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September 07, 2006

Why Consumer-Directed Health Care Won't Work

Over in the Wall Street Journal, more empirical scorn is being heaped on consumer-drected health care, this time in the form of a study showing that consumers have absolutely no idea what good health care is.  Researchers from the Rand Corp., UCLA, and Department of Veteran's Affairs had 236 elderly patients in two major managed care plans rate the quality of their health care.  Satisfaction was high, with the average rating a super 8.9.

Then the researchers sat down to rate the care these same patients received.  They compared care received to care that should have been received, checking on fundamental metrics like whether a patient received aspiring within an hour of being diagnosed with acute myocardial infraction.  Scores plummeted.  Despite the high level of patient-satisfaction, the researchers gave the care a failing grade of 5.5.  More interesting, the patients who rated their care as a 10 were just as likely to be getting low-quality care as those who reported a 5.

The problem?  Patients are not qualified to evaluate good care.  They're qualified to evaluate whether the doctor was nice to them, whether he explained things clearly, whether the wait time was short and the experience pleasant.  They do not know how well their care matched up to accepted standards of care, and they do not know whether the treatments they were given were comprehensive, well-targeted, or adeptly conducted.

This is why consumer-directed health care is a silly idea.  Consumers may be able to trigger a revolution in waiting room reading material and operating room decor, but if the doctor's diagnoses are delivered in a confident tone and he's kind while carrying out his treatment, they've no capability to separate good medicine from bad.  The concept that individuals are qualified to act as oversight for doctors has always been foolish, but now, again and again, it's being proven so.  And why shouldn't it?  There's a reason we accept expertise in our society, a reason we encourage specialization and comparative advantages.  If doctors need watchdogs, then we need to empower institutions or individuals with the education and ability to actually watch over them.  Patients, for all their good intentions, are easily fooled by a firm handshake, a pleasant nurse, and well-appointed waiting room.  Important as those things are, they shouldn't be the fundamental metrics for evaluating health care.

Cross-posted at Tapped

September 7, 2006 in Consumer-Directed Health Care | Permalink

Comments

Your third paragraph is mirrored closely by malpractice suits. Patients don't sue doctors who screw up; they sue doctors they don't like. That should have been a pretty strong indicator from the get-go.

Posted by: jhupp | Sep 7, 2006 11:58:53 AM

It's acute myocardial infarction.

Posted by: Anonymous | Sep 7, 2006 12:06:08 PM

I work in health insurance. As with many healthcare companies, "consumerism" is all the rage with my company's leaders right now. I'll tell you a much simpler reason why it won't work: Giving consumers a "choice" between shitty high-deductible plan A, shitty high-deductible/high-copay plan B, and ultra-shitty astronomical-deductible plan C -- all of which will of course come at the cost of ever-higher payroll deductions -- won't fly.

Healthcare consumers don't want "choice" for the sake of choice. They want rich benefit plans that don't cost a lot out of pocket. All the hollering about "consumerism" and "choice" is a distraction from the fact that private insurers are taking those options off the table.

It's fucked up, and it's going to backfire (from the point of view of the insurers) in about a decade when the public goes ballistic and demands the government step in.

Posted by: Toast | Sep 7, 2006 12:37:15 PM

I don't doubt the idea that consumers can't easily tell good care from bad, or perhaps more accurately fairly good care from great care, but I don't know that that necessarily supports your conclusion that therefore consumer directed health care doesn't make any sense.

Institutions or individuals with the experise to serve as watchdogs may not, and I would argue probably would not, have the motivation to do so. We typically see this sort of thing subverted by the very groups they are designed to provide oversight on.

Patients will have the motivation to evaluate whether their care is good or bad, but not the skills. An outside institution may have the skills, but supplying the motivation will be extremely difficult.

I think it is easier to get the skills, or substitutes for the skills, to the patients rather than to find a method to supply the motivation to the institutions.

Posted by: Dave Justus | Sep 7, 2006 2:55:35 PM

Toast, you say you "work" in health insurance. What does that mean? Are you a tele-customer service rep? Are you licensed to sell insurance?

I work with America's oldest health insurance company which was first to market with MSAs. Do you think we are making a mistake? Should I email the VP of Individual Medical and say stop! I'm sure upper management would love your opinion.

Tell me Toast, what is the name of the health insurance company that you put on your wife? I'm sure we can all learn a lot from you. Is that portable individual health insurance on your wife or is employer-based coverage?

ezra, I just talked with an ER doctor paying $1,400 a month. Our premium was less than $400 a month. He liked the Dependent Conversion Priviledge for his 3 children, which he did not currently have. You might not think he could make some of his own choices but I'm sure he knows much more than you if his child becomes hurt or sick. Just because someone can pay their deductible with tax free HSA dollars has very little to do with their choices of which facility to use with their daughter's kidney transplant.

Don't pay $1,400 a month, that's crazy. Many families have portable HSA insurance for less than $300 a month that pays to $8 million lifetime max per person. Then we pull the plugs. This coverage includes ZERO deductible on preventive services and a tiny little deductible on accidents of $100, then 100% coverage, including Rx. Don't forget this comes with a high tech online tax free HSA, including the VISA and HSA checkbook, with a mutual fund option.

ezra, wake up. How are you going to defend rich people deducting $1,400 a month for insurance from their taxes? Do you really think people are going to continue to pay $1,400 a month because you are telling them they are not smart enough to purchase coverage for less than $400 a month.

I know you ezra and you wouldn't pay $1,000 extra each month just so you can't go tax free. Nobody else is going to listen to you either.

Just go to NFIB and get their HSA program. America's largest small business association has picked a very good health insurance company. Tell them Ron sent you.

Save premium, eliminate taxes, build wealth.

It's time for your HSA.

Posted by: Ron Greiner | Sep 7, 2006 3:12:36 PM

CONSUMER-DRIVEN HEALTH CARE
A Two-act play.

[Scene 1. Doctor's office.]

PATIENT: "I'm here for my physical, doctor. But first, I'd like to know how much it's going to cost me so I can compare it to other practitioners in the area."

DOCTOR: "Well, I can't tell you what it's going to cost right now. I haven't examined you yet. And after I've examined you, you can't just decide not to pay and take your money elsewhere if you don't like what I say."

PATIENT: ...

[Scene 2. ER lobby.]

PATIENT: [Sticking his head through the door.] "Excuse me! I just got seriously injured falling off a ladder. Could you give me a rough quote on what the treatment for that would cost, 'cuz there are a couple more ERs I have to visit before I can excercise my Consumer Powers."

NURSE: "Well, we can't tell you what it's going to cost right now. We haven't treated you yet. And after we've treated you, you can't just decide not to pay and take your money elsewhere if you don't like what we say."

PATIENT: "Why does everyone keep -" [Dies.]

[End scene.]

Posted by: Chris | Sep 7, 2006 3:18:08 PM

Don't pay $1,400 a month, that's crazy. Many families have portable Viagra insurance for less than $300 a month that pays to $8 million lifetime max per person. Then we pull the plugs. This coverage includes ZERO deductible on preventive services and a tiny little deductible on accidents of $100, then 100% coverage, including Rx. Don't forget this comes with a high tech online tax free Viagra, including the VISA and Viagra checkbook, with a mutual fund option.

Just go to NFIB and get their Viagra program. America's largest small business association has picked a very good health insurance company. Tell them Ron sent you.

Save premium, eliminate taxes, build wealth.

It's time for your Viagra.

Posted by: I'm Not Ron Greiner And This Isn't Spam | Sep 7, 2006 3:21:41 PM

Why would I care if you go to America's largest small business association? I have nothing to do with them. You can say that real comments and the truth about CDHC is spam but you are just confused.

Chris, you have a PPO now yourself. Do you make sure your ER is in network? When you fall of a ladder do you really think people care with a little $100 on accidents then 100% coverage, like HSA insurance, about lower prices? But your traditional coverage doesn't limit your accident to $100 out of pocket does it?

I have a doctor as a client with bone cancer and he is way past the deductible. Do you think he really cares about saving the insurance company money? This post is a goofy leap just to bad mouth HSA qualifying health insurance. I'm sure ezra knows what he is doing. When I enrolled the 1st MSA ezra was 12 years old. I'm glad he has learned so much.

Posted by: Ron Greiner | Sep 7, 2006 4:28:23 PM

Most people will rate doctors, especially PCP's, on the three A's -- affability, availability, and last (and least) ability.

When more serious matters are at stake like surgery or cancer treatment strategy, it would be enormously helpful to have an unbiased, objective infomediary that can help the patient sort through the risks and benefits as well as the cost-effectiveness of various treatment options. Such an organization could also develop ways to rate oveall care quality of all doctors and hospitals. Pair such quality information with robust pricing transparency and, aside from treatment needed under emergency conditions, much more intelligent healthcare choices will be possible.

It would also be useful to know such information as: Board Certification, did the doctor do a fellowship in his or her specialty, has he or she been successfully sued more frequently than peers, and how many doctors or nurses does he or she have as patients (lousy doctors don't have any).

One of the main reasons healthcare costs are out of control is that patients are largely insulated from the cost and, therefore, neither know nor care what anything cost before the fact. To the extent that high deductible, consumer driven plans can mitigate that problem, it's a good thing, in my opinion. Even for people who have very high costs due to serious illness, many policies have lifetime benefit caps. In those cases, prices and cost-effective treatment are more important than many people think even if insurance is paying 100% of the bill (until the lifetime ceiling is reached).

Posted by: BC | Sep 7, 2006 4:40:31 PM

I think it is easier to get the skills, or substitutes for the skills, to the patients rather than to find a method to supply the motivation to the institutions.

Posted by: Dave Justus

Okay, first you start an accredited medical school within commuting distance of every high school in the country. Then you make attending them mandatory, or at least free. Then you require every business to allow its employees time off during the day to attend that school, because people in their thirties and older need those skills far more than people in the normal age range for med school...

Think I'm kidding? Well, mostly. But the skills to understand what makes medical care good takes a lot more than a subscription to Consumer Reports. I was recently looking over the annual state-mandated report card evaluating the quality of care at hospitals in the state. On heart attack treatment, for example, they evaluated whether hospitals took care of five (if I remember correctly) standard parts of treatment. I wouldn't have had a clue that most of those are important for everyone, and that's just one type of health problem, and it's not like you can shop around in advance.

The point is, you can make tweaks around the edges, but the magic of the free market depends on consumers having adequate information to make informed choices and that's often impossible in health care.

Posted by: Cyrus | Sep 7, 2006 5:07:48 PM

Cyrus,

I don't know that the assertions you make are true. I would expect that it takes signifigantly less skill to evaluate medical care than it does to be a doctor. There seems to be a lot of low hanging fruit here that patients with minimal education, or access to expert systems, could evaluate. The minimal metrics the study uses to conclude that the care is poor are there.

Even it it is as tough as you say it is, that doesn't necessarily invalidate my criticism. Since you haven't explained how getting the motivation to the intitutions will work, it could well be that educating people is as difficult as you say and yet still easier than motivating institutions.

I do think that there is a place for government intervention here. I would imagine that a few billion could go along way toward developing a medical diagnostic and treatment guide that is availible to anyone on the internet. Preventative and early diagnosis alone would probably make such a program cost effective.

In general, I am biased toward empowering people more than institutions. In my expirience, institutions often develop goals that are at best tangental and often inimical to the reasons they were created.

Posted by: Dave Justus | Sep 8, 2006 11:20:38 AM

Even it it is as tough as you say it is, that doesn't necessarily invalidate my criticism. Since you haven't explained how getting the motivation to the intitutions will work, it could well be that educating people is as difficult as you say and yet still easier than motivating institutions.

Well, if the institutions in question are state or federal hospital regulatory agencies, the motivation is pretty easy: the hospitals meet standards of care or they get fined or decertified, the regulatory agencies make their hospitals improve or the executive director doesn't get reappointed, candidates support the [effective] regulatory agencies or they don't get elected. Sure, that may be less pressing motivation than is felt by the patient, but it's motivation felt by people who can actually use it.

For another example, put the motivation/expertise question in the doctors themselves. If you're going to be operated on, would you prefer a depressed doc from a modern ER who's unsure if your insurance will ever get around to paying him (high expertise, low motivation), or a caring, conscientious doctor from the days when leeches were accepted medical practice (low expertise, high motivation)?

Posted by: Cyrus | Sep 8, 2006 1:13:50 PM

香水有毒
求佛
秋天不回来
不怕不怕
千里之外
秋天不回来
求佛
香飘飘
我们都是好孩子
不怕不怕
不要再来伤害我
天下无双
狼爱上羊
老公老公我爱你
寻找李慧珍
god is a girl
大城小爱
舞娘
老婆老婆我爱你
曹操
qq爱
约定
那一夜
隐形的翅膀
光芒
飞行部落
真爱
冰菊舞
死了都要爱
一万个理由
反转地球
my love
好姑娘
爱我别走
我不后悔
飞舞
yesterday once more
王子变青蛙
We will rock you
不得不爱
夜曲
发如雪
爸爸妈妈
爱我就别伤害我
我很想爱他
桃花朵朵开
神话
笔记
吉祥三宝
不想长大
暧昧
迷魂计
花田错
秋天不回来
求佛
香飘飘
我们都是好孩子
不怕不怕
不要再来伤害我
天下无双
狼爱上羊
老公老公我爱你
寻找李慧珍
god is a girl
大城小爱
舞娘
老婆老婆我爱你
曹操
qq爱
约定
那一夜
隐形的翅膀
光芒
飞行部落
真爱
冰菊舞
死了都要爱
一万个理由
反转地球
my love
好姑娘
爱我别走
我不后悔
飞舞
yesterday once more
王子变青蛙
We will rock you
不得不爱
夜曲
发如雪
爸爸妈妈
爱我就别伤害我
我很想爱他
桃花朵朵开
神话
笔记
吉祥三宝
不想长大
暧昧
迷魂计
花田错
秋天不回来
求佛
香飘飘
我们都是好孩子
不怕不怕
不要再来伤害我
天下无双
狼爱上羊
老公老公我爱你
寻找李慧珍
god is a girl
大城小爱
舞娘
老婆老婆我爱你
曹操
qq爱
约定
那一夜
隐形的翅膀
光芒
飞行部落
真爱
冰菊舞
死了都要爱
一万个理由
反转地球
my love
好姑娘
爱我别走
我不后悔
飞舞
yesterday once more
王子变青蛙
We will rock you
不得不爱
夜曲
发如雪
爸爸妈妈
爱我就别伤害我
我很想爱他
桃花朵朵开
神话
笔记
吉祥三宝
不想长大
暧昧
迷魂计
花田错
秋天不回来
求佛
香飘飘
我们都是好孩子
不怕不怕
不要再来伤害我
天下无双
狼爱上羊
老公老公我爱你
寻找李慧珍
god is a girl
大城小爱
舞娘
老婆老婆我爱你
曹操
qq爱
约定
那一夜
隐形的翅膀
光芒
飞行部落
真爱
冰菊舞
死了都要爱
一万个理由
反转地球
my love
好姑娘
爱我别走
我不后悔
飞舞
yesterday once more
王子变青蛙
We will rock you
不得不爱
夜曲
发如雪
爸爸妈妈
爱我就别伤害我
我很想爱他
桃花朵朵开
神话
笔记
吉祥三宝
不想长大
暧昧
迷魂计
花田错
秋天不回来
求佛
香飘飘
我们都是好孩子
不怕不怕
不要再来伤害我
天下无双
狼爱上羊
老公老公我爱你
寻找李慧珍
god is a girl
大城小爱
舞娘
老婆老婆我爱你
曹操
qq爱
约定
那一夜
隐形的翅膀
光芒
飞行部落
真爱
冰菊舞
死了都要爱
一万个理由
反转地球
my love
好姑娘
爱我别走
我不后悔
飞舞
yesterday once more
王子变青蛙
We will rock you
不得不爱
夜曲
发如雪
爸爸妈妈
爱我就别伤害我
我很想爱他
桃花朵朵开
神话
笔记
吉祥三宝
不想长大
暧昧
迷魂计
花田错
秋天不回来
求佛
香飘飘
我们都是好孩子
不怕不怕
不要再来伤害我
天下无双
狼爱上羊
老公老公我爱你
寻找李慧珍
god is a girl
大城小爱
舞娘
老婆老婆我爱你
曹操
qq爱
约定
那一夜
隐形的翅膀
光芒
飞行部落
真爱
冰菊舞
死了都要爱
一万个理由
反转地球
my love
好姑娘
爱我别走
我不后悔
飞舞
yesterday once more
王子变青蛙
We will rock you
不得不爱
夜曲
发如雪
爸爸妈妈
爱我就别伤害我
我很想爱他
桃花朵朵开
神话
笔记
吉祥三宝
不想长大
暧昧
迷魂计
花田错
香水有毒
秋天不回来
香飘飘
你是我的玫瑰花
求佛
千里之外
狼爱上羊
天下无双
上海滩
寻找李慧珍
不怕不怕
健康快乐动起来
号码
我们都是好孩子
对不起我的最爱
老婆老婆我爱你
爱上你这样的女人
qq爱
大城小爱
认真的雪
隐形的翅膀
光芒
god is a girl
舞娘
好姑娘
吹眼睛
真爱
老公老公我爱你
死了都要爱
太美丽
曹操
那一夜
my love
一万个理由
反转地球
今天你要嫁给我
yesterday once more
爸爸妈妈
发光体
爱我别走
夜曲
我很想爱他
We will rock you
神话
不得不爱
发如雪
为什么相爱的人不能在一起
蝴蝶
王子变青蛙
雨夜
香水有毒
秋天不回来
香飘飘
你是我的玫瑰花
求佛
千里之外
狼爱上羊
天下无双
上海滩
寻找李慧珍
不怕不怕
健康快乐动起来
号码
我们都是好孩子
对不起我的最爱
老婆老婆我爱你
爱上你这样的女人
qq爱
大城小爱
认真的雪
隐形的翅膀
光芒
god is a girl
舞娘
好姑娘
吹眼睛
真爱
老公老公我爱你
死了都要爱
太美丽
曹操
那一夜
my love
一万个理由
反转地球
今天你要嫁给我
yesterday once more
爸爸妈妈
发光体
爱我别走
夜曲
我很想爱他
We will rock you
神话
不得不爱
发如雪
为什么相爱的人不能在一起
蝴蝶
王子变青蛙
雨夜
香水有毒
秋天不回来
香飘飘
你是我的玫瑰花
求佛
千里之外
狼爱上羊
天下无双
上海滩
寻找李慧珍
不怕不怕
健康快乐动起来
号码
我们都是好孩子
对不起我的最爱
老婆老婆我爱你
爱上你这样的女人
qq爱
大城小爱
认真的雪
隐形的翅膀
光芒
god is a girl
舞娘
好姑娘
吹眼睛
真爱
老公老公我爱你
死了都要爱
太美丽
曹操
那一夜
my love
一万个理由
反转地球
今天你要嫁给我
yesterday once more
爸爸妈妈
发光体
爱我别走
夜曲
我很想爱他
We will rock you
神话
不得不爱
发如雪
为什么相爱的人不能在一起
蝴蝶
王子变青蛙
雨夜
香水有毒
秋天不回来
香飘飘
你是我的玫瑰花
求佛
千里之外
狼爱上羊
天下无双
上海滩
寻找李慧珍
不怕不怕
健康快乐动起来
号码
我们都是好孩子
对不起我的最爱
老婆老婆我爱你
爱上你这样的女人
qq爱
大城小爱
认真的雪
隐形的翅膀
光芒
god is a girl
舞娘
好姑娘
吹眼睛
真爱
老公老公我爱你
死了都要爱
太美丽
曹操
那一夜
my love
一万个理由
反转地球
今天你要嫁给我
yesterday once more
爸爸妈妈
发光体
爱我别走
夜曲
我很想爱他
We will rock you
神话
不得不爱
发如雪
为什么相爱的人不能在一起
蝴蝶
王子变青蛙
雨夜
一万个理由
狼爱上羊
那一夜
不要再来伤害我
大城小爱
寂寞沙洲冷
完美世界
爸爸妈妈
生日礼物
功夫
情人
不得不爱
发如雪
一眼万年
希望
第一次爱的人
夜曲
一万个理由
狼爱上羊
那一夜
不要再来伤害我
大城小爱
寂寞沙洲冷
完美世界
爸爸妈妈
生日礼物
功夫
情人
不得不爱
发如雪
一眼万年
希望
第一次爱的人
夜曲
一万个理由
狼爱上羊
那一夜
不要再来伤害我
大城小爱
寂寞沙洲冷
完美世界
爸爸妈妈
生日礼物
功夫
情人
不得不爱
发如雪
一眼万年
希望
第一次爱的人
夜曲
香水有毒
秋天不回来
求佛
香飘飘
我们都是好孩子
不怕不怕
不要再来伤害我
天下无双
狼爱上羊
老公老公我爱你
寻找李慧珍
god is a girl
大城小爱
舞娘
老婆老婆我爱你
曹操
qq爱
约定
那一夜
隐形的翅膀
光芒
飞行部落
真爱
冰菊舞
死了都要爱
一万个理由
反转地球
my love
好姑娘
爱我别走
我不后悔
飞舞
yesterday once more
王子变青蛙
We will rock you
不得不爱
夜曲
发如雪
爸爸妈妈
爱我就别伤害我
我很想爱他
桃花朵朵开
神话
笔记
吉祥三宝
不想长大
暧昧
迷魂计
花田错

Posted by: rwerswf | Sep 27, 2006 2:09:45 AM

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