Arnold Kling  

Third-party Payments and Vioxx

Pragmatism, continued... True Scarcity?...

Holman W. Jenkins writes,

a University of Maryland study found that the more generous a patient's insurance, the more likely he was to be taking a Cox-2 -- and the less likely he was to need it. For the patients with the best coverage, in fact, there was basically zero correlation to need.

...what insurers are selling these days is not true insurance but a mechanism to launder medical consumption through a third-party payment mill to qualify for a tax benefit.

Jenkins argues that the misuse of Vioxx was due to the fact that insurance companies, rather than patients, are the primary decision-makers.

I like the "mechanism to launder" phrase. It would have been useful to incorporate in You Call This Health Insurance?

For Discussion. Could it be that third-party decision-makers fill a consumer need, i.e., that we really do not want to make these decisions ourselves?

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COMMENTS (2 to date)
Lawrance George Lux writes:

No. No one polls Patients, but almost All I have talked with would prefer a reduction in the level of medication. Doctors proscribe--far too often, and Patients have to accept or lose medical coverage. lgl

Maurice Sonnenwirth M.D. writes:


OF course. In medicine and anything else. We delegate what we don't or can't do. (And we should: If I try to do something out-of-my-league fixing up my house, it costs me twice as much by the time I call for competent help to repair my "repair").

Patients should not necessarily be the decision-makers in medicine. I'm not an old-time "Just Obey Me" doctor, but I do know things that patients don't!

That doesn't mean patients should not try to learn and understand on their own, and physicians also have an obligation (even if time is short) to try to explain the why's and wherefore's of what they are prescribing/testing/doing. I have a diabetic daughter..and I can tell you, I had to relearn and newly learn things I never knew in med school...about living with a diabetic. I know parents NOT in the medical field, of diabetic children, who I think know more than 99% of the non-endocrinlogist docs out there.

Now, should 3rd party payers be involved with these decisions? Yes and no. When they take away our autonomy, as in saying "you can only prescribe this, that or this" in a class of drugs...because they are cheaper for that company...and yet, this patient does NOT do as well on this one as that one that's not covered..that's a problem for us.

Medicine remains an art. Prescribing is one of the most difficult things to do, because of, not only the conflicting studies about medications, but because of the huge number of variables of response in real human beings. Studies don't always clarify things for us. Having stats thrown at us and then drug decisions made by 3rd party payers based on those...well, it doesn't always pan our very well. (Evidence-based medicine? What's good practice this week was bad practice last year.)

Yes, doctors prescribe too much. That, too, is a complicated issue. We do it because the patients demand things from us (antibiotics for viral colds). We can argue and resist...but in the office or ER, it can be a problem. We do it because if we didn't cover this or that, and there was a the lawyers will be called in. So some of it is CYA, which is sad. Some of it is ignorance by the doctor! We throw up our hands when someone is not responding or has new complaints..and we just try something else.

People go to three or four or eight different doctors. They get meds from one, don't tell the 2nd about the 1st's meds, go to a 3rd, don't tell this one about the previous two docs' meds (etc.) ...then come to the ER and tell me they have no idea what medications they are on! But we'll get the list, call their primary doctor who is scratching his/her head because they have no record of ever having prescribed some of the 20 medicines this patient is on. THIS IS NOT a problem caused by insurers. This is not always because doctors don't communicate. Sometimes it's just that people, as patients, doctor shop and don't bother lettin' on what they are doing.

So it's not so simple as to just blame the doctors. Or the patients. Like many things in health care, it's a complicated mess of who's really at fault and who is doing the right thing.

This is the real world of what we deal with as physicians. Lots of folks have simple answers and solutions for us...but they're b.S. because of what I wrote above. Physicians are guilty of many things, and there are many bad physicians out there...but lots also give a damn and try to do their best under increasingly awful circumstances.

It's hard to know where to even begin fixing "medicine". But I read the econ. blogs on this, and there are many great comments and many great ideas...but many also don't take into account what the realities "on the ground" are.

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