Saturday, April 30, 2016

Medicine, Coded for Disaster

Pretty much all institutions, crafts, professions and pursuits go through a number of cyclical forces. At a high level we have things like centralized control vs decentralized, process vs art/craft, public / private, big factory "assembly line" sorts of approaches vs skilled craftsmen --- we could go on.

Writing computer code went from a highly individualized "art" prior to say "the 1970's" and then became an increasingly heavyweight "Design - review - Code - review - Test - review, with tracked "defects" at each phase with plenty of "metrics" to make the "Waterfall" a one shot through a supposedly constantly improving process. The process got way too heavy.

Then came the Internet and Open Source and it all blew up to free-lance "super coders" throwing source across the net with abandon  and rapid cycling new versions constantly. "Design" largely died and even "specifications". The coders took back control of software -- and it went pretty much back to being an "art" rather than a "profession".

Medicine has been both an art and very much a profession for at least hundreds if not thousands of years. It is the most personal and intimate of "personal services", with the level of trust required in your dealings with your doctor exceeding all other relationships in your life when the combination of trusting in both their care / concern / focus / wisdom / confidentiality / character AND highly skilled technical expertise as a package in a single person.

Much like religion, a government that seeks to entirely control your life cannot allow this sort of relationship to NOT be mediated by government and kept under strict control of government. The linked article gives a lot of detail of how we have slid into the hole we are now in, and how it is nearly certain to get MUCH worse.

Before long, these codes were attached to a fee schedule based upon the amount of time a medical professional had to devote to each patient, a concept perilously close to another Marxist relic: the labor theory of value. Named the Resource-Based Relative Value System (RBRVS), each procedure code was assigned a specific value, by a panel of experts, based supposedly upon the amount of time and labor it required. It didn’t matter if an operation was being performed by a renowned surgical expert—perhaps the inventor of the procedure—or by a doctor just out of residency doing the operation for the first time. They both got paid the same.
"Process" attempts to convert humans into plug compatible "parts". That was bad enough with programmers -- in which the best are able to produce 10-100x the "output" of the "average".  Measuring that output is exceedingly difficult -- "lines of code" are often used, but most assuredly "more is NOT better". As in writing, the tightest, best performing, most free of problems, easiest to understand, extendable, maintainable ... etc, etc makes programmers FAR from "plug compatible".

Doctors, having MUCH larger requirements relative to knowledge, skill, judgement, decision making, diagnostic acumen,  very personal communication / interaction, etc, etc are far far less "compatible" than programmers. I did a blog post discussing the difference between the pilots that crashed a plane in Buffalo a few years back and "Sully" Sullenberger who dead sticked an Airbus into the Hudson with no loss of life. Paying doctors "all the same" is insane  -- as is thinking that converting medicine into an "assembly line" with a bunch of "codes and process" is somehow going to "improve" it. What it does is shift power and renumeration to bureaucrats and devalues the unique skills of doctors.

So what we end up with is this:

In other words, we’re about to experience the two-tiered system that already exists in most parts of the world that provide “universal coverage.” Those who have the financial means will still be able to get prompt, courteous, personalized, state-of-the-art health care from providers who consider themselves professionals. But the majority can expect long lines, mediocre and impersonal care from shift-working providers, subtle but definite rationing, and slowly deteriorating outcomes.
The best doctors will end up in the private system, and a lot of solid doctors the next echelon down will just leave medicine because it is no longer a profession and they are professionals. What 90% of the population is increasingly left with is best described in this from Ayn Rand's "Atlas Shrugged".

“Let them discover the kind of doctors that their system will now produce. Let them discover, in their operating rooms and hospital wards, that it is not safe to place their lives in the hands of a man whose life they have throttled. It is not safe, if he is the sort of man who resents it—and still less safe, if he is the sort who doesn’t.”

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