Medicine: The Public-Health Model is Wrong

This Theodore Dalrymple post is a variation on a conventional argument whose unstated main premise is that medical cost decisions should be evaluated from a public-health perspective.

The annual medical is a kind of ceremonial or ritual which, according to its critics, is without rational foundation despite the fact that so many patients, and perhaps a majority of doctors, believe in it. This proves that superstition is not dead: but perhaps that is no fatal criticism of the annual medical after all, because superstition will never be dead. If it does not attach to one thing, it will attach to another.
[. . .]
In fact, most medicals are bureaucratic procedures rather than exercises in getting-to-know-you (as The King and I put it). The doctor asks a few questions, ticks some boxes on a computer screen, performs a perfunctory physical examination equivalent to examining a cubic inch of haystack to find a pin, and does a few selected blood tests, the interpretation of whose abnormal results (if any) will be far from straightforward. In fact, what has been done and measured in annual medicals over the years has changed, without any change in their ineffectiveness.

Ineffective for whom?

The answer depends on who is paying the bill. If it’s third parties such as govts or insurance companies then the conventional argument has merit: maximizing system utility is an important goal. However, if patients control their own medical spending then the main goals should be whatever the individual customers want them to be.

Dalrymple’s analyses are usually much better than this one. Perhaps his frame blindness in this case is a function of his background with the NHS.

14 thoughts on “Medicine: The Public-Health Model is Wrong”

  1. A few points:

    1. You could eliminate almost all medical functions except for Public Health (vaccinations, sanitation, smoking cessation etc.) and simple interventions (antibiotics, nursing) for childhood and mid life illness and get pretty close to the life expectations we see today. But this is not what we (the public) want out of medicine. We want to fix things no matter what age and are not as clueless as people think with regard to costs.

    2. The annual physical is often the only time people sit down with the physician in a semi relaxed mode. Lots of disease is pickedup incidental to any symptom so I’m pretty sure a competent doctor really does get good value from this.

  2. Right. What matters is that you are willing to pay. Arguments from public health are generally based either on willful tacit reframing of the premise of the argument or on naive acceptance of such public-health premises. In most areas of our lives we don’t accept the authority of busybodies to control our spending decisions as we often do with medicine.

  3. Anyone who is spending other people’s money – e.g. anyone on medicare, medicaid, veterans’ … – should simply be denied annual check-ups because a wealth of evidence shows them to be medically worthless. What you choose to waste your own money on is an entirely different point. Handbags, check-ups, unnecessary dental work, extravagant cars, fast women, and slow horses – your choice.

  4. No. You let people make their own choices. People who are poor or due govt svcs from Medicare or the VA should be given vouchers or paid directly so that they, and not third-party payers, control the spending.

  5. “…make their own choices.”

    Yes indeed, I’ll see your “voucher” and go one freedom-step further. Give those due govt. services “cash” with a memo-line of “health care” and let them spend it on whatever they like. Let free enterprise determine how those in the medical profession get paid.

  6. This is about Power and Money and the system is optimized to work for them and to further bankrupt the Americans. Or ‘Mericans.

    That’s what it’s designed to do and it does it well.

  7. This is about Power and Money

    Exactly. The Public Health Model, like the Precautionary Principle, is a pile of assertions masquerading as a theory for the purpose of rationalizing control by elites:

    -Your behavior imposes large costs on other people.

    -The obvious way to mitigate these costs is to put us in charge (give us power and money).

    -There are no other alternative courses of action (or inaction) that we should consider. In particular, radical alternatives that devolve decision making as much as possible to families and individuals are beyond serious consideration.

    When you get these assertions into the open they are easy to refute. The point of bundling them in bogus theories like the Public Health Model is to use elite authority to keep the assertions hidden.

  8. The October 4 New England Journal has an article that tells us where this is going.

    The proposal includes several controversial components beyond mandatory participation. First, hospitals would be exclusively responsible for the bundled-payment program and would control any financial surpluses, which may concern physicians and post-acute care providers who fear being cut out of the action. New clinical alliances are likely, however, because hospitals will perform better if they have collaborative relationships with these providers, and gainsharing with partners will be authorized. Second, whereas BPCI episode prices are determined primarily by each hospital’s historical spending, CCJR prices would be calculated using a blend of hospital-specific and regional spending. Initially, one third of the price would be based on regional averages, but fully regional pricing would be used by year 5 — benefiting low-cost providers but presenting challenges for providers with high complication rates, excess use of post-acute care, or sicker-than-average patients.

    I don’t want to make a seminar about this but this regulation places all surgeons, and eventually all doctors, in a position of servitude to hospitals. The vertical integration of medicine is what is planned. I have previously described the hospital I practiced in. Since then, in the past 18 months, they have fired the surgical group that ran the trauma center for 35 years. Hired a new group of surgeons nobody has ever heard of. I am hearing scary stories about what is going on with trauma cases now. The hospital has been buying up all the medical groups so all doctors are employees. My understanding is that the hospital wanted to buy the surgical group and the group declined. The hospital is now determined to run them out of the medical community and replace them with inferior surgeons who take orders.

    I am so glad I am retired.

  9. What would Carson do? Kennedy, you may have mentioned your impression in a previous post – if you did, could you give me a search word or something? If not, could you give your insight? I trust your perspective.

    The more I think about insurance not paying for oil changes and flat tires, the more it seems to me we look at health insurance in an unrealistic and unproductive way. I want catastrophic, of course – my county shouldn’t go broke if I get some hanging on disease nor my family – I should plan for it with regular payments, gambling as such insurance payments always are.

    However, annual check ups don’t have to be like Dalyrmple describes. Of course it is becoming more that way, but it would have been unnecessary in my 20’s and 30’s, probably caught some problems earlier in my 40’s and 50’s, and now, near 70, they are oftener than once a year. I’d like to know my physician before I have my first heart attack, for instance.

    Now, it isn’t just that we ignore costs because insurance is paying them, it is also because when we do see a bill, it is surreal. My podiatrist doesn’t make the kind of money that bill for “debreeding” or whatever the hell it is would indicate goes to him and his staff. I like and trust him and some of it is delegated, but surely in a sane society $500 wouldn’t be necessary for appropriate payment. I don’t know where it goes except into the bowels of our local health group which then takes care of the indigent and hires endless groups of sometimes surly staff to deal with government & insurance. If I paid, maybe I’d be more responsible (like not going barefoot) and take on more of the task myself. Oh, well, this is uninformed but from a belief the open market would encourage a lot of good practices and get rid of a lot of bad ones.

  10. I wrote a series of posts years ago, which are linked here, about what I envisioned as a workable reform. I was allowing the concept of a “safety net” more room than I would consider ideal, mainly because I think France proved that it could work. The French system has for years been the highest rated health care in Europe.

    I haven’t looked at Carson’s proposal. McCain in 2008 actually had a pretty good plan but he could not explain it and, besides, the financial collapse swept all before it.

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