Health Care: Who Knows 'Best'?

February 8, 2010 7:08 PM

Health Care: Who Knows 'Best'? "...comparative research on effectiveness is only part of the strategy to improve care. A second science has captured the imagination of policymakers in the White House: behavioral economics. This field attempts to explain pitfalls in reasoning and judgment that cause people to make apparently wrong decisions; its adherents believe in policies that protect against unsound clinical choices. But there is a schism between presidential advisers in their thinking over whether legislation should be coercive, aggressively pushing doctors and patients to do what the government defines as best, or whether it should be respectful of their own autonomy in making decisions. The President and Congress appear to be of two minds. How this difference is resolved will profoundly shape the culture of health care in America." Interesting NY Review of Books article by Jerome Groopman.
posted by cog_nate (29 comments total)

Insurance industry lobbyists, duh.
posted by delmoi at 7:12 PM on February 8, 2010 [4 favorites]

This field attempts to explain pitfalls in reasoning and judgment that cause people to make apparently wrong decisions

And by "wrong", economists mean "decisions that are not what we, as sociopaths economists, would have made".
posted by Pope Guilty at 7:26 PM on February 8, 2010 [3 favorites]

Pope Guilty, I think that's a mischaracterization. I don't think even most economists would claim to be totally rational actors. The puzzle comes from the fact that people, even when given perfect information and the natural incentive to maximize their own well-being (usually measured in dollars), don't always make the choices to make things best for themselves, within the framework of classical economics. They aren't saying money is all that matters and that these decisions are "wrong" (only within the context of the theory), but rather than pure economic theory can't explain all economic decisions that humans make.
posted by anifinder at 7:34 PM on February 8, 2010

The puzzle comes from the fact that people, even when given perfect information and the natural incentive to maximize their own well-being (usually measured in dollars), don't always make the choices to make things best for themselves, within the framework of classical economics.

Spot the operative phrase in that sentence.
posted by Pope Guilty at 7:43 PM on February 8, 2010 [2 favorites]

They aren't saying money is all that matters and that these decisions are "wrong" (only within the context of the theory), but rather than pure economic theory can't explain all economic decisions that humans make.

If fact, they're saying that even if money is the only consideration, classical market theory cannot explain all economic decisions that human makes. That's what the quote in the FPP means by "apparently wrong". The "apparent" is "according to classical market theory". These economists are trying to correct the theory to properly model human behavior.
posted by mr_roboto at 7:45 PM on February 8, 2010 [2 favorites]

Spot the operative phrase in that sentence.

"comes from the fact"?

C'mon, Your Holiness, give us something to work with here.
posted by mr_roboto at 7:48 PM on February 8, 2010

But there is a schism between presidential advisers in their thinking over whether legislation should be coercive, aggressively pushing doctors and patients to do what the government defines as best, or whether it should be respectful of their own autonomy in making decisions.

Please, don't hesitate to conceal your preference.
posted by setanor at 7:49 PM on February 8, 2010 [2 favorites]

My solution would be to require more granularity in what health insurance companies offer to insure against. If you are afraid of heart disease you can allocate a larger portion to the plan with your benefits reflecting your investment, if you are afraid of cancer you can allocate a larger portion to the plan with your benefits reflecting your investment (repeat with each)*. It would have the effect of making consumers more invested in their own well-being and narrowing the gap between the fear where insurance companies make their profits and the reality of actual settled claims.
Never going to happen.

*Yeah, I know, but they already know your likely claims. This would provide the opportunity to at least gamble knowing the table odds rather than against all the games in the house.
posted by vapidave at 7:58 PM on February 8, 2010

(The above for the people that can afford insurance.) Those excluded are another matter of course.
posted by vapidave at 8:03 PM on February 8, 2010

vapidave, I know you can buy policies specific to specific diseases (or at least one specific disease) because I work in oncology and a lot of our patients have cancer policies.
posted by joannemerriam at 8:17 PM on February 8, 2010

Really, everyone should get very specific DNA tests that tell them what to insure against. They'd pay accordingly, of course. Ideally these DNA tests would predict exactly what diseases they *would* get, and they'd pay for that. Other, healthier people wouldn't be burdened with their costs.
It's called not having insurance in the first place, and it works great, which is why Republicans are (as always) telling the truth when they say we have the best health care system in the world.
Having everyone pay for insurance that might not benefit them personally is just socialism, and we all know what that leads to: lutefisk.
posted by uosuaq at 8:31 PM on February 8, 2010

This field attempts to explain pitfalls in reasoning and judgment that cause people to make apparently wrong decisions

Reminded me of What's the Matter With Kansas - the question of why people deliberately make choices (inside the voting booth and outside it) contrary to their economic self-interest is a frustrating one for some people. I don't think this can solely be put down to "error," though - there's plenty of folks who know what's profitable and choose a different road because of other factors - personal ethical or religious views, disinterest in money above a certain level, etc.
Behavioral economics always looked interesting to me, although the few economists I've talked about it with seem skeptical. Not so much of the idea that people aren't perfect rational actors (no one I've ever met actually believes that) but of the idea that we have a sufficient grasp on human psychology to get answers to the questions the BE folks raise that are useful outside of extremely limited demographic or cultural groups.
posted by AdamCSnider at 8:33 PM on February 8, 2010

What may account for the repeated failures of expert panels to identify and validate "best practices"? In large part, the panels made a conceptual error. They did not distinguish between medical practices that can be standardized and not significantly altered by the condition of the individual patient, and those that must be adapted to a particular person.

As the government gets more involved with health care, I think this is a very important thing to keep in mind. There is a certain level where mandating certain behaviors and procedures is appropriate in health care (at a very basic, high level), and many levels where it is not. No treatment is going to be a one-size-fits-all treatment for an entire population. Now add to that a mix of competing methods, formulas, etc. and the picture gets hazier.

I work for a company that creates electronic medical record software (not a clinician, to be clear), and a perennial debates floating around is how to calculate creatinine clearance, a measure of a patient's renal function. Our system has to account for multiple different formulas that are used by different organizations. Even the most popular method of calculation, the Cockroft-Gault equation, has a number of variations based on different body weight calculations.

Renal function is very important, but how could you adequately set standards for it when there's so much variation in the way that it's calculated? When the article talks about 'best practices' with controlling blood sugar actually leading to adverse results I'm not the least bit surprised. That's such a micro-level thing, and considering the differences between people there's no way you can put down guidelines for their body chemicals like that and not be completely wrong a huge chunk of the time. Mandating that surgeons scrub down before entering the OR, on the other hand, is more the level at which legislation is appropriate.

Adding a bunch of financial incentives to certain behaviors also is going to have unfortunate PR consequences as it's going to feed that uproar over keeping the government out of our health care. Ultimately, most decisions should be left to individual health care providers.
posted by Consonants Without Vowels at 8:44 PM on February 8, 2010 [3 favorites]

AdamCSnider

A good deal of the research on BE is empirically-backed. One way to think about it is that not as an attack on rationality. Instead, some BE work notes the frequency of people's irrationality, and that it is so frequent that the irrationality can lead to predictable behaviors.

The argument in Groopman's article seems to accept the contribution of BE. The tension, therefore, is between those who would look to BE to nudge doctors to act in a certain way or require them to...but all in the context that they may very well be predictably irrational.
posted by Hypnotic Chick at 8:45 PM on February 8, 2010

I worry that this type of focus on micro-level best practices (to use an example from the article, requiring that all patients seen in the ED with pneumonia receive antiobiotics within four hours of admission) is sort of a distraction from the much larger problems with care delivery we face in the US.

We have a system that's relatively good at doing at expensive acute-care interventions involving lots of cutting-edge technology, specialists, and expensive imaging equipment, and does a much poorer job of primary care and especially of case management of chronic conditions to prevent them from reaching an acute crisis. One of the larger drivers for how expensive health care is in the US is the fee-for-service model, and all of the perverse incentives that flow forward from the pathetic reimbursement for evaluation and management as compared to the sexier whizz-bang stuff. God knows that when we look at countries in Europe that do health care for half the cost that we do, it's not because they're kicking our asses at doing clinical effectiveness studies; it's because their reimbursement structure is less insane than ours.

If we spent as much energy on finding a rational structure for rewarding internal medicine doctors for having as few of their patients get admitted from the ED with pneumonia as possible, instead of on figuring out the absolute, really-this-it-this-time gold standard protocol for treating those patients once they are admitted, we'd probably be in much better shape. For that matter, just figuring out how to make being a really good family practice doc as attractive and rewarding as being a radiologist or an anesthesiologist would be a good start. Right now there's a huge exodus away from primary care, and it's just making the problems we have worse.
posted by strangely stunted trees at 9:30 PM on February 8, 2010 [4 favorites]

vapidave, I know you can buy policies specific to specific diseases (or at least one specific disease) because I work in oncology and a lot of our patients have cancer policies.
posted by joannemerriam at 10:17 PM on February 8 [+] [!] [quote]

I'm happy to hear that, thank you for the information. It's a step in the right direction I think. (As long as the consumers take some responsibility and insurers aren't banking on fear vs. math. I remain afraid of that.)
posted by vapidave at 10:27 PM on February 8, 2010

My solution would be to require more granularity in what health insurance companies offer to insure against. If you are afraid of heart disease you can allocate a larger portion to the plan with your benefits reflecting your investment, if you are afraid of cancer you can allocate a larger portion to the plan with your benefits reflecting your investment (repeat with each)*. It would have the effect of making consumers more invested in their own well-being and narrowing the gap between the fear where insurance companies make their profits and the reality of actual settled claims.

This is just me but my solution wouldn't charge people thousands upon thousands of dollars in copays for misfortune.
posted by Talez at 11:45 PM on February 8, 2010 [1 favorite]

The concern over "best practices" seems to mask an important point - the importance of preventative care. Europe also does better (afaik) at supporting preventative care and just staying healthy. You can avoid the "best practices" approach but still do much better at this than we do. Pay (and encourage aggressively) for checkup visits while people are still healthy; pay for dentists; provide good public resources for exercise and recreation: none of these things involve telling people what type of medical treatments to get, but all of them will increase health outcomes and decrease health costs.

That is: I don't think the government should tell your doctor how to treat you; I do think the government should encourage you to take care of your health before you get sick.
posted by freebird at 11:49 PM on February 8, 2010

I think its fascinating that BE is finally influencing policy. I think using empirical research on human behavior to help guide the lawmaking process is a good idea. Anyone who has studied human behavioral psychology can attest to the fact that humans are often quite irrational and in many cases work against their own best interest (both individually and collectively). Some of these bad habits are trends, as one poster noted above, that can actually be predicited with statistical levels of accuracy. Using these facts to incentivize a society towards a better objective well being is a fantastic tool. I'm gonna have to pick up a copy of Nudge...
posted by jnnla at 12:59 AM on February 9, 2010

My solution would be to require more granularity in what health insurance companies offer to insure against. If you are afraid of heart disease you can allocate a larger portion to the plan with your benefits reflecting your investment, if you are afraid of cancer you can allocate a larger portion to the plan with your benefits reflecting your investment

This would be fascinating but disastrous demonstration of how people misprice risk.
posted by atrazine at 2:04 AM on February 9, 2010 [4 favorites]

"This is just me but my solution wouldn't charge people thousands upon thousands of dollars in copays for misfortune."

Nor would mine. What I'm on about is that there is a varying degree of control that you have over some health issues. Type 2 diabetes is more easily avoided than some types of cancer. Though as joannemerriam indicated above there is available some specificity in what you can insure against most plans are more vague. I think this has a couple of negative effects.
The first and probably more important is that it removes some of the burden from the consumer. They are less inclined to look at specific behaviors regarding their own health when there is no penalty for failing to act in their own interest relative to those who do (sounds idiotic I know but, well, smoking and whole aisles of your grocery store to pick 2 easy examples).
The second is totally unsupported but I suspect that somewhere in the insurance companies calculations there is a multiplier that reflects the difference in what you are willing to pay to ease the perceived fear of needing care for a specific concern vs. what it actually costs the insurance companies to provide care. This leaves room for exploitation. I would like for my premiums to reflect as much as possible the actual, rather than my perceived risk.

(It's entirely possible I'm being unclear. It's a big subject and if I am being unclear please forgive me.)
posted by vapidave at 2:05 AM on February 9, 2010

People are stupid?
posted by sfts2 at 5:50 AM on February 9, 2010

Maybe the states know best, or at least they wouldn't turn down control if they had it. They license doctors and they raise money from sales taxes, which is where the front line of monitoring and discouraging behavior should be. They can then get into the cost controlling business once their sales taxes are paying for it.

So the fed should pass a simple law and then provide matching funds up to 50% of the health bill for any individual on health care, preventive or otherwise. This race to the top would insure that nobody is rejected for health care and hopefully stop the creative accounting done to pay for the uninsured. If the states want to pay for it with fancy tiered insurance schemes so they can be in denial about socialized medicine, then let them, but voters will get tired of it after the comparative costs are made available by each state.
posted by Brian B. at 6:41 AM on February 9, 2010

Maybe the states know best, or at least they wouldn't turn down control if they had it.

Trust me, if Florida's track record is any indication, the states don't know best.
posted by saulgoodman at 7:59 AM on February 9, 2010

Cost-effectiveness is going to be a hard sell to the American public, not only because of the great value placed on each life in the Judeo-Christian tradition, but because the federal government has devoted many hundreds of billions of dollars to bail out Wall Street. To perform mammograms for all American women in their forties costs some $3 billion a year, a pittance compared to the money put into the bank rescue. The Wall Street debacle also made many Americans suspicious of "quants," the math whizzes who developed computer models that in theory accurately assessed value in complex monetary instruments but in fact nearly brought down the worldwide financial system. When a medical statistician says that imposing a limit on mammography is a "no-brainer," people may recall George Tenet's claim that the case for invading Iraq was a "slam-dunk."

Good god, what an awful paragraph. Is there a coherent thought in there?

"Oh shit, my word limit is almost up! Throw everything about cost effectiveness against the wall, something will stick!"
posted by jckll at 8:16 AM on February 9, 2010

vapidave, You are lauding the most evil, broken, and expensive part of our current healthcare system, known as adverse selection.

Adverse selection accounts for roughly one third of all American health care, all that money goes to paperwork not medical expenses. In other words, if you have more complex plans, you need more actuaries, accountants, secretaries, etc. who play games with those plans.

Any meaningful plan for significantly reducing the total cost of healthcare in the U.S. must simplify insurance by outlawing adverse selection activities of both the insurers and insured. If you don't target the paperwork by simplifying the plans, then you're just talking trade offs between quality and price.
posted by jeffburdges at 11:11 AM on February 9, 2010

I am advocating that the insurees not insurers, get to select.
posted by vapidave at 12:32 PM on February 9, 2010

Insured people tweaking their own coverage turns health insurance into a fancy complicated third party billing system, while eliminating the actual insurance function. Anyone who needs significant care spends vastly more because insurers hike the extra coverage rates for particularly costly diseases like leukemia while making the default coverage options useless. Everyone else spends more paying for the actuaries, accountants, secretaries, etc. that process the complexities. Adverse selection exists on both sides and hurts everyone.

You know, a French doctor often does not even bother having a secretary because the government's billing system is so incredibly simple. A doctor gets paid X when he preforms service Y, period. In fact, our French doctor can actually charge patients any price he wants beyond whatever the government pays, making the French system theoretically more capitalist among providers than the American system, although few doctors have sufficient stature to charge extra in practice.
posted by jeffburdges at 3:16 PM on February 9, 2010

"sociopaths economists"

I'm a sociopath and I find that comparison offensive.
posted by Eideteker at 1:41 PM on February 12, 2010 [1 favorite]