Capitating

Here’s a graph from The New York Times showing what happened to different treatments for high-blood pressure as new evidence came out about the efficacy of different courses of treatment:

It’s a bit hard to tell just by eyeballing the graph what that study said. The answer, however, is that diuretics performed the best. And they’re also the cheapest. In an evidence governed world, their use ought to have exploded — when the best treatment is also the cheapest, you expect it to dominate. As the Times reports:

“It should have more than doubled,” said Dr. Curt D. Furberg, a public health sciences professor at Wake Forest University who was the first chairman of the steering committee for the study, which was known by the acronym Allhat. “The impact was disappointing.”

The crux of the matter is that it’s difficult to spread knowledge of best practices throughout the medical community. And it’s especially difficult to do so when pharmaceutical companies are prepared to spend vast sums of money to ensure that accurate information fails to spread. After all, there are profits at stake. Just because a generic alternative to their treatments is cheaper and more effective is no reason, in the eyes of a sociopathic pharma executive, for doctors to prescribe it. So their marketing and PR teams go to work and, as a result, people die and profits stay high.

But beyond the pharmaceutical companies, the issue here is doctors. People are trusting them to look out for their interests. But doctors have little incentive to really cut through the garbage and stay abreast of the latest science. Ezra Klein observes that “If doctors were paid by capitation — if they got a fixed amount of money per patient, and they kept whatever they didn‘t use, as happens in England — it’s hard to imagine they wouldn’t have been more interested in these study results.” Bobby Jindal has, as I’ve noted earlier, put some proposals on the table for changing Louisiana’s Medicaid system that show some promise of possibly moving in a useful capitation direction. So hopefully we’ll see some experimentation in that direction. It’s tricky to work out capitation in a way that correctly aligns incentives, but fee-for-service medicine in which doctors get paid for doing treatments rather than for producing health outcomes it’s totally impossible.

On the other hand, my grandfather was telling me over Thanksgiving that a proposal along these lines was part of his dissertation many decades ago so it’s not like this insight is new — it’s just that the forces arrayed against it are powerful.