Friday, April 17, 2015

The Problem with Common Sense Solutions

I have written extensively on the problems of pragmatism and common sense*, usually predicating the argument upon the simple fact that what one persons sees as common sense is often not so evident to others. After all, if an answer were universally self evident, there would be no reason to argue for it. No one has to tell us to breathe or to drink fluids, but if someone has to tell you some political solution is self evident or common sense, that tells me the answer is only so obvious to the person making the argument.

But I have made that case os many times, I often forget there are other issues with supposed common sense solutions. For example, the problem I discussed in "The Problem of the Small Picture", that many supposedly common sense solutions only seem obvious, or appear as "win-win" answers, because the person examining them is unconsciously ignoring a host of costs and side effects, factors which would make the common sense answer look much less appealing were they included.

One of the best examples I have heard is the rebuttal to the argument used to prove supposed negligence for the makers of the Pinto (as well as a number of other small economy cars). The case against the Pinto was established as follows: it was known that under rare circumstances, in this case a full speed rear impact collision, the car might explode. The explosion could be made much less likely by the inclusion of a relatively inexpensive part. However, the manufacturers figured that such collisions are rare events, and so, even if they were sued for every such accident, it would be cheaper to settle than add the part.

Many people dismiss this as heartless, or placing money in front of lives, but the truth is, to make that argument, you must ignore a number of realities. You see, full speed rear end collisions are pretty rare, so there simply will not be a lot of such accidents. However, there are an almost endless number of such rare potential accidents, and all of them could probably be ameliorated by adding some part, in many cases probably an equally cheap piece. But, once you start thinking in that way, that any part which can save a life should be included -- or even should be included only if it costs less than $X -- you have suddenly started building an economy car that costs as much as a Rolls Royce, and weighs enough to bring mileage down to 10 mpg once more.

And that is what these common sense solutions ignored, the decision to not include the specific part was made because the cost, no matter how minimal, was not justified by the rarity of the problem. Yes, in the end, this left subcompacts less safe than, say, big steel luxury cars, but that is inherent in the design. If you want a cheap car with good gas mileage, you are going to sacrifice some safety. Anyone who does not recognize that is delusional. To then sue the makers for not including parts to compensate for every conceivable potential accident is foolish. If they did so, economy cars would become as costly and heavy as luxury cars, making them no longer desirable for their appointed role.

Perhaps another example would help.

When discussing medical insurance, many times people gripe about the absurdity of covering treatments while not paying for prevention. For example, insurance will pay to amputate a diabetic's feet, but not to buy the shoes that would prevent the need to do so. That is but one example, but it is one I heard often enough that it immediately came to mind. Of course, it is not entirely accurate, nor does it tell the entire tale. For example, in a few cases, where individuals suffer from a disease with well known degenerative properties, insurers will pay for certain, specific preventative measures, such as physical therapy, to prevent the worsening of the condition. But, then again, for the most part, the complaint is accurate. Outside of a handful of specific preventative treatments for specific existing ailments, insurers do not pay for preventative measures.

The argument offered against such a position is one that often comes across as common sense, presenting what seems to many a very sensible argument. According to advocates of covering preventative measures, it often would cost only tens of dollars, maybe hundreds, to prevent an ailment, while, on the other hand, treating that same illness can cost thousands, or tens of thousands, at the same time reducing the quality of life of the insured. In other words, not only does preventative care improve the quality of life of individuals, but it saves money for the insurer. According to these advocates, it makes so sense to oppose preventative measures, and only nonsensical bureaucracy, or an old fashioned attachment to the traditional way of doing things prevents insurers from following this new paradigm, saving them money.

That last argument should tell listeners that the argument is not quite as it seems, as, no matter how traditional and stodgy insurers may seem, it is still a business, still answers to stock holders and competes to produce better returns than its rivals. And so, if there were truly an answer that saved money, at least one firm would adopt that practice, producing better returns, and likely inspiring its fellows to do the same**.  If businesses are avoiding a practice that some claim will save them money, then there must be a very good reason, and usually that reason is, quite simply, that the savings claimed do not exist, or are offset by some other costs.

In this case, the answer if actually pretty obvious, once you stop viewing the problem with the myopia of those enamored with preventative care. The problem is the difference between treatment and prevention, a difference that the proponents of prevention gloss over in making their case.

We often hear, concerning treatment, that new technologies and new medicines are making treatment ever more costly, introducing countless new methods of treating a given ailment, and increasing costs tremendously. And insurers, for their part, do their best to avoid some of this cost escalation, mostly by denying coverage for any experimental treatments, and enacting other policies to favor the best combination of cost and effectiveness in treatments. However, even without such measures, there is still something about treatment that makes it attractive to insurers, and that is that treatment is inherently limited. No matter how many possible therapies there are, no matter how many new ideas come out about treatment, there is still an inherent endpoint to treatment, either you get better, or you die. (Or, in some cases, you reach a point where, while still alive, there are no more treatment options available, though this is becoming less common as more and more treatments become accepted.) Thus, even if they allowed patients to indulge in whatever treatment they wished, there would still be an inherent cap upon treatment, and it would be possible for insurers to predict the likely cost of any given ailment for any individual.

On the other hand, prevention is an open ended situation, and in more than one sense. For example, there is no limit to the number of possible preventative treatments you could pursue for any given condition. Unlike treatment where the eventual success of one therapy will foreclose spending on others, nothing prevents patients from undertaking multiple, simultaneous prevention therapies for the same illness.

But it does not end there. Prevention is also open ended in terms of time, as, unlike treatment, which ends with cure or death, prevention has no endpoint, no ultimate success. Until the patient eventually dies of some other cause, the patient can continue to undertake preventative measures for a given ailment for as long as he wishes***. So long as he lives and remains insured, he can continue to spend money on prevention, in the form of multiple therapies intended to prevent a given condition.

Which brings us to the third form of open endedness in preventative measures, the number of ailments against which one can act. Treatment is limited in this regard too. As the terminal events of cure or death provide a cap upon the number of different treatments and the duration of treatment, the need to actually be suffering from an ailment provides a cap upon the number of ailments for which one might be treated****. This is not the case with prevention. Since prevention is intended to prevent the onset of a given condition, there is no logical limit to the number of ailments against which one could take preventative measures.

Doubtless, were they inclined to cover preventative measures, insurers would take the obvious step of limiting preventative treatment to ailments one is likely to contract, as well as treatments which show a preventative benefit proportionate to their cost. However, even were such measures imposed, there would still be a far too open ended market. Even among those diseases which are probable for a given individual, the list is still quite long, and the number of potential preventative measures is equally long. So, even with some sensible limits in place, the insurers would still be facing nearly unlimited spending in the name of prevention. Why, if you really tried, almost everything you do could be covered under the rubric of prevention. Diet and exercise are claimed to be beneficial in preventing a host of problems, so why not have insurance pay for all of one's food and exercise? Similarly, stress is blamed for a host of ills, so why not cover anything that relieves it, from games to vacations to new bedding and a nice wine cellar? After all, they too are preventative measures? In fact, it is hard to think of any aspect of life which could not, with just a little creativity, be turned into a means of preventing disease.

Which brings us back to something I mentioned earlier, the handful of exceptions, those cases in which insurers are willing to pay for measures which we would normally call preventative. For example, physical therapy for those with back problems, intended to prevent the condition worsening.  In these few cases,  we can see why insurance might cover prevention, and also why it would have problems covering prevention in  a more general sense. In these cases, there are a few conditions which make prevention a sensible expenditure. First, the individual is diagnosed with a condition which not only makes the future ailment probable, but also makes the probability knowable. Second, the therapy is well established, specific and has a definite cost. Not to mention that its effectiveness in prevention is fairly well known. Given all of these factors, the insurer can figure how much the therapy will cost, even if carried out for the patient's entire life, versus the expenses of the illness they are preventing. This allows for a well reasoned evaluation of the cost and benefit.

On the other hand, general prevention, with countless treatments, a never ending time line, an infinite range of potential ailments to prevent, presents no means for reasonably calculating the relative costs and benefits. It is, in the end, simply an endless potential drain of resources, which is why insurers are perfectly sensible in avoiding that sort of endeavor, and why preventative care is such a terrible example of a common sense solution. Or, to put it differently, why it is such a perfect example of the shortcomings of common sense.

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* See "The Lunacy of 'Common Sense'", "'Seems About Right', Another Lesson in Common Sense and Its Futility", "A Look at Common Sense", "Res Ipsa Loquitur", "The Shortcomings of Pragmatism", "Pragmatism Revisited", "Pragmatism Revisited, Again", "The Plural of Anecdote is Not Data", "Rules of Grammar and Pragmatism", "The Problem of the Small Picture", "Keyhole Thinking", "Impractical Pragmatists", "In Defense of Zero Tolerance, or, An Examination of Law, Common Sense and Consistency", "No Dividing Line", "The Consequences of Bad Laws", "Questions of Law and Questions of Fact", "The Rarity of 'Common Sense'" and "Common Sense,Philosopher Kings, Arbitrary Law and Dictatorship".

** Of course, there is one case in which this would not happen, and that is a possibility when it comes to health insurance. If the government mandates specific coverage, or prohibits others, then insurers may not be able to act in their own self interest. Likewise, if government involvement causes distortions in the market -- eg. how DRGs in government insurance have altered how private insurers handle coverage -- private firms may not act sensibly. But, if preventative care saved so much money, it would seem certain insurers would find a way to implement preventative care and save themselves considerable money.

*** In a way this is a problem with our entire health insurance model. As I discussed in "Redefining Insurance... To Actually BE Insurance", true insurance would pay only for uncommon, unwelcome conditions, such as contracting a disease or an injury. Once insurance begins paying routine, predictable events, such as routine checkups, or preventative measures, it becomes an open ended, endless stream of payments. Since the trigger for payment is not something so unwelcome the insured would never seek to bring it on himself (as with, say, fire insurance, or life insurance), because these events are routine and innocuous, there is no limit on the number of times the insured may choose to use these services.

**** This is also why insurers are reluctant to accept trendy, ill defined diseases which are so often diagnosed based on impressionistic criteria impossible to confirm. (Eg Multiple Chemical Sensitivity) In some cases, there is no evidence these disorders even exist, but even when they do, certain ailments are used by quacks to explain every problem. The reason I mention these is such "free form" diagnoses basically allow treatment to become more like prevention, with no obvious criteria for either infection or cure, allowing open ended, endless treatment. (This is also why, for a long time, psychological disorders were either excluded or seriously limited, and even today are not viewed the same way as physical ailments. Whatever one's view on mental illnesses, the definitions of many are sufficiently nebulous and impressionistic, it is easy for an individual to accumulate a wealth of diagnoses, and equally difficult to ever determine if one is cured. Which is, in truth, part of my objection to modern views on mental health. See "Mental Illness".)



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