Friday, October 24, 2008

READ: Health Care and Baseball

Today's NY Times op-ed by Billy Beane, Newt Gingrich and John Kerry is a good example why it is pointless if not dangerous to discuss an issue as complex as healthcare in short format.  They try to make the case that the problem in US health care system is the lack of evidence-based decision making. 
Studies have shown that most health care is not based on clinical studies of what works best and what does not — be it a test, treatment, drug or technology. Instead, most care is based on informed opinion, personal observation or tradition.  It is no surprise then that the United States spends more than twice as much per capita on health care compared to almost every other country in the world — and with worse health quality than most industrialized nations.
The implication seems to be that other countries spend less on their health care because they are much better at determining what works and what doesn't, which strikes me as somewhat misleading.  Other countries spend less on healthcare per capita than the US simply because they either cannot afford to or do not want to.  And their outcomes are better on average simply because their healthcare system is more equitable.  The best care in the US is still by far the best care anywhere; the problem is just that fewer and fewer people are able to access it.

I am not saying here that evidence-based medicine is not the right way to go.  I just don't think we should be expecting magic.  There are many serious structural problems in the US health care and lack of data and evidence is only one of them and cannot be addressed in isolation.  

More practically, however, even if we agree that evidence-based medicine is what we need more of, I struggle to see how that can be achieved in the disjointed system of US health care where decisions, financing and delivery of care all exist in their own silos.  The authors suggest:
Working closely with doctors, the federal government and the private sector should create a new institute for evidence-based medicine. This institute would conduct new studies and systematically review the existing medical literature to help inform our nation’s over-stretched medical providers.
However, that seems a touch idealistic.  A lot of review and evidence already exists and is routinely ignored both by payors and providers alike.  Take the example of surgical robots which cost $2 million a piece, have questionable comparative quality outcomes, yet hospitals are tripping over each other buying them and not because they believe the robots are such good medicine.  When I talk to hospital CEOs and CFOs they often express downright hate for the robots.  They cost a lot, they lose money on every procedure they perform, yet - to stay competitive - they know they need to have one.  In a competitive market place there is always the temptation if not actual incentive to do more with more fancy technology, no matter what the evidence says.  

In fact, I am almost starting to wonder if the real argument here is that unless payments, care and decisions are somehow centrally coordinated, we can't ensure they will be both appropriate and economical.  And that, ladies and gentlement, is how this blogger would make an argument for government-run healthcare.  Or as McCain would probably put it, socialism.  Boo!!

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