A year and a half ago, I found myself strapped to a backboard in the back of an ambulance, unable to answer a simple question. My car had been totaled by a driver who was too important for red lights, giving me what a yogi would describe as a perfect opportunity to practice “just being”. But then the paramedic riding with me explained that the major trauma hospital was turning away arrivals due to workload, and he wanted to know which of the other two major hospitals they should take me to.
In that moment I realized that I had absolutely no basis for choosing between them. I flashed on recent incidents, one at each hospital, in which a patient was killed through stupid and preventable error (for example, by injection of improperly labeled cleaning fluid instead of MRI contrast agent). And I recalled at least one near-fatal horror story for each hospital from friends and colleagues. I wasn’t thrilled about trusting my life to either, and certainly had no basis for choosing between them. So there I was, in not a little pain and with an ever-so-gradually collapsing lung, at a loss for choice in what is supposed to be a thriving, consumer-choice-enhancing free market for health care services.
Conservatives love to romanticize the free market, and there are plenty of reasons to do so. One of those reasons is consumer choice and another is competition. But, as with everything flowing from the mouths of politicians and pundits, a whole universe of nuance is lost. And in the case of health care choice, there’s one Great Big Glaring lost nuance: information access.
The High, Hidden Cost of Information Hoarding
The one thing conservative pundits fail to mention about our free market is that information, like coffee or diamonds or medicine, is a valuable commodity. Companies tend not to give it away for free, at least not usually, and especially not when it makes them look bad versus the competition. The very information you most want as a consumer is left in private hands to disclose, or bury, as strategy dictates. So, as a consumer, you not only have to pay for goods and services with your time and money, you also have to pay for information with your time and money.
Its the information-hoarding aspect of the current United States market for health services that bothers me. It makes it crystal clear that consumer choice, at least on the big issues, is fairly meaningless. I can choose my doctor, and I can choose my hospital and my insurer, but the basis on which I make those decisions is as shaky and ephemeral as a castle built on quicksand. There is no meaningful comparison or rating by which to choose your doctor, your hospital, or even your insurance benefits (think you know what your benefits are? I’d guess you haven’t suffered a serious illness yet).
I’ve seen the very high-level hospital “scorecards”, which rate hospitals on heart attack survival, for example. But they tell me nothing about hospital’s oncology outcomes, or maternity practices, or their philosophy about flu shots, or the number of false negatives from their testing labs, or the number of preventable, fatal staph infections their patients suffer each year. The one, pitifully inadequate resource for patient choice, aside from anecdote or meaningless local popularity contests (”Seattle’s best surgeon” or “Houston’s best hospital” — best for what??), is the ability to search indeterminately stale public records to see if a disciplinary action has been filed against a doctor. There are a handful of online attempts to provide consumer information (ratemds.com, vitals.com, healthgrades.com, and others), but they are messy, voluntary, and beyond spotty. I have yet to find a rating for a single one of my doctors in any of them.
We have freedom of choice, but choice is meaningless without information, and the information is too costly to obtain. In the case of a new lip-plumping lip gloss, the information about whether it works or not is small: a few bucks and a few days. But in the case of hospital safety or a physician’s judgment, the cost can literally be your health or even your life.
Going Dutch
I was mulling this problem when I came across this fascinating interview with the Dutch health minister in the New York Times. According to the minister, the Dutch government establishes prices for health services, and consumers can choose from among just-shy-of a dozen insurance plans offering a range of basic coverage and a variety of premium options. Because the prices are controlled, the conservative “think” tank The Heritage Foundation would argue that the Dutch have socialized, or nationalized, or centrally-planned health care and that such approaches remove all patient choice. Yet Dutch patients have more insurance options to choose from than I do, and have a better level of service (at least as measured in convenience factors like after-hours consultations) than we have in the US.
Most interestingly, the Dutch government is instituting quality indicators (in other words, a rating system) for hospitals, giving patients a meaningful basis for choice. In other words, the Dutch health minister gets that it’s not just a question of how prices are set. He gets that a free market is not the only way to have competition or meaningful choice. Most importantly of all, he understands that without informed consumers, neither choice nor competition is meaningful or effective. Without access to information, the potential benefits of a “free” market system are just too costly.
I’m not advocating the Dutch system, though it certainly has some positives, and helps the Dutch exceed the U.S. in both healthy life expectancy and avoiding preventable deaths. I am advocating a systematic, centralized information resource for consumers. Since our health services market is a highly regulated hybrid market, why not regulate it a little more, in the direction of meaningful competition and consumer choice? Why not require and enforce detailed reporting by hospitals, clinics, CDC field personnel, and even insurers — and make that information available to consumers? Yes, that would cost money. But so, too, does hiding information about the worst and best service providers. The next time your Senator lectures you on the dangers of stifling the free market, ask him or her about the dangers of stifling outcome-based competition, patient choice, and meaningful reform through information hoarding. Ask him or her about the costs of caveat emptor, or “buyer beware”, in the health care market. The next time your Senator warns that health reform will mean tax hikes, ask your Senator when (s)he intends to cut the hidden tax burden imposed by information hiding.
Go Dutch, for Health
A year and a half ago, I found myself strapped to a backboard in the back of an ambulance, unable to answer a simple question. My car had been totaled by a driver who was too important for red lights, giving me what a yogi would describe as a perfect opportunity to practice “just being”. But then the paramedic riding with me explained that the major trauma hospital was turning away arrivals due to workload, and he wanted to know which of the other two major hospitals they should take me to.
In that moment I realized that I had absolutely no basis for choosing between them. I flashed on recent incidents, one at each hospital, in which a patient was killed through stupid and preventable error (for example, by injection of improperly labeled cleaning fluid instead of MRI contrast agent). And I recalled at least one near-fatal horror story for each hospital from friends and colleagues. I wasn’t thrilled about trusting my life to either, and certainly had no basis for choosing between them. So there I was, in not a little pain and with an ever-so-gradually collapsing lung, at a loss for choice in what is supposed to be a thriving, consumer-choice-enhancing free market for health care services.
Conservatives love to romanticize the free market, and there are plenty of reasons to do so. One of those reasons is consumer choice and another is competition. But, as with everything flowing from the mouths of politicians and pundits, a whole universe of nuance is lost. And in the case of health care choice, there’s one Great Big Glaring lost nuance: information access.
The High, Hidden Cost of Information Hoarding
The one thing conservative pundits fail to mention about our free market is that information, like coffee or diamonds or medicine, is a valuable commodity. Companies tend not to give it away for free, at least not usually, and especially not when it makes them look bad versus the competition. The very information you most want as a consumer is left in private hands to disclose, or bury, as strategy dictates. So, as a consumer, you not only have to pay for goods and services with your time and money, you also have to pay for information with your time and money.
Its the information-hoarding aspect of the current United States market for health services that bothers me. It makes it crystal clear that consumer choice, at least on the big issues, is fairly meaningless. I can choose my doctor, and I can choose my hospital and my insurer, but the basis on which I make those decisions is as shaky and ephemeral as a castle built on quicksand. There is no meaningful comparison or rating by which to choose your doctor, your hospital, or even your insurance benefits (think you know what your benefits are? I’d guess you haven’t suffered a serious illness yet).
I’ve seen the very high-level hospital “scorecards”, which rate hospitals on heart attack survival, for example. But they tell me nothing about hospital’s oncology outcomes, or maternity practices, or their philosophy about flu shots, or the number of false negatives from their testing labs, or the number of preventable, fatal staph infections their patients suffer each year. The one, pitifully inadequate resource for patient choice, aside from anecdote or meaningless local popularity contests (”Seattle’s best surgeon” or “Houston’s best hospital” — best for what??), is the ability to search indeterminately stale public records to see if a disciplinary action has been filed against a doctor. There are a handful of online attempts to provide consumer information (ratemds.com, vitals.com, healthgrades.com, and others), but they are messy, voluntary, and beyond spotty. I have yet to find a rating for a single one of my doctors in any of them.
We have freedom of choice, but choice is meaningless without information, and the information is too costly to obtain. In the case of a new lip-plumping lip gloss, the information about whether it works or not is small: a few bucks and a few days. But in the case of hospital safety or a physician’s judgment, the cost can literally be your health or even your life.
Going Dutch
I was mulling this problem when I came across this fascinating interview with the Dutch health minister in the New York Times. According to the minister, the Dutch government establishes prices for health services, and consumers can choose from among just-shy-of a dozen insurance plans offering a range of basic coverage and a variety of premium options. Because the prices are controlled, the conservative “think” tank The Heritage Foundation would argue that the Dutch have socialized, or nationalized, or centrally-planned health care and that such approaches remove all patient choice. Yet Dutch patients have more insurance options to choose from than I do, and have a better level of service (at least as measured in convenience factors like after-hours consultations) than we have in the US.
Most interestingly, the Dutch government is instituting quality indicators (in other words, a rating system) for hospitals, giving patients a meaningful basis for choice. In other words, the Dutch health minister gets that it’s not just a question of how prices are set. He gets that a free market is not the only way to have competition or meaningful choice. Most importantly of all, he understands that without informed consumers, neither choice nor competition is meaningful or effective. Without access to information, the potential benefits of a “free” market system are just too costly.
I’m not advocating the Dutch system, though it certainly has some positives, and helps the Dutch exceed the U.S. in both healthy life expectancy and avoiding preventable deaths. I am advocating a systematic, centralized information resource for consumers. Since our health services market is a highly regulated hybrid market, why not regulate it a little more, in the direction of meaningful competition and consumer choice? Why not require and enforce detailed reporting by hospitals, clinics, CDC field personnel, and even insurers — and make that information available to consumers? Yes, that would cost money. But so, too, does hiding information about the worst and best service providers. The next time your Senator lectures you on the dangers of stifling the free market, ask him or her about the dangers of stifling outcome-based competition, patient choice, and meaningful reform through information hoarding. Ask him or her about the costs of caveat emptor, or “buyer beware”, in the health care market. The next time your Senator warns that health reform will mean tax hikes, ask your Senator when (s)he intends to cut the hidden tax burden imposed by information hiding.