afghanistan’s income nowadays, $3 or worse. A revolutionary betterment of 10,000%, taking into account everything from canned goods to antidepressants, was out of the question. Until it happened.

Why did it happen? McCloskey goes on to write:

But none of the explanations gets it quite right.
What enriched the modern world wasn’t capital stolen from workers or capital virtuously saved, nor was it institutions for routinely accumulating it. Capital and the rule of law were necessary, of course, but so was a labor force and liquid water and the arrow of time.

What appears to have catalyzed this were ideas and liberty:

The capital became productive because of ideas for betterment—ideas enacted by a country carpenter or a boy telegrapher or a teenage Seattle computer whiz. As Matt Ridley put it in his book “The Rational Optimist” (2010), what happened over the past two centuries is that “ideas started having sex.” The idea of a railroad was a coupling of high-pressure steam engines with cars running on coal-mining rails. The idea for a lawn mower coupled a miniature gasoline engine with a miniature mechanical reaper. And so on, through every imaginable sort of invention. The coupling of ideas in the heads of the common people yielded an explosion of betterments. 

Power hungry statists and control freaks on both the left and right have been suspect of both liberty and change and have repeatedly attempted to vilify commercial interests which have been the drivers of growth and change:

Not everyone was happy with such developments and the ideas behind them. In the 18th century, liberal thinkers such as Voltaire and Benjamin Franklin courageously advocated liberty in trade. By the 1830s and 1840s, a much enlarged intelligentsia, mostly the sons of bourgeois fathers, commenced sneering loftily at the liberties that had enriched their elders and made possible their own leisure. The sons advocated the vigorous use of the state’s monopoly of violence to achieve one or another utopia, soon.
Intellectuals on the political right, for instance, looked back with nostalgia to an imagined Middle Ages, free from the vulgarity of trade, a nonmarket golden age in which rents and hierarchy ruled. Such a conservative and Romantic vision of olden times fit well with the right’s perch in the ruling class. Later in the 19th century, under the influence of a version of science, the right seized upon social Darwinism and eugenics to devalue the liberty and dignity of ordinary people and to elevate the nation’s mission above the mere individual person, recommending colonialism and compulsory sterilization and the cleansing power of war.

On the left, meanwhile, a different cadre of intellectuals developed the illiberal idea that ideas don’t matter. What matters to progress, the left declared, was the unstoppable tide of history, aided by protest or strike or revolution directed at the evil bourgeoisie—such thrilling actions to be led, naturally, by themselves. Later, in European socialism and American Progressivism, the left proposed to defeat bourgeois monopolies in meat and sugar and steel by gathering under regulation or syndicalism or central planning or collectivization all the monopolies into one supreme monopoly called the state.

McCloskey summarizes:

Rep. Thomas Massie, a Republican from Kentucky, had the right idea in what he said to Reason magazine last year: “When people ask, ‘Will our children be better off than we are?’ I reply, ‘Yes, but it’s not going to be due to the politicians, but the engineers.’ ”
I would supplement his remark. It will also come from the businessperson who buys low to sell high, the hairdresser who spots an opportunity for a new shop, the oil roughneck who moves to and from North Dakota with alacrity and all the other commoners who agree to the basic bourgeois deal: Let me seize an opportunity for economic betterment, tested in trade, and I’ll make us all rich.

I agree with McCloskey that political entities may create the necessary framework for betterment but there are limits as to what politics can accomplish. You cannot fix a fine watch movement with a ball peen hammer. Some might argue that enrichment is not a desirable end. I would suspect most of those making those claims do not live in abject poverty.  

 

How do we know who is a good doctor?

I am a following "the Incidental Economist" (Link) and Healthcare Triage News. Aaron Carroll blogged on pay for performance programs and wrote a commentary late last year on measuring quality (Link).  There was also an article in today's NYT examining narrow networks and limited access for patients to providers outside of their designated networks (Sorry, we don't take Obamacare - link). What do these items have in common? What they have in common is the need to be able to measure quality. Who care if you are locked into a narrow network if it delivers what you need well? We all sort of lock ourselves into narrow networks when we end up selecting specific physicians to deal with our health care problems.


As I see it, we have a very basic problem in that more often then not, those needing services are really not in a position to discern whether a given physician (or other health care provider) is really good at what we need them to be good at. (When I use the term physician, please view it as a short hand for health care professional delivering a service). Obviously for those physicians who do very specific life saving or function saving targeted interventions, we may be able to sort through who is at the top of the heap v. those at the bottom. Even that can be tricky. A good set of outcomes for an orthopedic surgeon who replaces hips may be due to the fact they are in a position to cherry pick or a less than optimal set may be due to them being the go-to person for difficult cases.


Even more challenging may be within the larger universe of providers who do deliver services where it is difficult to impossible to define what quality is? One can march through the different specialties in medicine and it is the exception rather than the rule that clear criteria can be defined which allows any given person to identify who delivers high quality care.  How does one determine whether a gastroenterologist is good at colonoscopy? Yes, one can look at complication rates but the primary purpose of the exam is not simply to avoid trouble. You can always avoid the complication of the procedure by not doing it. How can one determine if a thorough exam was actually done? Are more biopsies better than fewer? What are the actual deliverables? A similar situation may be relevant for dermatologists? What represents a good skin exam? How can this be measured?  For primary care physicians, what constitutes a good or excellent annual check up? Who is doing the best pelvic exams? Who is the best pathologist? Is it the ones who diagnose the most or the least cancers? How can one discern who are the best pediatricians?
Those with great technical skills may have less than optimal judgement, work ethic, or interpersonal skills. What problems do given physicians within specific specialties actually solve and just how good a job do they do in solving these problems? What information do we have at our disposal to address these issues? We do have the annual best doctors issues for local publications for most major cities. However, the selection process for these is a popularity contest which reminds me of elections for class president when I was in high school. It takes into account essentially no quality data. Furthermore, does any actual quality data linked to a given doctor or other provider reflect the physician competence or other aspects of the team over which they have little control?


It is not an unusual circumstance where I am asked by a friend to make a recommendation for care within my system. I know a number of my colleagues on a personal level but truth be told, I really have very limited insight into what type of physician they actually are. I have basically little or no access to hard numbers in terms of whether they solve the problems of patients who they see. There are exceptions (primarily those who I work with every day)  but for the most part I have not directly and consistently witnessed the bedside manner of most of my colleagues or have clinically significant knowledge regarding the quality of their problem solving skills.


Then move into a domain where people have marginal medical knowledge, experience, and insight and imagine how they make these determinations. They simply are flying blind. Patients and their families can determine if someone spends time with them, listens, and makes an attempt to communicate. These observations are important but may not track with the ability to fix whatever problem that needs to be fixed. The may be especially true when the services delivered are done so for goals which may be realized well in the future. Patients can be very impressed with the quality of a service delivered that they did not actually need. One can generate impressive numbers if one is in the business of delivering preventative care for diseases that never or only rarely happen.


This brings us back to the original question; what can we measure to determine who is the best? Perhaps even more important is what can we measure to determine who is simply good enough? Not everyone can access the best and always spending money to get the best may be a bad investment of someone's scare resources, especially if the stakes are not so high.  How can patients tell if the providers available within their networks will likely be able to meet their basic needs and goals?  I believe the path to being able to address this problem will require inputs from both those delivering care and those receiving care. It will mean looking at both high stakes environments and lower stakes environments. It will unquestionably require that we better define what the specific goals of care are. Service delivery without goals can never fail. As the saying goes if you have no destination anywhere you end up should be fine. Similarly service delivery without measurable goals can also never fail and service delivery where the measurements are not aligned with the patient goals will almost always fail.


The fact that measuring what is expedient has ended up not getting us to where we want to be should not come as a surprise and should not prompt us reject striving for measuring outcomes. For us to sink more and more money into an industry which has dismal quality control is simply not an option.