Consumer pressure for quality in medicine is very weak. How weak? Consider that readers of Consumer Reports are unusually wealthy and assertive as customers, and readers who answered a Consumer Reports
Robin, this is a bit off-topic for this post, but it's the only recent medical economics post I've seen, so here goes: a commenter on Megan McArdle's blog came up with a good question:
That brings up another point: What do the calculations of "percentage of GDP spent on health care" cover? If one system, like the US, has doctors paying high tuition at medical school, which is then passed on to consumers as higher health care costs, but another system has doctors' tuition paid "for free" out of other tax money, do these comparisons count the subsidized doctor education as part of "health care costs?" Or is that slid into "these countries spend more on education and less on health care?" Similarly, if a country decides that it wants to research pharmaceuticals through government research instead of using the profit system, are the taxes used to pay that counted as "health care costs" or as "this country saves on health care costs so it can spend more on science and research?"Maybe you could get some of your students to research it, like Lomborg got his students to examine some of Julian Simon's claims he had doubts about.
Because patients would still want their doctor to take into account their individual illness. Also, because (as I mention below) patients don't feel capable of interpreting such survey results.
Where do I obtain these objective ratings? Can I trust them? What if one hospital has an overall lower infection rate, but another has more knee replacements resulting in full mobility? How to I measure the trade-off (mortality vs. mobility) when deciding where to get my knee replacement done? What if I don't even know what statistically significant means?
Medicine is so far from being free market that the usual conclusions one might draw on the assumption that it is remain dubious. Lack of something provided is evidence of lack of demand in a largely free market. The shortages of toilet paper in Cuba is not strong evidence that Cubans don't want toilet paper.
Proper nutrition is the first medicine and food is much, much close to being free market, so if your views are correct they are likely to apply.
If subjective doc evals contain useful info about hospital quality, one could survey docs and use that to construct public ratings of hospitals. This would be much better than individual doc evals. So why aren't such survey results available if consumers are eager to get them?
Robin was obviously referring to looking at objective ratings of hospital performance for different treatments/conditions, not making uneducated judgments based on arbitrary criteria.
wasted a half-hour calling two hospitals and the surgeon to see what their fees were
I had similar experiences, and James Donald had a similar experience.
My wife was advised to get a colonoscopy. We shopped around, got a reasonable price at a doctor with a good reputation, negotiated with the insurance company, did all the stuff one does in an environment which actually has prices. Then after the colonoscopy was done, the hospital pulled a huge list of stupendously expensive charges out of their ass, most of which were obviously ridiculous or completely made up out of thin air, just trying it on to see what they could get away with, and all of which were charges we had definitely not agreed to, nor consented to in any way, formal or informal, written or unwritten. They just were not used to doing stuff on the basis that one has a definite price, and that the price one charges affects demand for one’s services. The concept seemed alien and incomprehensible to them. Mentally, they were socialists.
Relying on one's doctor's advice as to hospitals, or a hospital's reputation (record) for care of one's condition isn't the same as being indifferent to hospital quality, is it? Especially since choosing one's doctor for a procedure may dictate what hospital one uses for it.
I suspect most of that 11% of patients were actually just relying on their physician’s claim about a hospital’s record, rather than checking it out for themselves.
Do you really think patients are qualified to assess hospitals on their own? Shouldn't the laymen, realizing that he is unqualified, go with his physicians recommendation, despite the fact that the physician might be biased? It seems crazy to think I'd get better information by doing a google search.
When confronted with the fact that people trust prestigious institutions, this blog seems overly eager to chalk it up to a desire to affiliate with status rather than simply recognizing that individuals are limited and use prestige as their best metric for quality. Yes, of course I think both phenomena are at work and there are cases where you can experimentally distinguish. But this seems like a case of "when you only have a hammer...".
I would argue that the relevant data are simply not available to consumers, except (as you said) through their doctors' perceptions. Hand-washing is easy to observe but rather trivial next to surgical technique, and available statistics on outcomes are skewed by hospitals accepting different populations of patients.
In this environment, it is rational to rely on the opinion of someone with insider knowledge of the field, or failing that simply choosing based on price, which in this situation means coverage.
Goes for me, too. I had optional hernia surgery, wasted a half-hour calling two hospitals and the surgeon to see what their fees were (the surgeon had never gotten that question before, and had me call my insurance company), and then decided I'd rather go to the one in town than the one an hour away, even though it was at the top end of the price range I saw online.
The comment was from John Thacker at 1:20 this afternoon, I intended to include that attribution, then forgot until I hit the post comment button.
Robin, this is a bit off-topic for this post, but it's the only recent medical economics post I've seen, so here goes: a commenter on Megan McArdle's blog came up with a good question:
That brings up another point: What do the calculations of "percentage of GDP spent on health care" cover? If one system, like the US, has doctors paying high tuition at medical school, which is then passed on to consumers as higher health care costs, but another system has doctors' tuition paid "for free" out of other tax money, do these comparisons count the subsidized doctor education as part of "health care costs?" Or is that slid into "these countries spend more on education and less on health care?" Similarly, if a country decides that it wants to research pharmaceuticals through government research instead of using the profit system, are the taxes used to pay that counted as "health care costs" or as "this country saves on health care costs so it can spend more on science and research?"Maybe you could get some of your students to research it, like Lomborg got his students to examine some of Julian Simon's claims he had doubts about.
Are you sure they weren't communists or Nazis, mentally?
Because patients would still want their doctor to take into account their individual illness. Also, because (as I mention below) patients don't feel capable of interpreting such survey results.
Where do I obtain these objective ratings? Can I trust them? What if one hospital has an overall lower infection rate, but another has more knee replacements resulting in full mobility? How to I measure the trade-off (mortality vs. mobility) when deciding where to get my knee replacement done? What if I don't even know what statistically significant means?
Medicine is so far from being free market that the usual conclusions one might draw on the assumption that it is remain dubious. Lack of something provided is evidence of lack of demand in a largely free market. The shortages of toilet paper in Cuba is not strong evidence that Cubans don't want toilet paper.
Proper nutrition is the first medicine and food is much, much close to being free market, so if your views are correct they are likely to apply.
If subjective doc evals contain useful info about hospital quality, one could survey docs and use that to construct public ratings of hospitals. This would be much better than individual doc evals. So why aren't such survey results available if consumers are eager to get them?
Robin was obviously referring to looking at objective ratings of hospital performance for different treatments/conditions, not making uneducated judgments based on arbitrary criteria.
wasted a half-hour calling two hospitals and the surgeon to see what their fees were
I had similar experiences, and James Donald had a similar experience.
My wife was advised to get a colonoscopy. We shopped around, got a reasonable price at a doctor with a good reputation, negotiated with the insurance company, did all the stuff one does in an environment which actually has prices. Then after the colonoscopy was done, the hospital pulled a huge list of stupendously expensive charges out of their ass, most of which were obviously ridiculous or completely made up out of thin air, just trying it on to see what they could get away with, and all of which were charges we had definitely not agreed to, nor consented to in any way, formal or informal, written or unwritten. They just were not used to doing stuff on the basis that one has a definite price, and that the price one charges affects demand for one’s services. The concept seemed alien and incomprehensible to them. Mentally, they were socialists.
Relying on one's doctor's advice as to hospitals, or a hospital's reputation (record) for care of one's condition isn't the same as being indifferent to hospital quality, is it? Especially since choosing one's doctor for a procedure may dictate what hospital one uses for it.
I suspect most of that 11% of patients were actually just relying on their physician’s claim about a hospital’s record, rather than checking it out for themselves.
Do you really think patients are qualified to assess hospitals on their own? Shouldn't the laymen, realizing that he is unqualified, go with his physicians recommendation, despite the fact that the physician might be biased? It seems crazy to think I'd get better information by doing a google search.
When confronted with the fact that people trust prestigious institutions, this blog seems overly eager to chalk it up to a desire to affiliate with status rather than simply recognizing that individuals are limited and use prestige as their best metric for quality. Yes, of course I think both phenomena are at work and there are cases where you can experimentally distinguish. But this seems like a case of "when you only have a hammer...".
I would argue that the relevant data are simply not available to consumers, except (as you said) through their doctors' perceptions. Hand-washing is easy to observe but rather trivial next to surgical technique, and available statistics on outcomes are skewed by hospitals accepting different populations of patients.
In this environment, it is rational to rely on the opinion of someone with insider knowledge of the field, or failing that simply choosing based on price, which in this situation means coverage.
Goes for me, too. I had optional hernia surgery, wasted a half-hour calling two hospitals and the surgeon to see what their fees were (the surgeon had never gotten that question before, and had me call my insurance company), and then decided I'd rather go to the one in town than the one an hour away, even though it was at the top end of the price range I saw online.