Greed: Noticing the Difference between Liberals and Conservatives (and Objectivists)
Recently, a reader left me a comment recommending Atul Gawande’s article in the New Yorker: “The Cost Conundrum: What a Texas town can teach us about health care”. (http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?yrail).
In an engaging article, Dr. Gawande concludes that health care costs are high because doctors are greedy. Ordinarily I would parse the argument to identify any fallacies. But instead I will take the opportunity to make an observation about how people think about greed.
A conservative says, “Greed is bad, but that’s human nature. Market incentives should be established for doctors to channel their greed to the best interests of their patients.”
A liberal says, “Greed is bad, but human nature can be improved. Doctors should be made non-greedy.” (This is Dr. Gawande’s position.)
An Objectivist says, “Greed is good. If only barriers to greed could be removed, patients would be much better off.”
P.S. There is a fallacy in the New Yorker article. Anyone who sees it, feel free to comment.
posted by Li Kim Grebnesi at
6:23 PM
3 Comments:
Dr. Gawande notes, but does not address, the fact that the highest cost area (McAllen, TX) is also the area where the majority of care is purchased by the taxpayer, not by private insurers or individuals. He holds up private and voluntary medical organizations at the Mayo Clinic and Grand Junction, CO as laudable high-quality, low-cost providers, while holding up Dr. Gelman in McAllen, who is also a conservative radio commentator, as a kind of bogeyman. The irony is that someone like Dr. Gelman would probably be much less successful financially in the absence of the government-provided health care that he rues. I have little doubt that there is a culture among health care providers in McAllen of "gaming the system", in part because the system is constantly trying to squeeze them with progressively lower reimbursements per item, and because I have seen this kind of gaming of the system in my experience, although in my experience is was justified not as a way to enrich the physicians personally, but as a way to "secure more resources for the underserved," in clinics and hospitals.
But just as there the professional culture is different in different places, so is the patient culture. In a place like McAllen, TX, which is a Sun Belt combination of retirees and poor, largely immigrant families on public assistance, where few people are on the hook for their own health insurance or health care expenditures, the patient culture is to under-utilize prevention and over-utilize intervention. McAllen is an example of how per-capita expenditures are likely to change if socialized medicine were to be enacted.
In the last years before Massachusetts passed its recent health care law, Boston was a microcosm of a similar phenomenon. The only hospitals that were making money and growing were those that served a large indigent population, because the reimbursement rules allowed them to milk a statewide pool of funds, all while the hospitals that served people who paid for their care were closing, consolidating, or eliminating departments that brought in less money.
Dr. Gawande is right to hold up the virtue of "accountable care organizations". Of course, the first and foremost accountable care organization is the free market. (He fails to mention this, except to deride it with a straw-man argument that it would make negotiating bypass surgery like haggling over a rug in a souk.) The most accountability comes when individuals pay directly for what they receive. Next best is when the recipient contracts with a private, locally-based organization as payer. Least accountable is a distant, statewide or nationwide public payer that is less able to respond to individual, local or regional differences, and is less medically accountable than politically accountable.
While appearing hostile to the market, Dr. Gawande wishes the market's virtues of quality and cost discipline could be grafted on to the system, like getting rainbows without rain, or ice cream without a cow.
Thank you Peter. That's the second time you left a comment that was far more insightful than my original entry. Also (since this is a blog about logic), kudos for the identification of the straw man fallacy in the New Yorker article. The article also suffers from the fallacy of hasty generalization: Dr. Gawande's conclusion, that greed is what drives cost, is based on purely anecdotal evidence.
There is the comparison to ElPaso with the same demographics. Like all CEOs, Gelman seems to have set the tone for the hospital.
I agree with the statement: The most accountability comes when individuals pay directly for what they receive.
However, with so many years of employer paid premiums, and low co-payments, is a free market a realistic goal? When was the last time you paid 100% of a yearly physical, a biopsy, or an ultrasound? Yet we think nothing of paying cash or credit for the same veterinary procedures, keeping costs relatively reasonable. There is an insurance mind set that will be hard to change.
Therefore, a locally-based organization as payer is a good start toward reform.
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