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POLICY/QUALITY: Scales falling from eyes on road to Dartmouth! with UPDATE

Not long ago (September 2006) David Leonhardt wrote perhaps his worst article ever about health care called The Choice: A Longer Life or More Stuff – New York Times. This set me off on a series of memes about dogs and sores. In fact I wrote this:

Like a dog licking an open sore, the  NY Times again returns to the "we spend so much on health care because it’s worth it" meme in a ridiculous article called The Choice: A Longer Life or More Stuff. (This post was about a different NY Times author’s stupid article on the same subject last month). They then print a bunch of reader responses, sadly few of which point out the fact that compared to countries who spend less money we’re not getting "longer life" (although the first one does).

But none of them point out the simple truth. We spend that much because the system has been politically rigged so that it’s virtually impossible not to. There is no causal connection between the vague desire for increased life expectancy on behalf of the public, and the increase in health care system spending. But there is a huge causal connection between the desire for greater health care system revenue on behalf of the system stakeholders and the increase in health care spending– because we have a funding system set up on their behalf. Has the NY Times not heard of, say, Medicare Part D? Have they not heard of 30 years of Wennberg’s Dartmouth works which proves that high cost care has bugger-all to do with improved outcomes? This is like saying we need 5,000 nuclear warheads or a brand new attack fighter 15 years after the end of the cold war, or that the drug war is effective. It’s patently not because we need those things, but it’s because there are strong interests that have gotten them funded!

And then they kept doing it again and again. All based in large part on David Cutler’s work that assumes that paying a gazillion dollars for an extra year of of life is “worth it”. Even if the person concerned could only generate a buck twenty-eight in that year, in that currency that we use to measure value called, you know, money.

But something remarkable has happened. Leonhardt has found his way to Damascus Dartmouth and apparently Cutler (who always ought to have known better, and has apparently been saying sensible-ish things to Maggie Mahar) has too. Today in the NY Times he writes about how we’re wasting tons of money in inappropriate care, and perhaps we ought to have one of those cost-effectiveness institutes like those in other countries.And who knows, it might be politically possible, without “culture” stopping it—because the root cause is political.

Still, we shouldn’t be naïve: a lot of people would lose if medical care came to be based more on what actually worked. <SNIP> So reforming the system will require a fight — not just over the meaning of the word “universal” but also over finding tough, sensible ways to save money. As David Cutler, one of the Obama campaign’s health care advisers, said, “These things are really hard, so they ought to be in the foreground.” The simple truth is that medical spending can’t continue to rise at its current rate. Somehow, we need to make choices.

I love converts.

UPDATE: I’ve had a little back and forth with David Leonhardt. It’s not over yet and it hasn’t made it into his reader response list yet either. At the moment it looks as though he’s suffering from severe cognitive dissonance…I’ll print here if he doesn’t there sooner or later.

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