The parable demonstrates how free access and unrestricted demand for a finite resource ultimately dooms the resource through over-exploitation. This occurs because the benefits of exploitation accrue to individuals, each of which is motivated to maximise his or her own use of the resource, while the costs of exploitation are distributed between all those to whom the resource is available (which may be a wider class of individuals than those who are exploiting it). The paradigm example is the use by individuals of communally owned land for the grazing of animals owned privately by those individuals. As Hardin sees it, the utility to each individual of adding a single animal to his own herd is, more or less, the value of that animal; the cost to the individual is the consumption of the resources of that animal divided by the number of communal owners of the common. That is, the benefit to an individual of "hogging" a resource inevitably outweighs the cost where communal resources are concerned. All economically rational herdsman in the community will add as many animals as they can to their own herds and as quickly as they can (before other herdsmen do), meaning that the finite resources of the communal land will quickly become exhausted. Therein is the tragedy. Each man is locked into a system that compels him to increase his herd without limits in a world that is limited. Ruin is the destination toward which all men rush, each pursuing his own best interest in a society that believes in the freedom of the commons. Freedom in a commons brings ruin to all.
from Tragedy of the commons My son, the law student, is taking a class on the Tragedy of the commons. As I have slowly begun to understand the concept (and it does take quite some time), I have applied it to health care. The Dinosaur has a relevant post this week – This Patient Does NOT Get It (with apologies to Kevin)
Capitalism is a good way to do a lot of things, but what it has done to health care in this country — unfettered — is to bring it to the brink of destruction. Despite all the calls for doctors and legislators to "do something" about it, I believe Matthew Holt is right: "We'll eventually end up with a health care system like Brazil's where you can have anything you want if you're rich, and most of the rest of you can die in the slums." (quoted from 6 Dirty Little Health Care Secrets)
Oh great Dinosaur – you missed the concept here. Health care delivery is not capitalism. If it were capitalism, then patients would pay your charges or not be seen. Health care is rather following the logical path that the Tragedy of the Commons predicts. As long as neither physicians nor patients have economic accountability (because of the middle common ground) then we cannot possibly fix our system. Note that this explanation fits all one payor systems as well.
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why not apply it to another arena that makes health care concerns seems like a farce ? …there is the real tragedy of the commons, on our childrens’ doorstep.
http://www.panda.org/index.cfm?uNewsID=83520
some pertiment statements:
“WWF’s 2006 Living Planet Report, the group’s biennial statement on the state of the natural world, says that on current projections humanity will be using two planets’ worth of natural resources by 2050 — if those resources have not run out by then. It also confirms the trend of biodiversity loss seen in previous Living Planet reports.”
“We are in serious ecological overshoot, consuming resources faster than the Earth can replace them,” WWF International’s Director General James Leape said. “The consequences of this are predictable and dire.”
No, DB; it’s capitalism that allows people who have nothing to do with healthcare (the insurers) weasel their way into the relationship between doctors and patients and siphon out all the money.
Patients don’t have financial accountability?
You guys sometimes piss me off.
I pay four hundred bucks a month to insure my family each month. I pay over 150 bucks for meds every month. I pay 20% of every bill I incur. Right now we owe over ten thousand dollars in medical bills to various physicians, hospitiols, physical therapists, radiological groups, and so on.
I guess I must be missing something. I make a reasonable income but the amount of debt we have incurred is becoming crippling. That’s why the uninsured don’t go to the doctor. That’s why when they get your er bills they just through them in the trash. What;s the point of trying to pay a 1200 bill when you can’t afford daycare and rent.
Current charges for medical care-in total both hospital and physician because thats WHAT I PAY-are unsustainable outside of a health insurance system. We cannot afford the costs. In a true capitalistic system without health insurance most people would not get what is considered good care as they could never pay for it. I can’t imagine prices dropping that much outside of a health insurance system. You guys would see far fewer patients as most of us couldn’t afford to see you.
Quit blaming the patients for this mess. You make 5 times the median income on avarage in america. As a group you let yourselves get pulled into the insurance mess. Only fairly wealthy individuals such as yourselves really have the option of opting out of health insurance. Quit whining about how patinets don’t understand the burden and please donate to the Tina’s med bill charity
There is really an ethical delimma at the bootm of the common goods argument. More socialistic countries have decided that medical care is a basic right to prevent suffuring of the masses. Here we deny the basic care argument and assume medical care is only a good to be bought and sold. Every world religion teaches we should love and care for our fellow man but we don’t seem to act on that principal. It is not lucrative financially.
At some point our country will have decide if it’s okay to let others suffer and how much suffering is okay.
I’m not sure of your policy of linking to outside articles but two very timely articles today, one on consumer driven health care in the NEJM and one in the NY Times on the crisis of the uninsured, provide more insightful dialogue on these issues. As a health economist and consultant I do agree that we really have an insurance crisis in this country. The power and access to health care resources that arise from being able to afford health insurance have created complex issues for physicians and patients. Even Newt Gingrich has entered the debate on tranforming our health care delivery system…
The presence of medical “insurance” has added significant costs to the delivery of care. To what was once a simple transaction and accounting enterprise, a complete claims handling and consumer finance enterprise has been required of nearly every private doctor’s practice. This costs real money which in turn drives at raising prices, or where that fails, closes offices.
“Oh great Dinosaur – you missed the concept here. Health care delivery is not capitalism. If it were capitalism, then patients would pay your charges or not be seen.”
I agree with this. Healthcare is not capitalism. If it were, then after those patients were rejected -> the market would respond with low-cost alternatives, ie if you cant afford a mercedes, a buick alternative is available… that is capitalism. Captialism is not oligarchy, it is not artificial scarcity. Those MDs that only want to service MDs (pun intended) would have to produce real value for the additional service. Captialism includes competition, not flashing party credentials to expect secure returns.
there is a very real underlying assumption by medical professionals in this country that they are doing the public a favor by doing their job. A very lucrative, well-protected, and secure job…
Solutions:
go overseas:
retain your dignity, experience compassionate care, and enjoy the free market
(planet-hospital, etc)
scripting:
support nurses rights to write prescriptions. Nurses and techs with years of experience are very competent/able (i have been told this by several MDs). A nurse with 10+ yrs of experience has the ability and right to take care of your childs ear infection. the underlying effect of this political measure with get more supply immediately out there. Further, I believe since increasing number of doc would occur through political not market forces in this country, nurses right to script has more hope than say opening medical school admissions/ residency slots… However, even this has very slim chance of ever passing- possible hope lies in the boomers who as they age will need tangible real care- and demand this reform.
my 2 cents
Nurses have a “right” to care for a child’s ear infection or a “right” to script. NO THEY DONT. What gives them a right? Their “experience”- please. Nurses assume no responsibility- thier supervising physician does. No matter how much “experience” a nurse has she will never have the experience a doctor has.
I have and do work with multiple nurse practitioners in many different settings and their ability to handle anything that isnt 100% typical is well below that of a doctor. Period. “Well”, you say, “they will refer the tough cases to the physicians”. The problem here is that many of them dont recognize that the dont know what they are doing. They definitely cant make the long tail diagnoses and miss many of the short tail ones too.
In reply to Tina- sorry you or someone in your family has had medical problems. Dont equate your bills to physicians’ incomes. They are 2 very different things.
BUT, do you know what it costs to become a doctor? What is the avg debt coming out of medical school? What do doctors pay for malpractice insurance, esp an OB/GYN? As others have noted it costs alot of money to practice medicine in terms of both financial and emotional cost. Physicians have some of the highest suicide and divorce rates of any profession.
The average physician also works many more hours per day/week than the avg person in america. my plumber charges more per hour than I do. (especially if he has to come out on a weekend)
The tragedy of the commons does provide a way to think about excessive use of health care resources unconstrained by incentives for economy affecting either providers or patients. DB rightly points out that aligning incentives appropriately would reduce costs by reducing unnecessary care.
The difficulty is alluded to by the other commenters; health care is not capitalism but we don’t really wish it to be capitalism, for many reasons; we wish physicians to be qualified and we wish patients to be able to get needed care, even if they can’t afford it. If health care were really a free market, that is, if patient’s provided demand tied to their own resources and if barriers were removed to physician supply, we would not like the results.
The great divide in health policy regarding our health care system (at least so far as I can tell) is between those who wish to address its shortcomings regarding cost and coverage by making use of market-based mechanisms insofar as is possible, and those who argue that the market is simply an inappropriate model for health care. Those like DB, who favor the market, need to tell us how their measures would solve problems that an unfettered market would either not address or perhaps worsen, such as health care coverage for the less well-off. Advocates of government health care systems need to assuage the anxieties of those of us who blanch at the thought of American health care as a giant version of the VA. There is likely no ideal solution; but DB’s simple invocation of health care capitalism seems a bit facile. More capitalism might abate the “tragedy of the commons†aspect of the health care cost crisis—while worsening other problems.
terry-you are correct. only about 10% of my med bills are to physicians the rest are to hospitals and others. the ave person’s physicians bills aren’t so high, but the hospital bills are unpayable. I still “feel” the financial accountability for the procedures I get to the point where I don’t go to the ER anymore as I can’t afford those visits.
second, I disagree with your viewpoint on nurses. I am the ultimate long tail illness and I have made many drs go away befuddled. Nurses are more likely to listen and more likely to admit they don’t know what’s wrong than drs are. They also take more time discussing meds, treatments and followups. Drs get pimped to death I afraid in med school and develop a complex about not knowing the right answer. I had one scream at me once rather than admit she didn’t know what was wrong.
nurses should not replace drs. However I fully support have NPs set up low cost basic care care clinics at walmart. Too many folks can’t afford to see you guys and go without any care. NPs are a way to at least partially provide care to the poor and middle class in america.
NPs are not the answer. Lower income people tend to have more advanced illnesses at the time of presentation which will be well beyond the abilities of an NP. They can provide some care and studies do show many patients like NPs because they do spend more time and will listen.
Unfortunately the current reimbursement system forces docs to push thru lots of patients to make money. Thus they spend less face to face time than many like. I am privileged to work in a setting (the VA) with no productivity demands and I am salaried. I average seeing about 6-8 patients per half day and I can spend more time with my patients.
It seems to me that the inevitable answer to the Tragedy of the Commons is “the Heavy Hand of Government Regulation” that we are all supposed to resent so much.
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