Are Patients Too Dumb to Make Good Choices?

Austin Frakt refers us to this statement from a study of complexity in various markets:

The idea of consumer-directed health care, however, is going in the opposite direction in that it increases complexity for consumers, and possibly for clinicians. Using other markets as benchmarks, we would expect this push to fail, or at least to have limited success. Thus the goal should be to increase the complexity of health care where it can be managed in order to reduce complexity for patients, their families, physicians, nurses, and other clinicians.

He then piles on with an observation of his own:

One additional consideration is the cost of a complexity-induced mistake in each sector. The cost of a consumer making a poor choice of cellphone or plan is of a different order of that of making a poor choice of health care treatment. One way we manage telecom’s complexity is learning from experience. There’s a good chance you won’t make the same bad choice twice. How many times do you get to choose where to have heart surgery?

Can you spot what’s missing in all this? Answer below the fold.

Remember what is happening in health care. We pit bureaucratic payers against bureaucratic providers. At least that’s the way we used to describe it. Now it’s software against software. On the physician side alone, there are 7,500 tasks Medicare pays doctors to perform and the number is expanding to many thousand more. So providers buy computer programs to help them maximize against the payment formulas. Then the payers buy programs to help defend against the provider programs. Then we get another iteration, with better programs and better defenses, etc. How could this not be complicated?

But has anyone noticed how uncomplicated health care markets are where there are no third party payers or where they play a subordinate role? Walk-in clinics have posted prices that are easy for even a fifth grader to understand, while at a typical physician’s office no one seems to know what anything costs. Wal-Mart will give you a generic prescription for $4. Rx.com and other mail order prescription drug services are almost as easy to understand. But your local pharmacy can’t tell you what any drug costs until they know what insurance plan you are on.

Package prices are normal and easy to understand and coming down in real terms in cosmetic surgery and Lasik surgery, even though the typical hospital can’t tell you what any procedure costs ― certainly not in advance ― and whatever the cost, you can be sure it’s rising faster than the rate of inflation over time.

There is probably no bill in America more complicated than a hospital bill, unless you happen to be a Canadian coming to the United States for elective surgery. Canadians pay one price and they typically pay it in advance. So do Americans who take advantage of domestic medical tourism services.

As for the possibility of mistakes, hospitals in India (catering to the international, cash-paying, medical tourism market) post their quality metrics online ― mortality rate, infection rate, re-admission rate ― and compare them to such U.S. institutions as the Mayo Clinic and the Cleveland Clinic. How many U.S. hospitals do the same?

Bottom line: an enormous amount of what happens in medicine is not complex at all. In fact it’s very routine. What’s not routine is bureaucratic warfare that involves complicated payment formulas and complex strategies to maximize against them. Most complexity is artificial complexity created by the overuse of third-party payment, which is caused by unwise public policies.

Comments (68)

Trackback URL | Comments RSS Feed

  1. Jack Towarnicky says:

    The challenge here is to have individuals make as many decisions as are possible when they are consumers of health services with a focus on improving (or at least maintaining) health status. If we wait for the time when they are patients, too frequently those who need immediate care deploy much different consumer traits/decision-making criteria than those who can plan on specific needs. Compare the results with respect to lasix, cosmetic surgery versus acute care after cardiac arrest.

  2. Ken says:

    Right on. Good post.

  3. Dewaine says:

    “Are Patients Too Dumb to Make Good Choices?”

    Yes, technically, but they are better than the government.

    • Sabal says:

      If we have the smartest among us acting as the government, then we are making the best decisions. I don’t know how you can argue that dumb people and smart people should have an equal role in decision making.

      • Dewaine says:

        Because valuation is subjective. You can’t have a “smart person” making optimal decisions for a “dumb person” because they have different utility structures. Individuals are the only ones who can make the decisions that reflect their values.

        • Sabal says:

          But, we do know that some things are objectively good. So, when it comes to the big things, we can direct people accurately.

        • Sabal says:

          If someone decides to shoot up a bunch of people, we can objectively say that was bad and intervene.

          • Dewaine says:

            That’s an interesting point, although its also very dangerous. You’re suggesting that we judge people before committing any acts (how else could we prevent it)? If we deem someone’s values bad we have the right to stop them before they even commit the act? . That is a really slippery slope. That means whoever is in power will impose their believes on everyone else. You’re talking about religion being illegal from the left and homosexuality being illegal from the right. You’re talking about dictatorship.

            Even if you are merely saying that we should have government interventionists policies to stop shootings, there are always unintended consequences. We know that gun control puts law abiding citizens in danger. The problem fundamentally is that even the smart people aren’t smart enough to see everything.

      • Greg Scandlen says:

        Sabal, two things —

        — I hope you are kidding about the smartest people among us working for the federal government.

        — Some people may be brilliant about some things but really dumb about others. Have you ever seen a PhD try to change a tire? Sad. And there is no one on earth who knows more about my family and our needs than I do.

        • Sabal says:

          - I was saying that, theoretically, we could have the smartest people working in government. Obviously, that isn’t true right now.

          – I see your point, although if we had them placed in the right ways, we could utilize their strengths and avoid their weaknesses.

          • Dewaine says:

            My point is in line with Greg’s:

            “And there is no one on earth who knows more about my family and our needs than I do.”

      • John Fembup says:

        “If we have the smartest among us acting as the government, then we are making the best decisions.”

        I think you still need to explain how the “dumb people” are smart enough to elect the “smartest among us” in the first place.

        If you can.

        • Sabal says:

          Maybe the whole system needs to be restructured.

          • John Fembup says:

            Maybe?

          • John Fembup says:

            You didn’t answer my question.

            • Sabal says:

              I don’t know how it would work, but I’m sure that it is possible to structure society in a way that puts the smartest people in charge.

              • John Fembup says:

                “I don’t know how it would work, but I’m sure that it is possible”

                Sorry – no offense – but this response does not place you among one of the smartest.

              • Hoads says:

                So you believe in the infallibility of experts and a handful of experts can make better decisions than individuals relying on their own intuition and resourcefulness. That might work for exchanges that do not involve financial costs, but once money enters the picture, the “experts” can be manipulated by deep pockets and powerful influence – especially when these “experts” have no immediate relationship or accountability to you and/or sandwiched within a massive bureaucracy. What was once considered a necessary and justified arrangement can quickly become a bastion of corruption and misanthropy.

      • Allan (formerly Al) says:

        Sabal, we have a lot of experts in government, but how does government know they are experts? They really don’t except if the expertise they are seeking so happens to be in the area where the expert’s expertise lies and even there errors are frequently made. Many of the experts arise from academia, a place where successive failure can lead to advancement in one’s career. That differs from the private sector where failure can mean bankruptcy.

        Thus the government might choose a Nobel Laureate to advise them on economic policy where the expertise may have been very limited and the individual totally naive with regard to the economy as a whole. My guess is that the government picks those that advances the government’s ideology and even after the experts give their opinion that opinion is frequently modified even further so that once again it meets an ideology satisfactory to the one in charge (ideology plus reelection). That is why the ACA is doomed to fail when one determines success or failure based upon the ACA’s initial objectives.

  4. Greg Scandlen says:

    Complexity? Does anyone in this business actually know what they are talking about?

    Here is a comparison of the listing of plan choices for Pennsylvania in my new “Medicare and You” booklet. I chose at random just one of the hundreds of HMO and PPO plans available and will compare it to the Medicare MSA plan below –

    HealthAmerica (H3959) Health Maintenance Organization
    Member Satisfaction Rating – 87%

    Service Area – Allegheny County
    Monthly Premium — $95
    Out-of-pocket Limits — $6,000
    Primary Care Visit — $10
    Specialist Visit — $35
    Chemo Drugs – 15%
    Other Part B Drugs – 20%
    Home Health Care $0
    DME – 20%
    Annual Part D Deductible — $0
    Part D Drugs — $5 – $95 and/or 33%
    Additional Gap Coverage? – Some Generics, call plan

    ——

    Geisinger Gold Medical Savings Account
    Member Satisfaction Rating – 88%

    Service Area – Pennsylvania
    Annual Deductible — $3,000
    Annual Deposit — $1,500
    Cost Sharing After Deductible — $0
    Annual Out of Pocket Maximum — $3,000

    Note that the booklet doesn’t get the MSA OOP limit right. It is actually $1,500 after subtracting the annual deposit. Also btw the premium is $0

    • John Fembup says:

      Greg, you are correct about the available information. “Medicare and You” does not even tell us what our 2014 deductible will be. But this is not information related to shopping for “health care” It’s information related to shopping for “health insurance”.

      Those are very different consumer products.

      And for the past, oh, 30 years at least, neither our so-called thought leaders nor the pundits nor the media have bothered to help us distinguish the difference. In fact, the reverse: they have obscured the difference.

      So it’s no wonder the public is grossly uninformed about the health care and health insurance issues we face today. It’s not so much that people are incapable of making their own decisions. It’s more about so many forces that have effectively conspired to keep people ignorant of the basic issues in the first place.

      • Greg Scandlen says:

        John, I would like to agree with you that health “care” is apart from health “insurance.” Unfortunately, our expert whizzes have made that impossible. Note the varying coinsurance and co-pay rates in the description above. That directly affects the “care” side of the equation. Also, Goodman posted something recently that showed under Obamacare physicians will have to charge copays that vary with the patient’s income. How the hell is that going to work? My doctor has no information about my income. I guess now he will have to take an income history to supplement the medical history.

        • Don Crawford says:

          Apparently the IRS will be called in to figure out what subsidy if any a person gets under Obamacare. I supposed they could rule on amount of co-pay as well. Of course, they haven’t figured out what to do about fluctuations in income, but they will decide what we can have later. And of course, if they make a mistake you’ll have to pay for it. And if you aren’t subsidized, your health insurance prices will be extraordinarily high because of all the subsidizing and the requirements of what is covered and the requirements to cover pre-existing conditions.

          • John Fembup says:

            Yes Don it seems that today’s IRS can rule on just about anything it chooses.

            But Greg’s point is that I pay my copay at the office, when I visit my physician.

            So the office has to know what copay to charge me, right then and there.

            If my copay is based on my income, how will the doctor’s office know how much to charge me?

            Seems to me, IRS can’t help the doctor’s office do this. IRS only knows my income last year. Since then, I was laid off and now I have a part-time job. Or I’m not even working. Or I retired and took my SS. Shall my copay be set based on my last year’s income? Is that close enough for government work?

            • Don Crawford says:

              Just because the mechanism to do this is clumsy and difficult, I don’t expect that the government will refrain from providing yet another means-tested benefit. If your income has gone down and you think your co-pay expectation is too high I’m sure the government will have a lengthy and cumbersome process for you to appeal the level of your co-pay. Government bureaucrats have always been on salary, so they have no idea that people’s income could fluctuate from year to year and month to month. This process already is in place for college scholarships–basing it on last year’s income and requiring you to prove your income has changed after the fact. It won’t be worth the hassle to change your copay from $30 to $20 a visit. The IRS also expects you to pay “estimated taxes” based on estimated income that hasn’t yet been received and fines you if you guess too low. So even though it seems ludicrous, I wouldn’t put it past them to base your co-pay on last year’s IRS reported income.

  5. JD says:

    “As for the possibility of mistakes, hospitals in India (catering to the international, cash-paying, medical tourism market) post their quality metrics online ― mortality rate, infection rate, re-admission rate ― and compare them to such U.S. institutions as the Mayo Clinic and the Cleveland Clinic. How many U.S. hospitals do the same?”

    Real competition would do this.

  6. Deborah C. Peel, MD says:

    Today institutions control ALL uses and sales of patient health data, not us — Current technology systems violate our longstanding legal and ethical rights to decide who can see and use our health information. Institutions USE AND CONTROL our data to prevent us from learning about the costs and quality of treatment AND prevent us from being able to get our own independent advice about cost and quality.

    A vast army of hidden corporate users fights to prevent patients from getting electronic copies of their data from electronic health records systems AND from getting lists of the hidden users and sellers of their health data.

    To understand who the 100,s to 1000’s of hidden corporate users are see: http://www.theDataMap.org

    By controlling the nation’s health information institutions ensure the status quo and keep costs and quality opaque, they can continue to raise costs and prevent us from learning where to go for quality care.

    In the US, only patients care about quality and cost. Give us our DaM data: https://www.youtube.com/watch?v=0gpk-fbfg4Y

    Sign up to learn about the loss of health privacy at http://www.patientprivacyrights.org

    • Hoads says:

      Dr. Peel,

      Thank you for your pioneering of this work. People falsely believe those HIPPA forms they are asked to sign protects their medical information but the data map shows just how far and wide our medical information is shared and disseminated across a wide spectrum of players within the healthcare system who stand to gain wealth, power and influence with patients’ data.

      Knowledge is power and those with means who wish to exploit it have easy unfettered access. Patients and consumers are unknowingly abdicating their consumer and market power that used to be pursued, patronized and valued by corporate America. Once the powers that be corral our personal information and behavior patterns, empiricism then becomes a weapon to use against us.

  7. Sean Parnell says:

    Exactly right, I write all the time about patients who don’t seem to have too much trouble navigating the ‘complex’ health care system. Today was about medical tourism, http://theselfpaypatient.com/2013/10/09/abc-news-reports-on-medical-tourism/.

    One talking point that I think needs to be retired ASAP by free-market health care advocates is the bit about LASIK prices coming down. It’s true, BUT it gives the other side the opportunity to reply ‘well, that’s elective/unnecessary care, that’s different, real health care can’t work that way.’ They’re wrong of course (not to mention torturing the definition of elective), but why even give them that opportunity? Talk about hernia repair surgery that costs $3,200 at a place like Surgery Center of Oklahoma instead of $20,000 at the local hospital. Talk about colonoscopies that cost $800 by paying cash instead of $3,000 going through insurance. Talk about shoulder surgery costing $9,000 in India instead of $130,000 in the U.S.

    In other words, talk about things that everyone will immediately understand – this is not unimportant, unnecessary care, it’s care that real people need being bought in the market for much lower costs than what it costs when you go through insurance.

  8. H D Carroll says:

    The term “consumer directed health care” is a really bad one – I don’t think we are (or should) be saying that an arbitrary individual consumer expect to be able to choose by themselves correct medical care. However, “consumer directed health care payment decisions” are a different thing. Being involved in that aspect brings in a value system, for better or for worse, allowing people to measure options, not only from a medical efficacy basis, but from an efficiency basis. A person can decide if they “want” surgery, but not if they “need” surgery. Economic needs and wants (and therefore what comprises an economic good) are different, or was that not what I learned in econ classes? Maybe I wasn’t listening that close.

    • Greg Scandlen says:

      H.D. — I hope you learned about the principle of “agency” in your Econ classes, In dealing with complex systems we need the services of an agent, one who is chosen by us and accountable to us. In health care that suggests something akin to a concierge physician to advocate for you throughout the HC system.

  9. Gail Wilensky says:

    This is a very thoughtful response.

    There is clearly a division of people in the country – those who think the government needs to make these types of decisions for people and those who think that with proper information and incentives to encourage their use, most people can figure out what’s best for them.

    This longstanding division seems to have become a chasm…

    • John Fembup says:

      “seems to have become a chasm…”

      Yes. Exactly so.

      And therefore it seems clear to me that the best way up out of this chasm is simple: permit people to make their own decisions.

      If I want to choose my own insurance, LET ME.

      Or if I prefer, for example, LET ME call the office of John Larson or Chris Murphy and ask: what should I do?

      In this way, everyone gets what they want. If you want freedom, you get it. If you want to be told what to do, you get it. But this administration insists on an authoritarian path in which fewer than 50% of the people get what they want.

      So fergoddsake, postpone the individual mandate for at least one year, and let people choose.

      It will be at least a year before HHS gets ists systems in order, anyway.

      Pure political posturing stands in the way of this. You know – or should know – this is the best way forward for all of us.

    • Don McCanne says:

      Dr. Wilensky,

      You have long advocated for greater patient cost sharing as a means of providing patient incentives to select their health care more wisely. Please see my response to Mark Pauly regarding moral hazard.

      There are services that should not be selected based on price shopping but rather selected based on need. Police and fire protection are such services, and I would include health care. When you need police and fire services, you should not have to make a decision about cost sharing when your house is on fire or when someone is threatening physical harm. Those services should always be available, and funded equitably through the tax system.

      Although this is a view not held by many on this blog, health care services should also always be available, funded equitably by taxes (e.g., single payer). Other countries have shown that you do not have to require patient price shopping decisions to control spending in health care. Tax financed, prepaid health care systems distribute care more effectively at a cost much lower than ours.

      • David Hogberg says:

        You state that “health care services should always be available [and] funded equitably by taxes (e.g. single payer).” Instead of treating that as an axiomatic truth, let’s treat it as a hypothesis to be tested.

        There are about almost 2.9 million people waiting for treatment in Britain’s single payer system: http://www.telegraph.co.uk/health/healthnews/10246145/NHS-waiting-lists-are-longest-in-five-years.html There is no definition of “always available” in the above post, but I’m guessing there is no definition that accords with 2.9 million waiting for treatment.

        • Don McCanne says:

          Not all universal systems are plagued by excessive queues. Some OECD nations have used queue management and modest adjustments in capacity to tame their queues.

          Although the United States is not noted for excessive queues, I can assure you that many of my indigent and Medicaid patients were not even allowed a place in the queue for many specialized services. EMTALA helped for serious emergencies, but it did nothing for the financial hardships created by the rendering of such services.

      • Wanda J. Jones says:

        Don: Apparently you are willing to accept under-service in these pre-paid programs…Americans probably would not if they could see documentaries of the care as actually experienced. The National Health service in Britain is notorious for poor care.

        To agree that the government should made decisions for its citizens means we should all accept the “factorial” of everything turning out well is a high probability. That means that each factor’s separate probability times each other factor’s probability results in a positive decision as good or better than that which the individual could make. Make a list of the knowledge elements that should go into a surrogate decision, and do a factorial calculation. The odds against being right are apt to be in the millions.

        Once, a colleague said that “We should just throw the system out and start all over.” I asked him, “Where are the new healthcare workers and management people who are waiting in the wings to take over?

        As to the smartest people being found in government, isn’t it more likely that the smartest people today avoid working for the government like the plague? Thats why government programs substitute rules and regulations for judgment.

        Wanda Jones, MPH
        San Francisco

        • Don McCanne says:

          Wanda,

          Although there are instances of poor care in all countries, including the United States, the facts clearly refute your statement that the NHS in Britain is notorious for poor care. As an example, of 7 nations studied in the International Health Policy Survey, UK ranked second and US ranked seventh (last). A great many other studies provide comparable results.

          http://www.commonwealthfund.org/News/News-Releases/2010/Jun/US-Ranks-Last-Among-Seven-Countries.aspx

          We do not support government intrusion into the physician-patient relationship. All health care decisions should be made by the patient after consulting with the physician. The primary role that the government should have in a tax-financed system is to determine what care should be provided with our tax funds. As you are well aware, the private insurance industry is far more intrusive than public programs in making coverage decisions.

          As far as smart people in government, some of the finest professionals that I know in health care and in health policy work for the government. They are very dedicated individuals who care about the people of our nation.

          • Hoads says:

            Commonwealth, IOM, WHO have been deceptively hammering the US healthcare system for years using data measurements that support their preconceived thesis. Most all their parameters put more emphasis on access and equitability of healthcare versus actual quality measurements. Their use of mortality, cost measures, utilization of preventive care and similar, may be useful for public health, but are useless in measuring the quality of care received by individuals. Other than the cost of health insurance, U.S. patients consistently rank higher satisfaction with the care they receive than almost all of the EU.
            Ironically, UKers rank their health system quite high despite the fact they have the lowest outcomes when compared to the US and their EU neighbors. Funny how that happens- easy to place high value on something you perceive to be “free”. Germans’ satisfaction with their healthcare system is actually lower than ours.

          • Allan (formerly Al) says:

            Don, I am waiting for that list “to determine what care should be provided with our tax funds.” I am sure if that was your sole desire along with government funding to pay JUST for those items many of those advocating private markets could satisfy your desire. Why don’t you present the list of “what care should be provided”.

            • Don McCanne says:

              There would be no “list” for covered services since virtually all essential services would be included. For what might be excluded check England’s NICE program.

              Better yet, just observe how Medicare works. If you have a medical problem, you go to the doctor and it is taken care of. There is no “list” that needs to be checked, though there are some services and products that are not covered. Medicare does exclude some categories that we would cover, such as long term care. But for any specific service, you can look it up yourself at:
              http://www.medicare.gov/coverage/your-medicare-coverage.html

              • Allan (formerly Al) says:

                Don, I see what you are wishing for. If a person has a mildly deviated septum the government can pay for the cosmetic nose job because it is considered medically necessary. Physical therapy will be based upon a diagnosis rather than need so that some get more than enough care and others get too little. Same for most other medical care. You were a primary care physician so you should know this. You should also have seen the system being gamed over and over again so I don’t know why you believe what you do. We both want the same thing and obviously we both care, but we have to face the stark reality of human nature and its subsequent behavior.

                Why hasn’t this list you talk about, with or without NICE, been compiled and placed on the single payer website? It hasn’t because the care we both dream about is a dream not a reality, so we have to choose a better method than the one’s we wish for and dream about. Single payer stands for the comparative over treatment of those that are stars and diseases that have star power leaving the non star people and diseases with comparatively less care.

                Understand Don, I am perfectly willing to help those that need help even if taxpayer funding has to be used. I am not willing to support a program based upon star power combined with the one shoe fits all approach which is what single payer is today.

  10. Claire Smith says:

    Ahh, the market!

  11. Mark Pauly says:

    I live in a market (Philadelphia) where there are really only two private insurers, and one is for profit. You would think that at least one of them would have tried to make it less complex for me, but instead they seem more interested in getting me to jog or talk with a dietician, neither of which I will do. If insurers cause complexity, and they compete for my business, why don’t they solve it if it is that much of a problem? The answer (no surprise) is moral hazard. If I knew precisely what I would have to pay out of pocket and what I would get for every illness, I would be more likely to use some kinds of care. Put alternatively, the nagging fear that my insurance might ask me to pay more or make me argue with my doctor’s billing clerk deters my use of positive but low value care. Back up insurance coverage, and it will make sense to let me know how to spend money, now my money, not theirs. I know there are some high deductible insurers following this route but I wish more did and that the now much-touted “transparency” were advocated only for those with the kinds of incentives to use it efficiently, not as an engraved invitation to moral hazard, adverse selection, or overpricing.

    • Don McCanne says:

      Dr. Pauly,

      As you are well aware, John Nyman has added to your pioneer work on moral hazard. A great concern is that prices can deter individuals from obtaining care that they really should have.

      Rather than shopping for health care based on prices, patients would be better served by concentrating on becoming informed on their health care options for their given condition. Regardless of prevailing theory, people do not want any and all care that they can obtain as long as it is covered by insurance. Patients are not “dumb,” and I say that after decades of private practice.

      Providing care with first dollar coverage through a prepaid health system (e.g., single payer) provides patients with greater opportunities to select proper health care without having to negotiate financial barriers. It is choice in health care and not choice in insurance products that we really want. Your annoyance with the Philadelphia insurance market demonstrates that.

      Rather than depending on price shopping to control spending, well informed administrators can make decisions as to what services are covered by the system. That, along with administered pricing, has been very effective in controlling heath care costs in other countries.

      A single payer system would eliminate adverse selection, reduce overpricing, and would reduce the impact of moral hazard by providing services that are beneficial while not covering those that are detrimental or clearly wasteful.

      • Ken says:

        Don, somebody has to choose between health care and other uses of money. If your unconscious and on a gurney, other people will do it for you. So you are right about one thing — we are not always in a position to shop and choose.

        The same principle applies to you burning house and your need for police protection when you are being mugged.

        But the vast majority of what happens in health care is elective and easily subjected to individual choice.

        If you want others to make choices for you, join an HMO. If you want to make your own decisions, choose a CDHC plan.

        We don’t have to have one-size-fits-all health insurance.

      • Allan (formerly Al) says:

        @Don: “Regardless of prevailing theory, people do not want any and all care that they can obtain as long as it is covered by insurance.”

        I am a physician as well and despite what you say, while perhaps not wanting everything (who wants a daily colonoscopy?), patients do want many things but cease a desire for them when they have to pay for them. I’ll give two big ones that are easy to understand DME and physical therapy. If you are an internist check your diabetics that demand free shoes or if you are a urologist check the number of patients that get disposable catheters under Medicare at great cost. Check out how many patients end all thoughts of physical therapy as soon as their benefits run out. If you are not a doctor just go to your local gym and see who comes out of a car parked in a disability space with a disability sticker. It is surprising how individuals will utilize free things and special privileges even if it causes harm to those in need.

        Single payer is pie in the sky and politicizes medicine. The idea behind single payer is not a solution. It is the problem.

        • Don McCanne says:

          Really? You blame your patients?

          You prescribe special shoes for a diabetic that doesn’t need them, and the patient is at fault? You prescribe unnecessary disposable catheters, and the patient is at fault? You prescribe PT that the patient doesn’t need, and the patient is at fault? You certify disability for a disabled parking application for a person who is not disabled, and the patient is at fault?

          Or were these clearly indicated interventions that you appropriately prescribed?

          At the beginning of the managed care revolution, I was astounded by the physicians who had signed capitation agreements (incentives to provide LESS care) who were now blaming their patients for demanding too much care when these same physicians previously had been pushing marginal care which increased their revenues.

          Rather than complaining about dumb or greedy patients, perhaps instead the physician should be educating the patients to make smart health care decisions. With information asymmetry, shouldn’t that be the physician’s role?

          • Stella Baskomb says:

            “the patient is at fault?”

            No, the physician is at fault.

            Ask any malpractice attorney.

            • Allan (formerly Al) says:

              Stella in a way you make one of my points. Note how you indicate that the malpractice attorney can determine fault. He can’t. He is not a physician and requires expert testimony to make his case and in most cases that is physician testimony. The threat of suit creates far more costs in the medical community than people realize and those costs are both in dollars and care. Understand, I want malpractice attorney’s to exist as they help me to maintain quality, but the attitude that every bad outcome requires an attorney is much more expensive than many believe and causes many of the quality and marginal cost benefit problems we see today.

              • Stella Baskomb says:

                Al-Al, you say that I “indicate that the malpractice attorney can determine fault”

                I do no such thing. I simply suggest what the malpractice attorney will tell you if you ask her.

                Certainly the threat of lawsuits is a significant factor in physician behavior. It causes them to do more than they otherwise might, out of fear. That means medical utilization and therefore cost is higher than it would be if based on physician judgment alone. That behavior obviously increases cost. I agree with you on that.

                But the the point is, that physician behavior is rational and will not change in the present legal environment. So, IMO, what Don McCanne suggested (“perhaps instead the physician should be educating the patients to make smart health care decisions”) is a utopian statement, not a practical recommendation.

                • Allan (formerly Al) says:

                  “I simply suggest what the malpractice attorney will tell you if you ask her.”

                  Stella, I didn’t pick up on the intent of your remark, but I agree with you about the utopian beliefs that some people hold so dear.

                  Allan

                  • Don McCanne says:

                    Wow! If the concept of physicians educating patients to make smart health care decisions were only a utopian dream, our health care system would be in much worse shape than it really is. But since you seem to prefer to frame the concept in terms of malpractice attorneys, we can speak of “informed consent” – a long standing practice of educating patients to make smart health care decisions. We have met Utopia and it is us (apologies to Walt Kelly).

                    • Allan (formerly Al) says:

                      Yes, Don, some beliefs are utopian as I believe some of yours are, and that is where I believe some of your ideas fail. Nothing wrong with physicians playing a part in educating their patients (that is part of the job description), but that still doesn’t guarantee that they or their patients will make the right decision. I will say, however, that the decisions made by the patient in his own self interest will likely be a better decision than the one made by the guys in Washington.

          • Allan (formerly Al) says:

            “Really? You blame your patients?”

            Don, some of the things may be by prescription and I didn’t permit those games, but I was faced with patient demands on a regular basis as are all physicians. This leads to a competitive advantage for those physicians that are willing to give into the competitive pressure to provide all the goodies that will be paid for. That is how the HMO’s initially became so popular, free glasses, free hearing aid, etc. while skimping on care for those truly in need. You might find that to be appropriate. I don’t.

            Don’t tell me you are a saint and that these things never cross the path of your vision. I guess in your practice you never noted how Physical Therapy treats the code number and not the patient. Thus much of that physical therapy ends up wasted. Don’t tell me people aren’t going out to dinner when Medicare pays for the visiting nurse and home physical therapy (one has to be homebound and there is no way for the physician to know). They do all the time and don’t tell me that every patient that needs catheters has to get the maximum number per month that Medicare will prescribe or even has to have the throw away catheters. I wonder if those self pay folk that need to self catheterize use so many catheters or even used them at all.

            The fitting of the shoe was not my problem, but in the past being pushed to write a prescription that wasn’t needed for the patient became my problem and a giant waste of time and Medicare financing for those that were weak under pressure. Remember the podiatrist at least in the past advises the patient of the need for the shoe and then requests a prescription from the Internist before the podiatrist is paid for this service.

            I am not the one that general prescribes the disability sticker and there is no cost to Medicare or insurance for that product. I used that as an example to demonstrate that many people will over utilize privilege or gift whenever given even though they know it is to another’s disadvantage. Here where I reside it is frequently near impossible for a truly handicapped individual to park in a disabled space as they are used by those not in need. Generally I told most of my patients requesting one that they needed a disability space at the far corner of the parking lot so they would get exercise walking to and from the mall or store. Too much coverage and too many gifts frequently work to the disadvantage of the patient’s health.

            I don’t blame the patient who is just doing what is in his best interest and is not illegal. You can put that idea to rest. I blame the powers to be that might think like you and put me in a position creating a division between my patient and myself. They even create a potential for suit when something ill befalls the patient because I refused to add the extra goody that in my medical judgement wasn’t needed. I won’t lose the suit and never have even in one of the highest malpractice areas of the country, but one can sue for any reason.

            Maybe you close your eyes when patient enters your doors with complaints created to game the system. I am not saying they don’t have the disease, rather they have a few added complaints. I’m an Internist that dealt with a large geriatric practice and the gamesmanship practiced was astounding in frequency.

  12. Lis says:

    Yes, everyone in the U.S. is too stupid. Hospitals don’t know what to charge, consumers have no idea of prices, insurance companies don’t correctly compute the actual cost of any of those 7,500 procedures, physicians entertain huge back offices to process mountains of paper work for something about which they know nothing.

  13. Allan (formerly Al) says:

    I am a retired physician who dealt mostly with those that had multiple illnesses so that even the guidelines could not be followed on a large percentage of my patients. I found it relatively easy to treat this patient population. What I found impossible to deal with was the bureaucracy in medicine that caused delays in treatment and tremendous amounts of my time. The amount of money this bureaucracy is wasting without providing better care is probably in the range of 30 – 50% and long term probably substantially more.

  14. PJ says:

    “But has anyone noticed how uncomplicated health care markets are where there are no third party payers or where they play a subordinate role? Walk-in clinics have posted prices that are easy for even a fifth grader to understand, while at a typical physician’s office no one seems to know what anything costs.”

    This is so true.

  15. George says:

    You raise a very important point about complex systems, John,
    Part of the “chasm” we face may be the failure of us to distinguish between a complex adaptive system–brains, immune systems, and diseases included–and complicated mechanical systems erroneously labeled as “complex.” In fact, most engineered systems, both technological and social, are merely very complicated. And among the many reasons they fail to ameliorate low value patterns in humans, with and without diseases (complex adaptive systems, one and all), is that they cannot, truly cannot properly emulate, substitute or cure the human condition. And so, being merely, if often very complicated, they tend to enforce top down control as a substitute for adaptive responses to emergent phenomena. We should not be surprised that complicatedness always falls, not only from its inherent engineering defects, but its mismatch to primary empirical reality, also known as quality.

  16. Hoads says:

    Health insurers and governments benefit from complexity and inefficiency and strategically rely upon it. Both currently utilize high tech when it benefits them for internal management and skimp on technology that would benefit the end user . There is no reason in the world why health insurance payment, billing and reimbursement systems are not as seamless as those utilized by credit card companies or why government has no system in place to track legal immigrants who over stay their visas or systems to prevent fraud in Medicare.

    And how outrageous that Obamacare does nothing to improve billing, benefits statements, etc. –the one area that frustrates both patients and providers.

  17. David Hogberg says:

    To quote Thomas Sowell: “It is hard to imagine a more stupid or more dangerous way of making decisions than by putting those decisions in the hands of people who pay no price for being wrong.” And that’s exactly what happens when decisions are taken out of the hands of patients and put into the hands of “experts.” I’ll trust the patient who is risking pain and maybe even his life to make the right decision about what treatment he needs over someone who isn’t risking that.

  18. jmitch says:

    So, for those of you who believe in pure market-based health care and price transparency, please tell me how I should answer a patient who comes to my ER with abdominal pain and asks, before I’ve examined him, “Doc, how much is this going to cost?”

    • Don Crawford says:

      Tell him the charge to check him over–diagnostic charge, same as at a mechanic–and once you see what the problem is you can tell him what cures he can choose among and what those will cost.
      Doctors need to be motivated to find inexpensive ways to diagnose illnesses. Right now the opposite is true. They will make more money for their clinic if you have a boatload of tests costing the insurance company thousands of dollars. I’ve gone in with exactly that problem, was afraid it was appendicitis, had a surgery consult, and we decided not to do surgery. The pain went away in a couple of days. That shouldn’t have cost a lot. Of course, I have no idea what it cost because I didn’t pay it.

  19. alberto mejia-pol says:

    I think, maybe patients with money in their pockets are able to decide that issue… But I wonder what could happen to a patient at the momment of an accident or illness, and does not have the money in his pocket to pay for redered services??…

  20. alberto mejia-pol says:

    I think, maybe patients with money in their pockets are able to decide that issue… But I wonder what could happen to a patient at the momment of an accident or illness, and does not have the money in his pocket to pay for rendered services??…

  21. John R. Graham says:

    Markets reduce complexity because suppliers have to simplify their offerings to win customers. Academics must be completely divorced from the real world if they do not understand this key factor of business success.

    Any successful entrepreneur will tell you that success comes not from having a complicated new product, but by simplifying it in the eyes of the customer, no matter how complicated the product is.

    Government in charge has made the system more complex, leading to one third or more of U.S. health spending being wasted (http://tinyurl.com/ljb7mz2).