teleonomy

I recently read an interesting article from the December 6th (2004) edition of the New Yorker.1 Gawande reports on a trend he'd like to see broaden in the medical community: disclosure of doctors' records.

He does not mean simply their historical background, but he argues for the inclusion of statistical measures of doctors' performance. Although his argument for why this is a good idea seems to be shrugged off2, the existence of a bell curve in medical practice seems to make the case for requiring disclosure fairly self-evident, especially in instances where the doctor or hospital falls on the lower slope of the curve.

But the more interesting issue, which Gawande only hints at, is how patients will use this new information. Hospitals and HMOs will certainly be in a position to expend time and money on the problem of interpreting doctor grades, but for the consumer, this increase in the volume information may turn out to be superfluous in many health care decisions. Patients will be, after medical professionals and institutions, the third major consumers of this new information. How does access to this information affect patient choice, such as it exists in the HMO field?

From the perspective of the HMOs, the ball seems to already be in play.

"Recently, there has been a lot of discussion, for example, about 'paying for quality.' (No one ever says 'docking for mediocrity,' but it amounts to the same thing.) Insurers like Aetna and the Blue Cross-Blue Shield companies are introducing it across the country. Already, Medicare has decided not to pay surgeons for intestinal transplantation operations unless the achieve a predefined success rate."3

If medical insurers are taking this into account, it that would seem to be to consumers' benefit.

But what if the consumer has access to the information directly? What if family members decide that the standards set by an HMO or hospital simply are not high enough? Or will they be willing to settle for a somewhat middling quality in health care?

The question might seem to be answered most simply by economics, with the formulation being something like:

1) What is the quality of care available locally?

2) How does that compare with the highest available care?

3) What is the cost-benefit tradeoff of increasing the quality of care, including things like transportation to better clinics and the cost of more expensive medicines or treatments?

If the question were so straight-forward, we would expect to see a stratification tied to income level. Higher-income consumers would have access to the information, the time to incorporate it, and the extra income to invest in better health-care quality. Lower-income consumers would have less access, time, and money to spend and would therefore be relegated to lower tiers of quality.

However, if patients and their family members have access to the comparative data and know that they cannot afford top quality treatment, what will happen? How will they react, knowing that they are priced out of the best health care? Is this not exactly the problem that Medicare and Medicaid were supposed to fix in the first place?

To complicate this issue, Gawande gives us the interesting example of Honor Page, the mother of a cystic fibrosis patient.

"I asked Honor Page what she would do if, after all her efforts and the efforts of the doctors and nurses at Cincinnati Children's Hospital to insure there 'there was no place better in the world' to receive cystic-fibrosis care, their comparative performance still rated as resoundingly average.
'I can't believe that's possible,' she told me. (...)
After I pressed her, though, she told me, 'I don't think I'd settle for Cincinnati if it remains just average.' Then she thought about it some more. Would she really move Annie away from people who had been so devoted all these years, just because of the numbers? Well, maybe. But at the same time, she wanted me to understand that their effort counted for more than she was able to express."4

The doctor-patient relationship, in this case, has an (inestimable) value, influencing what would seem to be a straight-forward economic decision.

Often, economic formulas fail to take into account the fact that human beings, as a rule, do not follow the wisdom of economics in decision making. This isn't a case of stupidity on either the part of consumers or economists; it is, rather, a misunderstanding of the psychology of decision-making. This is not limited to health-care, either.

"The most widely known fact about George H. W. Bush in the 1992 election was that he hated broccoli. Eighty-six per cent of likely voters in that election knew that the Bushes’ dog’s name was Millie; only fifteen per cent knew that Bush and Clinton both favored the death penalty. It’s not that people know nothing. It’s just that politics is not what they know."5

Christopher Caldwell identifies the underlying problem in another New Yorker piece addressing decision making. "A few decades of research has made it clear that most people are terrible choosers—they don’t know what they want, and the prospect of deciding often causes not just jitters but something like anguish."6

We do not necessarily make political decisions the way John Locke insisted that we should, and an increase in volume of available information through newspapers, twenty-four hour cable news, and blogging has not changed that fact. Why would health care operate any differently? For most healthy people (and Americans, with the exception of the 60% rate of maintaining excessive weight, are overwhelmingly healthy), health-care decisions will be confined to catastrophic circumstance; these circumstances foreshorten the time allowed for making decisions. Digesting relative rates of performance between clinics is not a viable option for people who's relatives need immediate care. For the majority, then, who will most likely only interact with the health-care system under the stress and constraints of traumatic illnesses, economic decision making simply is not an issue. In these instances, it is easy to imagine that economically unquantifiable elements -- such as the comfort-level with the institution, trust in the doctors, and personal investment in the clinic -- will, as Page hinted, play an important role in the decision-making process.

Will consumers then be satisfied settling for average (or even below-average) health care, knowing that they doctors are "good people" who "tried their best"? Possibly. But comparing the relative scores of various surgical teams will probably only benefit those with both high levels of income and long-term health problems. The quality of catastrophic care will still be tied to circumstances of time and location: in other words, luck.