Choice is Overrated

[DermViser]

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So apparently health care choice is overrated: http://www.nytimes.com/2014/03/06/opinion/in-health-care-choice-is-overrated.html

 

[fuzzytoad]

As you adequately put, the problem is choice.

But we already know what you are going to do, don't we? Already I can see the chain reaction: the chemical precursors that signal the onset of an emotion, designed specifically to overwhelm logic and reason. An emotion that is already blinding you to the simple and obvious truth: she is going to die and there is nothing you can do to stop it. Hope. It is the quintessential human delusion, simultaneously the source of your greatest strength, and your greatest weakness.

Really though, who reads the New York Times?

 

[Psai]

Why do I get the feeling that the people making the rules are selling out their colleagues for their own benefit? The ACA is nothing more than a give-out to insurance companies as can be noted by the fact that it requires everyone to purchase health insurance but does not do much to actually guarantee health care. I mean, it's basically a discount card for purchasing insurance except that high co-pays and deductibles lead to unreasonable out of pocket costs so what's the point? This legislation is supposed to control costs but only ends up obfuscating them, putting another barrier between the patient and the doctor. Anyway, I knew this article would be a joke as soon as I saw that it was published in the New York Times.

 

[fuzzytoad]

Well in theory the ACA reduces consumer-side insurance costs through an economy of scale effect, which is to say that risk is distributed across a greater number of people allowing insurance companies to pay less. There is also an upside (though uncertain in extent) to greater preventative/early care measures that would be possible with universal coverage.

In reality, insurance companies squeeze doctors and supporters of obamacare would rather let the media demonize physicians (despite the fact physician compensation is a minor factor in their overall health costs) than lose their precious reform.

Back on topic, the author of that article is dreaming if they think insurance companies know enough about medicine to
(a) know what "quality care" is or how to measure it
(b) be incentivized to offer better deals for higher quality networks, unless there were market pressure to do so (ie. consumers increased their selectivity and competitors pushed for quality)

The reforms suggested, in principle, are sound. But they do not, I think, reflect what is possible or even feasible without significant institutional reform (ie. reform related to how medicine is practiced, not how people pay for it).

 

[DermViser]

As you adequately put, the problem is choice.

But we already know what you are going to do, don't we? Already I can see the chain reaction: the chemical precursors that signal the onset of an emotion, designed specifically to overwhelm logic and reason. An emotion that is already blinding you to the simple and obvious truth: she is going to die and there is nothing you can do to stop it. Hope. It is the quintessential human delusion, simultaneously the source of your greatest strength, and your greatest weakness.

Really though, who reads the New York Times?

We're obviously not talking about those instances. This is something like cancer - in which only certain hospitals are equipped to handle those type of cases (i.e. availability of clinical trials, doctors who specialize in the disease at hand).
This isn't choosing a resort.

 

[DermViser]

Well in theory the ACA reduces consumer-side insurance costs through an economy of scale effect, which is to say that risk is distributed across a greater number of people allowing insurance companies to pay less. There is also an upside (though uncertain in extent) to greater preventative/early care measures that would be possible with universal coverage.

In reality, insurance companies squeeze doctors and supporters of obamacare would rather let the media demonize physicians (despite the fact physician compensation is a minor factor in their overall health costs) than lose their precious reform.

Back on topic, the author of that article is dreaming if they think insurance companies know enough about medicine to
(a) know what "quality care" is or how to measure it
(b) be incentivized to offer better deals for higher quality networks, unless there were market pressure to do so (ie. consumers increased their selectivity and competitors pushed for quality)

The reforms suggested, in principle, are sound. But they do not, I think, reflect what is possible or even feasible without significant institutional reform (ie. reform related to how medicine is practiced, not how people pay for it).

The "quality physician" for the insurance company would be the one who decreases' its' costs the most. There is a reason that HMO's failed horribly. People realized that HMO doctors were no longer on their side, but on the side of the insurance company. Literally the antithesis of who a doctor should be fighting for.

 

[fuzzytoad]

Haha, I love that my Matrix troll fit enough into this context that you would miss it (or perhaps not a Wachowski Bros fan?). I think we see eye to eye on this though.

In general, quality in medicine is notoriously difficult to quantify. IMO

The "quality physician" for the insurance company would be the one who decreases' its' costs the most. There is a reason that HMO's failed horribly. People realized that HMO doctors were no longer on their side, but on the side of the insurance company. Literally the antithesis of who a doctor should be fighting for.

Agreed. Quality in medicine is notoriously difficult for even doctors to measure. Part of the reason is that there is no clear definition for what quality is. Metrics that matter to patients like "time needed before returning to work", "comfort during stay", "chance of returning complication/related readmission" are eschewed for esoteric statistics regarding the accuracy of tests or, in the best case, umbrella stats like survival rate. Even if these metrics were included in how we think of quality, we would still have to find a way to normalize them to initial severity of conditions (to prevent hospitals from, say, inflating their quality by admitting healthier patients).

But it is important to develop a better system for quality discrimination from a patient POV, if nothing else than to push for a better system through market pressure. Opaque measures of quality create the illusion that there is little or no difference in care between providers, suggesting that choice is, indeed, overrated.

 

[TooMuchResearch]

The "quality physician" for the insurance company would be the one who decreases' its' costs the most. There is a reason that HMO's failed horribly. People realized that HMO doctors were no longer on their side, but on the side of the insurance company. Literally the antithesis of who a doctor should be fighting for.

Then again, the consult happy, test happy community docs don't necessarily have the patients' best interests in mind either.

 

[DermViser]

Then again, the consult happy, test happy community docs don't necessarily have the patients' best interests in mind either.

Yes, but the confounding variable is malpractice lawsuits. Also, it's based on how medicine is practiced these days. What a generalist did several decades ago, is no longer the case - hence more consults.

 

[DermViser]

Haha, I love that my Matrix troll fit enough into this context that you would miss it (or perhaps not a Wachowski Bros fan?). I think we see eye to eye on this though.

In general, quality in medicine is notoriously difficult to quantify. IMO



Agreed. Quality in medicine is notoriously difficult for even doctors to measure. Part of the reason is that there is no clear definition for what quality is. Metrics that matter to patients like "time needed before returning to work", "comfort during stay", "chance of returning complication/related readmission" are eschewed for esoteric statistics regarding the accuracy of tests or, in the best case, umbrella stats like survival rate. Even if these metrics were included in how we think of quality, we would still have to find a way to normalize them to initial severity of conditions (to prevent hospitals from, say, inflating their quality by admitting healthier patients).

But it is important to develop a better system for quality discrimination from a patient POV, if nothing else than to push for a better system through market pressure. Opaque measures of quality create the illusion that there is little or no difference in care between providers, suggesting that choice is, indeed, overrated.

There is a clear difference in your options for cancer care at MD Anderson or Memorial Sloan-Kettering vs. your usual community hospital. In the case of cancer, that decision can affect your life.

 

[fuzzytoad]

Right, but this is a vast minority of cases. In any case the article argues that insurance companies should negotiate with these institutions where expertise unique to its faculty are required.

I'm speaking more generally about the necessity of choice in healthcare as a channel for accountability and a driver for increased value (which first requires that quality is defined).

There's no doubt that insurance related politics should play no role in restricting a patient from care where rare expertise is a decisive factor. But what I think you are suggesting is to extend coverage to all providers (since the alternative would just be to pay the uninsured fee), which simply isn't feasible within the current system.

 

[TooMuchResearch]

Yes, but the confounding variable is malpractice lawsuits. Also, it's based on how medicine is practiced these days. What a generalist did several decades ago, is no longer the case - hence more consults.

Given the basic medical issues that get consulted on in community hospitals, I don't think you can attribute everything to malpractice risk. I see docs look things up in their own specialty in UpToDate before acting on UpToDate's recs because they aren't familiar with a topic, but they are perfectly happy ordering useless tests or consulting ID for CAP. ID consult for CAP for ****** sake.

 

[DermViser]

Given the basic medical issues that get consulted on in community hospitals, I don't think you can attribute everything to malpractice risk. I see docs look things up in their own specialty in UpToDate before acting on UpToDate's recs because they aren't familiar with a topic, but they are perfectly happy ordering useless tests or consulting ID for CAP. ID consult for CAP for ****** sake.

Depending on the patient's risk factors, the drug you look up on UptoDate is not necessarily the drug you should be using. Guidelines are just that...to guide you in your clinical decision making. They aren't protocols. Clinical care is the time to use clinical judgement and experience, which doesn't fit the book that you learn in a medical school Microbiology course.

 

[DokterMom]

Choice is a wonderful thing in a perfect market where information is freely available and consumers are able to make well-informed, rational decisions. Is there anyone here who really thinks healthcare falls into this category?

 

[fuzzytoad]

Choice is a wonderful thing in a perfect market where information is freely available and consumers are able to make well-informed, rational decisions. Is there anyone here who really thinks healthcare falls into this category?

Is this what you learned in econ101? You think people buy cars or houses or hell, just about anything, with perfect information and cognitive clarity? There is no such thing as a perfect market but that doesn't imply that its theoretical properties do not persist in reality. If you had relevant infrmation , you could make an informed decision just the same way you don't need to be an automative engineer to buy a car.

There are certainly reasons why healthcare should not be unregulated, but the absence of a perfect market is not one of them.

 

[TooMuchResearch]

Depending on the patient's risk factors, the drug you look up on UptoDate is not necessarily the drug you should be using. Guidelines are just that...to guide you in your clinical decision making. They aren't protocols. Clinical care is the time to use clinical judgement and experience, which doesn't fit the book that you learn in a medical school Microbiology course.

You either misread or I mistyped.

I see docs using uptodate as their primary clinical judgement tool for complicated things they don't understand in their own specialty while also consulting for very, very simple things.

 

[DokterMom]

Is this what you learned in econ101? You think people buy cars or houses or hell, just about anything, with perfect information and cognitive clarity? There is no such thing as a perfect market but that doesn't imply that its theoretical properties do not persist in reality. If you had relevant infrmation , you could make an informed decision just the same way you don't need to be an automative engineer to buy a car.

There are certainly reasons why healthcare should not be unregulated, but the absence of a perfect market is not one of them.

I'm not suggesting we need 'perfect' information, but some basics like "How much will this cost?" or "How good/bad is this doctor?" would be nice.

 

[DermViser]

I'm not suggesting we need 'perfect' information, but some basics like "How much will this cost?" or "How good/bad is this doctor?" would be nice.

😆😆😆😆

 

[bakedbeans18]

As you adequately put, the problem is choice.

But we already know what you are going to do, don't we? Already I can see the chain reaction: the chemical precursors that signal the onset of an emotion, designed specifically to overwhelm logic and reason. An emotion that is already blinding you to the simple and obvious truth: she is going to die and there is nothing you can do to stop it. Hope. It is the quintessential human delusion, simultaneously the source of your greatest strength, and your greatest weakness.

Really though, who reads the New York Times?

I exclusively read the Miami Herald and Le Monde. Occaisionally I will read Highlights when I'm at the dentist though.

 

[SouthernSurgeon]

Back on topic, the author of that article is dreaming if they think insurance companies know enough about medicine to
(a) know what "quality care" is or how to measure it
(b) be incentivized to offer better deals for higher quality networks, unless there were market pressure to do so (ie. consumers increased their selectivity and competitors pushed for quality)

Have you heard of regional collaboratives? Or accountable care organizations? Or shared savings programs?

 

[fuzzytoad]

Have you heard of regional collaboratives? Or accountable care organizations? Or shared savings programs?

No, but they sound like institutional structures - not anything that has to do with ACA or insurance policy in general. I was specifically referring for the inability for government regulation alone to accomplish these goals (as many people expect the ACA to do), not clever management. I'll look into it.

 

[SouthernSurgeon]

No, but they sound like institutional structures - not anything that has to do with ACA or insurance policy in general. I was specifically referring for the inability for government regulation alone to accomplish these goals (as many people expect the ACA to do), not clever management. I'll look into it.

You expressed skepticism about how insurance companies could measure quality of care of if they even want to, and that they wouldn't be incentivized to offer better deals. I was giving some examples of the innovative things insurers (both public and private) are trying to do in QI and cost savings areas.

 

[fuzzytoad]

I'm skeptical about the idea that insurance companies/government are better regulators of quality than a marketplace with quality indicators relevant to consumers. Are ACO indicators regularly used by customers of insurance/insurance claimants when choosing a policy/provider, or by the government, when allocating subsidies? Are ACOs mainly supported by medicare? What incentive do private insurance companies have for signing on? How often to they update their metrics, and how do they link their metrics with a real improvement in the value (roughly, quality/cost) for patients?

My problem with taking choice out of the equation and applying blanket quality standards (going off the 2013 ACO white paper) across all providers is that markets have consistently demonstrated that giving an informed consumer a range of choices naturally leads to resource allocation with the highest return on investment; that is, the greatest value. Applying broad quality metrics with purely internal relevance only forces providers into stricter policies regarding how they deliver care, regardless of which policies work, which policies work better than others, and which do not. More grievously, it assumes that all providers have some well-defined standard for quality, regardless of the purpose and specialty of the institution. In a world of constrained resources, raising a universal bar is hugely wasteful when certain points of leverage matter more than others.

Obviously, what I just said is incredibly general, but my argument is specifically about the importance of choice in a marketplace - not how healthcare should work in all its gorey detail. That said, I don't claim to be making statements that health care strategy organizations are unaware of, and ACOs certainly seem to mean well. But until I see widespread adoption of these measures and definitive data supporting greater value of care, I'm going to withhold judgement on their effectiveness.

 

[notbobtrustme]

and people wonder why our medical system is 10 kinds of ****ed up.

single-payer, let patients see who they want and let doctors use medical judgement to solve medical problems, not dilly-dally around insurance underwriters and ridiculous quality measures.

 

[DokterMom]

I'm skeptical about the idea that insurance companies/government are better regulators of quality than a marketplace with quality indicators relevant to consumers.

If there were any indicators of quality that consumers had access to, I wouldn't disagree. But IMO, that's one of the fundamental problems with the healthcare business -- There are no such indicators. Consumers can't make informed choices because no information is available.

 

[evilbooyaa]

Are you guys saying that every single cancer patient should get treatment (or at least a secondary consultation) at MD Anderson or MSKCC since all other hospitals or treatment sites clearly have worse outcomes (citation needed)? Especially for something like colon cancer (not a rare diagnosis under any definition of that word)?

Did you guys even read the article?

In the end, the patient with colon cancer was able to get a second opinion at the University of Colorado Cancer Center, where the specialists were in her network. They reassured her that she didn’t need chemotherapy after all. She paid nothing out of pocket. She was lucky, because she was able to see a high-quality specialist despite her plan’s restrictions. But this shouldn’t come down to luck; it should be the basic standard of care.

The title has literally nothing to do with his opinion. He believes that choice SHOULD be incorporated:

Finally, insurance companies — which desperately want to avoid repeating the managed-care backlash — should incorporate a “safety valve” for patients like the mother with colon cancer in Colorado. They should allow any enrollee who develops a serious condition like cancer to obtain a second opinion at a recognized center of excellence (like Memorial Sloan–Kettering, for cancer, or the Cleveland Clinic, for heart disease) for the price of an in-network deductible or co-payment.

He wants insurance companies to allow patients to get a second opinion at MSKCC (if they have cancer) without paying more. Sure, that's not how the current system is, but that would be a step in the right direction, right?

Emmanuel probably sent this in and the NYT changed the article headline (like so many newspapers do) so that it would get more press.

The concept of in or out of network is not a new one. Don't know why everyone is blaming ACA for that old concept.