Healthcare efficiency

healthcare, fallacy

Yesterday I had a discussion on healthcare. One part of the discussion was on efficiency being a target. My argument was that while efficiency is a good thing to strive for, it mustn’t be the only thing, because efficiency also means a less robust system. Something we saw with the COVID crisis, with our lowest number of beds per capita in Europe (apart from perhaps the UK). Making efficiency the single number we determine quality by, opens us up to problems deriving from only looking at aggregate numbers. An HN post on Goodheart’s Law reminded me of the given to this type of problem. A reply to the topic in particular gives a concrete example:

Agreed. We had a doctor who refused to believe that my partner’s symptoms were relieved by a specific procedure - because there were no reports of other people’s symptoms being relieved by this procedure. But by this logic, no such report could ever get recorded!

It is critical that subjective, experiential data is cross referenced with objective data in order to control for errors in both. Both kinds of data are fallible for different reasons.

In my opinion, the erosion of subjectivity from science is probably a driver of the loss of objectivity in politics.

Evidence based medicine, the primary method used for determining what is most efficient, has sometimes felt like it was used not have to think; as if using knowledge or skills besides the ones that have a body of work, a long history, indeed, statistics, to back it up.

This line of thinking is throwing out the baby with the bathwater.

Which brings me to the second part of the discussion: the allegiance and duties of the general practitioner. One such doctor recently revealed that she wanted to protect the testing capacity, even if patients were willing to pay out of pocket, because she felt pressure on the healthcare system had to be avoided.

To me, this is wrong. Any system as pervasive and vital, and with so many stakeholders as the healthcare system must incorporate and encourage criticism, different people who represent the various interests that may conflict in the system. Some people will be in charge of making sure the system as a whole remains affordable, and these people will be working behind a desk somewhere, perhaps an insurer. Others are in charge of what the best treatment is, people in academic hospital most likely. And GPs are the representatives of their patients: they must do what they can to get their patients the best care they can get. They mustn’t internalize the budgetary side of care, nor challenges of capacity or any other consideration besides those of the patient who has entrusted their health with their GP. Balancing the interest is the job of the beancounters, not medical staff. If triage would be part of the normal healthcare routine, I think we have arrived at a system which is wholly insufficient and outside of what we should expect in a society that calls itself civilized and is by any earthly measure wealthy.

Today an HN post mentioned the bad job done regarding the COVID crisis. In Sweden, but a commenter remarked also in the Netherlands, as shown in the ’excess deaths’ calculated by the Guardian. The underreporting of COVID cases is roughly the grey area over the dashed line, where the Netherlands indeed seem to give the worst score, save for perhaps Italy. Goodheart’s Law can also mean statistics are massaged to provide a more flattering statistic, and this analysis seems to have caught some countries red-handed.

One of the things that amazed me in march and april (see my posts here) was how the Dutch government (by way of the National Institute for Public Health and the Environment, or RIVM) seemed to be entirely unprepared. Where in Germany in the aftermath of the SARS crisis in 2002-2004 a playbook for such an event was written in 2013. The RIVM wasa trailing WHO advice by about 2 weeks, and then, until about a month ago, was very testing-averse, as Dutch healthcare is in general. In the Northern Netherlands hospitals famously deviated from this national policy and did perform all the testing their capacity could handle (and they worked on expanding their capacity outside of the national system) and they have starkly reduced infection and mortality rates as a result.

It all reminds me of how the Brits see their National Health Service. And unfortunately, that is not the only similarity. For all the evidence based thinking, people including those in healthcare itself, seems to have have more faith than facts. I’ve never met anyone, including the numbers reported by the CBS statistics office, who could tell me what healthcare actually costs, despite the national DBC-accounting system invented for insurers. Through the grapevine, I’ve heard this is very politicized issue. All behind the scenes of course, on account of the commercial interests at stake.