Unintended consequences of health policies – heeding HL Mencken and Gary Klein


Category : Medical Rants

Unintended consequences of health policies can have dramatic negative impacts.  HL Mencken wrote 98 years ago,  “Explanations exist; they have existed for all time; there is always a well-known solution to every human problem—neat, plausible, and wrong.” (https://quoteinvestigator.com/2016/07/17/solution/)  When policy wonks and legislators and rule makers seek to solve problems in medicine they seemingly forget this admonition.

Here are 3 examples of poorly considered solutions:

  1. Electronic health records – in the abstract this seems like an obvious idea.  But the problem they address is very complex and we had to adopt them before they were really ready to make practice go smoother.  We can all name the unintended consequences of EHRs.  If you want to better understand the prematurity of their forced adoption please ready Bob Wachter’s excellent account – The Digital Doctor
  2. The 4 hour rule for community acquired pneumonia.   This well meaning rule from CMS started the trend towards overuse of antibiotics for patients who do not have pneumonia.  The influences of this rescinded rule persist today.  Some estimate that 25-30% of admissions for CAP actually have a different diagnosis.
  3. Myriad rules restricting physician prescribed opioids.  My colleague Stephan Kertesz (and his national associates) have written extensively on this topic.  Here is one example article – Opioid Prescription Control: When The Corrective Goes Too Far

How does one avoid these problems?  I have written previously about Gary Klein’s pre-mortem exam process. How to Host a Pre-Mortem Examination and Keep Your Projects Alive  The concept is rather straightforward.  Before one starts a project (and each of the examples I cite are actually projects meant to improve health), you bring in front line people (in health, physicians, nurses and other health care workers) and ask them to imagine what could go wrong.  Then comes the difficult part.  The wonks, legislators and rule makers must actually listen to the concerns prior to adopting their “brilliant” ideas.

This problem invades health systems, hospitals, and independent practices.  You can all contribute additional examples.  And the sad thing is that these problems are preventable.  If only …

Comments (1)

they are not really all that preventable. There are physicians among the regulators. Physicians occupy some of the loftiest levels, including CEO of my own medical network and still offer directives of limited wisdom.

And physicians do not do a lot better. We all want to be paid more for the things we do. None of the proposals that I have seen advocating for better payment include a provision for doing something that enhances value in exchange for that.

Regulation and adjustments in process usually are put in place to solve a problem, solutions that have an upside and a downside, not all that different from the clinical trials that we read intended to advance medical care. There are plenty of trials that don’t advance medical care on analysis and every trial has a section on adverse effects of what is done. That’s just thinking like a doctor.

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