Tuesday, May 27, 2014

Paine vs. Burke

“Do we want to fix our health-care system by empowering expert panels armed with the latest effectiveness data to manage the system from the center or by arranging economic incentives to channel consumer knowledge and preferences and address some of the system’s discrete problems?”
That sentence comes from the concluding chapter of a book I have just finished reading.  Yuval Levin’s The Great Debate is a summary of the competing philosophies of Thomas Paine and Edmund Burke who were famous essayists and pamphleteers during the last part of the 18th century, and particularly during the American and French revolutions.  They are given credit for having articulated the disparate points of view that underlie what we have come to know as the liberal and conservative branches of politics.
To oversimplify, Paine – seen as a father of liberalism - believed that as individuals we are able, through the application of reason and principles, to reconstruct society in whatever way we see fit without regard to what came before or will come after.  Burke – a conservative - saw the institutions of society as reflecting the accumulated wisdom and experience of the past and believed that changes and improvements should come incrementally. 
As with so many other things, perhaps the truth lies somewhere in between.  In general, I find myself agreeing with Burke, but as the same time I can identify with Paine’s high regard for the importance of the individual and impatience with those who resist measures that seems to be logical and reasonable.
Paine and Burke made enormous contributions to the modern, Western world as we know it and for that we should all be grateful.  And it is sobering to realize that the opinions we think we invented ourselves often have their roots in the thinking of people we never heard of.

Monday, May 19, 2014

More on ERs
The economics of hospital Emergency Rooms continues to be a puzzle.
The May 14 issue of The Boston Globe reports that Steward, a large for-profit hospital chain operating in Southeastern Massachusetts, has entered into an affiliation with AFC Doctors Express, a growing urgent care provider with nine clinics in the area served by Steward.
The story under the byline of Robert Wiseman pointed out that a patient who ran up a $2000 bill in an emergency room could perhaps be treated in a Doctors Express clinic for $200.
The story did not go on to mention that if the affiliation resulted in a patient transferring from the high to the low cost facility, and if nothing else changed, Steward would lose financially.  If it is was a fee-for-service patient, Steward would lose more income than it would save in cost.  If the patient were financed by capitation, the amount paid for the urgent care visit would be more than the amount saved. 
Steward being a for-profit enterprise funded by clever venture capitalists, I suspect it understands the economics of all this very well and that what it is after from Doctors Express is a new batch of patients, enough of whom will also use its ER to offset any such loss.
Discussing the reasons for the affiliation, Dr. Ralph de la Torre, CEO of Steward, was quoted as saying “We need to get some of these visits out of emergency rooms and into urgent care centers, which are far more convenient and a less stressful environment for patients.”
He didn’t mention any cost savings, leaving discussion of the economic puzzle to reporter Wiseman

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