3 ms·

It's not that the marketplace is working -- it's that we've perverted and destroyed the marketplace and instead we have a free-for-all for handouts based on pol

by dkarl 16y ago

It's not that the marketplace is working -- it's that we've perverted and destroyed the marketplace and instead we have a free-for-all for handouts based on policies created by whatever gets votes. When did an efficient marketplace for medical services ever exist in the United States? "Buyers" have always depended on the ethics and professionalism of doctors; very few people have the education and sophistication necessary to second-guess them. People have always tended to trust doctors, if only because it was the least bad option, and when they don't trust doctors, the result is a thriving market for superstition and quackery. So if the buyer's decision is reduced to which doctor to trust, then you need a way to compare doctors' performance. Creating a way to compare doctors' performance would be a big undertaking requiring some kind of unified, centralized push for standardization -- almost certainly by the government. There may be other ways to actively construct an efficient market, but simply removing the perverting force of regulation will not restore a previously existing efficient market, because the market for medical care has never been efficient, regulation or no.

carbocation 16y ago
Hi. Future doctor here. I agree with both of you (I don't think it's paradoxical to do so). To augment your point, consider that if doctors are left to regulate themselves, you run into the additional problems of self regulation (or lack thereof, for both thoughtful and malicious reasons but generally to bad effect). Patients, even in the information age, cannot yet synthesize enough information to generally be intelligent, independent consumers of medical care. There is too much bogosity that has to be filtered out, and most people aren't good at that. (What??? Drug X killed 1 person once??? Well I'm not taking it! [Nevermind that Drug X has saved hundreds of thousands of lives.]) I don't think I'm being elitist, because physicians suffer the same problems, though perhaps to a lesser degree. While they might be more informed consumers of health care generally, a cardiologist probably doesn't have any strong, evidence-based opinions of which is the best treatment for their cancer. (I mean, besides fearing doxorubicin.) Their training in understanding the primary literature is probably their only advantage (and their training in outdated chemotherapeutic agents from medical school is probably their major disadvantage).
- jquery 16y ago
  > Patients, even in the information age, cannot yet synthesize enough information to generally be intelligent, independent consumers of medical care Most people don't know anything about cars, nor are even able to comprehend the complexity of your average vehicle, yet through trusted 3rd-party sources manage to find and purchase these extremely complex machines in a mostly-free market. Maybe as a future doctor you can explain why trusted third-party certifications would not emerge to protect the public if the government stepped out of the process? (I am genuinely curious)
  - carbocation 16y ago
    Health care is like auto repair more than it is like purchasing an auto; you were born with this vehicle. I don't understand enough about cars to decide if I should buy Fuel Additive X that's being heavily marketed. Whether I buy it or not is pretty unimportant, because it's just for my car. If someone is trying to sell me an angioplasty, how am I supposed to decide for myself if I need it? Unfortunately, guessing wrong about the necessity of an invasive procedure is more risky than choosing the wrong fuel additive. No consumer guide can answer that question - and if it can, it can just label itself "medical school" and I'll respect that. Let's say that some guide says "angioplasty does not reduce mortality except in the setting of unstable angina or myocardial infarction, so don't get it." The doctor could come back and say, "yeah, but you have diabetes and that guide didn't look at studies with patients with diabetes." (Stuff like this is true and critically important to understanding clinical trials.) Or maybe you have atypical vascular architecture so the guides don't address that. I'm basically trying to get at clinical equipoise. Clinical equipoise occurs more often than you might think; it's a time where well-meaning doctors can disagree with one another because there is not specific enough data (or none at all) to answer the question at hand. I don't see a guide handling that. (Note that I'm saying nothing about whether or not patients can choose physicians intelligently - I think they do it quite well via word of mouth - but I'm referring specifically to the consumption of medical care like medicines and procedures.)
    - jquery 16y ago
      First, thank you for your thoughtful and detailed reply. > Note that I'm saying nothing about whether or not patients can choose physicians intelligently I don't think I communicated very well... I was referring almost exclusively to this. Even this might be too specific... picking a good "provider" (e.g., a "brand", one level above a physician) might be the best an individual could do (since evaluating an individual physician might be too difficult). It's all academic, really. Since the government pays for medical services directly (via Medicare and Medicaid) it's a given that the government has to pay for a huge organization to vet the individuals and groups its reimbursing. This means there's not as much of a "hole" for the private market to fill...
jquery 16y ago
> Creating a way to compare doctors' performance would be a big undertaking requiring some kind of unified, centralized push for standardization -- almost certainly by the government. I find this a dubious claim. We have entire thriving industries of third parties who evaluate complex products and services. I don't see how medicine is any different in that respect, from, say, finance or engineering.
- carbocation 16y ago
  Things that would make those quantifiers very rich: (1) Objectively assessing the severity of illness, regardless of what illness (or constellation thereof) the patient had. (2) Objectively assessing the degree to which a physician's intervention improved an outcome, and the distance between the true outcome and the best outcome (and the null / no treatment outcome). I think that those two make medicine qualitatively more difficult to quantify in a useful fashion. (Though there are lots of useless ways to quantify medical interventions and physicians.) If you think you have some good ideas for solving those two problems, you have the chance to become very rich; please contact me if so (seriously).
  - jquery 16y ago
    I appreciate your elaboration... it really has me stumped. I understand the extreme difficulty of objective evaluations of individual performance in highly technical professional fields. But to the extent this problem is intractable, I'm not sure how adding government makes it tractable. Maybe I'm coming at it from the wrong angle?

by dkarl 16y ago

carbocation 16y ago

Hi. Future doctor here. I agree with both of you (I don't think it's paradoxical to do so). To augment your point, consider that if doctors are left to regulate themselves, you run into the additional problems of self regulation (or lack thereof, for both thoughtful and malicious reasons but generally to bad effect). Patients, even in the information age, cannot yet synthesize enough information to generally be intelligent, independent consumers of medical care. There is too much bogosity that has to be filtered out, and most people aren't good at that. (What??? Drug X killed 1 person once??? Well I'm not taking it! [Nevermind that Drug X has saved hundreds of thousands of lives.]) I don't think I'm being elitist, because physicians suffer the same problems, though perhaps to a lesser degree. While they might be more informed consumers of health care generally, a cardiologist probably doesn't have any strong, evidence-based opinions of which is the best treatment for their cancer. (I mean, besides fearing doxorubicin.) Their training in understanding the primary literature is probably their only advantage (and their training in outdated chemotherapeutic agents from medical school is probably their major disadvantage).

jquery 16y ago
> Patients, even in the information age, cannot yet synthesize enough information to generally be intelligent, independent consumers of medical care Most people don't know anything about cars, nor are even able to comprehend the complexity of your average vehicle, yet through trusted 3rd-party sources manage to find and purchase these extremely complex machines in a mostly-free market. Maybe as a future doctor you can explain why trusted third-party certifications would not emerge to protect the public if the government stepped out of the process? (I am genuinely curious)
- carbocation 16y ago
  Health care is like auto repair more than it is like purchasing an auto; you were born with this vehicle. I don't understand enough about cars to decide if I should buy Fuel Additive X that's being heavily marketed. Whether I buy it or not is pretty unimportant, because it's just for my car. If someone is trying to sell me an angioplasty, how am I supposed to decide for myself if I need it? Unfortunately, guessing wrong about the necessity of an invasive procedure is more risky than choosing the wrong fuel additive. No consumer guide can answer that question - and if it can, it can just label itself "medical school" and I'll respect that. Let's say that some guide says "angioplasty does not reduce mortality except in the setting of unstable angina or myocardial infarction, so don't get it." The doctor could come back and say, "yeah, but you have diabetes and that guide didn't look at studies with patients with diabetes." (Stuff like this is true and critically important to understanding clinical trials.) Or maybe you have atypical vascular architecture so the guides don't address that. I'm basically trying to get at clinical equipoise. Clinical equipoise occurs more often than you might think; it's a time where well-meaning doctors can disagree with one another because there is not specific enough data (or none at all) to answer the question at hand. I don't see a guide handling that. (Note that I'm saying nothing about whether or not patients can choose physicians intelligently - I think they do it quite well via word of mouth - but I'm referring specifically to the consumption of medical care like medicines and procedures.)
  - jquery 16y ago
    First, thank you for your thoughtful and detailed reply. > Note that I'm saying nothing about whether or not patients can choose physicians intelligently I don't think I communicated very well... I was referring almost exclusively to this. Even this might be too specific... picking a good "provider" (e.g., a "brand", one level above a physician) might be the best an individual could do (since evaluating an individual physician might be too difficult). It's all academic, really. Since the government pays for medical services directly (via Medicare and Medicaid) it's a given that the government has to pay for a huge organization to vet the individuals and groups its reimbursing. This means there's not as much of a "hole" for the private market to fill...

jquery 16y ago

> Creating a way to compare doctors' performance would be a big undertaking requiring some kind of unified, centralized push for standardization -- almost certainly by the government. I find this a dubious claim. We have entire thriving industries of third parties who evaluate complex products and services. I don't see how medicine is any different in that respect, from, say, finance or engineering.

carbocation 16y ago
Things that would make those quantifiers very rich: (1) Objectively assessing the severity of illness, regardless of what illness (or constellation thereof) the patient had. (2) Objectively assessing the degree to which a physician's intervention improved an outcome, and the distance between the true outcome and the best outcome (and the null / no treatment outcome). I think that those two make medicine qualitatively more difficult to quantify in a useful fashion. (Though there are lots of useless ways to quantify medical interventions and physicians.) If you think you have some good ideas for solving those two problems, you have the chance to become very rich; please contact me if so (seriously).
- jquery 16y ago
  I appreciate your elaboration... it really has me stumped. I understand the extreme difficulty of objective evaluations of individual performance in highly technical professional fields. But to the extent this problem is intractable, I'm not sure how adding government makes it tractable. Maybe I'm coming at it from the wrong angle?