Thoughts on Cato, Thanksgiving, Capitalism and Public Safety

I returned to the northeast after a five-day stint in our nation's capital at the annual American Society of Tropical Medicine and Hygiene conference. Not much to say about that today except for one thing: Trop Med includes scientific symposia on all number of diseases, but the two biggest players are malaria (accounts for a bit less than half of all sessions in the conference) and my own field, flavivirues (dengue, West Nile Virus, Yellow Fever and a few others, which accounts for maybe 30 percent of the conference). You'd think, given that flavies are the second-biggest draw in terms of the sheer weight of presentations and amount of research that it represents, that they'd have rooms big enough to accomodate interested participants, right? You'd be wrong if you thought that. The rooms for the flavi presentations were wide enough but too shallow—maybe 7 or 8 rows deep—and as a consequence there were maybe 40 or 50 people standing near the entrance milling about trying to catch the talks. Not so great in terms of crowd dynamics. It was hard to concentrate with all the movement, people were regularly walking in front of the speakers to try to find places to sit, those sitting felt bad for having a comfy seat while others stood around (or at least I did). In short, a mess.

Now, don't you think the organizers knew that there were going to be 400 versus 300 people coming to those sessions, and arrange for the appropriate room? It's not like this stuff has changed much in the past few years. Might there be some kind of bias against the virus people from the malaria crowd? Hmmm.

Anyway, I left the conference early (early) Sunday morning and caught a cab to Union Station. (As far as I'm concerned, in the northeast corridor the only civilized way to travel is by train. Takes a little longer, but it beats being publicly strip-searched after waiting an hour in line before being thrown into a flying tin can where you have exactly one inch of wiggle room and the passenger in the seat ahead of you leans their seat back, making comfort a complete impossibility. Gimme the train any day over that!) While winding through the streets of Washington, we drove by the offices of The Cato Institute. Say what you will about their politics, but they have a lovely building.

After we passed it, I began thinking about Cato's little YouTube clip that I wrote about last week. Recall, the title was "You Are

Not The Customer," and it went on to argue in various ways that government intervention in the healthcare system would only make matters worse. That's of course in keeping with Cato's philosophy, which is that free-market solutions are virtually always the best solutions. One odd thing about the clip is that they complain about the wacky computer situation in the current healthcare system (they are right to complain; it really is that bad), but imply that that's because government legislated it...only their overall argument is to prevent the encroachment of government into healthcare by opposing the current legislation. In other words, the lousy system we've got is mostly because of a free-market model. Another point they never mention is that other countries—and by "other countries" I mean "virtually all other countries with standards of living comparable to ours"—manage to have perfectly functional health systems that are either run directly by the government (Great Britain) or have insurance systems mostly or entirely administered by the government (Western European countries, Canada). And these countries manage to spend, in all but two or three cases, less than half of what we spend on healthcare in the US. Remember this the next time we talk about the decline and fall of, say, American manufacturing and consider how much insurance premiums hurt the bottom line of so many corporations.

Cato's need to regard every political and social issue through the lens of free markets and the benefits they provide is actually neatly shown in the title of their piece: you are not the customer. Cruising by their offices at five in the morning, I was struck by the oddness of that title. For instance, they didn't say "the government will make you sicker," or "you're just another number to a bureaucrat," but they focus on your identity as a customer. But how is being a "customer" in healthcare related in any meaningful way to being a customer when you go food shopping, buy a cell phone, or look for a place to live? As a customer, you have a right to expect that the fridge you buy will function, at the very least, as long as the warranty applies...and if it doesn't last much beyond that warranty you'll probably heavily consider buying a different brand next time. (This is why the Rubin family will no longer be buying any products of the Magic Chef company, whose fridge lived a paltry 18 months, six months beyond its warranty.)

But how do you do that in health care? Do you march into the hospital and demand that the staff have Grandma—who in her prime smoked two packs a day and drank enough Bloody Marys to make Boris Yeltsin blush, and did this for forty years—doing the Lindy Hop in the next 24 hours, or else? Do you request a refund after you develop a wound infection after your gallbladder surgery (a known complication)? Do you pay your primary care physician only if the pills he or she gives you make you feel better?

Doctors are very much like plumbers, electricians, and car mechanics: they have a specialized knowledge base that makes it difficult at best for a layperson—a "customer"—to judge their body of work. Unless you have specialized training, you pretty much have to trust them in their diagnoses. Of course, as anyone who has taken an Old Yeller-type automobile to a car shop knows, a mechanic can give you options: "if I just fix the fan belt, your '93 Chevy Celebrity can probably make it another six months...if we add a carburetor and an alternator to that, maybe you'll get another year beyond that." You as a customer can make some informed decisions based on that information. But is that really the system one would want in medicine? "Well, pay for these drugs now, and your chance of a massive heart attack and a long rehab costing your family $30,000 in five years will be cut in half. Or you can just start saving up for The Big One. Which would you prefer?" There's a reason why discussions about money are at something of a remove in healthcare. You couldn't imagine some doctors taking financial advantage of situations with stressed-out families terrified of losing a loved one? Is that really how everyone would benefit? David Goldhill, the CEO who critiques the current system in the Cato piece, does I think helpfully point out how peculiar the system of financing has become in medicine, where the actual value of an MRI is...well, it's totally unclear. But imposing a "customer" model onto that system without even beginning to consider some of the implications of that decision is, to my thinking, scarily naive.

One last thought on this theme. Happy Thanksgiving, everyone! I hope that you are all off to reunions with family and friends. Many of you will be traveling, especially by car. Some good news: car travel (at least on highways) has gotten remarkably safer over the past few years. We are at the lowest level of highway fatalities in the past 40 years. Some of this has to do with the recession as there are fewer people on the road, but a lot has to do with various engineering changes made both inside the car and out. This week NPR did a series on car and highway safety (which can be found here and here) and the stories are worth the listen, requiring less than 20 minutes of your time.

Highlights: one of the reasons why cars now have audio/radio controls on the wheel is to prevent you from taking your attention away from the road to change stations, adjust volume etc. Now you can keep your eyes on the road and flip stations to your heart's delight. Not bad, right? Capitalism in action, yes? Even more enlightening (to me, anyway) was this: you are also safer on the road because of some simple-yet-enlightened changes to the physical structure of the highway: rumble strips now can be found on the sides of most interstates to jolt into vigilance that person with a wandering (or sleepy) mind who has drifted out of the lane; caps on the end of roadside rails (instead of the older kind that "dove" into the ground) prevent cars from running up onto them and vaulting into the air; and cable guardrails have been installed increasingly to prevent cars from crossing medians.

Who is responsible for these changes to the road that keep people safer? Civil engineers! But how could such a thing be possible? After all, they don't work for profit, now do they? They're just merely government employees. And as well all know, because we've heard it for thirty solid years since Reagan became President, "government is not a solution to our problem, government is the problem." What say you, Ron?

—br

More Myths of the Healthcare System

Billy Rubin's Blog returns after a three-month hiatus (for professional reasons, largely), its slumber awakened by a link forwarded by a friend on Facebook. The link, entitled "You Are Not The Customer", is a nine-minute clip put out by The Cato Institute and featuring the commentary of Game Show Network CEO David Goldhill. It puts forth the argument that what has made American health care so bad is that there has not been enough free-market thinking guiding health insurance. That is, if we had even less government involvement and just let the system 'do its thing,' so to speak, we could eventually clean up this mess. Since the current system is mostly not overseen in any direct or even indirect way by the federal government, what could he be talking about? My best guess is that he's proposing that Medicare is what's screwing up all the pricing and keeping us in the dark ages, although he never explicitly says this. In a similar vein to Cato's free-market perspective, the libertarianish Gregg Easterbrook has been wondering why not simply apply standard pricing models to health care outside of catastrophic insurance—and doing this in football columns on ESPN! (Thus making it about the only football column worth reading.)

The tone of the whole clip is certainly an order of magnitude more intelligent than the more popular objections coming from that ideological end of the political spectrum, which as far as I have been able to tell has amounted to screaming "Socialism!" and "Death Panels!" and "Tyrrany!" and not much more. And while I don't share for the most part Goldhill's or Cato's perspective, I do agree, at least in theory, with some of the questions they raise. And (apparently) like them, I definitely believe that there are deep structural problems in American health care.

That said, Goldhill absolutely screws the pooch on one particular point, one that he appears to regard as the centerpiece of why anything other than a 'pure' laissez-faire capitalist model is doomed to failure. Here he tries to peddle a myth just as insidious as the Death Panel nonsense.

About two minutes in, he starts to complain about the shocking failure of hospitals to adopt computer technology. While his father was ill in the hospital, Goldhill says, "this hospital was less computerized than my dry cleaner...my dry cleaner is concerned enough about losing shirts that he's fully computerized, and the hospital's not as concerned about losing lives? Why is that? Why weren't those investments made? Why do they need to be made by the government?" Later (about 3 1/2 minutes in) he picks back up on the theme with his 'guy on the street knows more about this stuff than the healthcare pinheads' shtick:

"The reason my local sushi bar gave its waiters hand-held ordering devices was not because of the National Sashimi Act passed by Congress...its because they want to get the orders right and [do it] quickly. They capture some of that benefit--and by the way, the customer captures some of that benefit--from that fairly simple thing. The lack of information technology investment in health care is not the problem. It's a symptom."

I admire, from a rhetorical standpoint, his use of a well-grounded, easily visible example. And to a point, he's right: I work for a hospital on the weekends that uses a DOS program for its computerized order entry and electronic medical record. It's functional, I guess, but amazon.com would laugh a product like that out of its board room if someone came in and tried to sell it as the model for ordering books. Everything else at this hospital is state of the art: MRIs, CT scans, remodeled ICU & Surgical wings—all the stuff one can think of in a fine community hospital, but the information technology is from about two decades ago. And the good news (for the hospital) and the bad news (for you) is that they're no different from any other hospital—if anything, their system may be a little better because it's not prone to crash by being DOS based.

There's only one problem with his analysis, one little fact that makes this apparently sensible criticism look like the canard that it really is. The fact is this: there is one computerized system that would fulfill Goldhill's wildest dreams. It's user-friendly, it combines the electronic medical record with computerized order entry, physicians love it. Even IT nerdy-types love it. And it's been around for more than a decade. What is this amazing piece of technology and why hasn't it revolutionized health care the way the home computer revolutionized small business?

Well, it's called "VistA" (not to be confused with the Microsoft operating system), and it was not developed by someone trying to get shirts dry cleaned or a sushi order right—meaning it was designed without profit in mind. (I think that deserves an exclamation point: it was designed without profit in mind!) VistA is the computer system of the Veteran's Administration, was commissioned by the US Federal Government and began operating in 1997, and it was then and continues to be the Rolls Royce of healthcare information systems. Having worked at a VA during medical school, I can assure you that it was a joy to work with and I have yet to see its equal. As you can see here, VistA has a main page that has all the goodies a doc needs to retrieve the relevant info: a relevant medical history, a current medication list, links to scans, tests, notes, the whole shebang—just like having a chart in your hands only infinitely easier to deal with.

Your Veterans benefit from this cost-effective, error-reducing system every single day—Lord knows they should—and they do it in a seamlessly linked nationwide system. If you're a Vet from the great town of Mansfield, Ohio and are on vacation in San Diego and you come down with appendicitis, the docs at the SD VA have your whole medical chart at their fingertips. Not bad considering how easy it is for patients to forget critical medications or allergies—assuming they are even conscious—where the lack of such information can lead to life-threatening complications. Meanwhile "private" medicine continues to struggle with thousands of different systems all over the country, few of them integrated (as an east coaster, I cannot comment on Kaiser Permanente's system with which I have no firsthand experience), and none that I have seen best the VA's Little Information Engine That Could.

Best part? Since this is your tax dollars at work, the software for VistA is in the public domain. Oh yes, it's a free program just waiting to be plucked out for eager hospitals who want happy physicians and greater productivity. So why hasn't this magnificent, almost revolutionary system been snatched up by every profit-oriented hospital in the country? A variety of reasons (and indeed some hospitals have adopted it), but the most important is that because the VA is a government-run health system, it never needed to trouble itself with translating medical codes for billing. Adequate billing obsesses every hospital CEO because insurance and medicare reimbursement is the lifeblood of the private health system, so while VistA may be marvelous for, you know, patients and their providers, it's useless for generating money under the current system. So I would say that Mr. Goldhill has this particular argument about as completely upside-down as possible: not only has the free enterprise model been unable to develop information technology nearly as well as a not-for-profit government-run system, it additionally can't even make use of the blue-ribbon technology that the government is willing to give away gratis! (And in the ultimate irony, other countries who see the value of the VistA technology are adopting it, as this article notes about Mexico's VistA use even surpassing that of the VA itself. Just think about this: we taxpayers have funded a system that we can only have access to as Veterans, but civilian Mexicans can benefit from this technology?! What would Lou Dobbs say?)

—br

PS--The blog is back! We took some time off, but are planning on weekly visits from now on. Please continue to drop in suggestions, questions, links and quibbles.