Agency: A Case Study

The latest bit of life-threatening trivia that's seen some major media coverage has been the fear of a link between vaccines and autism. Such a link does not exist. The science is there, is solid, and is not an evil plot. So why does the myth persist? As the linked-to story in Wired says, parents are willing to do anything out of love for their children. They are eager and willing to believe in alternative cures, or in radical measures to save their children. A lot of emphasis has been places on this as a failure of rationale choice: vaccines are inherently safer than the diseases they protect against. A striking visual example is this chart discussing the risk of taking the HPV vaccine versus the risk of not doing so. HPV not in any way associated with Autism, but the case against HPV is similar: well-publicized incident of a side effect gone wrong, or of the potential for a harmful side-effect, with little real coverage of the damage caused by not taking the vaccine. To scientists (and, generally, to rational human beings) this makes no sense: the least risky action is desired, and should be taken.

So why the resistance to vaccinations? Agency.

People see themselves as having control over whether or not to get a vaccination; they are upset at laws about mandatory vaccinations, which to them imposes the risk of side effects. In refusing to be vaccinated or vaccinate their own children, this people are acting against the only risk they perceive: that caused by vaccines themselves.

They are, at the same time, assuming that disease is a factor beyond their control. Getting infected by any of the diseases that a vaccine would protect against is seen as something against which they are powerless (or, more likely, unaware), and so isn't a risk to avoid. They've seen/read/researched the stories about things gone terribly wrong with vaccines. But the renewed outbreak of diseases like measles (basically non-existent for my generation and the one immediately preceding it) doesn't register as a new risk. These people, these parents fearful of autism (or more generally the mercury in all vaccines) are making a terrible assessment of the possible risks, but it's not irrational - they just have no idea of the risks where the balance of risk falls.

Most relevantly, they don't see getting vaccinated as reducing risk. Because exposure to disease isn't something they have control over, but exposure to medicine totally is. It's a major disconnect they've developed between vaccinations and disease. The solution? Coming from my social-sciencey background, I'm inclined to think that the problem can be solved by a reframing of vaccination. Vaccinating is a choice just as much as not vaccinating is, and the positive good caused by vaccines is little publicized, and even more rarely seen as an actual decision.

We humans remember when things go wrong. We have a terrible problem with forgetting when and why things went right.

Obama Healthcare Quickie

Obama just gave a press conference on healthcare, and my thoughts will probably go up here tomorrow. For now, though, here's a redirect to my blog series on healthcare from the beginning of summer.

Equally important: here's an amazing New Yorker article about why paying-per-test is a terrible plan, and why the Mayo Clinic Model is kind of brilliant.

The Problem of Modern Healthcare, pt 3: Doctors as For-Profit

As outlined in post 1 of this series, McAllen (in Hidalgo County) manages to have the highest healthcare costs in the country at the same time that it has among the worst care provided. This is in stark contrast with places like the Mayo Clinic, where low cost and high quality healthcare combine. The most obvious and glaring difference between the two systems is the goals of the doctors. In McAllen, they are for-profit and paid for procedure, and they let this focus determine the kind of care they provide. At the Mayo Clinic, doctors are salaried, and so while they are well off, they have no need to order procedures for procedures sake. Instead, Mayo Clinic doctors put the emphasis on effective care, rather than expensive care. And it works.

If this sounds a little socialist, it's because it is, in a way. It is very much a not-for-profit ethos, and it knows that the profit motive here doesn't lead to best care. The US already has a class of people engaged in nonprofit work, as government employees, with 6 figure salaries, who could stand to make a lot more in the private sector but instead function as civil servants. The federal court system is a great example of this - it combines job security, meaningful work, a generous pension, and a 6-figure income to take brilliant and qualified people and employ them appropriately.

The example isn't perfect; the fact that the private practice of law generates millions for the kind of people sought out as public servants limits the candidate pool. And in medicine, it makes the Mayo Clinic model riskier, as doctors are drawn towards the greater wealth accumulation (and accompanying security) of for-profit medicine. But that doesn't' mean a civil-service model for healthcare doesn't exist.

In part 2, I mentioned that the single-payer debate is mostly meaningless as far as the pricing of medicine is concerned. Government can, however, be much more involved in price structuring of medicine, and as the payers of doctors under a single-payer program, they can change medicine from the source of wealth it is to McAllen doctors into a stable, well-paying civil service job. As a corollary, government can also offset the high costs of medical school with loans and debt forgiveness, a power almost unique to government and one that would make the profit-seeking of doctors less vital. This, more than anything else, is the promise I see inherent in any talks of universal healthcare reform. But it doesn't actually require a single payer model to come into being.

The Mayo model came about in a very profit-centric world. It thrived and expanded. Government doesn't need to be in control to allow that kind of success to continue. They just need to stop disincentivizing against it. Providing debt forgiveness for doctors who work in Mayo-model or similar clinics, changing away from a pay-for-procedure model, and providing additional benefits to salaried doctors are all within reach of government legislation.

It just takes effort, observation, and political will.

The Problem of Modern Healthcare, pt. 2: Who Pays is Moot

From the New Yorker Article mentioned in part 1 of this series, the most crucial three paragraphs:

As economists have often pointed out, we pay doctors for quantity, not quality. As they point out less often, we also pay them as individuals, rather than as members of a team working together for their patients. Both practices have made for serious problems.

Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coördination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later? Getting the country’s best electrician on the job (he trained at Harvard, somebody tells you) isn’t going to solve this problem. Nor will changing the person who writes him the check.

This last point is vital. Activists and policymakers spend an inordinate amount of time arguing about whether the solution to high medical costs is to have government or private insurance companies write the checks. Here’s how this whole debate goes. Advocates of a public option say government financing would save the most money by having leaner administrative costs and forcing doctors and hospitals to take lower payments than they get from private insurance. Opponents say doctors would skimp, quit, or game the system, and make us wait in line for our care; they maintain that private insurers are better at policing doctors. No, the skeptics say: all insurance companies do is reject applicants who need health care and stall on paying their bills. Then we have the economists who say that the people who should pay the doctors are the ones who use them. Have consumers pay with their own dollars, make sure that they have some “skin in the game,” and then they’ll get the care they deserve. These arguments miss the main issue. When it comes to making care better and cheaper, changing who pays the doctor will make no more difference than changing who pays the electrician. The lesson of the high-quality, low-cost communities is that someone has to be accountable for the totality of care.

Emphasis mine. Not that the single-payer/insurance debate isn't a valid one. But it's not a valid one when it comes to absolute cost. That will come from changing the autonomy of doctors, which I discuss in part 3 of this series.

The Problem of Modern Healthcare, pt. 1

The New Yorker recently had an article examining how healthcare in the US goes wrong. The article is a great read, in-depth and devoid of the classic free-market/single-payer argument that pervades the discussion of healthcare reform in the US today. Notably, the article focused on two separate methods of healthcare practice in the US. Healthcare in McAllen (in Hidalgo County), where average medicaid costs are $15,000/person, and the practices of the Mayo Clinic, which costs medicaid an average of $6,688 per person. McAllen also has some of the poorest health of anywhere in the nation, while the Mayo clinic is a national leader in quality. The fascinating part of the article is that these differences happen within the current free(ish) market for healthcare in the US, and they go against standard logic that more $ = better. Here's my breakdown of the salient points in the article:

The McAllen Model:

• high doctor autonomy
• doctors paid per service rendered, not salaried
• extra tests/medicines incentivized
• do the expensive thing by default
  
• reliance upon patients with medicare = almost unlimited pool of money available to patients
• patients always choose more services, assuming more = better
• the culture of the doctors is very much medicine ==> wealth
• as a corollary, doctors make millions and are the major landowners in the county
  
• this is rather justified by the high initial costs of getting into and practising medicine
• the other justification for such wealth accumulation, fear of/protection from malpractice lawsuits, isn't really a threat in Texas, where McAllen is located

The Mayo Model

• doctors salaried, at a decent pay level
• doctors paid in 6 figures
  
• doctors work in concert as medical team, rather than as individuals
• preventative medicine is offered more consistently, as doctors have no reason to want to do more expensive things later
• wait to see if low-cost methods work before recomending expensive methods
• patient-first healthcare considerations are emphasized

While this may seem obvious (profit-incentive for doctors doesn't equal good care for patients), it's a point that renders almost moot the debate over single-payer healthcare. (See part 2 of this post for a full excerpt explaining why).

It does, however, is present a strong case for doctors being civil servants (or quasi-civil servants, which I'll get into in part 3 of this post.