Medical systems in three phrases.

Finding things wrong with the US medical system is like dynamiting fish in a barrel.

Finding ideas for improvements isn’t any harder.

Implementing such ideas or even simply validating whether they are good ideas is much, much harder.

But one day I stood back and considered the “system” while keeping in mind three little phrases.

1) Who cares? It’s not my money.

2) You get what you pay for.

3) First, do no harm.

There may be other phrases as pithy and relevant. I don’t know. Can you think of any?

Let’s flesh these phrases out:

Who cares? It’s not my money.

Medical expenses are disconnected between payer and payee. Given regulatory realities, if you want to control your own medical expenses, you need a competing system – in another country.

But, going to another country is not often an option. US medical expenses are dominated by Medicare/Medicaid. Medicare/Medicaid don’t pay foreign medical bills.

When you are insulated from the price of medical care, your are not the customer. You are the product, perhaps. The raw material, perhaps. But you are not the customer.

Imagine buying something from Mr. Someone without knowing the price until your bank account has been debited for that Wells Fargo money order you sent to Mr. Someone. Ah, you would be the “mark”, perhaps, but not the customer.

You get what you pay for.

We all deeply know that “cheap” is cheap and “expensive” is high quality.

When you are sick or broken, do you want a cheap fix? Gosh no! You want the best money can buy. Since you have no clue what particular fix you want, it’s safest to go with the expensive fix and hope for the best.

Just try to justify a cheap fix for someone else’s body. Don’t you look horrid? Yes, you do, you uncaring cheapskate.

So, the existing medical system is a cost maximizing system. By demand.

First, do no harm.

Medical practice is not perfect. Many diseases and other negative attributes of our bodies are not dealt with well at all. This will always be true.

So how does the “system” find cures or fixes?

Carefully. By “hill climbing”.

“Hill climbing” is a simple, universal search method. When hill climbing, you start from where you are and look around your neighborhood for a better place to be. You go to that place and do the same thing again. And again. And again. Until you find yourself in the best place in your neighborhood. You have found what you are looking for. Search complete.

For example, imagine looking for a cure for cancer.

You have a current therapy for cancer. But is there a better one?

Well, you *could* search for one by randomly trying all sorts of things:

* Homeopathic beets.

* Up-beat music.

* Vegetarian fish.

* And so on.

But, “First, do no harm.” Ignoring the current, best therapy can certainly qualify as doing harm. So, to find a better therapy, you modify the current, best therapy by just a very little. Usually, you add something to the current best therapy – an extra “medicine”. Just enough to check a similar, nearby therapy. Carefully. Then, if this new therapy is an improvement, you switch to it, and do the process again. Carefully.

As a strategy, hill climbing can work very well. Unless the possibilities are vast or the best therapies don’t have wide, easily found slopes leading up to them.

Hill climbing gets stuck on what are called “local maxima” – the best place in the vicinity. Not the best place. Only the best place near the searcher’s current location.

Hill climbing is not a good way to find breakthroughs. Breakthroughs happen when someone gives up on current practice and flies off on a tangent. Doing harm.

Consider ants when they know their food source. They file to and fro, slightly improving the path to the source by cutting corners until the path is short and easy. They do no harm.

When the path is broken, the ants wander around in a peculiar random way, casting about for some indication of food.

They can die wandering randomly. “Tough break, Mr. Ant. Hard times call for hard measures. You do yourself harm for the greater good.

Uh, huh. Sell that to Hippocrates and his oath.

So there you have it. Food for thought.

2 thoughts on “Medical systems in three phrases.

  1. Re: Who cares? It’s not my money.

    Saying “given regulatory realities” and then waving away the structural protections from competition, choice, and noting the “insulation” (disagree, anon) by complaining
    about the regulatory reality is begging the question. From my perspective:

    There are no posted prices.
    Prices change after the fact.
    Healthcare is attached to employment.

    The first two break the price mechanism. The last is a “regulated” market to the point some pinkos start barricading streets.

    “legitimate pricing” is another narrative with which I’m sure you’ll find issue.

    Re: You get what you pay for.

    I’d argue you get what you’re told to get by the doctor. Is your doctor paid on commission?

    Re: First, do no harm.

    Sounds like you’ve been reading Derek Lowe. All the low hanging fruit is gone. Umm, medicine has played the “Do No Harm” note for a long time. But unless we’re turning a blind eye and ignoring literally within one generation recent socially transformative medicine that came about through a lot of harm, you have got to be fucking kidding me.

    Furthermore, people are people and do ridiculous things when they think they can give hope and when they are given hope. That’s why we have the FDAs of the world. But they certainly aren’t perfect. Are you saying (I’m guessing from shell shock) the FDA and AMA are effective at stiffling modern medical science and progress?

    BTW, there are papers on this. Write down your gut feel before checking the research.

  2. “No posted prices” and “prices changing after the fact” are results of “who cares it’s not my money”. Why post prices, after all? It’s not like the customers don’t know the prices. They do. The patient is not the customer, so why would a hospital waste time telling the patient the prices? And why would the patient care, anyway? “Who cares it’s not my money”.

    Now, if the providers had to deal with individual patients as customers they’d have to re-organize their pricing and advertising to handle thousands or millions of customers, not just a handful of institutional customers who have conflicting incentives for higher and lower prices.

    Which, yes, that gets to my issues with that editorial you linked. There is nothing illegitimate with having a unique price for every customer. In volume, doing so just becomes too hard to manage and sell. Or why your phone no longer has per-minute calling rates inside the entire US. So, though that editorialist’s heart is in the right place, he’s trying to fix a broken system with another layer of bureaucracy, soviet style.

    Agreed, that “health care” (no, please, let’s not speak in DC-speak, here 🙂 It’s “health insurance”.) is tied to employment. One of those classic, ’30’s mistakes. That those in DC say “health care” when they mean “health insurance” (which isn’t often insurance at all!) tells you how hard it would be to change that mistake. Sigh.

    “get what you pay for”: Doctors are human, too. They don’t want to give their patients junk.

    Derek Lowe: Have never read. Wow! Looks like Uncle Tom!

    It is interesting that many of the big-deal medicines were found and developed back in the days of cheaper humans.

    To be fair, one could argue that money being thrown around has substituted for cheap test subjects.

    And, to be fair, effective medicines are like firearms, inherently dangerous. So, yes, you deal with them carefully, using simple, proven rules.

    Yes, the FDA does put a damper on things. It’s their job and they are what happens when a world is ruled by a bureaucracy. First thing in importance: Lose no bureaucratic job.

    What’s weird is that I’ve spent a few years now hearing about the unthinking straight-jacket minds in the FDA, but whenever I read their actual papers, they seem quite reasonable. Common sense, really. Just common sense. Well, except perhaps in people’s interpretation of their rules for device development and manufacturing as one-large-production-volume-size-fits-all. … Ah, the waterfall model. Sheesh.

    The AMA is a state sanctioned, medieval guild, may the Lord bless them.

    “paper on this”: On what? No FDA?

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