The Covert Rationing Blog

Patients, Doctors, and Remote Third Parties

December 27th, 2007 by DrRich

Why not just eliminate the middleman?

In an interesting posting on EconLog, noted economist Arnold Kling, PhD (in answer to an essay by Richard Dolonar on why it’s important for doctors to individualize clinical decisions) says,

“My own view is that a remote third party probably can use statistical evidence to make good recommendations for a course of treatment.”

(Thanks to DB’s Medical Rants for pointing us to this quote.)

Now, Kling is no far-left radical, pushing for centralized control of healthcare (and everything else). Indeed, he’s now with the Cato Institute, and before that he taught economics at George Mason University. So he’s earned his conservative and/or libertarian chops. In fact he’s not really calling here for “remote third parties” to have final authority on what’s best for individual patients. Rather, he thinks patients should make that decision for themselves, weighing the recommendations of data-driven guidelines promulgated by remote experts, against the ego-toss’d recommendations from their all-too-fallible doctors, or, as Kling sarcastically refers to them, their “heroic personal saviors.” (Such sarcasm, regular readers will not be surprised to hear, is as abhorrent to DrRich as it probably is to you.) Kling is saying: trust patients, spending their own money and armed with good evidence-based recommendations handed down from experts, to make the right decisions for themselves.

In concept DrRich supports this last notion. Indeed, a chief theme of this blog has been that doctors have been coerced into doing the bidding of their true masters - the ones who determine their professional viability, namely, the government and the insurance carriers - to the great detriment of their patients. So as things now stand, many patients who place full reliance on their doctors, trusting that they’ll get all the information they need to make good medical decisions, are putting themselves in peril. Smart patients will seek out all the information they can about their own medical conditions, so they can confirm that their doctors are indeed presenting them with all their reasonable options, and so they can more intelligently discuss and evaluate those options. And certainly, expert-endorsed guidelines would be an important part of that research.

But there are at least two fatal flaws with Kling’s synthesis.

The first flaw, of course, is the idea that a remote third party, wielding evidence-based data, can make good treatment recommendations for individual patients. This idea is false on its face, as others have demonstrated far more eloquently than DrRich can. (See, in particular, DB’s many posts on the fatal conceit of evidence-based guidelines.) The chief problem is that evidence-based guidelines are designed to yield what’s best for a population (that is, they aim to improve the average outcome across a population of individuals), and cannot possibly “know” what’s best for each individual within that population. And more particularly, in a healthcare system based on covert rationing, the centralized guidelines that determine what’s “best” for a population may not always be aiming for the best clinical outcomes. A favorable economic outcome is likely to be a more pressing, more hidden goal.

The second flaw is the idea that patients, even very intelligent patients armed with “perfect information,” can by themselves reliably sort through the morass of conflicting evidence and conflicting opinions that invariably inform any set of clinical recommendations (whether made by vaunted teams of completely objective experts from on-high, or by one’s inherently flawed, conflicted and ego-driven personal physician). This would be the case even if the healthcare system were perfectly aligned to help patients.

But it’s not. The healthcare system, whether we’re referring to the half controlled by the feds or the half controlled by insurance companies, is increasingly and more openly hostile to individual patients. Individual patients, what with their chronic, expensive illnesses, are in fact the chief threat to the healthcare system. One way or another, their interests have got to be stifled, and this blog has tried to chronicle some of the many ways in which the stifling occurs.

As a result, patients are no more capable of navigating the gratuitous obstacles and hidden hazards laid out before them by a hostile healthcare system (which silently prays they will, in frustration, just go buy themselves some alternative medicine remedy, then crawl under a bush and die while contemplating their qi), than are accused felons of navigating a complex and hostile legal system that’s bent on sending them away for 15-20.

We should note that it is for this very reason that accused felons are assigned an advocate, an individual who is charged to take their part, to help them navigate all the legal hazards, to do everything possible to see they are treated fairly, and that they are given every reasonable chance to prove their innocence. Lawyers, as much as we might like to castigate them, are absolutely critical to a civil society.

And this is the reason why patients (according to traditional, though now quaint, medical ethics) are also supposed to have an advocate, an individual who is charged to take their part, to help them navigate all the medical hazards, to do everything possible to see that they are treated fairly and that all available medical options are made open to them, and that they are given every reasonable chance of a good clinical outcome. Patients, in other words, need doctors who are devoted to the classic precepts of their profession. Such doctors, as much as Kling and others might like to diminish their importance, are absolutely critical to a civil society.

But, as we have seen, severing the classic doctor-patient relationship is Job One under a system of covert rationing. Doctors simply cannot be allowed any longer to place their patients first. They’ve got to place the needs of their true masters first. They’ve got to keep the government and the insurers happy or they’re out of a job.

And this brings us back to Kling. DrRich can agree with his notion that patients ought to be armed with the high-quality information they need to determine their own medical destiny. DrRich can even agree that relying solely on the information provided by today’s doctor is generally not advisable. But DrRich cannot agree with the reason it’s not advisable. Doctors aren’t so much inherently flawed by ego and other intrinsic character flaws (at least, no more than any other group of humans), as they are operating under duress, under imposed constraints, and under external coercions that systematically and purposefully prevent them from discharging their professional obligations.

Nor can DrRich agree with Kling’s proposed solution. No centralized set of recommendations, evidence-based or not, can fix this problem for patients - especially when the expert bodies that make those recommendations are controlled by the same entities that have, with malice aforethought, killed the medical profession for the express purpose of stripping patients of their advocates.

DrRich has trouble seeing a solution to this problem that is not radical. He does not see how doctors can resume their rightful place as their patients’ advocates and remain in what has become the traditional healthcare system. Perhaps enough doctors to make a difference will leave the traditional healthcare system, shedding themselves of the third parties who now control their behavior, and re-establishing their practices (and revitalizing their profession) with a new commitment to the doctor-patient relationship. If not, then perhaps some new profession will establish itself (call it “personal healthcare advocates,” comprised of trained health professionals who are ideally but not necessarily physicians) to fill the great void that threatens the safety of every American patient. (If this latter should happen, then Kling’s plan - which is merely a very small step away from eliminating the middleman entirely - could be employed with at least some form of advocate protecting the welfare of patients.)

But, my good Dr. Kling, a fine economist such as yourself should realize that a remote third party can no more make good recommendations for individual patients trying to survive in the rough and tumble of the healthcare system, than can a remote third party make good recommendations for individual businesses trying to compete in the rough and tumble of the marketplace.

Posted in General Rationing Issues, Primary Care in America

6 Responses to “Patients, Doctors, and Remote Third Parties”

1. Dr. Wes wrote on 12/27/07 at 5:01 pm :

   Brilliance in a nutshell. Well done!

2. Dr. Val wrote on 12/27/07 at 10:11 pm :

   Terrific post. Dr. Kling needs to spend a day with me in my inner city clinic to get a reality check on the average person’s ability to analyze data and make educated medical decisions. Then he should develop lymphoma and be told that Medicare is not going to cover his chemo (though it has been proven to extend life and perhaps cure the disease) because his “remote third party” has decided that it’s in the best interest of the population to spend that money researching the utility of homeopathic remedies.

3. Marilyn B. wrote on 12/29/07 at 12:06 pm :

   Thank you Dr. Rich. Beautifully written. I greatly appreciate your advocacy. I don’t get a lot of traffic, but may I link to you from my little blog?

   Not as dramatic Dr. Val’s example, but as a thyroid patient who has to fight constantly for a dose of meds that allows me to function (and keep my blood pressure/cholesterol down!) rather than just fit the minimum lab standards I have longed to sentence a large population of doctors to a year on tapazole.

   Happy New Year!

4. DrRich wrote on 12/29/07 at 1:06 pm :

   Marilyn,

   Thanks for your comment - and by all means, link away.

5. SamEyeAm wrote on 12/29/07 at 3:27 pm :

   Dr. Rich, I have seen a few examples of patient advocates and wanted to share them with you. All what you have blogged is 1000 percent accurate and precise. In many areas of medicine we are seeing new forms of practice designed to serve a specific organ system. Ophthalmology in the form of modern ambulatory based surgical centers and laser vision correction centers are two prime examples of the modern advocate. If your Grand Unified theory is correct, ultimately the wonks will attempt to kill off the outpatient surgery trend much in the same way they are now attempting to kill off the specialty based hospital trend.(sorry for the digression) Despite the reduction in Ophthalmic surgical fees by several hundred percent (past 25 years). Modern outpatient Ophthalmic surgical centers are still financially viable entitys.

   As a laser vision correction specialist, I routinely encounter patients armed to the eye-teeth with all manner of digital web research combined with analog word of mouth experience in order to select the best combination of laser vision technology and surgeon/center. It is amazing when a human has the ultimate financial responsibility and liability (possible blindness), the supreme effort a patient makes to decide where, how, who, and when to undergo laser vision correction. Despite all the information collection and data analysis, many patients are still clueless and subject to jedi mind trick marketing and technical kool-aid. Without a true advocate lacking a conflict of interest patients interests will always come in a distant last place. Unfortunately in a system with each to his own serving his or her best interest in the Randian paradigm, the rich,intelligent, knowledgeable will always be screwing the poor and ignorant. My mother a retired physician said it best: “with all the changes in healthcare, doctors will adjust and continue to thrive and ultimately the patients will suffer the most” After more than 30 years of medicine/neurology solo practice that woman summed it up in one sentence.

   The next time you speak with a patient, take a moment to observe and “feel” their fear. Patients are rightfully and consciously afraid of a complex system where there wants and needs are subordinate to the machine and politics of medicine.

   Dr. Rich, I agree patients need advocates but the few physician advocates who speak out within these systems are swiftly silenced and destroyed. Quick sham peer review will destroy your reputation and possibly your career unless the “disruptive physician” undergoes psychiatric outpatient/inpatient treatment to avoid National Practioner databanking and medical board license suspension. The problem with attorney advocates is that they simply dont care AS MUCH as physician advocates. Attorneys are not selected and filtered from the general academic population to care however ethics and empathy are core subroutines of most physicians. As a group attorneys lack empathy with their clients. Physicians dont have clients we have patients.

   Until state legislation and federal laws such as HCQIA ( http://www.hcqia.net/ ) can be overturned, overt physician patient advocacy will be a career damaging activity for the advocate physician. Until then I suggest that if you are a physician the only way to advocate for patients is in the form of GUERILLA advocacy. Much like in a guerilla war a lone individual physician cannot stand toe to toe with a major hospital system or insurance company.

   You must engage the enemy but stay off the grid.

6. SamEyeAm wrote on 12/31/07 at 5:33 pm :

   Dr. Rich, you mentioned the patient advocate and wrote: “Doctors simply cannot be allowed any longer to place their patients first. They’ve got to place the needs of their true masters first. They’ve got to keep the government and the insurers happy or they’re out of a job…

   Dr. Rich, while we look remotely to insurance companys and the federal government as the “true masters”. I think we need to call the 800 lb gorilla the 800 lb gorilla master of most physicians, the regional hospital system. Most of these hospital systems function with state/federal peer review immunity and certificate of need protection. Revenue easily generated in the hundreds of millions to billions (sometimes non-profit tax exempt) create major economic employement engines. The mafia would be so lucky to have all angles covered like modern hospital systems. Most doctors working within these hospitals are marionettes with invisible strings controlled like “Plato’s Stepchildren”, http://www.ericweisstein.com/fun/startrek/PlatosStepchildren.html

   Ironically physicians are in the best position to advocate for their patients unfortunately the vocal advocate usually winds up here:

   http://en.wikipedia.org/wiki/Sham_peer_review

   The situation is so augean, that if you told someone outside of medicine such a reality existed they would think you a liar or crazy.

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