March 29, 2007

An Interesting Article

Posted by Eric at 11:14 am | Category: Medicine, Politics

As always in a society largely governed by utilitarian concerns, triaging is a huge aspect of policy and the distribution of goods by the government. We have limited abilities to provide, and mostly, whenever a government program provides, the problems it addresses grow to meet the budget of that program.

Thus, Peter Schuck and Richard Zeckhauser (via Greg Mankiw) write about triaging and getting rid of “bad apples” that tend to ruin good programs for others, whether it’s the constant disruptor in housing and schools, the chronic freeloader in welfare, or even those negligent patients who don’t take care of themselves properly. I definitely think that triaging health care is something that needs to happen. I don’t really think that universal health care will be that feasible, and even if some minimal system of that sort does occur, it won’t cover all goods and services. There will still be triaging, regardless of how much the government spends on medicine or other welfare programs, because costs always increase to meet and exceed the budget of that program (and as the budget grows bigger, a larger percentage goes to government waste, I think).

Triaging sounds distasteful, but I really do think that it will help enormously, especially in health care. The health care spending distribution, for example, is extremely skewed and concentrated: the top 5% of patients (in terms of the cost of their most health care expenses) spend almost 50% of the national health care money. The bottom 50% of patients spend 3% of the health care. A more detailed table and some interesting statistics appears here. I’m not saying that the distribution in and of itself is bad—it’s sort of inevitable, I think, particularly with the massive voting power of the elderly and just the way health care is structured—but the presence of such a skew would mean that if we focus on weeding out specifically the bad apples that appear at the very top of the distribution, that we could free up a substantial amount of money to help a larger number of people.

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3 Responses to “An Interesting Article”

  1. Apollo Says:
    March 30th, 2007 at 7:30 pm

    I respect your view that triaging is a potential measure to take toward curb medical costs, but I think the arguments Schuck and Zeckhauser make are complete bullshit. The type of argument that suggests that the “bad apples” should be removed from classrooms (and placed in remedial programs, or nothing) until their behavior improves is exactly why New Orleans has such a crappy public school education system and why it consistently ranks among the lowest in the country. There are very few cases in which the mainstream, conventional society will pay sufficiently for the remediation and correction of deviants. People like to ignore problems, not solve them: it’s much easier to cut out deviants than actually try to restore them to normality. Schuck and Zeckhauser make a numerically compelling argument by saying that if we cut out the expensive tail end of the distribution, we can reduce our costs drastically. That’s probably true, but being economists, they don’t at all take into consideration who makes up this 5% of patients. That is, they don’t consider that it isn’t too hard to become one of the 5%, no matter who you are or what preventive measures you have taken to stay in good health.

    I primarily object to the notion that it’s ethically and morally acceptable to abandon patients who can be helped (i.e. no futility in providing care) and want to be helped (i.e. they have indicated whether through a living will, someone with a power of attorney, or they themselves have said so). Do you really want to put doctors in the role of judging whether or not you deserve to live or die? This is merely propagating the disparities that allow health status to be a social determinant. It is absolutely essential to the mission of this profession to not be judgmental in providing care, and furthermore, it is against current law to do so (e.g. medical treatment must be provided, by law, to all patients who arrive in the ER).

  2. Apollo, M.D. » Blog Archive » Why won’t Social Darwinism just die? Says:
    March 31st, 2007 at 12:24 pm

    [...] (i.e. what some call the “middle class”). Nonetheless, they properly identify that costs and demand will tend to increase to meet or exceed the budget allocated to a program. That is, as much as I and other health care providers argue that people are not at fault for their [...]

  3. Eric Says:
    March 31st, 2007 at 2:33 pm

    I was afraid this sort of misinterpretation was going to happen. Perhaps I should have pre-emptively staved it off.

    Note that they aren’t arguing just to wholesale cut out the long tail of medical distribution. Just because they’re “economists” doesn’t mean they don’t employ logic; economists are some of the smartest people on the face of the planet, having to study human behavior. They’re arguing that if we focus our attention on the bad apples (which happen everywhere) that happen in particular in that 5% distribution, we can have great savings. It’s not a matter of cutting out the unfortunate and leaving them out to dry; it’s about making sure each person only gets their due share, so that everyone gets the maximum benefit possible. Isn’t being fair an important thing? Consider the Clinton welfare reforms; by pushing for people to be gainfully employed or seeking employment, we both cut costs to welfare and made it less a stigma to be relying on the safety net. That’s the argument that Schuck and Zeckhauser were making. Plus, it’s not about just cutting people out of programs; it’s all about making proper incentives, which we just don’t have right now in the medical system.

    And there was no argument about abandoning people who can be helped. I’m talking about discouraging people who don’t need help, who just suck up the resources where they can find them. People like that exist, unfortunately. They’re not all bad; they exist on a continuum. Some people do that more than others. They need more discouragement than others. Other people don’t. They don’t need discouragement. By matching incentives to delinquency, we get a more cost-effective system that is better respected by all, and thus more easily funded by the public.

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