Tuesday, January 26, 2010

To Mandate Or To Nudge

Regardless of the fate of the current healthcare bill the crisis will not go away. Any meaningful legislation to come must address the matter of inclusion, and containment of premiums. Yes, we have a rapacious health insurance industry. But even beyond that, at the heart of cost control are the often needless procedures, tests, medications even surgeries ordered by physicians. How to rein them in?

A few months ago a panel of medical experts issued guidelines for mammography in women under fifty. This was a longitudinal study weighing benefits and risks. They published their recommendations to a hew and cry.

Woman's advocacy groups were outraged. Older radiologists felt their turf being trampled and may have wondered about the next payment on their Lexus while young doctors had to be concerned over their student loans.

The panel took a step back and had some explaining to do. Recommendations became suggestions. The weight of statistics became politicized and revealed new fissures in the landscape. The term Evidenced Based Medicine (EBM) entered into our national discourse.

Having received my education, such as it was, in science I have always found myself in that camp. I have developed a nose for hokum; a healthy skepticism (I call it) toward anecdotal, shoddy, pseudo-medicine and folksy remedies. The word evidence does not mean something fixed and ossified, though I suppose we often witness resistance to change. For the most part science is defined by curiosity and imagination along with rigorous peer review. When the Center For Disease Control speaks, I listen.

The issuance of guidelines has revealed a division within the White House itself. Peter Orszag argues for mandates while Cass Sunstein favors what he terms a nudge approach. The latter would offer educational material to providers along with disincentives to continue with outmoded protocols.

Mandates would be more directive with certain prohibitions in place to dissuade doctors from continuing what is deemed excessive or counterproductive models of treatment based on the considerable weight of established statistical evidence in a particular field which yields more favorable outcomes. There are indeed instances where less has proved to be better for the patient.

All of us may be seen as part of more than one larger group, yet we also feel unique. We don't mind being included in age or gender classifications or even certain disease categories but we also like to regard ourselves as unique and therefore exempt from new paradigms.

I wonder if Americans are rather alone in the industrial world, resisting a group identity. Is this an extension of U.S. exceptionalism? We say, fine, that antibiotics are worthless against upper respiratory viral infections but I want it anyway because last year I took one capsule and the symptoms vanished overnight. Maybe mine was bacterial. Maybe there was a secondary infection. Bad medicine, says the guidelines and so it is because the excessive use of antibiotics develops resistant strains. Does the individual care about the community?

This is where I want to leave it, posing the question for further thought; not only regarding healthcare but the larger issue of how we think of ourselves within or outside of a group and subject to policy directives.

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