Utilitarian Utopianism: What Dr. Emanuel is Missing
Jokes about physicians are a staple among investment advisors, businessmen, real estate professionals—pretty much everyone observing the unintended comedy of the medical decision-making style applied outside the physician’s narrow circle of professional competence. The solitary self-confidence, the ability to vanquish doubt and make life-or-death decisions in the setting of imperfect information—attributes essential in treating an individual—don’t “scale well,” as economists might say, certainly not to tens of millions of patients at a time.
But there is always the temptation to eschew humility and, with the best of intentions, go just a little too far: The physician as philosopher-king, wielding science backed by coercive state power. And all for your own good!
I’ve been there. Typical scenario: A morbidly obese patient with chronic renal insufficiency enters the ER suffering from an untreated leg ulcer, now so badly infected the limb will require amputation, the consequence of uncontrolled diabetes and unrestrained cigarette smoking, among other factors. If only I could have made him follow my recommendations after I saw him last year, this poor man wouldn’t be writhing in pain and facing the loss of a limb. Command-and-control is the medical style, after all. Unfortunately, take-charge impulses, admirable enough in your personal doctor, never survive passage through the alimentary canal of any government bureaucracy.
Which brings us to Dr. Ezekiel Emanuel, Rahm’s more cerebral brother. Writing in
the New York Times today, Dr. Emanuel gives us his prescription for “smart cuts” to Medicare spending that will help patients without rationing care.
Smart cuts eliminate spending on medical tests, treatments and procedures that don’t work — or that cost significantly more than other treatments while delivering no better health outcomes. And they can be made without shortchanging patients.
Dr. Emanuel then goes on to highlight spending on Aventis therapy for breast cancer, colonoscopies for the elderly and routine coronary artery stent placement. And you know what? If you accept Dr. Emanuel’s utilitarian frame, he may be right: these treatments may well be cost-ineffective on a population basis.
Do you know any populations? Are there any populations in your family?
I didn’t think so.
Population science is an essential scientific tool. The data gleaned from the clinical studies Dr. Emanuel alludes to are appropriately factored into physician recommendations to patients. As you might expect, under today’s Medicare system the patient is insensitive to the marginal cost of any therapy, leading to a propensity to over-consume and thereby increase costs. Dr. Emanuel argues that CMS is paying for ineffective treatments and your choice may drain money out of a limited taxpayer budget. But he opposes exposing individuals to more of the costs generated by their choices, preferring instead to remove the choice from the patient entirely. The gloves come off when he gets to his preferred structural fix, ObamaCare:
The responsibility for ending unnecessary medical spending needs to be placed in the hands of doctors and hospitals. This can happen only if we change our fee-for-service payment system. Today doctors and hospitals that develop new programs to keep patients healthy lose money in two ways. They spend money re-designing care and then, with fewer office visits and hospitalizations, the payments they receive go down.
The seeds of a solution lie in the accountable care organizations, medical homes and bundled payment reforms that were authorized by last year’s Affordable Care Act. Accountable care organizations are groups of health care providers and hospitals that work together to treat patients. Medical homes coordinate primary care services. And bundled payments consolidate the many costs of an episode of care, like a hospitalization, into a single payment, incentivizing efficient delivery of tests and treatments. All of these reforms allow payments to be based primarily on the number of patients cared for and the quality of that care rather than on the volume of services provided.
Wait a minute: Under fee-for-service, my physician has a strong bias in favor of treating me. No individual attention, no reimbursement. Dr. Emanuel argues that this incentive results in overtreatment. In an “accountable care organization,” my doctor will be preoccupied with treating the “population” to earn his daily bread. Couldn’t this create an inverse incentive to undertreat the marginal individual? After all, if the population is doing fine then a whole lot of individuals don’t have to be attended to very carefully. And if the numbers don’t look so good in any particular, can’t the bean counters adjust the population “denominator” to make the percentages acceptable? This sort of statistical jiggering happens all the time in the UK's National Health Service, perhaps the world's largest ACO. And since all this care continues to be free or nearly so to the patient, the global budget will inevitably tighten. Won’t the politicians then cut the ACO budget secure in the knowledge that Emanuel’s non-rationing physicians have every incentive to fiddle the “science” to marginally but critically and incrementally adjust the line between treatment and no treatment, chance and no chance, care and no care?
The new leftist motto: “My body, my ACO's choice!"
The Founders and Framers did not establish a society where the experts—even accomplished physicians like Dr. Emanuel—get to make decisions for the rest of us, even when they are right and we are wrong. Millions of individuals making choices, assessing the best science and bearing in some manner the economic consequences of their decisions—often making mistakes—created the most successful nation in human history, including the most advanced health care system. We can tighten the grip of the state on our personal health care decisions by further centralizing Medicare or reform the program along free market lines, as per Rep. Ryan’s budget roadmap. The choice, at least for now, is ours.
ObamaCare delenda est.
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Comments :
Re: Utilitarian Utopianism: What Dr. Emanuel is Missing
There is very little difference between what went on in the Soviet Union and what Ezekiel Emanuel is proposing, and the results will in the long run not be much different either.
May '11
Re: Utilitarian Utopianism: What Dr. Emanuel is Missing
Just saying "Death panels" is more succinct, and this post won't fit on a bumper sticker. But I actually do have to concede that Dr. Emmanuel has a point. Unnecessary tests and treatments have a cost to the patient as well as the government / Obamacare "trust fund" that pays for them. This leads me to what might be known as the First Law of Princeton Plainsboro Teaching Hospital, as explicated by Paddy Chayefsky: Never, ever, set foot in a hospital as a patient if you don't have to, and usually not even if you do have to.
Aug '10
Re: Utilitarian Utopianism: What Dr. Emanuel is Missing
As they pulled back from the decision to let Kathleen Sebelius and Mr. Streisand ( Dr. Kiley) write the entire bill, POTUS and his aide looked for someone to stamp their imprimatur on the bill somehow . hummm... who to call ? Guess we can be glad it wasnt the agent brother ?
Re: Utilitarian Utopianism: What Dr. Emanuel is Missing
You've got that right. The singular, leftist-infuriating genius of Sarah Palin: grabbing the essential problem of the ACO and boiling it down to two unforgettable words.
My next post will be shorter.
Dec '10
Re: Utilitarian Utopianism: What Dr. Emanuel is Missing
I wish Emmanuel was "missing" it. Instead, he's a hardened ruthless leftist. He has all the same information you and I have, George.
He knows that, while the UK diagnoses the same number of breast cancers proportionally, its survival rate is much lower than ours because, by the time the patients' cancers are found, they're 10 times bigger than the ones found in the US.
Frequent early screening costs money, not lives. Up until now, we've thought it was worth it. But the Left never talks survival rates. It baffles people with BS statistics about cost-effectiveness in the population. It's willful deception. It's sickening. And evil. There, I said it. Dr. Emmanuel is evil. People will suffer and die because of him.
ObamaCare delenda est.
Dec '10
Re: Utilitarian Utopianism: What Dr. Emanuel is Missing
President Palin coined the term "death panels" in a facebook post. The truth is Sarah Palin drove both the awareness and the debate about the dangers of Obamacare. Without her participation, Obamacare wouldn't enjoy its current widespread public disapproval.
ObamaCare delenda est.
Aug '10
Re: Utilitarian Utopianism: What Dr. Emanuel is Missing
Rather have somebody coining phrases than printing billions . Yeah Sarah.
Sep '10
Re: Utilitarian Utopianism: What Dr. Emanuel is Missing
It's all a neat trick this caring society game.
Take a large portion of the income generated by a man's labor, spend it on a national healthcare system to care for everyone.
If and when he has urgent need for expensive treatment to save his life or the life of a loved one, the system can refuse him if it's a poor use of resources. And, he can't afford another option because he never had access to a large portion of the income generated by his labor.
May '10
Re: Utilitarian Utopianism: What Dr. Emanuel is Missing
While vouchers send libs into conniptions, fainting spells, and attacks of the vapors, sign me up. I'll be able to choose my plan, and suppliment it with whatever money I can beg or borrow, or I can decide to use a cane instead of getting a knee replacment and fritter the money away on something frivolous like paying my property tax. I'm 60 BTW & would rather have a voucher than the system we're headed toward.
But you know what I'm really worried about? Not whether I can get a replacement arterial stent or a colonoscopy (we're all going to get them anyway administered by the IRS to make sure we aren't hiding any untaxed earnings up there), I'm concerned about getting efficacious pain medication if I need it. First because the death panels won't pay for it (and won't let me pay for it myself), second because the damn war on drugs will come down on my doctor if he prescribes it.
My message to government is simple: get your foot off my neck, your hand out of my pocket, hand me that bottle of paregoric, and leave me alone.
May '10
Re: Utilitarian Utopianism: What Dr. Emanuel is Missing
Just because Emanuel said it, and it is part of ObamaCare doesn't mean it is 100% wrong. ACO's are fine- if that is what the patient chooses. And fee-for-service undeniably runs up costs, but arguably less due to conscious unneeded treatment than because of third-party payment.
The issue is not ACO or not, it is who makes the decisions: bureaucrat committees, or patients- and that occurs based on who controls the dollars. That's why ObamaCare is designed to undercut HSA's.
That's why the Republican theme should be to acknowledge that there is no free lunch, can't get stuff for nothing. The motto should be "The Choice is Yours".
Re: Utilitarian Utopianism: What Dr. Emanuel is Missing
Duane Oyen: Just because Emanuel said it, and it is part of ObamaCare doesn't mean it is 100% wrong. ACO's are fine- if that is what the patient chooses. And fee-for-service undeniably runs up costs, but arguably less due to conscious unneeded treatment than because of third-party payment.
The issue is not ACO or not, it is who makes the decisions: bureaucrat committees, or patients- and that occurs based on who controls the dollars. That's why ObamaCare is designed to undercut HSA's.
That's why the Republican theme should be to acknowledge that there is no free lunch, can't get stuff for nothing. The motto should be "The Choice is Yours". · Aug 24 at 2:30pm
Exactly.