Who Should Tell Your MD What to Do?


In this Wall Street Journal op-ed, Norbert Gleicher suggests that expert panels won’t improve health care because the the quality of the research on which they would base their physician practice guidelines is not reliable. Instead, he suggests that our system can self-correct when experts lead us astray. He asserts that we have a “well working free market of ideas in health care, where effective therapies can rise to the surface and win out.”

I’m somewhat sympathetic to Dr. Gleicher’s point about a government-imposed clinical review process, but he overstates the case about a current free market of ideas. Individual insurance companies and Medicare currently make payment decisions with regard to therapeutic judgments every day. How are they informed, and what are their sets of vested interests? Much of that remains hidden from public view.

Meanwhile, too, doctors and hospital practice what Brent James calls “regional medical mythology,” patterns of care divorced from scientific evidence, based as much on the local supply of specialists and what they learned from their predecessors as any other factors.

Perhaps what Dr. Gleicher is trying to avoid is the replacement of this array of unscientific medicine with the establishment of a centralized panel of unscientific medicine. In essence, he is suggesting that it is worse for the federal government to get it wrong for the whole country at once than for the individual participants (payors, MDs, and hospitals) to get it wrong each in their own way.

Seriously, though, one can apply some analytical rigor in support of Dr. Gleicher’s thesis. Just as a diversified investment portfolio does better over the long haul in terms of risk mitigation, so too might the country do better over time with a diverse set of views as to appropriate diagnostic tests and therapies.

Paul Levy is the President and CEO of Beth Israel Deconess Medical Center in Boston. He blogs about his experiences at Running a Hospital, one of the few blogs we know of maintained by a senior hospital executive.

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7 replies »

  1. I love this quote from the WSJ piece: “well working free market of ideas in health care, where effective therapies can rise to the surface and win out.”
    There is no free market in U.S. healthcare. Very far from it.
    There is a complete lack of visibility and there is a huge seperation between the service providers and the consumers, with insurance companies in the way.
    For example, consumers/patients have no real ability to see price lists for difference services from different doctors and hospitals and to see quality-type surveys of doctors and hosptials. The AMA makes sure patients/consumers don’t get access to this type of stuff. How can you have a free market when you have no way of knowing what you are buying and what price you are paying? In addition, most states are dominated by either one or two insurance companies, so no real competition in health insurance either.

  2. Robert,
    I would rather have a government bureaucrat involved than a insurance bureaucrat. At least we the tax payer and voter can control the government bureaucrat, we cannot control the insurance bureaucrat. As tax payers and voters we can always change the system or remove the government bureaucrats. We cannot do that with an insurance bureaucrat. That is how it works all over the world, where healthcare is often a big issue in many elections and government budget negotiations.

  3. I think health care should be between a doctor and his/her patient. No insurance companies, no red tape, etc. Health care is TOO important to be left to politicians and government bureaucrats.

  4. Its a tough call! Though risk management and ‘diversification’ of the portfolio may be good overall, it may harm some communities greatly, especially more remote ones. If only there could be a happy medium?

  5. You can’t compare a diversified portfolio to national health care. Years of research have shown that market principles are, at the very least, extremely different and unpredictable when it comes to medicine. Asymmetrical information, lack of transparency, etc… these things make a ‘free market of ideas’ a suspect solution to health reform.
    More importantly, it’s a huge generalization to say that the evidence basis for clinical practice is not reliable. For many things, of course, that’s true. But more and more research is being done, and the evidence base grows daily.
    Existing panels that review literature take this into account, and are generally very conservative in making strong statements. A large responsibility of any health board tasked with making clinical practice guidelines would be to first review the quality of the evidence, before even looking at what the evidence indicates.

  6. “Let’s not miss the point here. We do not need health “care” reform but rather we need health “insurance” reform. The care is fine.”
    You can’t be serious.

  7. Let’s not miss the point here. We do not need health “care” reform but rather we need health “insurance” reform. The care is fine.
    Having said that we will never actually have health “insurance” reform until the insurance industry loses it’s anti-trust exemption. Currently they are allowed to collude and price fix and very obviously that is what drives up the costs of premiums. If we repeal this exemption they will actually be forced to compete.
    Right now health insurance companies compete for nothing. They do not compete to lower premiums, they do not compete to lower deductibles, they don’t even compete to lower co-pays. They certainly do not compete to keep providers on their panels happy. So we are to believe they want more competition?
    As it is they are massive corprate entities that just lay there and rivers of money flow to them. The only thing they work hard at is developing the illusion that they are suffering and struggling to the keep costs down on behalf of bettering America. They do that so well because…they can collude on a message and then price fix the premiums.
    Do they deserve to keep this exemption? No. If we repeal this exemption would prices plummet…you bet. why? Because they’d actually have to compete.
    One must ask if premiums, co-pays, and deductibles all sky rocket while fees to providers drop yearly..where is the money? Where is the competition? It’s fixed.

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