This was by grocery shopping weekend. So, I just got back from the Arlington Mass. Stop N Shop.
As I have previously stated, I am A George W. Merck Fellow at the Institute for Heath Care Improvement in Cambridge Mass. I will be here until July 2010 having left family and friends in Madison Alabama in late June 2009. I have only managed to get home twice. I receive and stipend from the Merck Family Foundation and a smaller stipend from my sponsoring organization, Huntsville Hospital. I am off salary for the year. My family and I therefore have to manage our very limited resources carefully. If any of us stray away from our common resources, we are all hurt by it. So, I put back chips, ice cream bars, and a few other items that would have made me a free rider. How does this relate to health care. Let’s start with the ancient Greek philosophers.
Thucydides stated:
[T]hey devote a very small fraction of the time to the consideration of any public object, most of it to the prosecution of their own objects. Meanwhile, each fancies that no harm will come to his neglect, that it is the business of somebody else to look after this or that for him; and so, by the same notion being entertained by all separately, the common cause imperceptibly decays. (Thucydides, The History of the Peloponnesian War, bk. I, sec. 141).
Source: Tibor R. Machan – the Ludwig von Mises Institute
Aristotle wrote on the problem:
That all persons call the same thing mine in the sense in which each does so may be a fine thing, but it is impracticable; or if the words are taken in the other sense, such a unity in no way conduces to harmony. And there is another objection to the proposal. For that which is common to the greatest number has the least care bestowed upon it. Every one thinks chiefly of his own, hardly at all of the common interest; and only when he is himself concerned as an individual. For besides other considerations, everybody is more inclined to neglect the duty which he expects another to fulfill; as in families many attendants are often less useful than a few.
In other words, when individuals are not owners of resources, they are not able to assess their value; and, when resources are publicly owned, their use will be systematically hasty and imprudent.
The IHI fellows met for lunch last week and the conversation was dominated by the current state of health care reform. The public option is still alive but on life support, a Senior IHI talks about health care as a “zero-sum game” and we continue to see embarrassing reports on the state of health care in the USA including the recent County rankings, wherein my home Perry County Alabama ranked 67th out of 67, the Commonwealth Fund and the Joint Commission state rankings that show very little progress with the Deep South continuing to lag the rest of the USA while the USA lags behind the entire industrialized world, and the promise of comprehensive health care reform seemed to be vanquished on a cold Massachusetts election night.
The Commons is suffering the Prisoner’s dilemma which goes like this:
Two suspects are arrested by the police. The police have insufficient evidence for a conviction, and, having separated both prisoners, visit each of them to offer the same deal. If one testifies (defects from the other) for the prosecution against the other and the other remains silent (cooperates with the other), the betrayer goes free and the silent accomplice receives the full 10-year sentence. If both remain silent, both prisoners are sentenced to only six months in jail for a minor charge. If each betrays the other, each receives a five-year sentence. Each prisoner must choose to betray the other or to remain silent. Each one is assured that the other would not know about the betrayal before the end of the investigation. How should the prisoners act?
In health care, the “prisoners” are physicians, patients and insurers. All three groups are mostly concerned about what benefits them the best and not what is the most cost-effective, which has resulted in the tragic end game of dysfunctional incentives.
The zero-sum is someone wins and someone loses but the commons suffer this tragedy, so we all lose. “Specialist” (primarily proceduralist) physicians who earn in excess of $5oo,oo0 annually do not want to make less but would like to make more if possible. Patients” seem to prefer the best possible surroundings and amenities, whether or not these add to the quality of their care and outcomes.
In the “commons” known as our health care system, there are several types of “free-riders,” all of whom drain care and/or money from the public system. The most obvious example is a person who does not have health insurance but uses a hospital emergency room when he requires care. The cost of this care eventually gets passed on to those who do have health insurance, either in the form of higher premiums or denial of coverage by an insurance company.
http://bareleft.blogspot.com/2010/01/health-care-and-tragedy-of-commons.html
Governments, commercial insurers, and most employers still pay for people’s healthcare costs, collectively, while often fighting with each other over who is liable in particular cases.”
In A New England Journal article( August 2009) a possible solution set was framed very eloquently:
“For patients, the emphasis must be on personal responsibility. The current U.S. system is not structured to provide incentives for less expensive preventive care and healthier lifestyle choices. This failure has led to spiraling costs associated with largely preventable diseases. By contrast, insurance companies in the Netherlands have devised plans rooted in libertarian paternalism, offering patients discounts for healthy lifestyle and diet choices. This approach acknowledges process, which empowers patients, rather than outcomes and has led to sharply reduced costs and healthier patients.
Providers must address the well-documented disparity in cost and quality of care for even common conditions such as hypertension. A process-based metric for evaluating physicians — one that is easily grasped by the general public — will encourage transparency, force physicians to examine and ameliorate their deficiencies, and allow patients to make truly informed decisions, encouraging greater ownership.
And finally, payers must acknowledge health care’s status as a longitudinal concern, not a momentary one. Long-term-contract models such as that of India’s ICICI International have been demonstrated to lead to improved clinical outcomes and cost savings. Longer contracts would incentivize insurers to focus on preventive care and address end-of-life concerns, since a disproportionate share of Medicare dollars is spent in the final months of life.”
http://healthcarereform.nejm.org/?p=1644
A Forbes magazine article summed it up this way:
If you want to know what went wrong with our health care system and the best way to fix it, all you have to do is look back a few decades to a time when health care was a community concern, considered as essential as any public utility. It should be again, not just because it makes sense but also because it’s the most profitable way to go.
The irony in the current debate over a “public option” health plan is that we once had a form of socialized medicine. Blue Cross, the most recognizable name, began in 1929 as a tax-exempt insurer covering a community of teachers in Dallas. Blue Shield was started as a tax-exempt insurer to cover employees of mining and lumber companies in the Pacific Northwest, with a group of local doctors providing care through a service bureau.
So in the end, “Lasting changes to the current paradigm must incorporate adjustments to the incentive structures. If we do not address these motivations, even with the best individual intentions, the U.S. health care system will continue its trajectory of unsustainability to the point of collapse.”
William Lloyd described a this example in his “Lecture on the Notion of Value” in 1833. He observed that when pastureland was held in common (a practice that existed in Boston which still has “the Boston Common”, now a nice public park) – cattle owners have a short-term interest in having all their cattle graze on it. Unfortunately, when all do so, the commons are soon overgrazed, and the common pasture becomes worthless for all.
What a tragedy!
–Ron
Chasing Quality Health Care 