Tuesday, October 20, 2009

Who should tell your MD what to do?

In this Wall Street Journal op-ed, Norbert Gleicher suggests that expert panels won't improve health care because the the quality of the research on which they would base their physician practice guidelines is not reliable. Instead, he suggests that our system can self-correct when experts lead us astray. He asserts that we have a "well working free market of ideas in health care, where effective therapies can rise to the surface and win out."

I'm somewhat sympathetic to Dr. Gleicher's point about a government-imposed clinical review process, but he overstates the case about a current free market of ideas. Individual insurance companies and Medicare currently make payment decisions with regard to therapeutic judgments every day. How are they informed, and what are their sets of vested interests? Much of that remains hidden from public view.

Meanwhile, too, doctors and hospital practice what Brent James calls "regional medical mythology," patterns of care divorced from scientific evidence, based as much on the local supply of specialists and what they learned from their predecessors as any other factors.

Perhaps what Dr. Gleicher is trying to avoid is the replacement of this array of unscientific medicine with the establishment of a centralized panel of unscientific medicine. In essence, he is suggesting that it is worse for the federal government to get it wrong for the whole country at once than for the individual participants (payors, MDs, and hospitals) to get it wrong each in their own way.

Seriously, though, one can apply some analytical rigor in support of Dr. Gleicher's thesis. Just as a diversified investment portfolio does better over the long haul in terms of risk mitigation, so too might the country do better over time with a diverse set of views as to appropriate diagnostic tests and therapies.


Anonymous said...

I think your last paragraph is particularly cogent, but over time these diverse views should become increasingly convergent as evidence accumulates, in any given medical condition or procedure. This process is unacceptably slow and uneven in our country. Some therapies which have long ago been accepted as standard are still not practiced in some areas. Other therapies which are new and unproven become subject to groupthink or faddism and are rapidly adopted with no real underlying logic. "Expert" panels can be expected to be contaminated with the same fallacies, but given the legitimacy of government blessing.
It seems to be a matter of choosing the lesser of two evils, the proper choice being very unclear to me at the moment.

nonlocal MD

BeenThereDoingThat said...

Paul, I would be interested to get your response to 2 recent shows of This American Life (available via podcast) having to do with healthcare delivery, policy, and insurance. The show runs on WBUR, as you may know, and provides what seems like an authoritative viewpoint. I may also ask for John Halamka to weigh in. Here are the URLs for the 2 shows: "More Is Less": http://www.thisamericanlife.org/Radio_Episode.aspx?sched=1320
"Someone Else's Money": http://www.thisamericanlife.org/Radio_Episode.aspx?episode=392
-- [from a former healthcare IT manager, now in banking IT :( ]