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Medical Forum / General / General / September 2005the moral-hazard myth: gladwell
"The issue about what to do with the health-care system is sometimes presented as a technical argument about the merits of one kind of coverage over another or as an ideological argument about socialized versus private medicine. It is, instead, about a few very simple questions. Do you think that this kind of redistribution of risk is a good idea? Do you think that people whose genes predispose them to depression or cancer, or whose poverty complicates asthma or diabetes, or who get hit by a drunk driver, or who have to keep their mouths closed because their teeth are rotting ought to bear a greater share of the costs of their health care than those of us who are lucky enough to escape such misfortunes? In the rest of the industrialized world, it is assumed that the more equally and widely the burdens of illness are shared, the better off the population as a whole is likely to be. The reason the United States has forty-five million people without coverage is that its health-care policy is in the hands of people who disagree, and who regard health insurance not as the solution but as the problem." THE MORAL-HAZARD MYTH by MALCOLM GLADWELL The bad idea behind our failed health-care system. Issue of 2005_08_29 http://www.newyorker.com/printables/fact/050829fa_fact Great topic, But somehow I missed the moral hazard part Please explain. I have a disability. Many thanks. > Great topic, > But somehow I missed the moral hazard part [quoted text clipped - 3 lines] > > Many thanks. Well, they argue if you had better insurance, you would see more doctors and cost the nation more. So, they want either no insurance, or large out-of-pocket co-pays. The problem is that we now pay 2.5 times EXTRA for this fake theory than does the average industrialized nation. My dental insurance (chew-on-the-other-side.com) turns down claims at least 3 times before it pays and has a gang of clerks to do this. This is the story of free-enterprise insurance. > THE MORAL-HAZARD MYTH > by MALCOLM GLADWELL [quoted text clipped - 20 lines] > and who regard health insurance not as the solution but as the > problem." I've often wondered about the medical propaganda machine which blames illness on patients, as if we want cancer and so forth and so on. If you believe the health crazies, we would all live forever if all we ate was oatmeal or something. >> THE MORAL-HAZARD MYTH >> by MALCOLM GLADWELL >> The bad idea behind our failed health-care system. >> Issue of 2005_08_29 >> http://www.newyorker.com/printables/fact/050829fa_fact ..................... > I've often wondered about the medical propaganda machine which blames >illness on patients, as if we want cancer and so forth and so on. If you >believe the health crazies, we would all live forever if all we ate was >oatmeal or something. I do not believe the health crazies, but there are vastly different hereditary and environmental individual effects. The health crazies, and a large proportion of medical people, believe that treatment and prevention of disease can be done by the use of SIMPLE formulas. Genetics is quite important; overeating can promote Type 2 diabetes only in those with the appropriate genes. We already know of breast cancer treatments which only work in women with a certain genetic makeup, and drugs which have different marginal efficiencies in different races. It is also the case that, if one compared two treatments for two genetically similar individuals, one might prefer the results of one, and the other the opposite. The moral hazard is letting "those in power" have the right to decide which actions are appropriate. This is inevitable with any major government involvement, and is hard to avoid with any prepaid care system where third parties have to decide anything about the care a patient receives. To have an economically sound process, the evaluator of risks and benefits of a procedure have to be the one receiving them.  SignatureThis address is for information only. I do not claim that these views are those of the Statistics Department or of Purdue University. Herman Rubin, Department of Statistics, Purdue University hrubin@stat.purdue.edu Phone: (765)494-6054 FAX: (765)494-0558 >>> THE MORAL-HAZARD MYTH >>> by MALCOLM GLADWELL [quoted text clipped - 33 lines] > an economically sound process, the evaluator of risks and > benefits of a procedure have to be the one receiving them. Herman, the so-called moral hazard, which is a myth, is put on the patients in the article I cited, NOT the providers. However, you are right in saying that the simplistic formulas pushed by the establishment are harmful in many, many circumstances. My wife was put on a beta blocker to 'help' her. It did the opposite and finally her doctor realized that. But you know, first you try the usual and customary. I cannot take aspirin, for example, or most of the subsitutes. Must be genetic but no one knows why. Statins raise cance risk, but that does not seem to count. The differentials between very high statin use and the lack of so-called incidents is two percent. 2%!!!! But what are the risk? They don't count to researchers if the risk is another disease they are not studying. They observe the fact and say it is 'causal.' !!! Imagine. >>>> THE MORAL-HAZARD MYTH >>>> by MALCOLM GLADWELL >>>> The bad idea behind our failed health-care system. >>>> Issue of 2005_08_29 >>>> http://www.newyorker.com/printables/fact/050829fa_fact .................... >>> I've often wondered about the medical propaganda machine which blames >>>illness on patients, as if we want cancer and so forth and so on. If you >>>believe the health crazies, we would all live forever if all we ate was >>>oatmeal or something. >> I do not believe the health crazies, but there are vastly >> different hereditary and environmental individual effects. >> The health crazies, and a large proportion of medical >> people, believe that treatment and prevention of disease [quoted text clipped - 4 lines] >> with a certain genetic makeup, and drugs which have >> different marginal efficiencies in different races. >> It is also the case that, if one compared two treatments >> for two genetically similar individuals, one might prefer >> the results of one, and the other the opposite. >> The moral hazard is letting "those in power" have the right >> to decide which actions are appropriate. This is inevitable [quoted text clipped - 3 lines] >> an economically sound process, the evaluator of risks and >> benefits of a procedure have to be the one receiving them. > Herman, the so-called moral hazard, which is a myth, is put on the >patients in the article I cited, NOT the providers. No, it is the providers, which included, unfortunately, the ones who administer the finances. They cannot act other than simplistically, as there is never enough third-party money supplied. However, you are right >in saying that the simplistic formulas pushed by the establishment are >harmful in many, many circumstances. My wife was put on a beta blocker to >'help' her. It did the opposite and finally her doctor realized that. But >you know, first you try the usual and customary. I cannot take aspirin, for >example, or most of the subsitutes. Must be genetic but no one knows why. How could they know why; the genome has barely been studied, and even mutations in the "non-coding" section of the genome are known to have effects. When my doctor prescribed an antidepressant at my suggestion, the first one prescribed apparently did a fairly good job, but developed bad reactions. It was dropped quickly, generally a bad idea, but several months late, I asked again. This one seems OK. Does it have other side effects? None that seem to be recognizable. We can only use what is known, plus brains. We do not know enough; I cannot get enough information to properly apply my statistical knowledge from much of what has been published. I can take aspirin, uncoated, with no risk of local bleeding. Likewise, opiates do their job for me, with no indication of anything else happening, including sedation. However, I react badly to muscle relaxants and alpha blockers. >Statins raise cance risk, but that does not seem to count. The >differentials between very high statin use and the lack of so-called >incidents is two percent. 2%!!!! But what are the risk? They don't count >to researchers if the risk is another disease they are not studying. They >observe the fact and say it is 'causal.' !!! It is not clear if the 2% risk outweighs the benefits; YOU, and only you, must be the one to decide in your case. However, at least one article I read, which had partial breakdowns, indicated that statins provide a cardiovascular benefit in only about 1/3 of the elderly, and may well do harm to a fair number. I might be able to do better with more detailed information, but judging from that report, I would be well advised not to take them if only cardiovascular events were considered. But doctors have only seen the recommendations based on poor studies, without the consideration of KNOWN factors. We are now subject to the moral hazard of those who cannot even understand the data, and certainly not the values of their patients, making decisions. We have to educate the patients, as far as possible, and provide for those who know how, not physicians, to help evaluate the relative importances the patients have for the combinations of results. This can be combined with the input from both to compare the possible treatments. > Imagine. SignatureThis address is for information only. I do not claim that these views are those of the Statistics Department or of Purdue University. Herman Rubin, Department of Statistics, Purdue University hrubin@stat.purdue.edu Phone: (765)494-6054 FAX: (765)494-0558 >>>>> THE MORAL-HAZARD MYTH >>>>> by MALCOLM GLADWELL [quoted text clipped - 42 lines] > other than simplistically, as there is never enough > third-party money supplied. The so-called moral hazard was invented to stop the customer from using too much medical care. Insurance companies want to stop claims. If you have fire insurance, would you burn your house down to get a new one? That kind of thing. > However, you are right >>in saying that the simplistic formulas pushed by the establishment are [quoted text clipped - 6 lines] > > How could they know why; the genome has barely been studied, Correct. We are living in the dark ages when it comes to drugs. The first round of medical chanages was controlling infectious diseases. After that, we now await medicine to go after the diseases of old age, such as cancer. Even dinosaurs died of cancer so whatever the genetic issues, they go way back in evolution. > and even mutations in the "non-coding" section of the genome > are known to have effects. When my doctor prescribed an [quoted text clipped - 22 lines] > It is not clear if the 2% risk outweighs the benefits; YOU, > and only you, must be the one to decide in your case. You would have to know quite a bit to be able to challenge your doctor. We do, but I bet the ads will influence 99% of patients. > However, at least one article I read, which had partial > breakdowns, indicated that statins provide a cardiovascular > benefit in only about 1/3 of the elderly, and may well do > harm to a fair number. It is getting to the point where all of us know someone harmed by statins. It makes you wonder if the FDA even cares to note the issues. I might be able to do better with > more detailed information, but judging from that report, I > would be well advised not to take them if only [quoted text clipped - 11 lines] > This can be combined with the input from both to compare the > possible treatments. If the side effects are even known Herman. Often, they are not. >>>>>> THE MORAL-HAZARD MYTH >>>>>> by MALCOLM GLADWELL >>>>>> The bad idea behind our failed health-care system. >>>>>> Issue of 2005_08_29 >>>>>> http://www.newyorker.com/printables/fact/050829fa_fact .................... >>>>> I've often wondered about the medical propaganda machine which blames >>>>>illness on patients, as if we want cancer and so forth and so on. If >>>>>you >>>>>believe the health crazies, we would all live forever if all we ate was >>>>>oatmeal or something. >>>> I do not believe the health crazies, but there are vastly >>>> different hereditary and environmental individual effects. >>>> The health crazies, and a large proportion of medical >>>> people, believe that treatment and prevention of disease [quoted text clipped - 4 lines] >>>> with a certain genetic makeup, and drugs which have >>>> different marginal efficiencies in different races. >>>> It is also the case that, if one compared two treatments >>>> for two genetically similar individuals, one might prefer >>>> the results of one, and the other the opposite. >>>> The moral hazard is letting "those in power" have the right >>>> to decide which actions are appropriate. This is inevitable [quoted text clipped - 3 lines] >>>> an economically sound process, the evaluator of risks and >>>> benefits of a procedure have to be the one receiving them. >>> Herman, the so-called moral hazard, which is a myth, is put on the >>>patients in the article I cited, NOT the providers. >> No, it is the providers, which included, unfortunately, >> the ones who administer the finances. They cannot act >> other than simplistically, as there is never enough >> third-party money supplied. > The so-called moral hazard was invented to stop the customer from using >too much medical care. Insurance companies want to stop claims. If you >have fire insurance, would you burn your house down to get a new one? That >kind of thing. You would be surprised; many do, especially after removing the contents to a place they will not be discovered. And there are people using too much medical care even without such a motive. If seeing the doctor is cheap, and time is not important, many will go to a doctor for the slightest ache; the pain pill needs to be chosen carefully. And that sniffle might be pneumonia, for all you know, and that sore leg might be a muscle tear. That stomach ache may be appendicitis. There are lots of others. >> However, you are right >>>in saying that the simplistic formulas pushed by the establishment are [quoted text clipped - 4 lines] >>>for >>>example, or most of the subsitutes. Must be genetic but no one knows why. >> How could they know why; the genome has barely been studied, > Correct. We are living in the dark ages when it comes to drugs. The >first round of medical chanages was controlling infectious diseases. After >that, we now await medicine to go after the diseases of old age, such as >cancer. Even dinosaurs died of cancer so whatever the genetic issues, they >go way back in evolution. >> and even mutations in the "non-coding" section of the genome >> are known to have effects. When my doctor prescribed an [quoted text clipped - 6 lines] >> enough; I cannot get enough information to properly apply >> my statistical knowledge from much of what has been published. >> I can take aspirin, uncoated, with no risk of local bleeding. >> Likewise, opiates do their job for me, with no indication of >> anything else happening, including sedation. >> However, I react badly to muscle relaxants and alpha blockers. >>>Statins raise cance risk, but that does not seem to count. The >>>differentials between very high statin use and the lack of so-called >>>incidents is two percent. 2%!!!! But what are the risk? They don't >>>count >>>to researchers if the risk is another disease they are not studying. They >>>observe the fact and say it is 'causal.' !!! >> It is not clear if the 2% risk outweighs the benefits; YOU, >> and only you, must be the one to decide in your case. > You would have to know quite a bit to be able to challenge your doctor. >We do, but I bet the ads will influence 99% of patients. If they are that easily influenced, should they be able to have a say in deciding what medical care anyone else should get? If you can't decide for yourself, why should I let you get away with being in on deciding for me? >> However, at least one article I read, which had partial >> breakdowns, indicated that statins provide a cardiovascular >> benefit in only about 1/3 of the elderly, and may well do >> harm to a fair number. > It is getting to the point where all of us know someone harmed by >statins. It makes you wonder if the FDA even cares to note the issues. The FDA has been given a mission which does not make sense, and seems not to be able to make intelligent decisions. Being bureaucrats, they have to go "by the book", except when they are being politically bullied. Letting us know and make decisions is not in their list of options. I can give you examples of decisions they made which were in this class. >I might be able to do better with >> more detailed information, but judging from that report, I >> would be well advised not to take them if only >> cardiovascular events were considered. >> But doctors have only seen the recommendations based on >> poor studies, without the consideration of KNOWN factors. >> We are now subject to the moral hazard of those who cannot >> even understand the data, and certainly not the values of [quoted text clipped - 4 lines] >> This can be combined with the input from both to compare the >> possible treatments. > If the side effects are even known Herman. Often, they are not. If the side effects are not know, nobody should be liable if they occur, provided that full explanations of the known risks and benefits are given. One drug, used for a long time to ease the problems of morning sickness, is no longer on the market because of lawsuits which the company won; they lost none. The income from the drug was less than the cost of the lawsuits. The FDA should be charged with seeing that the full information is available, and not with protecting people against their stupidity. Nor should any other part of the government. I do not know if this comes under tpm, but my adult daughter should not have an operational airbag in front of her, and I should have one in front of me. The government does not provide for this possibility, even when the problem has been clearly pointed out. SignatureThis address is for information only. I do not claim that these views are those of the Statistics Department or of Purdue University. Herman Rubin, Department of Statistics, Purdue University hrubin@stat.purdue.edu Phone: (765)494-6054 FAX: (765)494-0558 > It is getting to the point where all of us know someone harmed by > statins. It makes you wonder if the FDA even cares to note the issues. I know people harmed by seat belts. Should we ban their use? >> It is getting to the point where all of us know someone harmed by >> statins. It makes you wonder if the FDA even cares to note the issues. >I know people harmed by seat belts. Should we ban their use? No, but we should make legislators and their supporters fully responsible for damages if there is legislation to require them. Triple damages may not be enough. "It is hard to imagine a more stupid or more dangerous way of making decisions than by putting those decisions in the hands of people who pay no price for being wrong" Author Thomas Sowell This applies to all who try to order others how to live for their own good without putting their substance behind their machinations. SignatureThis address is for information only. I do not claim that these views are those of the Statistics Department or of Purdue University. Herman Rubin, Department of Statistics, Purdue University hrubin@stat.purdue.edu Phone: (765)494-6054 FAX: (765)494-0558 >>> It is getting to the point where all of us know someone harmed by >>> statins. It makes you wonder if the FDA even cares to note the issues. [quoted text clipped - 12 lines] > for their own good without putting their substance behind > their machinations. Try urban planners for a start. |
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