In the New York Review of Books, Dr. Jerome Groopman has a terrific article on behavioral economics and health care. Among his key points is that federal standards for best practices shouldcbe imposed, if at all, in ways that allow doctors, patients, and health-care-providing institutions freedom of choice, because what the federal goverment decides is the best practice may turn out not to be:
Over the past decade, federal "choice architects"—i.e., doctors and other experts acting for the government and making use of research on comparative effectiveness—have repeatedly identified "best practices," only to have them shown to be ineffective or even deleterious.
For example, Medicare specified that it was a "best practice" to tightly control blood sugar levels in critically ill patients in intensive care. That measure of quality was not only shown to be wrong but resulted in a higher likelihood of death when compared to measures allowing a more flexible treatment and higher blood sugar. Similarly, government officials directed that normal blood sugar levels should be maintained in ambulatory diabetics with cardiovascular disease. Studies in Canada and the United States showed that this "best practice" was misconceived. There were more deaths when doctors obeyed this rule than when patients received what the government had designated as subpar treatment (in which sugar levels were allowed to vary).
There are many other such failures of allegedly "best" practices. An analysis of Medicare's recommendations for hip and knee replacement by orthopedic surgeons revealed that conforming to, or deviating from, the "quality metrics"—i.e., the supposedly superior procedure—had no effect on the rate of complications from the operation or on the clinical outcomes of cases treated. A study of patients with congestive heart failure concluded that most of the measures prescribed by federal authorities for "quality" treatment had no major impact on the disorder. In another example, government standards required that patients with renal failure who were on dialysis had to receive statin drugs to prevent stroke and heart attack; a major study published last year disproved the value of this treatment.
Dr. Groopman associates this freedom of choice with the "libertarian paternalism" of Obama aide Cass Sunstein; tougher measures, including financial penalties, to force doctors and patients into "best" practices, Dr. Groopman associates with another Obama aide, Peter Orszag. Read the whole thing, as they say. Thanks to reader R.L. for the link.
