Health policy makers make lousy chess players

After 12 years of blogging, I wonder if I should have titled my blog “unintended consequences.” So many rants focus on the unintended consequences that follow from health care policies.

The aphorism (falsely attributed to Samuel Johnson) states, “The road to hell is paved with good intentions.”

Too often our policy makers, be they bureaucrats in government, insurance company managers or guideline creators, think like a chess beginner. They see the problem, and take the obvious solution. As H. L. Mencken did say, “For every complex problem there is an answer that is clear, simple, and wrong.”

Chess masters make a move and then do a mental pre-mortem analysis, predicting in their minds what the implications of the move are. Where will we be after that and several more moves?

Too often in health care, as well as other policy areas, we ignore the unintended consequences of premature solutions. Too often we hear the excuse that there was a good reason for the policy.

As examples, first consider the 4-hour rule for antibiotics in pneumonia patients. Any hospitalist or ID expert could have predicted the unintended consequences, yet Medicare adopted the rule that led to much unnecessary antibiotic use.

Consider the VA appointment scandal. If we give bonuses to administrators for decreasing appointment waiting times, and do not provide money for adequate primary care physicians, we will stimulate dishonesty in some administrators. This outcome is sad, but predictable.

In Great Britain, they had a performance measure that rewarded shorter waits for appointments. This indicator improved, but continuity decreased. Duh?

RBRVS provides a great example of this naiveté. The original NEJM paper is a classic left brain economic analysis that totally ignores the possibility (which became the reality) of the difficult of assigning fair relative values.

Policy wonks are too quick to embrace these new solutions to a problem. They rarely think about what the policy would induce. They are lousy chess players. They do not look ahead.

Unfortunately, I do not see a solution for this problem. We fail to remember Mencken’s admonishment. We act too often without careful consideration of all the expected and unexpected consequences. Unfortunately too many of the unintended consequences are predictable, if we would just take time to think.

Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.

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  • QQQ

    “Too often our policy makers, be they bureaucrats in government,
    insurance company managers or guideline creators, think like a chess
    beginner. They see the problem, and take the obvious solution. As H. L.
    Mencken did say, “For every complex problem there is an answer that is
    clear, simple, and wrong.””

    ———————————————————————————————————

    It still goes against the foundation of this country, the freedom to choose. This is a forced way of life, We, the ordinary people have no say in it as most people do not. I am amazed at the number of people in the country who do not comprehend that they have no choice here. The elite no what is best for the rest of us, many have said so that wrote or endorsed laws. They will continue, once we have become complacent with this more life changing laws will be put forth because you can not take care of yourself according to them. No matter how good it sounds you lose your free agency, its not worth it.

  • southerndoc1

    “Unfortunately, I do not see a solution for this problem. . . . too many of the unintended consequences are predictable, if we would just take time to think.”

    Um, maybe this is an area where our medical societies could stand up and represent physicians and patients? You know, like the ACP and their Board of Regents . . .

    • Robert Centor

      ACP will be releasing a series of papers on this subject over the next year. In fact we are working to “step up”

      • southerndoc1

        Thanks for the reply, and that’s good to hear.

        I just hope that the ACP’s efforts are truly pro-active, and not just reactions to problems created years or decades ago (false quality measurement and P4P being good examples of bad initiatives that the medical societies should have come out against in, say, 1990 or so).

  • rvell50

    Policymakers are too ready to initiate regulations without the input of stakeholders and too reluctant to make adjustments once the foolishness of their regulations becomes apparent.