What David Sedaris Can Teach About Health Care

David Sedaris had a comic piece in the New Yorker about socialized medicine that is, as you’d expect, pretty funny. While it’s not exactly a policy wonk piece chock-full of statistics, I do think it’s worth thinking about. One of the important flaws that policy wonks focus on in the American health care system is the incentive structure—the claim is that fee-for-service incentivizes the system to push for more care rather than better care. I think that’s important, but the role of culture is not unimportant here.

Here’s Sedaris describing a visit to the doctor:

There’s a pharmacy right around the corner, and two blocks further is the office of my physician, Dr. Médioni. Twice I’ve called on a Saturday morning, and, after answering the phone himself, he has told me to come on over. These visits, too, cost around fifty dollars. The last time I went, I had a red thunderbolt bisecting my left eyeball.

The doctor looked at it for a moment, and then took a seat behind his desk. “I wouldn’t worry about it if I were you,” he said. “A thing like that, it should be gone in a day or two.”

“Well, where did it come from?” I asked. “How did I get it?”

“How do we get most things?” he answered.

“We buy them?”

The time before that, I was lying in bed and found a lump on my right side, just below my rib cage. It was like a devilled egg tucked beneath my skin. Cancer, I thought. A phone call and twenty minutes later, I was stretched out on the examining table with my shirt raised.

“Oh, that’s nothing,” the doctor said. “A little fatty tumor. Dogs get them all the time.”

I thought of other things dogs have that I don’t want: Dewclaws, for example. Hookworms. “Can I have it removed?”

“I guess you could, but why would you want to?

It’s easy to see how this encounter with the doctor could’ve gone differently—he could’ve ordered a test on that eyeball, or done something to remove that fatty tumor. Instead there’s an “enh, whatever” attitude that prevails and seems to serve Sedaris quite well, insofar as nothing has happened to his eye and as far as we know he is not cancerous.

And there’s little with the structure of the system to discourage a more activist stance—the visits are conducted along fee-for-service lines, and yet the results are strikingly different than the prevailing results in many regions of the United States. Some of the cultural difference is because of the patient (Sedaris writes, “For my fifty dollars, I want to leave the doctor’s office in tears, but instead I walk out feeling like a hypochondriac, which is one of the few things I’m actually not” and elaborates that he wants to hear fancy technical terms and whatnot. A more pushy patient might demand that “fatty tumor” get removed forthwith), but much of it is the doctor also.

So it’s probably a mistake to assume that changing the incentives will do the entire job. But what changed incentives might do—if announced loudly and persistently enough—is help signal that a change in culture is necessary.

Don't Know What We Don't Know: Cancer Studies Edition

A pretty remarkable story came out yesterday:

During a decade as head of global cancer research at Amgen, C. Glenn Begley identified 53 "landmark" publications -- papers in top journals, from reputable labs -- for his team to reproduce. Begley sought to double-check the findings before trying to build on them for drug development.

Result: 47 of the 53 could not be replicated. He described his findings in a commentary piece published on Wednesday in the journal Nature.

The result was corroborated by another study from Bayer. It’s again another example of not knowing what we don’t know—and, with the article speculating that the scientific bias towards accepting the hypothesis (especially if interesting) rather than rejecting it, one might imagine similar things are true of results in other fields.

The typical hope here is for comparative effectiveness research, but one can take an extreme skeptical view and wonder why the same biases that skew the original work wouldn’t skew the comparative work also.

It’s also unfortunate that the results of which studies were unable to be reproduced wasn’t released. After all, as the article notes, many different pharmaceutical companies are making investment decisions based on this research—and it suggests some of the potential benefits of making sure as much knowledge is free as possible.

The Devil Mandate

Did you realize the Supreme Court was in session earlier this week? Might’ve been some arguments about health care? Of course there was, and of course the Supremes are considering striking down the whole law. This leads Matt O’Brien to argue that insurers saw the news and are cheered:

One reasonable conclusion is that Wall Street's betting that Obamacare will either be struck down in its entirety or upheld in its entirety. Both would be very, very good news for healthcare companies. The death of the individual mandate, alone, would be bad news for Big Insurance.

It’s correct that losing the mandate alone would be bad news for insurers—but I’m not sure the entire law being struck down is all that wonderful for insurance companies specifically and the health care industry more broadly. Obamacare has many elements that envision a much different health care industry than the one around today, but it’s not that hostile to the system. It really could go so much worse, and with continuing inflation in health care and pressure on public budgets, the risk of it becoming so much worse increases. That scenario has a lot of uncertainty. The devil you know can be so much more friendly than many of the devils you don’t.

Cheating and High-Stakes Testing

The AJC has a super article about cheating on standardized tests. It probably should cause some hard questions to be asked:

The analysis shows that in 2010 alone, the grade-wide reading scores of 24,618 children nationwide — enough to populate a midsized school district — swung so improbably that the odds of it happening by chance were less than one in 10,000.

And:

Big-to-medium-sized cities and rural districts harbored the highest concentrations of suspect tests. No Child Left Behind may help explain why. The law forced districts to contend with the scores of poor and minority students in an unprecedented way, judging schools by the performance of such “subgroups” as well as by overall achievement.

Hence, high-poverty schools faced some of the most relentless pressure of the kind critics say increases cheating.

Improbable scores were twice as likely to appear in charter schools as regular schools. Charters, which receive public money, can face intense pressure as supposed laboratories of innovation that, in theory, live or die by their academic performance.

This will almost certainly need more study to see how widespread cheating on these sorts of high-stakes standardized tests. There have been some recent gains on standardized tests—how much of that is attributable to cheating? The impact of charter schools on test scores is ambiguous—but how much of that ambiguity might be removed if we knew that a disproportionate number of them were cheating, as the AJC article suggests? These questions need further study.

Pittsburgh Brawl

A WSJ and Jeffrey Young piece in Huffington Post reveals one of the big tensions in health care post-ACA. The articles examine a situation in Pittsburgh in the middle of a market share fight (I’ve written about that exact subject here). It seems that the University of Pittsburgh Medical Center is prepared to reject patients who are insured by Highmark, an insurer, due to Highmark’s acquisition of a struggling health group. They feel that it will boost Highmark’s attractiveness and thereby lessen market share and bargaining power.

As Young points out, agglomeration among health care entities is probably a necessary byproduct of an integrated system. Most of the health care systems health policy people seem to admire—your Kaisers, your Geisingers, your Intermountains—are integrated insurer/health care providers housing many different groups. On the other hand, big hospital groups will definitely also raise prices. It’s something that needs disentangling.

At any rate, such aggressive tactics are not something I’ve heard of the innovative providers engaging in as frequently. In fact, Geisinger usually uses the patients insured by third-parties to subsidize their innovative activity. I’m not suggesting the two situations are exactly the same, but I do think it’s worth thinking about.

The Robots Are Probably Coming For The Surgeons, Too

I appreciate this Atlantic article questioning whether robots are currently more effective than surgeons—technological reporting is too often dominated by slightly-naïve acceptance that this stuff all works—but I found this note to be a bit naïve to end with:

"Robotics is a tool, albeit the most technologically advanced and expensive one, but a tool nonetheless," says Dr. Bernard Park, the chief of thoracic surgery at Hackensack University Medical Center. "No technology will ever replace the critical importance of a skilled, thoughtful surgeon."

“Ever” is an awfully long time, isn’t it? I’m fairly confident we’ll see robots infringing on surgeons’ domains more and more because we’ve seen it for most other professions; for example, see software replacing grunt-level lawyers for coding depositions. Indeed, it’s not as if health care people are totally innocent of robots—they’re starting to introduce them to the hospital (though, again, for low-level stuff).

Let’s consider the stuff robots might do better than human surgeons:
1) Robot “hands” don’t tremble.
2) Robots do not get tired.
3) Robots do not forget tools inside the people they’re operating on.

And so on—I’m sure you can think of additional things which a robot might be really good at that people might not be so good at. Again, you don’t have to be at the-singularity-is-coming level of techno-optimism to believe that this is the case.

Totally Not-Policy Related

But this ad really is incredible (as in unbelievable):

(via Andrew Sullivan)

This reminds of this ad:

How did anyone think this is a good idea, again? Forget women--I don't see how this works on men.