Arnold Kling  

Medical Guidelines Commission?

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In this essay, I write

the effectiveness of activist medicine can only be judged in a statistical sense. To know whether the procedures were appropriate, you have to know the distribution of outcomes that occurred when those procedures were used in many similar cases. The issue is not whether patient A obtained relief, but whether the procedures followed in diagnosing and treating patient A were those that best balanced the probabilities of safe and successful treatment with the cost.

My proposal is that either a consortium of health insurance companies or the government establish a formal mechanism for evaluating the benefits of medical practices. Call this a Medical Guidelines Commission (henceforth the Commission).

My thinking is that decisions in health care can be decentralized, but information needs to be more centralized, so that patients and doctors have a statistical fact base to use for their decisions.

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COMMENTS (3 to date)
Lancelot Finn writes:

Good essay, Arnold. Kudos to you for taking on a tough but important question. And kudos for adopting a stance that seems contrarian for a libertarian to take, advocating centralization (albeit of information only).

The problem with your view, as I see it, is that you've recognized market failures, and advocated a government intervention, but that leads to the question of government failures. If you're going to propose the creation of a new government commission, you need to deal with public-choice objections.

First, how do you prevent the Commission from being taken over by bureaucrats who want to centralize even more? Democrats who support socialized medicine might seize on this proposal as a Trojan Horse for socialized medicine. "It was proposed by a libertarian," Democrats will say, to disarm conservative objections. And then they'll expand its powers and funding until it runs as much of American health care as it can get its hands on.

Second, since a government Commission won't have competition, and since govt. bureaucrats tend to have infinite job security, what will make the statisticians at the Commission do a good job? How do you get their incentives right? Worse, they might get captured by bleeding-heart impulses that undermine the public good. Consider, for example, a patient who dies because a doctor didn't perform a procedure that would have saved this particular patient but would be expensive and superfluous in the vast majority of cases. If sued for malpractice, the doctor can use the Commission's guidelines in court, so he gets acquitted, good. But what happens next? Pretty soon there will be a cover of Time magazine with a picture of the little girl who died, and who was acquitted because of the Commission's guidelines, lambasting the Commission in that magazine's brainless way for deciding who lives and dies based on cold profit considerations. That the Commissioners, secure in their jobs, rather than doctors, worried about their livelihoods, made the decision, will make their ruthlessness seem even more gratuitous and unconscionable. But then, it probably won't come to that. The Commission's guidelines will probably be "captured" by the same forces that drove the explosion of activist medicine in the first place.

What I'm driving at is that while technical fixes may have their place, what we really need is to do battle with a certain idea, namely that life is sacred and each person has infinite worth. This may be true in the eyes of God but it cannot be true in the eyes of the state. To believe that is a luxury that we can't afford. For a person to die because they couldn't afford medical treatment is now considered a scandal, a disgrace. We need to learn to think of it as a sad fact of life.

My other remark is that it would help to introduce some competition into the structure of the Commission itself by making it interactive... somehow. Statistics are dumb. In the process of condensing information into an easily manageable form, they squeeze a huge amount of information out. They need to be forever supplemented with anecdote. So maybe you could set up a powerful website with room to accomodate and publish, real-time, vast quantities of comments, from patients and doctors, concerning different procedures, their efficacy, and other new ideas or problems in the practice of medicine. You'd need cash to drive this engine. Professional doctors who contributed would be paid for their contributions, perhaps in a tournament model where contributions that were judged to be the best would receive large awards, while others would receive very little. There would be room for anonymous comments, properly vetted. Hopefully a sort of "medical blogosphere" would emerge, with its own system of commerce and rewards which would interact with the medical system as a whole, pushing forward systemic changes.

Robert Schwartz writes:

Arnold, how does your idea differ from this:

Agency for Healthcare Research and Quality (AHRQ), a part of the U.S. Department of Health and Human Services, is the lead agency charged with supporting research designed to improve the quality of healthcare, reduce its cost, improve patient safety, decrease medical errors, and broaden access to essential services. AHRQ sponsors and conducts research that provides evidence-based information on healthcare outcomes; quality; and cost, use, and access. The information helps healthcare decisionmakers—patients and clinicians, health system leaders, and policymakers—make more informed decisions and improve the quality of healthcare services.

AHRQ supports the development of evidence reports through its 12 Evidence-based Practice Centers and the dissemination of evidence-based guidelines through the Agency's National Guideline Clearinghouse™.

AHRQ will:

* Meet the information needs of its customers—patients and clinicians, health system leaders, and policymakers—so that they can make more informed healthcare decisions.

* Build the evidence base for what works and doesn't work in healthcare and develop the information, tools, and strategies that decisionmakers can use to make good decisions and provide high-quality healthcare based on evidence.

* Develop scientific knowledge in these areas but will not mandate guidelines or standards for measuring quality.

The National Guideline Clearinghouse™ (NGC) is a comprehensive database of evidence-based clinical practice guidelines and related documents. NGC is an initiative of the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. NGC was originally created by AHRQ in partnership with the American Medical Association and the American Association of Health Plans (now America's Health Insurance Plans [AHIP]).

The NGC mission is to provide physicians, nurses, and other health professionals, health care providers, health plans, integrated delivery systems, purchasers and others an accessible mechanism for obtaining objective, detailed information on clinical practice guidelines and to further their dissemination, implementation and use.

Arnold Kling writes:

Robert, the passages you quote make the mission of AHRQ seem spot on. But the strategic plan appears to dilute the mission.

It appears to me that AHRQ is the end result of a sequence of re-orgs and mission redefinitions, rather than a focused project team.

Fundamentally, its lack of independence makes it a bureaucratic stepchild, so it will not live up to its potential.

At least, that's my impression.

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