Expertocracy, Paternalism, and “socializing” health care costs

If you haven’t already surmised, I confess it—the Wall Street Journal is my newspaper of record. (Apologies to the half of the country that prefers the New York Times.) Last Saturday’s WSJ review section carried a piece by Drs. Pamela Hartzband and Jerome Groopman of Harvard, decrying the “Rise of the Medical Expertocracy.” These two—particularly Dr. Groopman—have been writing thoughtfully about medicine for a while.
Their point: policy makers and citizens, regardless of whether they say they favor government or private-sector approaches, agree that all our health questions can and should be answered by the right panel of experts. It’s just a matter of whose experts we choose. Democrats have the Independent Payment Advisory Board, Republicans have insurance companies and their experts. Either way, the experts will “Figure out what works, and what doesn’t…pay for value and empower consumers…[and] no one will come between us and our doctors.”
Touche.́ I certainly have argued for so-called “best practices” in this blog. But these two doctors point out that expert opinions often conflict, outcomes cannot be guaranteed, rational patients do not make decisions primarily based on data, and “much of medicine still exists in a gray zone where there is not one right answer.” Moreover, “beyond safety protocols, there is scant evidence that [‘best practices’] improve our health.” What we are left with, they argue, is an objectionable new form of paternalism, when we should be emphasizing clinical decisions that are “based on a patient’s goals and values.”
These points are all well-taken and mostly correct. Where I would push back:
1) It seems to me that there IS a place for some clinical trial-driven “best practice” research, particularly regarding high-cost technologies of unproven or dubious value, where physicians have an (inappropriate) incentive to use them, either because entrepreneurship gets in the way or reimbursement rules are misplaced (see also the posts by Joe Gibes on Feb 17 and Steve Phillips on Feb 22);
2) It also seems to me that there is broad agreement that we should “socialize,” or share, at least the most egregious medical costs across large groups of people—whether through “public” or “private” options. We Americans are haggling over the most prudent and just way to do that. But what if the patient’s goals and values differ from others sharing the costs, not just regarding matters that most readers of this blog would consider moral concerns (e.g., paying for abortions), but also regarding questionable treatments? For example, I’m not so sure I’m willing to pay for someone else to receive Avastin for breast cancer, outside of a clinical trial. I don’t think it works. At some point, “We’re not paying for that” seems inevitable.
I suspect this new paternalism is here to stay. It may be soft, or not so soft. How much of it should we accept?

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Mike Dudley
Mike Dudley
8 years ago

Jon- thanks for pointing this essay out- I had missed it. Groopman is one of my favorite writers on medical care; I served with him on a few HIV advisory boards a few decades ago and he was one of the clearest thinkers I have ever met.

It think your blog and his essay point out the fallacy in thinking we can regress towards a “best practice” and that will suit anyone. Trying to get “one size fits all” based on the current clinical trial paradigm flies in the face of where therapeutics has been heading: personalized medicine. Population-based studies only help from the perspective of the payer, not from the patient. The patients still stands at the roulette wheel. As one of my mentors taught me, one’s chances of response to treatment is always 50-50–it will either work or not.

The more I think about this, the more I think this model will fail. Perhaps the proposal suggested by others that everyone gets a certain medical savings account(ie, like a phone card)over your lifetime. You spend it on what you think is best (based on your “objectives and goals”, as Hartzband and Groopman suggest) may be a far more cost-efficient and satisfying approach.

As someone once said long ago: there are no experts. I’d rather do this than have my care regressed to some mean.