fricat1ve

There's nothing like Boston or NYC in the control states. If the effect is as big as they seem to think--a 21% increase in mortality--that should be visible on a plot of deaths over time.

The "objective metrics" part is key. Medical records are generally written in a way that weaves a standard narrative of the doctor as either a hero/savior or a valiant defender of a lost cause.

Doctors only get investigated when derogatory facts accumulate to an extent that this "standard narrative" collapses. It's not really an objective or scientific standard.

As far as a performance evaluation that directly scores a surgeon's judgment and whether the procedures s/he is performing are actually beneficial...in the absence of a big screw-up or complaint, I don't believe there is any forum to do that after training is complete.

In the US, if the surgery is in hospital:

- Well-regarded hospitals will vet surgeons before granting privileges.

- Average hospitals give out privileges fairly easily if there are no actions against a person's license.

- There is a "collegial" review of big screw-ups that carry major reputational risk.

- As with any fee-for-service firm, "rainmakers" are highly sought after and get away with more.

- Privileges are difficult to take away once granted. (Have stronger legal protections than academic tenure in some states.)

If the surgery is in an ambulatory surgery center or doctor's office:

Basically anything goes. Ice-pick lobotomies, tonsillectomy mills, boob job factories in strip malls....all have happened in recent US history. About as well-regulated as traveling carnivals.

One problem is that fee-for-service incentives strongly distort what people think they "know full well."

A better way to make this claim would be to plot the mortality rates for the states over time and show that the rates in those places requiring reporting begin to diverge as the new policy is implemented.

Even consent itself is something that's overly fetishized in our society. It's a sign that a group's common understanding of people's basic rights and responsibilities has fallen apart. So everything comes down to some idealized notion of "consent" which, in a well-functioning society, is necessary but not sufficient to determine whether an action is acceptable or not.

> if you want a cure for cancer, you have to pay scientists to look for it.

We do that. It's a two-tier system where the public pays for the science and the companies fish ideas from the science to make into medicines.

>The fact that it's hard is the reason it's expensive.

No, the reason it is expensive is because we've signalled that we are willing to pay large amounts of money, essentially regardless of the actual benefit extended by the state of the art treatment. Even if the state of the science doesn't have much to offer in the way of a cure, you can count on the private sector to make drugs that push the envelope of what we are willing to pay.

But because the job that the private sector does is not the "rate limiting step" as it were, dumping more cash on them is just wasted money.

There was a story that checking ID's on plane tickets was at the top of the airlines lobbying wishlist after 9/11 so they could curtail the practice of people selling unused tickets to another (same gender) person.

>If it wasn't, why has it taken this long for someone to take ownership of that huge pile of risk-free money

Maybe because no one thought of it before?

The picture you're painting is fine if you're evaluating a handful of candidate molecules each with, you'd guess, a 5% chance of having the right PK profile or something.

But for major breakthroughs, there are "unknown unknowns" that make it impossible to estimate that likelihood. It's nice to think that, if you let the full value be captured, it would incentivize more people to pursue one-in-a-million "lottery ticket" cures, but it just doesn't work that way. They're not lottery tickets if they have incalculable odds.

For the most part, the difference between management and cures is in this latter category. I.e. we don't have a cure because we just don't know how to do it, not because we were too cheap to invest in the biochemical trench warfare to find the right molecule.

>People should be willing to pay as much for it as the alternative

Maybe. But maybe there's also something wrong with expecting that much. Somehow Sidney Farber didn't decide that he was going to charge the families of kids with ALL the actuarial value of the remainder of their lives.

It can be frustrating to see the public, out of ignorance, grossly misjudge the relative contributions to health of, say, a vaccine developer relative to a self-promoting surgeon. But there is something new and rather strange with this way of seeing medicine as a "capture the value"-type enterprise.