Leavitt's Dystopian Vision

I feel like David Broder needs to think harder about this:

What I learned about Leavitt in his years as governor is that he is blessed with vision that sees future policy challenges and developments more clearly than most politicians. In this case, he is visualizing a radically different kind of medical marketplace, in which families armed with specific information about the treatment success and prices of hospitals and doctors can shop at will for the best quality and most affordable care.

Maybe there's some situation in which this would be a good thing, but mostly it sounds terrible.

By contrast, here's an anecdote. Some time ago, I noticed that the sole of my foot was incredibly painful to walk on. I took off my shoe and sock and saw some kind of weird grossness bumpy thing down there and could tell that that was the epicenter of the pain. I called my doctor's office describing the problem as best I could and asked for an appointment. I got one about two days in the future (waiting times! even in America!) and hobbled around until then. I went into the office, the doctor looked at my foot, immediately diagnosed it as an abscess and did some incision and drainage and then -- bam! -- it was done. That involved poking me with a sharp object, which seemed like it would be an unpleasant experience, but I trusted that it was the right way to go because he's a doctor and I came to his office to be told what to do with my foot not to do independent research, ask around, start haggling, second-guess everyone, and generally remain in pain while I tried to sort things out according to Magical Market Medicine.

People want to live in a world where, when you have a medical problem, you locate a doctor and that doctor either does what needs doing, or else points you to an appropriate specialist doctor who does what needs doing. Shopping around for gadgets or browsing bookstores is fun for those of us who are into them; others like clothes-shopping or shoes. But nobody wants to shop around for medical treatment. That sucks. Sick people want treatment.

Comments

Typical of a socialist leftist. Being a perfected christian conservative practicing personal responsibility, I shopped around for my cardiac operation installing a pace maker and got a great deal.

Posted by Dick Cheney | October 21, 2007 3:35 PM

From The Dying Earth, by Jack Vance:

"What are your fees?" inquired Guyal cautiously.

"I respond to three questions," stated the augur. "For twenty terces I phrase the answer in clear and actionable language; for ten I use the language of cant, which occasionally admits of ambiguity; for five, I speak a parable which you must interpret as you will, and for one terce, I babble in an unknown tongue."

Posted by James Gary | October 21, 2007 3:57 PM

Indeed you did, Dick!

Posted by sglover | October 21, 2007 3:57 PM

The emergency squad arrives. "Mrs Jones, it looks like your husband has had a stroke. If he gets treatment in the next hour, he might recover fully. What hospital should we take him to? It's your decision. Maybe you'll want to do some internet research and check on prices."

Posted by Bloix | October 21, 2007 4:02 PM

Yes, of course shopping around for a provider is a terrible idea when you're talking about a relatively simple-to-treat acute problem. So let's consider patients with chronic disease(s), who account for about 75% of all health care spending.

When someone has congestive heart failure or asthma or a slow-progressing cancer or diabetes, how is that patient supposed to know where to get the best care? Leave the price issue out of it--let's just focus on how a patient knows which specialists and centers to go to for the best, most effective, most up-to-date care for a complex, lengthy illness. Do you think most primary care doctors take the time to compare quality outcomes for every health care provider in a 20-mile radius (or, god forbid, nationwide) so that they know where to refer their patients for a specific problem?

The problem with those who get rankled when the word "markets" is mentioned with regard to health care is that they assume that all health care is pretty much the same. Providers are pretty much the same. Patients just need access to care, and the care they get will probably be pretty good no matter where they go.

Unfortunately, the bulk of the evidence shows that there are vast differences in quality between providers, both on the organizational and the individual physician levels. Without some sort of mechanism to sort out the information that tracks this quality--like, say, a market in which providers compete to provide value for patients--how are patients supposed to choose the best care? And how are insurers (private or public) supposed to reimburse it?

How do we separate the high-quality from the mediocre providers and reward or punish them accordingly?

Posted by wadeaminute | October 21, 2007 4:06 PM

Indeed, what makes the "shopping around" idea perfectly insane is the presumption that you already have the diagnosis.

But it's an insight into how high on the hog some politicians and commentators are living, that they assume people have large numbers of hospitals and practitioners to choose from, and can pretty much go where they please for medical care. Or that this might be a good thing.

In reality, ending up with three different doctors practicing in three different hospitals is basically a nightmare. Any rational person would take what they're offered as part of a deal to get everything under the same roof. That, in fact, is why people go to 'community hospitals', which really aren't good at anything, but are in the community.

The only people 'shopping around' for good pricing are the Medicare bureaucrats. Everyone else who is 'shopping around' is looking for the best care they can get, regardless of the price. Not a real triumph of market theory.

Posted by serial catowner | October 21, 2007 4:06 PM

But nobody wants to shop around for medical treatment.

Too true. I don't even like to shop around for things I want, when I'm feeling fine. Now I'm supposed to get on the Internet (or whatever) and compare clinics when I think my leg might be broken?

Plus, I really don't understand how (if it's even supposed to be) this comparison shopping stuff is relevant to the problems of insurance. Even if I shop around and find the lowest possible price for a procedure, it's still going to be expensive--I'm going to need insurance to pay for even the "most affordable" hospital bed, surgery, MRI, etc.

I can decide I don't need an iPhone if the price is too high: The Invisible Hand, and all that crap. But appendix surgery is not the same thing as an iPhone.

Posted by &y | October 21, 2007 4:07 PM

Love the Jack Vance reference.

I have another anecdote: Several weeks ago my wife required emergency surgery, out of the blue. I had two days, minus time for freaking out, to find out everything I could about brain tumors and their treatment. Should I have spent that time shopping around? Oddly enough, there is little in the way of public information comparing different surgeons, hospitals, or treatment strategies. So we winged it (at least it feels that way to me), and now she's fine.

(Except for the aftermath of dealing with our insurance company, of course. As of today, they've denied every claim--incorrectly, we think. If nothing changes, though, we're $75,000 in the hole. I don't know how long it will take to work this out, if it does work out, but that's a different topic. I bring it up only because not everyone is lucky enough to have a family to run interference on paperwork.)

Posted by RSA | October 21, 2007 4:10 PM

I dunno, I kinda take pride in paying attention to what's going on with the meat I'm dragging around.

Posted by Senescent | October 21, 2007 4:16 PM

"Leave the price issue out of it--let's just focus on how a patient knows which specialists and centers to go to for the best, most effective, most up-to-date care for a complex, lengthy illness."

That's like going "hey, let's talk about whether or not a war went well, but let's just forget about all of those troop formations and all of that death." Consumers respond to prices in a market relative to market quality. Neither exist in a vacuum and trying to understand a market while ignoring one won't really get you anywhere.

Posted by Reality Man | October 21, 2007 4:16 PM

And obligingly, up steps 'wadeaminute', who starts by saying "leave the price issue out of it" (say, wasn't the price issue the very topic being discussed?) and goes on to demonstrate ignorance of how a primary care doc operates.

Yes, doctors do know who is supposed to be the best, and who costs the most. The average primary care doc uses that knowledge a dozen times a day. For most of their referrals they look at what the patient can afford to pay and what the patient will be charged. If you don't have an unusual problem, and you don't have much money, they will usually suggest that you go to an "average" facility so you won't get bankrupted by fancy treatments you don't need.

'wadeaminute' seems to think doctors are like hardware store clerks, who just give you a big stupid look if what you ask for isn't sold by their own store. It doesn't work that way at all.

Posted by serial catowner | October 21, 2007 4:23 PM

It's funny, according to Adam Smith divisions of labor are the source of the wealth of nations. Yet it comes to health care, Smith's disciples say we should throw the division of labor out the window and have everyone become his or her own actuary and diagnostician. That's the only way a true "free market" in medical care could work, after all, with genuinely "savvy consumers" having the same information as a specialist with over a decade in training.

Posted by Matt Stevens | October 21, 2007 4:35 PM

But what I really wonder is whether all these DC/NYC pundit-types have gotten a lot stupider in recent years...or where they really always this stupid, but none of us noticed as much until sharp young bloggers came along to point this out...

Posted by RKU | October 21, 2007 4:37 PM

Oh, I can answer that one- the pundits for the NYT and the Post (with a few exceptions like Russell Baker) have never been worth reading.

Go back as far as you like, read critically, and you'll find they either employ huge amounts of caveat to fill their column without taking any risk of being 'wrong', or they charge boldly ahead spouting the conventional rightwing 'wisdom' of the day ("Chavez is a thug") without offering any facts to substantiate their claims.

You can save enough time to have a good marriage by never reading them.

Posted by serial catowner | October 21, 2007 4:46 PM

But nobody wants to shop around for medical treatment. That sucks. Sick people want treatment.

That's simply not true, Matt. What is true is that not everybody is comfortable in this role. And it may be equally true that nobody ought to be forced to be a "shopper" for medical treatment. But plenty of folks desire an active role as consumers of healthcare. The system ought to be able to accommodate them, too.

Posted by Jasper | October 21, 2007 4:48 PM

I've tried to do price shopping on medical care. It doesn't work. Hospitals simply do not give out price quotes for their services. The way it works is that you sign paperwork agreeing to pay whatever they want to charge you. And then they charge whatever they think you can afford. There is no way to know what a procedure will cost until you get the bill. So how can I make an informed decision?

Posted by fostert | October 21, 2007 4:48 PM

But what I really wonder is whether all these DC/NYC pundit-types have gotten a lot stupider in recent years...or where they really always this stupid, but none of us noticed as much until sharp young bloggers came along to point this out.

It's OT, but this this wackiness in the national dialog feels like a recent development to me. It's hard to imagine A.M. Rosenthal or Willam Safire writing the kind of half-assed columns that are the stock-in-trade of Broder/Brooks/Friedman et al.

Posted by James Gary | October 21, 2007 4:52 PM

Why, I suppose if you need a nose job or lip enhancement or something - then you do enter a "medical marketplace". Everything else should be done via a health care system; same concept as a justice system or national defense.

Posted by abb1 | October 21, 2007 5:16 PM

Reading the conservative commentary makes it pretty clear they just do not know what they are talking about. Nor are they consistent.

You never hear them saying people should shop for paramedics when they have a heart attack, or that people should shop for policemen when the store is robbed.

When it comes right down to it they are basically hypocrites. I have never met a conservative yet who was not willing, indeed eager, to sign up for Medicare the minute they became eligible. They know, as do the rest of us, that Medicare provides the best care in the world and can never be cancelled.

If socialized medicine is good enough for conservatives when they are most in need of medical care why isn't it good enough for all of us right now?

Posted by ken | October 21, 2007 5:19 PM

Presumably, for things like your foot problem, you do your shopping around for price when you first move into a neighborhood and choose a primary care physician. Once you have the problem, you don't need to shop around because you already have a doctor.

If you become dissatisfied with him/her, then you find another one.

Then whenever you need a referral to a specialist or for special care, you make certain that he knows your preferences (in terms of price, wait times, etc.) and he uses that information when making the referral decision.

If we relied less on third-party payments, this type of thing would become more standardized.

Yes, this will not work for emergency care, but it would likely work on a substantial portion of non-emergency medical care.

Posted by Glaivester | October 21, 2007 5:29 PM

Man, this is an incredibly lame line of argument Matt. There might be good arguments for limiting the amount of choice available to consumers of medical care, but I can't find one in your piece.

First, I take it that the claim of the table is that it would be a good thing for people to have the option of shopping around, haggling, doing consumer research, second-guessing, etc. within a system where exacting minimal standards of care are maintained by a national regulatory agency.

Yet, you seem to be arguing against the claim that it would be good to have a system in which people feel compelled to shop around, haggle, do consumer research, second-guess, etc. even for cases requiring relatively simple treatment for minor ailments.

Unless you are arguing against that straw man, I don't understand your claim that "nobody wants to shop around for medical treatment. That sucks. Sick people want treatment." Of course they don't want this; sick people don't want to have to shop around. But who is advancing that proposal? Perhaps some libertarians who don't want any regulatory apparatus, and want to leave it to consumer demand and competition to drive sub-standard practitioners out of the market. But that is clearly not Broder's position or Leavitt's position.

You are also working with an unduly narrow conception of what "shopping around" involves. It is not always something that only occurs at the actual time of need. Consider car care. If my car dies and I have to work tomorrow, I want to take it right into the shop, and get immediately to whatever work needs to be done without an investigative rigmarole. Similarly, even if my need is not urgent, I also don't want to have to shop around for something routine like an oil change or a new tire. The degree of care necessary doesn't merit the time investment in research.

However, even in those urgent or simple cases, I will usually take my car to a shop that I vetted before and whose reliability I have come to trust. People are always exchanging notes about auto mechanics: which ones seem to have lower prices, work quickly with low labor costs, have late hours, don't hustle you for unneeded extra care, exhibit solid craftsmanship etc. They do the same with doctors. (For people of my parents age, conversations about doctors and their comparative virtues and vices are a very frequent topic of conversation among their peers.)

And when one's car needs major, time-consuming repairs, one commonly does a lot more investigation and shopping around, at the actual time of need, than one does in the simpler cases. I see no reason why people wouldn't be interested in doing the same thing if they need a knee replacement, but don't need it tomorrow.

Medical care being more important than auto care, it is worth it for us as a society to invest in a regulatory apparatus that pre-guarantees a minimal acceptable level of medical care. But that surely doesn't mean that there is no remaining need for consumer choice.

In some sense, nobody "wants" to have to shop around for anything. You say, "people want to live in a world where, when you have a medical problem, you locate a doctor and that doctor either does what needs doing, or else points you to an appropriate specialist doctor who does what needs doing." Sure, people would also like to live in a world in which every practitioner of every practical art is just as good as every other practitioner of the same art, and in which they are all uniformly excellent. But there are limits to our ability to achieve such a world, and do so in an economically efficient way. We are willing to do more in the area of planning and regulation to achieve something approximating that uniformity in the medical world. But the regulation will always be imperfect.

Posted by Dan Kervick | October 21, 2007 5:31 PM

I disagree with Matt Yglegias.

The whole point of a forum like Healing Well is to discuss drugs, surgery, and doctors for chronic diseases.

It's also a form of emotional support, because it feels awfully lonely when a person has an embarrassing chronic disease. Some people don't know if the surgery a doctor is recommending is the final step. Maybe there's a last ditch drug treatment like Remicade (an immuno-suppressant drug which costs thousands of dollars per dose). There are different types of surgery as well.

Also, there are differences between hospitals, and if someone is planning a major surgery, it makes sense to go to a hospital that is the cleanest and most sterile you can afford.

Maybe it's not the case outside Michigan, but here at least, I've seen hospitals with dirty floors, patients with filth on their ventilators, etc. Then you go to a hospital like University of Michigan in Ann Arbor, and it's a world of difference.

Emergency surgery because of car crashes or heart attacks are a different thing entirely.

Posted by stm177 | October 21, 2007 5:40 PM

The easiest way to get a good deal on health care is not by haggling or shopping around but by buying in bulk. When my father was hospitalized a few years ago, his medical bill was $45k. His insurance company settled it with the hospital for $23k. You can imagine that he wasn't going to find a half-price hospital just by shopping around.

Posted by Bo | October 21, 2007 5:41 PM

This is an insane idea. There is a reason medicine is increasingly specialized and that it takes years of training. Lots of the big money stuff like heart attacks, strokes and accidents begin as emergencies where time is vitally important. Now consumer are going to have to learn to make informed decisions about highly technical, emotionally charged issues--oh please.

I am a careful consumer. You should see me shop for a new washer, but really I think that there is a major difficulty with applying market principles to medical care. Maybe that why no other industrialized country in the world even thinks of it. Medicare for everyone.

Posted by Ellen | October 21, 2007 5:42 PM

Dan Kervick gets it exactly backwards. The problem here is that the market does not work to limit the cost of healthcare, because (1) most people are not in a position to comparison shop when they need health care (either because they have acute needs (heart attack, etc), they do not have the intellectual capability to assess the claims of doctors, or the cost of comparison shopping (in time and money) is much higher than the expected utility of such shopping, (2) the current medical funding system provides that doctors will be paid for performing tests and procedures that are medically appropriate, (3) the insurance companies, who are the only gatekeepers in the system, have their own oligopoly, and (4) individual bargaining does not work in an insurance system because of pooling problems (all of the insurance companies would want to insure only the healthy and leave those most in need in the lurch, which is the opposite of what society wants). So, the choices are (1) government run (or mandated) insurance that guarantees universal coverage and has some form of government bargaining to keep costs down, (2) the current system (which is widely acknowledged outside of right wing circles to be disfunctional) or (3) waiving of the hands to presume that enough people actually could and would engage in bargaining to drive costs down. Unsuprisingly, those who hate the use of the government for social betterment, faced with the wide-scale revolt against the current system, have opted for the fantasy of #3.

Posted by ephus | October 21, 2007 5:45 PM

You can't trust the typical physician or hospital to implement best current practice. There's a lot of variation in success/survival rates for things as common as coronary bypasses and if you don't do careful comparisons and decide accordingly, you materially increase your risk of death. You can't even trust the average surgeon to wash his hands properly.

On the other hand, you need to know a lot to do these kinds of investigations and essentially nobody (well under 1 in 100) can do it. In fact, as a corporate body, it's doubtful that the government can, mainly because they have a lot of motives other than just wanting the best answer.

Posted by gcochran | October 21, 2007 5:50 PM

Hmm, Dan, but what about police, firefighters, schools - should you be able (having done your homework) to call the most competent police department around? And what's going to happen when some hospitals have a waiting list for next 5 years while others are empty? There seems to be the same problem here as with the school vouchers.

Posted by abb1 | October 21, 2007 5:57 PM

"You can imagine that he wasn't going to find a half-price hospital just by shopping around."

That's not entirely true. The key is how you shop around. If you want a cheap hospital, you should shop around for a good lawyer. Having legal representation during the negotiations will typically cut your costs in half. My rule is that if I get charged more than $5000, then I will hire a lawyer and negotiate.

Posted by fostert | October 21, 2007 6:01 PM

You morons, don't you know the way to avoid health problems is to work out like Mike Huckabee did? A jog a day keeps the brain tumor away.
Jeez, you libruls.

Posted by Average Joe Sexpack | October 21, 2007 6:24 PM

Here's my contradictory anecdote: Recently my insurance changed, so I had to get a new dentist. I went to one of the five that was covered under my plan. I learned that I had three cavities and for a variety of reasons didn't trust her. One of the worst parts of the experience was that not only would she not explain anything, but she would make all sorts of jargon-y comments about my teeth without explaining what it meant to me. Since the fillings wouldn't be covered by my insurance either way I went back to my old dentist that I liked, told me that I only had two cavities, and then explained what was going on in the third tooth so I could decide if it was worth getting it filled (it wasn't).

Does this mean that I should shop around for a doctor (or prices) every time I get sick? Of course not, that's silly. But it means understanding what the options are and the reason for the diagnosis are very important, and that the initial shopping around for a good doctor is important, too. I read some compelling research a while back that argued that one reason poorer people have worse health is that even if they have access to health care they tend to treat doctors as authority figures, whereas middle class people tend to treat doctors more as intelligent peers so they demand better and more appropriate treatment.

Posted by Kyle | October 21, 2007 6:34 PM

A central fact that's largely being missed here is that people do shop around. Mothers trade stories at the baby pram traffic jam. Say you have a problem, and people offer advice. Conversely, studies regularly show that most people consult a friend, a significant other, or a pharmacist before they actually seek the opinion of a medical professional.

They want to know if the problem is worth the cost of going to a doctor. And part of knowing that is reports from others about whether it 'worked'.

So the problems with the health care system that we talk about are the problems remaining after people have shopped around.

Broder is claiming that putting a nutrition label on the services and a unit-price label on the store shelf will solve our health care problems by making health care affordable.

But that didn't work with groceries. The world's greatest agricultural system still can't feed everyone in the USA.

Why would it work with health care?

Posted by serial catowner | October 21, 2007 6:51 PM

If you become dissatisfied with him/her, then you find another one.

Which is great, because there's usually a two-month wait for new patients at a primary physician. So, if you're dissatisfied with the initial diagnosis or treatment, you get to suck it up.

the problems with the health care system that we talk about are the problems remaining after people have shopped around.

And the problems of self-imposed triage -- looking online, talking to friends and people with similar symptoms -- don't generally get enough publicity, because they're not commercial transactions.

On Dan Kervick's point: the appropriate comparison isn't car repair, where the metrics are fairly simple -- cost of parts and labour, reliability and honesty of shop -- but car purchasing, where things get a lot more complex courtesy of human-lizard hybrids in shiny suits. The sheer opacity of healthcare pricing makes finding a mechanic look like buying a bunch of bananas.

Posted by pseudonymous in nc | October 21, 2007 7:35 PM

"But that didn't work with groceries... Why would it work with health care?"

I don't know what you mean by "worked," but I definitely think that nutrition labels and unit-price labels make me a more imformed grocery shopper, and make it easier to get more value for equal money. No they don't solve every grocery-related problem, but I think they are a definite net plus for those shoppers who make use of them. Those who don't can just ignore them, and experience no change in their shopping experience.

Posted by student worker | October 21, 2007 7:38 PM

If we're arguing on anedcote, I spent a whole lot more of my insurer's money than Matt did. When I learned that I'd need a nephrologist for long-term monitoring, I shopped a fair amount. When I didn't like my first choice, I switched. When it became clear that I'd need a transplant within a year or two, I compared again and decided which of the three nearby hospitals was best. I looked at several diferent "region's best doctors" lists, talked to other patients in a support group, and for the transplant found a list of success rates for the procedure on a web site. (The procedure was a success). I never considered price, because I wasn't paying.

There's alot of evidence that people do shop for doctors. When preschool parents chat, they start talking about pediatricians pretty soon. All of the city glossy magazines devote an issue every year to the best doctors. Major hospitals advertise on local television, especially on shows pitched to the elderly.

Posted by old guy | October 21, 2007 8:15 PM

A water pipe in my house breaks. Horrors! Water everywhere. I need it fixed NOW. Clearly, I don't have time to shop around for a plumber. Market failure! We must create a single-payer National Plumbing Service now.

Posted by Mixner | October 21, 2007 9:01 PM

Well, I just recently found out a) that what I've been suffering from for the last 14 years is (neural) thoracic outlet syndrome, combined with pectoralis minor syndrome. I did this by a) tracking down the best physical therapist I've ever had (WS Liao, [Phd. NY State U.]at National Taiwan University Hospital in Taipei), and asking my current, second best physical therapist (at USC hospital) to email him and ask about the technique he used for the 3 weeks he treated me before handing me over to one of his patients, and b)getting on the internet. I am finally getting better! Part of the reason it took 14 years, of course, was because in the meantime I broke a bone in the same area and took 9 operations to get it fixed right, but the main reason is that all doctors are fucking idiots. Even the ones at Major Teaching Hospitals. Even the ones on Best Doctors lists. Shopping around does no good because every last one of them is a completely worthless piece of shit.

Posted by godoggo | October 21, 2007 9:08 PM

Mixner's apple pies: uncharacteristically filled with nothing but oranges. Obviously, the free market in fuckwit trolls is less than efficient.

Posted by pseudonymous in nc | October 21, 2007 9:09 PM

I love you too, pseudonymous in nc. Anyways, there's a missing "b)" in my first sentence there. Here it is: "b) what to do about it."

That is all.

Posted by godoggo | October 21, 2007 9:16 PM

Oh look, pseudo tried to make an actual argument, for once:

the appropriate comparison isn't car repair, where the metrics are fairly simple -- cost of parts and labour, reliability and honesty of shop --

The metrics of a health care service may be equally simple.

The sheer opacity of healthcare pricing makes finding a mechanic look like buying a bunch of bananas.

That's an argument for greater transparency of pricing, not against a market-based system of supply and demand.

Posted by Mixner | October 21, 2007 9:18 PM

Gee, Mixner, why hasn't the market-based system of supply and demand, in its wisdom and benevolence, provided us with greater transparency of pricing in the health care sector?

Posted by LaFollette Progressive | October 21, 2007 10:12 PM

A water pipe in my house breaks. Horrors! Water everywhere. I need it fixed NOW. Clearly, I don't have time to shop around for a plumber. Market failure! We must create a single-payer National Plumbing Service now.

Funny you mention that, because something similar actually happened to me when I lived in the "Alternate Universe Where Plumbing Operates On The Same Rules As The Present US Healthcare System." You see, the plumber showed up and asked what kind of plumbing insurance I had. I didn't have any because I couldn't afford it, so he fixed the broken pipe and then gave me a bill for half a million dollars--I ended up selling my house to cover the damn bill. That was a big reason why I plane-shifted to this universe, where at least it's only the health-care system that's f*cked up.

Posted by James Gary | October 21, 2007 11:53 PM

The sheer opacity of healthcare pricing makes finding a mechanic look like buying a bunch of bananas.

That's an argument for greater transparency of pricing, not against a market-based system of supply and demand.

Mixner, I long for the day when I get to watch a clown like you haggle with your cardiac surgeon for the cheaper stents, and by the way, how come he isn't using this cool procedure you read about last month in Popular Science anyway? I want to see you drive a hard bargain as your BP bottoms out. Show us how's it's done, hero!

Posted by sglover | October 22, 2007 12:07 AM

market fundamentalism meets cyber-libertarians and the result is the ugliest, stupidist baby in the world......

Posted by nick | October 22, 2007 12:25 AM

Obviously shopping for acute/emergency care makes no sense, so let's follow wadeaminute's post and look at the strongest case for a "choice-based" program. We need to draw a distinction between shopping around for service and shopping around for outcomes.

We don't have the expertise to make judments on particular treatments (second opinions are intended to highlight borderline cases, not to let the patient determine his own course of treatement). This is enshrined in law; that's why I can't prescribe myself drugs, for example. Maybe we want to unlock the system so I can prescribe my own treatment (james fallows, renaissance man, actually wrote a book or an article on this at one point). But in today's world service is not something we get to choose. On this front, choice *as a solution* (as opposed to just a nice thing which is probably cost-neutral) is stupid.

Shopping by outcome is a different matter. As someone who works with statistics, given an intended course of treatment I am at least as capable as most doctors of determining which doctors would be most effective in carrying it out (see oldguy's post above - good for you, oldguy!). In this sense, promoting market drivers almost makes sense. If Republican plans for rewarding informed consumers actually *helped make us better informed about which hospitals were successful treating which problems*, there might be an iota of merit to them. But then we're back to square one. If we actually knew an operation was useless or a doctor was inefficient, who would go there anyway? People aren't getting useless treatments because they're fun...

Where are the unbiased third parties that are going to give us the hospital vs operation mortality ratings? (I'm aware the evidence-based medicine people have made some progress in this direction). And how can we publicize this information without strongly discouraging doctors from taking on challenging cases? These are interesting questions, and prerequisites to choice-based improvement in health care.

Finally, while more careful outcomes-based shopping might lead to better care for those who have insurance, why would it lead to lower costs to those who currently don't have it? That's not clear at all.

In the meantime, why not effin' insure everybody?

Posted by ask2 | October 22, 2007 1:06 AM

ephus and abb1,

It is true that most consumers have imperfect information and minimal expertise in evaluating medical care. The same is true in many other markets for services provided by expert practitioners. That doesn’t mean there is no room for rational comparison shopping. The shoppers just need to apply criteria that they do understand, based on reliable reporting from other consumers or evaluators: information of waiting times, doctor/patient communication, overall customer satisfaction, success rates, etc.

People also don’t all have the same preferences in the area of medical care. Some may prefer no-nonsense speed and efficiency over friendliness and bedside manner, whereas others want a lot of hand-holding and lollipops. Surely these are health care deliverables over which consumers could rationally exercise choice.

Matt alludes to some sort of “dystopia”, but does not make it clear what dystopian scenarios he has in mind. One would infer it has something to do with people being unable to get a foot abscess treated, a broken leg put in a cast or a forehead stitched without going through some complicated shopping process. But that’s silly, and has little to do with the topic of Broder’s editorial. One could have a system in which there is a healthy level of consumer choice, but where people are still know there are various places they can go on a moment’s notice for quality urgent care that meets an acceptable minimum standard.

Matt also suggests that the desirability of consumer choice – i.e. shopping – for some kind of good or service has something to do with whether we find shopping for that good or service “fun” or a nuisance. But this is surely a rather small side issue. We shop because we have limited resources, a variety of options for spending them, and must make rational decisions over how best to spend those resources. We will appreciate having the options – rather than finding the existence of the options regrettable – if we think the existence of these options produces economic benefits, and allows me to satisfy my overall preferences better than I could in a market where there were few choices. I personally dislike most kinds of shopping. But I'm glad I have many purchasing options when there is something I do need to be.

As I said, there may be good reasons for limiting consumer options. For example, the left is generally opposed to vouchers in education. Why? Because they know vouchers would take resources out of public school systems, and create a market for education which is even more in inegalitarian than the education market we have now. In order to build a market for health care that is not wildly inegalitarian, it might be good to limit the options available to individual consumers, and pool resources so that they are controlled by fewer payers. It might be good for individuals and families to cede some of their bargaining power as consumers over to large group payers, who can use their sheer size and their superior information and expertise to push for more quality and lower cost.

But that’s not a reason Matt offered. He seems to be under the impression that people don’t even want choices in health care. In his world, people are apparently big babies filled with doctor-worship, who just want a built-in guarantee of uniform medical awesomeness, so that they can thoughtlessly march on down to the neighborhood medical treatment store and get what they need from some doctor daddy, exercising even less choice than they would over a purchase of a pack of gum.

Posted by Dan Kervick | October 22, 2007 2:49 AM

A water pipe in my house breaks. Horrors! Water everywhere.

Actually, I think this is a good example. If it's really an emergency, i.e. your health or even your life is in danger - then, obviously, you'll call 911. You can't be expected to perform a research and cost/benefit analysis in this situation.

But even if this is not a 911-emergency, remember, every house owner is typically required to have an insurance. So, you'll probably call the plumber who has the largest ad in the phonebook and the house insurance will reimburse you later. That's all there is to it.

Posted by abb1 | October 22, 2007 3:02 AM

Dan, I think there's something to say for not having to worry about researching doctors' credentials and prices when your foot is swollen with abscess. If you agree, then, I think, what follows is that there at least shouldn't be extraordinary differences between doctors' prices and especially their qualifications.

In non-critical situations (cosmetic surgery being probably the most radical example) - I agree, it's nice to have a choice, but I guess this is not what Matt is talking about here.

Posted by abb1 | October 22, 2007 3:23 AM

It's OT, but this this wackiness in the national dialog feels like a recent development to me. It's hard to imagine A.M. Rosenthal or Willam Safire writing the kind of half-assed columns that are the stock-in-trade of Broder/Brooks/Friedman et al.

I don't remember a single column by Rosenthal that didn't sound like the rantings of schizophrenic, and I don't remember any by Safire that didn't read like they weren't intentional disinfo. Look up Safire's crap on Wen Ho Lee if you ever want to see some serious fabrication.

The op-ed gig has been a sweet one for three or four generations of scribes who could crank out text on a deadline. They have always been enormously over-rated, even (especially?) including ol' Walter Lippman, who was maybe the orignal establishment shill of the "American Century". One good thing going on these days is that the op-ed gasbag's days are numbered.

Posted by sglover | October 22, 2007 3:29 AM

S.J. Perelman said it best, "I don't know much about medicine, but I know what I like."

David Broder is a squishy idiot.

Posted by Jeffrey Davis | October 22, 2007 9:23 AM

To the people who think the system should be transparent enough so that I would be able to shop around for the best treatment for chronic deseases (as opposed to emergencies):

Why should I be the one who has to shop around for this information? Wouldn't be my insurance (who is [or better: should be, if the system worked] intersted in bringing the costs down and the quality of care up), which has (or should have) much more expertise in these things than I have, in a much better position to do that? Why can't I contact my insurance so that they could tell me "Well, you have illnes XY, and, according to our data, treatment AB by Doctor CD in EF is the most (cost) effective."?

I guess that if the system worked that way, than the health care market could do wonders on costs.

But if this "shopping around" is too complicated/too much of a burden for insurers, than sure as hell it is for me.

Posted by Patrick | October 22, 2007 11:04 AM

abb1,

Actually, I think this is a good example. If it's really an emergency, i.e. your health or even your life is in danger - then, obviously, you'll call 911.

It's not a health or life emergency. It's an emergency threat to your home.

But even if this is not a 911-emergency, remember, every house owner is typically required to have an insurance. So, you'll probably call the plumber who has the largest ad in the phonebook and the house insurance will reimburse you later. That's all there is to it.

I take it you're a renter, given your strange belief that homeowners' insurance is mandatory. It isn't. So why, again, should health insurance be?

Posted by Mixner | October 22, 2007 9:41 PM

James Gary,
Funny you mention that, because something similar actually happened to me when I lived in the "Alternate Universe Where Plumbing Operates On The Same Rules As The Present US Healthcare System."

In what relevant way are the rules different?

LaFollette,
Gee, Mixner, why hasn't the market-based system of supply and demand, in its wisdom and benevolence, provided us with greater transparency of pricing in the health care sector?

Because there isn't the demand for it.

Posted by Mixner | October 22, 2007 9:46 PM

Mixner, house insurance certainly is mandatory as long as a bank or mortgage company owns any part of the equity. Which is true in a vast majority of cases.

Now, why do you think they make it mandatory? See, even when it's a young, strong, healthy house - its bank will still force it to buy an insurance for itself.

Posted by abb1 | October 23, 2007 9:37 AM