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Sunday, November 22, 2009

A Rose by Any Other Name...

I am not sure how much you have followed the latest solution du jour to fix our health care woes- reforming physician compensation models.

My punch line- "there are lots of way to compensate physicians and they are all bad".

So what stuns me most about the level of dialogue in this debate is the notion that the people who work in the trenches are really that stupid. Economists are an odd lot.

I think all of you know my position on rationing so I needn't discuss it again, but I want to take you for a walk for a moment down memory lane...

In the 1990's, HMOs, trying to keep costs down, actually paid some physicians more to do less testing, etc... this saved the HMOs, and therefore their members, lots of money.

Sadly a few instances arose- I am not sure how frequent these were and in truth I suspect they were rare- where it was found that the financial incentive to not perform testing negatively influenced patient care. Again, I suspect this was probably rare (though I don't know for sure) but the instances made headlines and juries reacted with massive economic damage judgements against the providers. In short order these compensation models vanished (at least as far as I know).

Fast forward to November 2009. This is the state of where we are today.

I want to highlight a small passage for your consideration:

The Finance Bill proposed automatic reimbursement reductions for doctors who order up the most care for Medicare recipients with similar medical and demographic characteristics. That was meant to respond to the research showing big disparities in spending on medical services for similarly-situated patients in different communities. But, Democratic sources say, that proposal ran into charges that it would promote rationing-and even function as "a death panel by proxy"-by compelling doctors to arbitrarily reduce care. So the final bill takes a less direct route toward a similar end. It requires Medicare to begin studying the utilization patterns of doctors participating in the program. And then it establishes a "values based payment modifier" that would, in a budget-neutral manner, increase reimbursements for physicians found to deliver high-quality care at lower cost, and reduce them for physicians at the other end of that spectrum. "It will, we believe, have the same net effect [as the original proposal]," said the Democratic aide. "It should change behavior around that threshold."

Does a rose by any other name smell as sweet?

As I have said many times before and will probably say again, the most expensive thing of all is the loss of trust. What does this do for your trust when eventually learn about it and realize that physicians are now paid by the government to do less testing when they see you?

Forgetting the obvious truth that HMOs are out to kill you but the federal government is here for your protection (as long as your protection is not less important than some other person/agenda that faction of the government is also trying to protect), do they really think physicians/attorneys/nurses, etc... are really that stupid?

Again, I am not necessarily opposed to this- though if I were czar I would do it differently- as I do understand the predicament we are in (at least I think I do).

But my point is that it was always trust in the system that was always the most important issue in the first place. Do you think most Americans understand this issue? When they do, will it help them feel more secure? If you are a conservative suspicious of government involvement to begin with, what will you think?

What has happened to this collective? We will send our children off to die to protect us (may or may not be a good idea) but we cannot accept small levels of personal insecurity so that we all personally benefit?

Like the issue we are seeing with vaccinations, where heroes of mine have created the following blog, this issue is clearly a mirror of things like the credit crisis, etc...

The most expensive thing of all is the loss of trust and all when a rose by any other name...

FYI- here is an article dated 2000 which basically discusses the same thing.

Forgive me if I have to let it slip once again: the more things change, the more they stay the same... ;-)


Debra said...

Thai, following your last post, I basically did NOT tell you, as I could have ? should have ? that I thought that you have already, to a certain extent, sold your soul to the system in the idea that you HAD to report certain mothers for being "dangerous" in child care. Y'all rather blithely assumed that I was a good mother at the time, or that I was grossly overestimating the extent of my maternal incompetence. But... this simply is untrue. My own psychological training is sufficient for me to evaluate just how flimsy a mother I was at the time (one of my Daddy's favorite stories was of a med school professor who announced to the class that his aneuyrsm had just burst and that he was about to drop dead, which he promptly proceeded to do, (yes, it IS nevertheless possible to be lucid about one's... melancholic state in my case...)).
You are right to talk about trust, Thai because...
medecine is just NOT business.
And... what is going on in healthcare translates our misguided ideas about... what MONEY is worth.
Does... spending more money = getting better care ?
Is that TRUTH ?
I think that we can all, on this blog, say that this is NOT true.
The problem is... why do we, as a collectivity, seem obsessed with the idea of translating value into...+ and - $ ?
Why do we... start talking $ whenever there is a problem, and start throwing..$ when we see one ?
Why do we... BELIEVE this ? Because... it is indeed a belief. Like.... GOD is a belief, you guys.
As I say in the jungle... we believe in... numbers. We believe in... abstraction, and the greatest abstraction around is that... number. And.... coupling it up with...$, that is just too good a temptation to pass up...

Debra said...

I forgot to add... we believe in numbers BECAUSE, we just individually and collectively can not manage to muster belief AND trust in ANYTHING or ANYBODY else. It really is... that simple...

Thai said...

Deb re: "sold your soul"

I know this. Indeed I absolutely gave it willingly long ago and am frustrated that others refuse to do the same- though I recognize it is their choice.

I also know what the consequences will be if they do not.

And re: trust and money

Dink and I have spoken quite a bit on this. If you were not following the conversation, perhaps this will help:

Trust is a form of money. At some level they are absolutely interchangeable. AND as is the nature the duality of all things, trust and money are also very much distinct.

And just as changing dollars into euros always entails a conversion cost (remember the issue of symmetry breaking releasing energy I was so stupid to not see?), so too is the same true with converting dollars to trust and vice-versa.

Hope this helps ;-)

Dink said...

Great post, Thai. It does a nice job of showing the inescapable quagmire of attempting to issue simple rules over complex situations. And Jenny McCarthy is a beacon of misery flashing to the People magazine subscribing masses.

I was going to post today too (but decided it would be a shame not to give your post at least 24 hours). You see, Dan Brown has angered me. I got caught up in The Lost Symbol which had some interesting factoids about early U.S. history and some renaissance alchemists for the first 300 pages or so. Then it disintegrates into a total cluster%*^&. I was breaking out into hives and nearly puking for the last 100 pages (I always finish books; plus this was like a train wreck where you're horrified but can't stop staring at the wreckage). Honestly, its embarrassing. Were his editors threatening him? Did he need to come up with the down payment on a new yacht? Coke addiction? Was the Vatican planning a second Inquisition? I honestly don't know what would force a writer to do what he just did.

" med school professor who announced to the class that his aneuyrsm had just burst and that he was about to drop dead, which he promptly proceeded to do"

I love stories of reason over emotion. Like that pilot Sully who crash landed into the Hudson; the audio tapes reflect a person who will not be bullied into panic. I have not, uh, achieved that overriding composure (as evidenced by recent rage over book).

And Kitty, sorry to hear about the rough times with your first cub. Its good that you and others have been open with their experiences so post-partum depression can now be acknowledged (and therefore fought). Kudos for honesty and bravery!

Previous post:

I had heard of the Gelsinger tragedy; a shame on many levels. And some surface-level reading on gene therapy still makes me feel like we're trying to fix a Swiss watch with a tire iron and Elmer's glue, but what can we do? Learning is an ugly process.

Dink said...

"Trust is a form of money. At some level they are absolutely interchangeable"

Which is why I've kind of been viewing the price of gold as an inverse "trust-o-meter". Almost $1200/oz now (twitch, twitch).

I had an insane Spanish teacher in high school. She told us of her "wonderful" childhood in South America. She had a full staff to torment. Upon coming to the U.S. she was miffed to find out she would no longer have serfs. But the reason her family came to the U.S. was to escape a civil war that was getting too close to their gated compound. I don't believe she put it together that the royal lifestyle was unsustainable and that being middle-class in a stable society was preferable. Twitch...

Thai said...

And in the mean time, fundamental reform continues to remain politically unpopular.

I guess as long as the Chinese are willing to let their own die in order to save the money so that we don't have to make the same tough choices, all will be well.

If they eventually decide they love their parents as much as we love ours, heaven help us.

We can obviously see the effect the inability to resolve issues similar to this has had on Europe... Though interestingly Europeans have not had as much difficulty addressing health care issues as Americans- funny how different countries each have their own Achille's heel.

I wonder if it has much to do with national differences in trust?

Addendum, I found the following link. According to their summary data, it does, but to a much smaller degree than I tend to give credit.

The Most Fabulous Objects In The World

  • Hitchhiker's Guide To The Universe trilogy
  • Lord of the Rings trilogy
  • Flight of the Conchords
  • Time Bandits