Arnold Kling  

What Every Worker Believes

A Depression-Era Solution on H... Replying to Thoma on Health Ca...

1. I should have more autonomy.
2. I should be rewarded more for my own ideas that work.
3. I should be penalized less for my own ideas that fail.
4. Competition that is innovative or inexpensive is unfair.

That is the Universal Worker World View.

Brad DeLong and Mark Thoma make health care management sound really, really simple. Step one, government takes over. Step two, government creates new goals and objectives. Step three, behavior changes. In fact, given the Universal Worker World View, getting from step two to step three is not so easy.

In this country, health care providers are administered remotely. The doctor fills out the form and sends it to a remote office at an insurance company or government agency.

A naive view is that we can change behavior by tweaking the forms. Instead, I have a more radical view, which is that doctors need hands-on supervision.

The reason I think that health care providers need hands-on supervision is that most of the health care spending in this country goes for complex patients, such as my late father in his final stages. Our current treatment processes for those patients are what is most wasteful and ineffective about our health care system. If you are going to reduce costs significantly, you need very different management systems. I made this argument at length in this essay and on this podcast.

With more hands-on supervision, I see doctors having less autonomy, less reward for their own ideas that work, more punishment for their own ideas that fail, and more uncredentialed competition. Given the Universal Worker World View, I expect them to raise objections, to put it mildly.

Every doctor wants to be Marcus Welby, the beloved sole practitioner. But the most expensive patients require teamwork. They require a very different management approach.

The only way I can see the health care delivery process changing is under the competitive pressure of the market, driven by consumers. Instead, the more you bring health care under the political process, the more you entrench the existing system.

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GU writes:

Be careful Arnold, the AMA might put out a hit on you if you keep this up!


The strategy I suggest is pointing out that the current system harms patients, and that doctors might have to give up some autonomy to best serve their patients. Frame it as: satisfy the doctor's own selfish needs vs. staying faithful to the hippocratic oath.

spencer writes:

It looks to me like all you are proposing is a modest modification of the HMO model.

The HMO model was suppose to be a modern corporation using advance management techniques and motivated by long run objectives to reach exactly the type of solutions you are seeking.

What would be the difference between the HMO model and your model?

Lord writes:

How can it change under the competitive pressure of the market when no such market exists? Is it even politically possible to create such a market? I have my doubts.

Glen writes:

In reference to the 'What Every Worker Believes'.

This also applies to businesses today.

Ajay writes:

Hear, hear. Regarding a team approach, I will note that there is a relatively new position in hospitals called a hospitalist, someone who is supposedly there to keep track of the entire patient experience. I don't know if they handle patients like your dad but I heard of someone taking such a position two years ago and that their hospital in Texas was looking for more hospitalists. I don't know if your highly ranked hospital in St. Louis doesn't have hospitalists when a hospital in Texas does or why that would be, other than the obvious fact that the medical system is highly variable and broken.

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