Code Red: Two Economists Examine the U.S. Healthcare System

January 16, 2008

My Right Wrist

Filed under: Competition,Report Cards — David Dranove and Craig Garthwaite (from Oct 11, 2013) @ 9:00 am

David Dranove:

An article in the Sunday Chicago Tribune about hospital report cards reminds me of just how difficult it is for most consumers to shop for high quality medical care.  There is nothing more important than our health and there is abundant evidence that the quality of health care varies widely across providers and is often unacceptably low.  Yet consumers spend far more time shopping around for cell phones and DVD players than they do for hospitals and doctors.

Part of this is what I call “Lake Wobegone Syndrome.”  (You remember Garrison Keillor’s Lake Wobegone, where “men are strong, women are handsome, and all of the children are above average.  Well, we live in a kind of medical care Lake Wobegone, where every patient believes that their provider is above average.  That’s hogwash, of course.)  But part of the problem is that it is virtually impossible to be a well-informed healthcare consumer, even if you tried.  So Illinois wants to join the swelling ranks of private and public sector organizations publishing hospital quality “report cards.”  Unfortunately, the state missed its target date for releasing the rankings.  Even if the state did publish rankings, which were to cover things like surgical mortality and preventable medical errors, I don’t think it would have been very helpful.
It certainly would have done me very little good during my latest encounter with the healthcare system.

You know about my wrist surgery.  I had capsulodesis surgery to repair an old ligament tear.  A bone in the wrist was repositioned and held in place with wrist capsule.  I have had some complications that have caused me great pain and may threaten my long term prognosis.  I don’t know if my provider was at fault, and I wonder if I did my due diligence when I chose him.  Like most patients selecting specialists, I relied on a referral from my primary care physician.  The only “shopping” I did was to learn that the surgeon was trained at top hospitals.

I could not have done much more.  There are no report cards for this procedure.  Even if they were, they probably would have covered things like surgical mortality or preventable medical errors.  The things I would really want to know about – pain, functional status, nerve damage – are not even on report card radar screens.  This is a problem for lots of patients trying to be good shoppers.  Patients seeking the best possible care for joint replacement, asthma, diabetes, even cancer, have little useful information to go by.  Those who bother to search out websites like HealthGrades learn about things like surgical complication rates – stuff that is easy to measure given current documentation, but barely the tip of the quality iceberg.  This is like trying to buy a new car when all you know is the rate at which the transmission breaks down.

Many states are working on improving report cards and most of the presidential candidates are talking the talk as well.  Do they realize how much more needs to be done?  We need to collect so much more data about outcomes, and we also need to collect more data to perform adequate risk adjustment.  Who will collect this data?  How will it be linked across providers so we can relate long term outcomes to the doctors and hospitals that provided the initial care?

But here is the rub.  I would not have needed this surgery or suffered all the subsequent complications if I had been properly diagnosed twelve years ago when I first injured my wrist.  (The doctor told me that I probably had a mild sprain when, in all likelihood, I had a complete ligament tear.)  No one has yet to produce a report card for diagnostic accuracy.  Yet isn’t that at least half of what matters in medicine?  Medicine in the United States has always glamorized surgeons, who in an important sense are nothing more than highly paid mechanics.  The report card movement will let us all down if it does not include the diagnosticians.  I don’t have any good ideas about how to make this happen.

I have heard you warn about a possible race to the bottom if price competition intensifies without commensurate quality competition.  Has my experience left me overly depressed?  Can we have meaningful quality competition?


William White:

You focus attention on a critical issue.  It’s a nice idea to provide consumers with information to allow them to better shop for care.  But what information and how to use it?  I think you make two important points I would like to follow up on.

The first point is that at the level of individual treatments, expect possibly for a few relatively high volume, high risk procedures like open heart surgery, it may not be possible to say very much.  I suspect meaningful data you or I could use to shop for a wrist surgery isn’t going to happen anytime soon, especially where there are extenuating circumstances—e.g. repair of an old injury.  Personally, what I’d like best to know is whether I’m dealing with a delivery organization that has a strong commitment to monitoring and seeking (successfully) to improve it.  However, how to evaluate this clearly isn’t simple.  I’d bet: a) your providers would be the first to say they have a strong commitment to quality improvement; and b) the problems you had never got on their screen.

A second important point is that quality improvement efforts tend to emphasize procedures and not cognitive dimensions of care.  I’d argue there is nothing unique about this.  The focus on procedures runs through the whole system.  A good example is the Medicare RBRVS payment system for physicians.  At least nominally, a long standing goal of the RBRVS has been increasing relative payment for evaluation and management services, including diagnostic evaluation.  But as Paul Ginsburg and Robert Berenson point out in a sobering article in the New England Journal this spring (NEJM 356:12), de facto the tilt of the system over time has been to discourage physicians from practicing in primary care and to encourage a procedurally oriented style of care.  If we are serious about high quality care, we need to fix not just information collecting and reporting systems.  We need to rebalance how we pay for care to make sure evaluation and management get appropriate attention.

3 Comments

  1. David and Will, I could not agree with you more that today’s report cards provide limited help in ranking health care providers on treatment outcomes and aspects of patient satisfaction that we care most about. Sometimes I rely on referrals from my primary care physician to find a specialist to help me out. For conditions that do not need to be treated immediately, I ask advice from friends who have lived in Houston for longer than I have, or I get recommendations from physician researcher colleagues.

    However, I am puzzled as to why report cards are not at least a little better than they appear to be right now. After all, with the evolution of the web, the costs of collecting report card data and analyzing it have fallen dramatically. My health insurer Aetna started trying to survey customers on their experience with health care providers a couple of years ago. I didn’t notice many ratings on the website, so I did not consult it. I just tried checking it a few minutes ago, and the ratings seem to have disappeared. Yet I would be happy to fill out an online survey if Aetna emailed one to me after every visit. I would be curious to know other members’ experience with hospitals and doctors—whether they felt as though their treatment was effective, and whether they were treated in a prompt and respectful fashion.

    At Rice, we had a problem getting students fill out teaching evaluation forms at the end of the semester when we moved to an online system. The registrar’s office then implemented a restriction that students could not view their grades online until they had filled out evaluations on all of their professors. Compliance jumped immediately to almost 100%. Perhaps insurers could introduce a small “carrot” to encourage patients to fill out physician surveys, say, 10 cents per survey, payable in a rebate at the end of the year.

    I also wonder if internet sites such as Yelp.com will help in terms of getting the word around on the quality of healthcare providers. The younger generations are happy to write extensive reviews on their favorite restaurants, bars, hairstylists, and other services. Perhaps as they get older, and more healthcare problems start popping up, they’ll be more apt to post their opinions of providers on public site.

    I hope that we move forward with efforts to encourage report cards on the efficiency of health care providers. Notice that I didn’t say report cards on the “cheapest” providers. What I’d like to know is which hospitals and doctors provide the biggest bang for the buck? Now that’s not easy to define either. But we have huge ranges across hospitals in the costs of providing complex surgery in this country. Much of this is due to differences in how skilled their teams of doctors and nurses are at avoiding complications from surgery, how organized they are in running their operating rooms and following discharge protocols, and how much effort they put into avoiding hospital-acquired infections. Much of this data exists, and presenting it in a public format would be a great way to help insurers and patients shop for better care. Report cards may not be a cure-all, but we certainly can do better in this area.

    Comment by Vivian Ho — January 21, 2008 @ 11:26 am

  2. I think consumer savvy will only change when public education changes. Kids get sex ed in their health class curriculum 3-4 times during the course of middle school and high school. I think sex ed is great and there’s always more to learn in any subject, especially a science / medical one (new protections, new contraceptives, etc) but when do we teach health consumerism?? When do we teach people to understand that it is their responsibility now, in this complex healthcare scenario, to doc-shop, and, more importantly, to keep their doctor on his/her toes. A well informed patient is the best defense against medical neglect such as the type that happened to David when he first hurt his wrist.

    If he’d known about the speed of a sprain heal, he might have noticed this didn’t heal like one. Sure the doctor should have kept the possibility open, but when did this happen? During the managed care era? If doctors rarely say “come back and let me check it again” now, they did even less so a decade ago.

    What will accomplish a major change in quality of medical care? None of us knows, but I venture to guess that web blogs will at least begin to make consumers demand better care. If David could gone onto a blogsite called, say, “mywristhurts” he might have been encouraged to get further testing and care for his injury by others whose serious wrist injury had at first been ignored too.

    I recently researched a legal/health issue for a friend, and the most interesting discussion I could find of her problem was on a blog, and only on a blog. I am one of those skeptics who accept information only from official, academic or agency websites. But honest talk about medical problems is only on blogs.

    Our kids (and all citizens) need to learn how to look up information on reputable websites about their medical condition, how to find a blog of people with the same condition or who have had a similar experience, how to ask the questions they will need to interact with doctors in an informed way to get the answers they need.

    In a way, blogs provide something we’ve never had before. If Dave talked about his injury to enough people he might meet one or two people who could put him in touch with someone else who had a similar problem… the six degrees of separation thing. But now we can get in touch with lots of people with whom we would never have had a chance to get to interact, and learn from each other’s experiences.

    As for what all the politicians are promising…baloney. Bring in the regulators, but also, let the buyers beware, be web savvy, and be wise!

    Comment by Cathy Casriel — February 11, 2008 @ 3:25 pm

  3. Cathy’s comments remind me of an exchange I heard at a conference on consumer directed health plans. One of the panelists was a big CDHP supporter and he had just finished describing how patients would be able to take responsibility for their own medical care. Illinois State Representative Mary Flowers was in the audience and offered this response, “I don’t want to be my doctor…I want my doctor to be my doctor.”

    I don’t think Representative Flowers was trying to avoid responsibility. I think that she was acknowledging the daunting and frightening prospect of trying to sue a few hours on the Internet to substitute for years of medical training and practicing experience. I agree with her.

    There is substantial evidence of a powerful learning curve in medicine. Brand new doctors are far less capable than experience docs. Doctors encountering a set of symptoms for the first time are prone to make many errors. Even my simple wrist pain could have represented many things, with many potential courses of treatment. Imagine if I required surgery or a complex combination of drugs (that might interact with other drugs.)

    Had I had access to blogs, I might have learned that an X-ray might have been helpful, but lots of folks who didn’t need them would probably also clamor for them. And beyond that, then what? I fear that at some point early in the process, we will have to let our doctors be doctors.

    To paraphrase and old saw, a patient who treats himself has a fool for a doctor.

    Comment by David Dranove — March 7, 2008 @ 9:14 am


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