The Rest of the Story

I had other things to do, did not get anything written for Grand Rounds this week.  But at least I can link to it: Pharyngula is the host this week.  He even managed to find a unique format for the presentation, and to make an observation that must have seemed profound:

Doctors seem to spend a fair amount of time wondering why they became a doctor, and how to train more doctors.

Indeed.  

His use of the percentages of medblogging topics as an indicator of how doctors spend their time fails in two areas: it does not account for time spent sleeping, since hardly anyone blogs about sleeping.  Unless you count dreaming, and doctors rarely reveal their dreams.  And it does not account for time spent doing paperwork, which is what I am supposed to be doing right now.

I know my syntax is lousy tonight but that is because I am listening to my new Patti Smith CD;  Mother Rose is brilliant, by the way.  As is Radio Baghdad: "They're robbing/The cradle/of civil-/-ization."

If I had gotten to it, I would have submitted this:

Are some medicines so good they should be free? In diabetes, U-M study finds, the answer can be yes

Lives and money could be saved if co-pays for ACE inhibitors were eliminated Result has implications for Medicare drug plan that begins in 2006

Written by Kara Gavin
July 19, 2005

ANN ARBOR, MI - Nothing in life is free, the old saying goes. But maybe some things should be, according to a new University of Michigan Health System study.  Specifically, researchers find, a group of medicines called ACE inhibitors should be available at no cost to the 8 million Americans over age 65 who have diabetes. These drugs are so beneficial for these patients that even giving them away ultimately would save the Medicare system and society large amounts of money by preventing heart attacks, strokes and kidney failure, the study shows.

And of course, the drugs would save lives, and make life better for patients. The findings, based on a sophisticated computer analysis, appear in the July 19 Annals of Internal Medicine [abstract]. [...]

Says lead author Allison Rosen, M.D., M.P.H., Sc.D., “Patients' out-of-pocket costs such as co-pays are a blunt instrument designed to keep patients from over-using medications, but they create barriers to the use of essential and non-essential medications alike. Our analysis shows that removing all patient costs for diabetes patients taking ACE inhibitors could save Medicare both lives and money.”

The same may be true for other drugs that have a major preventive benefit, she says; future studies will assess what would happen if patients could get them free or at a reduced cost.

That principle, called the “benefit-based co-pay,” is gaining more attention in the insurance field as a more sophisticated way to structure prescription drug benefits. But Medicare's new drug plan currently doesn't provide for the approach.  [...]

Why is this so fascinating?  After all, it is totally unsurprising.  Note that I don't mean to imply criticism of the study: even if the result was entirely congruent with expectations, the study still had to be done, in order to have any hope of convincing anyone to actually do what obviously makes sense to do.

The study is fascinating, because it points out a couple of sociological issues.  For one: it points out the divergence in understanding, between insurers and everyone else, of the purpose of health insurance.  Insurers think that the purpose of insurance is to protect people from unexpected costs.  Typically those would be costs associated with some unpredictable, potentially-catastrophic event.  Everyone else thinks that the purpose of health insurance is to pay for the cost of health care.  

One implication is that people who get health insurance are not getting what they think they are paying for.  Put another way, people think are paying for something else, when what they get is health insurance.  This simple misunderstanding is a source of great consternation on both sides.  Insured people complain that they are not getting what they paid for, and people who provide insurance are frustrated endlessly when people complain, endlessly.  This is inevitable when people think they are buying apples, but the merchant is selling oranges.

This brings us to the second sociological issue: there isn't an objective way to settle the question of what health insurance "really" is.  Some people think it is one thing; others think it's another.  Despite attempts over the millennia, no one had been able to come up with an ultimate arbiter for the meaning of words or phrases.  So what to do?

The study suggests what we should do.  Throw out both definitions of the phrase "health insurance."  Think of it in a new way.  On an abstract level, health insurance is a mechanism that civilized societies have, of redistributing wealth in such a way that most people end up better off.  More specifically, it is a way of allocating a certain percentage of finite resources, in such a way as to improve the average health of the population in the most cost-effective way possible.  

I suppose that some may argue that the concept of "fairness" should be in there somewhere, but that's a big can of worms I'm leaving unopened at the present time.