A few more words on health care costs

As I noted last week, there are a couple of essays in the latest NEJM that touch on this cost issue. Weinstein and Skinner make the point, rather over-elaborately I would say, that within a given regime of cost-effectiveness, spending more will tend to produce better outcomes; but that you can get the same or better outcomes for less money by shifting to more cost-effective service delivery. The point seems to be that it would be relatively painless -- at least for consumers -- to begin by worry about comparative effectiveness and not worrying so much about setting budgets or trying to make the socially radioactive decision about how much we're willing to spend per QALY. If we can just stop doing useless or more expensive but no better stuff, we can get ahead without confronting the Death Panels.

A group to large to enumerate (starting with Stephen Swensen and ending with Donald M. Berwick), in the same issue, discusses the need to transform the medical industry from a "cottage" industry in which each practice is akin to an independent artisanal shop to a modern, post-industrial model in which there are overarching systems in place to assure quality and conformity to standards. You don't want every airplane you fly in to be independently owned and operated by its pilot, with essentially no regulation except the right to sue him after you crash; so why do people want their doctors to work that way?

This seems fair enough in principle -- much of the resistance to performance standards in medicine stems more from romantic nostalgia than from good sense. Still, it's very tricky because every patient is indeed different and there are a fairly limited number of standards that are always, or almost always, right for everybody. Hitting the sweet spot between standards of practice and clinical judgment is really, really hard.

In any event, I want to leave this discussion for now with the observation that libertarians have painted themselves into a very awkward, weird corner on this issue. They are insisting on their absolute right to receive unlimited amounts of useless or even harmful drugs and medical procedures, and to make other people pay for it, so long as they are lucky enough to be over 65, privately insured, or indigent and categorically eligible. Note that even people who aren't so lucky as to have insurance still have to help pay for the lucky people's unlimited, useless medical care because part of it is funded from general tax revenues. That's the libertarian, right wing, Republican, Sarah Palin position. Literally. Unequivocally. And note that no proposal for rationing or cost effectiveness analysis stops somebody who can afford it from paying out of pocket for a brain transplant or whatever else they want -- these proposals only prevent people from forcing others to pay. And yet libertarians decry them.

That is truly weird, warped and twisted. Do they ever actually think?