Bad Medicine

I have, apparently, had a comment (innocuous, I thought) deleted at Catron’s site. He’s up in arms over a piece in Slate by Jesse Pines and Zach Meisel* that suggests that hospital administrators have a financial incentive to bed insured patients coming from clinics over uninsured ED walk-ins, and that a good solution would to create performance incentives that reward short wait times for ED patients.

Here’s him:

The authors of this disgraceful piece of agitprop would have their readers believe that the people who run hospitals deliberately allow people to languish in their ERs for financial gain. The suggestion is not merely slanderous. It is absurd on its face.
I have worked in hospital finance (at institutions large and small) for more than two decades and have never met an administrator or finance person (not one) to whom such an idea would even occur. Where I have worked, suggesting such a policy would get you fired.

As a free-marketeer, Catron could have chosen to point out competing incentives that the Slate authors ignore (for example, a commenter points out that diverting ambulance traffic when the ED is overfilled is costly), or explain why rewarding shorter wait times would be counterproductive. In any case, the relevant response would have contained data or logic, rather than moral outrage.

* Note: I have worked with Jesse Pines in the clinical setting and greatly respect his academic work

**UPDATE**
A commenter at kevinmd writes:

Their hospital sounds similar to my urban academic center. No one’s intentionally stated that the goal is to shaft the urban poor in favor of the well-insured, but the policies are set up to accomplish the same thing. Patients routinely wait 48 hours in the ER for floor beds after being admitted (tying up ER beds while up to 50 patients sit in the waiting room) while direct transfers from suburban hospitals arrive on the floor. We constantly hear about how the hospital hopes to “improve the payor mix,” i.e. that they’d rather take the well-insured suburban patients over the Medicaid/insured locals who come in via the ER.”

Lesson: you must be well-informed to make accusations of slander. White Coat calls the Slate piece a “conspiracy theory,” an accusation which I think indicates economic illiteracy. As I’ve said here in the comments already, it’s all about the incentives, baby. Beyond that, though, White Coat has a shaky grasp of the power of small differences in probability to make huge differences in profit (don’t let that man into Vegas). And, a final (and perhaps clearer) restatement of my point, to attack the Slate piece without addressing why hospital administrators don’t explicitly reward shorter ED wait times (which everyone has done) is a non-sequitur. Meanwhile, back at kevinmd, dermatologists are accused of cherry picking their patients for financial gain and nobody seems to mind. Hospital CEOs don’t face the same choices?