Patients as drones

Let me tag on to Marc’s excellent post on the recent Krugman piece.  Seldom have I read a more internally incoherent argument (and for Krugman, that is saying a lot).

Krugman makes the highly relevant point that “We’re talking only about what will be paid for with taxpayers’ money. And the last time I looked at it, the Declaration of Independence didn’t declare that we had the right to life, liberty, and the all-expenses-paid pursuit of happiness”  (this is a rare, lucid moment for Krugman, where he remembers his roots and sets aside his usual reverence for all conceivable government spending).

I couldn’t agree more.  “One way or another, government spending on health care must be limited.”  This essential point is ignored on both sides of the aisle.   The looming crisis in Medicare cannot be solved without cutting costs, and cutting costs means purchasing less care.  But how?  And who decides?

It is at this point when Krugman’s argument devolves into a strange and antiquated world where where wise doctors give orders and patients follow.  Nowhere does he even suggest that within this world, where the doctor-patient relationship is “almost sacred,” that patients are people whose autonomy and desires should be respected.  He thinks it is appalling to treat them as “consumers,” but isn’t the heart of being a consumer the freedom to choose one’s own path.    This is the world of Marcus Welby, where wise, benevolent doctors give orders to their trusting (but mindless) patients.  Gives me chills.

Yet at the same time these doctors are not to be trusted.   “We can’t maintain a system in which Medicare essentially pays for anything a doctor recommends…And that’s especially true when that blank-check approach is combined with a system that gives doctors and hospitals — who aren’t saints — a strong financial incentive to engage in excessive care.”  So, patient preferences have no role, and doctors are not to be trusted.  Who does get to decide, then?  Well,… (insert drum roll here)…the all-knowing government bureaucrat of course!  In Krugman’s world, government regulation is always the answer.

I’m actually a strong supporter of cost-effectiveness research and of the Independent Payment Advisory Board (or something like it, at least).  When spending out of the public purse, we have to have ways to say no (Three Cheers for Death Panels!).  Somehow in their recent attempts to oppose everything Obama-related, Republicans forgot who they were, and they became endorsers of unlimited Medicare spending (imagine if we ran food support programs the say way: “come to the supermarket and take whatever suits your fancy”).  The  fundamental principle for health care reform should be that everyone needs “skin in the game,” which is just a newfangled metaphor for the old idea that markets need to discipline behavior.   A system where neither patients nor doctors face any consequences for unnecessary, ineffective, or excessively costly care cannot work.

Consumer-driven health care is not just about the benefits of “comparison shopping,” as Krugman claims.  It is about individual responsibility and accountability.  It is about getting what you pay for and paying for what you get.   It is about putting the patient and his/her family—not the doctor, not the insurance company, not the government bureaucrat or legislator—at the center of the medical decision-making process.

So, Paul, the reason we want to refer to patients as consumers is not that complicated.  It is because we all deserve the dignity that being autonomous human beings accords us, and we all should be expected to take responsibility for the consequences that autonomy will bring.

7 thoughts on “Patients as drones

  1. The problem with pushing Healthcare participants to have “more skin in the game” will not work as long as there is EMTALA, Ever Increasing Copays and Co-Insurance, and two systems that (Medicare/Medicaid and Private Insurance) that do not operate under the same frameworks.

    I agree that Krugman’s piece is rambling, but the problem is the private insurance market does not fundamentally operate in the same way as government markets. Any comparison is pointless, like comparing Apples and Oranges.

    1. But I’m not comparing private and public health care systems. Rather, I’m stating a principle that can be applied broadly, namely that parties involved (patients, doctors, hospitals, insurers) should all face incentives to implement cost-effective care. That principle is applicable to virtually all health insurance and health care delivery systems in the US–public and private.

  2. But seriously sick people are almost by definition not autonomous, and are often not in the best condition to make decisions.

  3. In Krugman’s world, and that of those that agree with him, healthcare is a right, an entitlement (by their actions Republicans agree, btw). To allow market forces, supply and demand and the notion of the patient as consumer, to ration the delivery of care and accumulation of costs is inherently unfair. He agrees that healthcare is a finite resource and so constructs a system by which our betters in some government entity make the decisions about who gets which care. To him that is the only fair approach.

    To win the argument you will need to convince him either that a market construct is an equally, or more, fair way to distribute care and cost, or that healthcare is not a right.

    Either way, good luck with that…

  4. It sounds so reasonable to support an IPAB. Everyone should live within their budget constraints and incentives ought to work that way. But a government board is a government board and will make choices on the incentives, seen and unseen that determine its composition. However it may function initially, you can bet the farm that it will change to reflect shifting power relations in society.

    Rather than make multiple layers of a nationally funded system, we should think federally, and look only to states to support and manage their own plans. When all is said and done, you can drive out of a state. It is increasingly more difficult to drive out of the US…and now that’s true even when you are in different countries. No, when you support another panel, as reasonable it sounds, you just give the purveyors of power another mark on their scoreboard–you dot the “i” in Leviathan.

    1. I agree about moving to the state level. But given that isn’t likely to happen, we need agressive cost controls on Medicare if it isn’t go to run the whole government into the ground

  5. What is pragmatic and practical changes with circumstances. No board or agency of government ever really remains independent. I say the IPABs sound nice, but they will not last. They will keep the concentration of power and the freedom to choose precisely where it should not be–at the center. In this case, maybe we should follow Nero’s example…

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