On 2016 Jun 02, David C. Norris commented:

Drs Goitein¹ and Lee² agree that debate over the proper role of physicians in controlling costs languishes in unsatisfactory condition. Goitein objects to the evasiveness of policy statements that advocate such a role; Lee derides the debate's stubborn persistence and sheer bulk. Against the Hegelian dialectics Lee alarmingly invokes as a remedy, I advocate instead the clarity of thought and expression rendered by a simple economic concept.

Goitein's premise is that physicians' bedside preferences over quality and cost should be, as economists say, lexicographic. That is, just as dictionaries rank 'azygous' lexically before 'baa', physicians should rank treatment options first on quality, and then — only within strata of equivalent quality — on questions of cost. Objecting that maximizing 'value' defined as "the ratio of quality to cost" violates this principle, Goitein recapitulates the theorem that a real-valued utility function is incompatible with lexicographic preferences. Lee for his part, although neither affirming nor denying Goitein's normative premise, clearly advances the corresponding positive claim: despite value-based incentives, physicians retain lexicographic preferences over quality and cost. In supporting this claim by citing "powerful counter-balancing forces"² of opprobrium against bedside rationing, Lee recapitulates the theorem that lexicographic preferences are attained in the limit where one good (reputation) is worth infinitely more than another (incentives).

Formulated thus, the debate comes into focus as a broad expanse of potential consensus, punctuated by disputes over a few, scientifically testable propositions. The formulation also shows promise as a means for holding debate accountable to logic. It shines withering light, for example, upon a conflicted notion of 'value' about which its very architect says both "value [is] defined as the health outcomes achieved per dollar spent"³ and "Value, as I define it, is created only when health outcomes are not compromised; lower costs are value-creating only when corresponding outcomes are unchanged or improved."⁴ We may in all fairness ask Lee to which of these incompatible definitions he subscribes, a Hegelian dialectical synthesis being mathematically debarred.

Perhaps the best contribution this economic concept makes is to abstract away the coarsest features of debate, along with their attendant trivialities (said theorems), thereby redirecting our attention to the substantive considerations on which a genuinely productive discourse can progress. Chief among these will be embarrassments to the classical economic conceit of 'perfect information', inasmuch as "there is no evidence to suggest"⁵ remains enthroned as arbiter of equivalent quality in the face of uncertain comparative effectiveness.

[1] Goitein L, 2014

[2] Lee TH, 2014

[3] Porter ME, 2010

[4] Porter, ME. What is value in health care? NEJM. 2011;364:e26

[5] Braithwaite RS, 2013

On 2016 Jun 02, David C. Norris commented:

Drs Goitein¹ and Lee² agree that debate over the proper role of physicians in controlling costs languishes in unsatisfactory condition. Goitein objects to the evasiveness of policy statements that advocate such a role; Lee derides the debate's stubborn persistence and sheer bulk. Against the Hegelian dialectics Lee alarmingly invokes as a remedy, I advocate instead the clarity of thought and expression rendered by a simple economic concept.

Goitein's premise is that physicians' bedside preferences over quality and cost should be, as economists say, lexicographic. That is, just as dictionaries rank 'azygous' lexically before 'baa', physicians should rank treatment options first on quality, and then — only within strata of equivalent quality — on questions of cost. Objecting that maximizing 'value' defined as "the ratio of quality to cost" violates this principle, Goitein recapitulates the theorem that a real-valued utility function is incompatible with lexicographic preferences. Lee for his part, although neither affirming nor denying Goitein's normative premise, clearly advances the corresponding positive claim: despite value-based incentives, physicians retain lexicographic preferences over quality and cost. In supporting this claim by citing "powerful counter-balancing forces"² of opprobrium against bedside rationing, Lee recapitulates the theorem that lexicographic preferences are attained in the limit where one good (reputation) is worth infinitely more than another (incentives).

Formulated thus, the debate comes into focus as a broad expanse of potential consensus, punctuated by disputes over a few, scientifically testable propositions. The formulation also shows promise as a means for holding debate accountable to logic. It shines withering light, for example, upon a conflicted notion of 'value' about which its very architect says both "value [is] defined as the health outcomes achieved per dollar spent"³ and "Value, as I define it, is created only when health outcomes are not compromised; lower costs are value-creating only when corresponding outcomes are unchanged or improved."⁴ We may in all fairness ask Lee to which of these incompatible definitions he subscribes, a Hegelian dialectical synthesis being mathematically debarred.

Perhaps the best contribution this economic concept makes is to abstract away the coarsest features of debate, along with their attendant trivialities (said theorems), thereby redirecting our attention to the substantive considerations on which a genuinely productive discourse can progress. Chief among these will be embarrassments to the classical economic conceit of 'perfect information', inasmuch as "there is no evidence to suggest"⁵ remains enthroned as arbiter of equivalent quality in the face of uncertain comparative effectiveness.

[1] Goitein L, 2014

[2] Lee TH, 2014

[3] Porter ME, 2010

[4] Porter, ME. What is value in health care? NEJM. 2011;364:e26

[5] Braithwaite RS, 2013