CHOICES
Most patients have limited choices in healthcare today. And the choices they make are not based on data. (So much for fact based decision making.) Even non-urgent choices such as a primary care provider (PCP) are more likely based on personal recommendations of friends and neighbors. And specialist choices stem from PCP recommendations. And hospital choices are dictated by the specialist. Not always, and not entirely, but usually. There is little to no shopping and price doesn’t enter into the decision.
Quality of care--as defined by NQF--is also not a factor, although there are efforts by AHRQ to make data on these indicators more readily available. It is not clear, however, that patients will or can uses this information, and also not clear that the measures actually reflect “quality” from the patient’s perspective.
For the most part, patients assume quality in the sense of expecting the practitioner to be qualified and to deliver care according to current guidelines. They depend on hospitals, state agencies, and accrediting organizations to ensure the quality of practitioners. And to some extent, this works--at least for what Donabedian calls the status aspect of quality. Does the practitioner have the right initials after his name, and are they real? Hospitals generally require physicians on staff to be board certified--and they check. All of this, however, ignores the process and outcome aspects of care.
It has been argued that patients don’t know enough to evaluate the quality of care issue. This is true only for the technical aspects of performance and is both paternalistic and insulting to the intelligence of patients. Besides, there are the service aspects of quality that are not addressed: how long to the next appointment? Is he on time seeing patients? Is the hospital environment clean? Can I find the place? Parking? Does he listen to me? Spend enough time with me?
We all make decisions based on quality and cost. For most things, we can find out the features and costs of competing products or services. This is one reason cars and computers are cheap today. Not true in healthcare. And this is one reason healthcare is so expensive today.
Who would shop for cost in healthcare? Only those who pay for it. Not patients, because we pay only the insurance premiums. HMOs used to approach this, but in a perverse manner. They would first control the patients, and then tell practitioners what they would pay for services. Or tell patients what services they could or could not have. This didn’t work well, and HMOs were forced to retreat to a more traditional insurance role. And costs went up. They were not really shopping for price but dictating price, and that’s an important distinction.
Can you imagine Walmart complaining that they have to have low prices, that customers just won’t pay them a fair price for their goods and services? That’s what healthcare providers said. Walmart aggressively seeks to provide low prices, and they’re proud of it. Have you ever seen a hospital do that? “Have your appendectomy here. Lowest prices in town.” Effective price competition would do this, and healthcare costs would come down. I remember a discussion with a patient in Boston over costs for her breast biopsy. I calculated that she could have taken a taxi 40 miles to a surgery center in Worcester, leave the meter running while she had surgery, and still save almost $2,000. But she didn’t know that and had no way of finding out.
As noted previously, Medicare pays widely different fees for the same procedure within the same geographic area. Suppose, instead, they shopped for price and sent all patients to the lowest cost provider who could provide the desired technical and service quality of care. Do you think others would begin to compete for that business? Would they find ways to provide that care for a lower price?
Quality of care--as defined by NQF--is also not a factor, although there are efforts by AHRQ to make data on these indicators more readily available. It is not clear, however, that patients will or can uses this information, and also not clear that the measures actually reflect “quality” from the patient’s perspective.
For the most part, patients assume quality in the sense of expecting the practitioner to be qualified and to deliver care according to current guidelines. They depend on hospitals, state agencies, and accrediting organizations to ensure the quality of practitioners. And to some extent, this works--at least for what Donabedian calls the status aspect of quality. Does the practitioner have the right initials after his name, and are they real? Hospitals generally require physicians on staff to be board certified--and they check. All of this, however, ignores the process and outcome aspects of care.
It has been argued that patients don’t know enough to evaluate the quality of care issue. This is true only for the technical aspects of performance and is both paternalistic and insulting to the intelligence of patients. Besides, there are the service aspects of quality that are not addressed: how long to the next appointment? Is he on time seeing patients? Is the hospital environment clean? Can I find the place? Parking? Does he listen to me? Spend enough time with me?
We all make decisions based on quality and cost. For most things, we can find out the features and costs of competing products or services. This is one reason cars and computers are cheap today. Not true in healthcare. And this is one reason healthcare is so expensive today.
Who would shop for cost in healthcare? Only those who pay for it. Not patients, because we pay only the insurance premiums. HMOs used to approach this, but in a perverse manner. They would first control the patients, and then tell practitioners what they would pay for services. Or tell patients what services they could or could not have. This didn’t work well, and HMOs were forced to retreat to a more traditional insurance role. And costs went up. They were not really shopping for price but dictating price, and that’s an important distinction.
Can you imagine Walmart complaining that they have to have low prices, that customers just won’t pay them a fair price for their goods and services? That’s what healthcare providers said. Walmart aggressively seeks to provide low prices, and they’re proud of it. Have you ever seen a hospital do that? “Have your appendectomy here. Lowest prices in town.” Effective price competition would do this, and healthcare costs would come down. I remember a discussion with a patient in Boston over costs for her breast biopsy. I calculated that she could have taken a taxi 40 miles to a surgery center in Worcester, leave the meter running while she had surgery, and still save almost $2,000. But she didn’t know that and had no way of finding out.
As noted previously, Medicare pays widely different fees for the same procedure within the same geographic area. Suppose, instead, they shopped for price and sent all patients to the lowest cost provider who could provide the desired technical and service quality of care. Do you think others would begin to compete for that business? Would they find ways to provide that care for a lower price?
