December 30, 2004

Hayek, Hospitals, and Healthcare

That NY Times, Gina Kolata article is really two articles woven together. The first (see my other post) is that Hospitals have just discovered the 20th Century regarding measuring performance. But the second idea, that socialized medicine creates this operational retardation, just proves the laws of unintended consequences and begs us to consider Einstein's great thought about the circle of insanity.
The federal government is now telling patients whether their local hospitals are doing what they should.
Feel Better?
For now, the effort involves three common and deadly afflictions of the elderly - heart attacks, heart failure and pneumonia - and asks about lifesaving treatments that everyone agrees should be given but that hospitals and doctors often forget to give.

Medicare expects that now that the hospitals' performances are public, many will try to improve. "People will begin to feel a little awkward if everyone else is doing better and they're not," Dr. Jencks said.

The next step, Dr. Jencks said, is "aligning payment with what you want people to do."

To that end, Medicare has a pilot program to pay hospitals for improving on a number of quality measures, including mortality rates and readmission rates for hip or knee surgery. Hospitals in the top 10 percent for a given condition, for example, will be paid an extra 2 percent. The agency will pay less if performance deteriorates. The project involves 278 hospitals affiliated with Premier, a nationwide organization of nonprofit hospitals..

"Basically, it was a flip of coin, whether you got good medical care or you didn't," Dr. Asch said. "It didn't matter where you lived. The shortfalls were constant."

"That challenged us to ask why these medical care problems were so pervasive," he said.

At least part of the answer, he and others say, is that doctors are unaware of their shortfalls and are rewarded no matter how well they do.

"That will be a bitter pill to swallow, and I'm not sure people will swallow it," Dr. Califf said. "There's a lot of money being made on things that don't work well."

Dr. Jencks agreed.

"I would say we are moving much more slowly on trying to prevent overuse than in trying to fix underuse," he said. "If I tell a physician he shouldn't do a surgery he wants to do, I personally would anticipate a lot more resistance than if I told him he should give a medicine he wasn't thinking of giving.

"Medical care is one of those very strange parts of the economy where you get paid no matter what the quality of the service you provide," Dr. Asch said. "It is like you went to a car dealership and your Mercedes is going to cost you the same as your Yugo.
So here's the question?

Why do we think the government should intrude more to fix this? Do we really discard the ideas from The Fatal Conceit and content ourselves that the government will get it right this time. Our big fat bloated Federal Health Care System will be nimble enough and smart enough to pick the right things to measure?

I'm sure they will reply that only those courses of treatment with "expert consensus" will be measured, and as the article states, only those treatments that "everyone already agrees on" (whatever that means).

Michael Crichton owns the Consenus Canard
I want to pause here and talk about this notion of consensus, and the rise of what has been called consensus science. I regard consensus science as an extremely pernicious development that ought to be stopped cold in its tracks. Historically, the claim of consensus has been the first refuge of scoundrels; it is a way to avoid debate by claiming that the matter is already settled. Whenever you hear the consensus of scientists agrees on something or other, reach for your wallet, because you're being had.

Let's be clear: the work of science has nothing whatever to do with consensus. Consensus is the business of politics. Science, on the contrary, requires only one investigator who happens to be right, which means that he or she has results that are verifiable by reference to the real world. In science consensus is irrelevant. What is relevant is reproducible results. The greatest scientists in history are great precisely because they broke with the consensus.

There is no such thing as consensus science. If it's consensus, it isn't science. If it's science, it isn't consensus. Period.

In addition, let me remind you that the track record of the consensus is nothing to be proud of. Let's review a few cases.

In past centuries, the greatest killer of women was fever following childbirth . One woman in six died of this fever. In 1795, Alexander Gordon of Aberdeen suggested that the fevers were infectious processes, and he was able to cure them. The consensus said no. In 1843, Oliver Wendell Holmes claimed puerperal fever was contagious, and presented compellng evidence. The consensus said no. In 1849, Semmelweiss demonstrated that sanitary techniques virtually eliminated puerperal fever in hospitals under his management. The consensus said he was a Jew, ignored him, and dismissed him from his post. There was in fact no agreement on puerperal fever until the start of the twentieth century. Thus the consensus took one hundred and twenty five years to arrive at the right conclusion despite the efforts of the prominent "skeptics" around the world, skeptics who were demeaned and ignored. And despite the constant ongoing deaths of women.

There is no shortage of other examples. In the 1920s in America, tens of thousands of people, mostly poor, were dying of a disease called pellagra. The consensus of scientists said it was infectious, and what was necessary was to find the "pellagra germ." The US government asked a brilliant young investigator, Dr. Joseph Goldberger, to find the cause. Goldberger concluded that diet was the crucial factor. The consensus remained wedded to the germ theory. Goldberger demonstrated that he could induce the disease through diet. He demonstrated that the disease was not infectious by injecting the blood of a pellagra patient into himself, and his assistant. They and other volunteers swabbed their noses with swabs from pellagra patients, and swallowed capsules containing scabs from pellagra rashes in what were called "Goldberger's filth parties." Nobody contracted pellagra. The consensus continued to disagree with him. There was, in addition, a social factor-southern States disliked the idea of poor diet as the cause, because it meant that social reform was required. They continued to deny it until the 1920s. Result-despite a twentieth century epidemic, the consensus took years to see the light.

Probably every schoolchild notices that South America and Africa seem to fit together rather snugly, and Alfred Wegener proposed, in 1912, that the continents had in fact drifted apart. The consensus sneered at continental drift for fifty years. The theory was most vigorously denied by the great names of geology-until 1961, when it began to seem as if the sea floors were spreading. The result: it took the consensus fifty years to acknowledge what any schoolchild sees.

And shall we go on? The examples can be multiplied endlessly. Jenner and smallpox, Pasteur and germ theory. Saccharine, margarine, repressed memory, fiber and colon cancer, hormone replacement therapy. The list of consensus errors goes on and on.
Feel better about Government involvement here?

This same Federal Gov't that itself can't account for billions in expenditures each year is the best, most flexible and knowledgable place to decided what procedure to track?
In the two-volume report, "Government at the Brink," issued in June by the Senate Committee on Governmental Affairs, it is reported that the figure is significantly higher. The report states, "The Education Department reported in its financial statements that it had $7.5 billion in the bank, when it actually owed that money to the U.S. Treasury." This amounts to a discrepancy of $15 billion. The books of the education department were actually off by a total of $15 billion — about one-third of what the department spends annually.
What do you think our patron saints would have to say? ... ask him, him and watch this.

Look, if the government measures it, rewards it and punishes those not complying, they'll get results. Hospitals will follow those requirements to a "T". All industrial processes organize and adapt to to the metrics; make the numbers. But where does that ultimately lead?

I'm glad the government woke the hospitals up and now they check whether they actually do what they prescribe, but it was the government's intrusion into this market that caused the lax controls in the first place. We are insane to think that long term they won't make it worse still.