A couple of thoughts:

Conservatives believe the decision-maker in health care is the consumer. Liberals believe it's the doctor. And so conservative policies try to change consumer behavior. Liberal policies try to change doctor behavior.

The obvious answer is that its both. The problem, of course, is that neither side wants to acknowledge the other in fear of giving up a political advantage, so we're instead left with a relatively non-productive dialogue on health reform. But anyways...

Patients can't easily check their doctor's work.

Agreed. Make that part of health reform. People should be able to "check the work" of their doctors.

Honestly, I'm surprised patients even have an opinion on that.

I'm not. You may be showing your age here-- capitation was a raging hot topic in the 90's. People understand a fixed fee turns the physician from an advocate to something that is somewhat antagonistic between patient and doc.

Patients mainly know to ask for what their doctors tells them to ask for. That's a bit less true in the age of WebMD

Two points.

1. You're understating the change over the last decade, as the internet came on board. There is a big difference between patient knowledge in 1994 and now. Doctors know more, no doubt. But the ratio continues to shrink-- particularly as the amount that a physician knows continues to decline as well, relative to the total amount of medical information that exists (which grows faster than a physician's knowledge).

2. The trend is clearly continuing to move in one direction-- more informed patients. Think 2020-- the Administration's time horizon for reform-- why are we not reforming the system to match a patient's increasing ability to access knowledge themselves?

A liberal would say that people don't worry about cost when they're dealing with their daughter's life. They largely offload decision-making to the doctor, and so the key is that the doctor has appropriate incentives and evidence to help them make wise decisions rather than to enable desperation.

This is somewhat a strawman. You always like thinking about health care purchasing in the acute, life-threatening situation. A lot of health care isn't that. But in all situations-- does the father want their daughter to be seen by a physician or hospital that is high quality? Wouldn't data on whether providers comply with treatment and safety guidelines be extremely important data for that father? That they are experienced in what ailment the daughter has? (See recent article on Mass General closing its pediatric cardiac surgery department, after a few children died. The Boston Children's Hospital nearby does 2,000 surgeries every year, Mass General does around 50. Wouldn't Dad want to know that? Shouldn't he be able to?) Why isn't this part of reform? (Hint: 1) legitimizes "conservative" view of consumer-directed care 2) will piss off doctors. Politicians scared of them).

Either way, one thing worth noting is the degree to which no one in the system currently has an incentive to control costs. Doctors and hospitals pass unlimited costs onto insurers. Insurers pass those costs onto employers. Employers take those costs out of wages. And individuals don't know their missing wage increases are a product of their health care costs. You're never going to control costs if you can't break some portion of this chain.

So this is increasingly dated-- employers aren't passing those costs on solely as wages anymore-- they can't (costs going up too much). So instead larger portions of premiums are now paid by employees and benefit designs are being impacted, which leads to higher deductibles and higher co-pays. Employees all over this country are hearing about the health plan is going up 15%, employers can only put up x%, so the rest needs to be in premium sharing or changes in benefit design that employees will cover. This is why people say they are concerned about health care. Its increasingly wrong to say that the costs are "hidden" and people are unaware. That's less and less true every year. Costs are increasingly an issue, but folks just aren't at the point of taking their medicine-- yet.

Finally, its funny that you posted this right after my comment on the last post. (Had I pointed you towards this poll?) So again, why is the policy easier than the politics? I don't see any clear policy fixes here.

ezra, great post. i have a couple comments to add -

first, is the lack of inclusion of ER costs and the role of ER physicians in any of this. ER docs will be the first to tell you that they perform boatloads of expensive (virtually always) unnecessary tests and procedures. that is not because they are greedy, but because they are performing work on total strangers, with whom they have no history and they want to make sure that they don't get sued. pure and simple.

so revamping malpractice law is a key step in lowering costs. i'm not talking abour torte reform here (something popular with conservatives) but rather a collection of blue sky laws that are developed with the idea of keeping costs down. if Joe the ER Physician performs test A, B, and C on patient that presents X symptoms, but NOT extremely expensive test D (e.g. CT scan), then no matter what the outcome Joe is immune from lawsuit. these laws would have to be developed collectively, and there may be 1 in 10,000 people who have a bad outcome because they didn't get that CT scan. but, until then, we are all going to be paying for the CT scan done on every john doe who shows up at the ER with a tummy ache.

second comment:

A liberal would say that people don't worry about cost when they're dealing with their daughter's life.

a more common scenario is when we're dealing with grandma's life. the amount of healthcare money that is spent on a person in their last few weeks of life is a huge percentage of the total money ever spent. so, if we want to control costs, we, collectively, need to take a hard look at how much money we want to spend on people (in terms of ICU stays, for example) that are not going to survive the hospital visit anyway. it's not a small deal. but everyone wants to feel like they are doing everything they can for their parent/grandparent &c. so we run up bills in futile efforts, bills that again we all end up paying as a society, one way or the other.

Insurers do have a very strong incentive to control costs right now Ezra: their own profit margin. Unfortunately they choose to do so by cherry picking who gets coverage at all and by refusing to pay for treatments that they had promised to cover.

But for now, the public prefers that doctors get paid for each thing they do than on a salary basis

I think you're misreading the question. There's a difference between being paid a yearly amount for a patient's care (capitation) and being paid a salary. Capitation incentivizes the physician to undertreat. Salaries are effectively neutral in regards to treatment decisions.
I think the respondents were answering a question about capitation, not salaries.

Conservatives seem to think that patients should negotiate everything with the doctors -who, after all, are the ones who in the end must prescribe drugs, tests, etc. I've done some of this negotiating with my doctor, and it is not particularly easy. For one thing, doctors are busy and don't like to spend their time haggling with patients.

If I find it difficult when I am relatively well educated and sophisticated about these things, I'm sure there are millions who can't possibly hold their own in such a negotiation. It really is not realistic.

yea what anonymous says. I think that question was worded poorly in the poll.

I can say the average responder thinking. Yea I only want the doctor to get paid when he sees me....Isn't that what my co-pay is for? Why should they pay my doctor a yearly amount when I may not see him this year.

If my doctor prescribes a useless MRI, I have no way of knowing the MRI was useless.

Though if you find out that the doctor was getting a kickback from the MRI clinic, you may have suspicions.

Also, what Virginia said: the problem with wisewon's position isn't just the varying quality of the information available, but the fact that -- like parents who are able to find and move to a better school district -- the quintessential "informed health consumer" is the middle-class person with time and money to play the system.

Ask dumb questions, get useless answers.

1. Asking people for opinions on matters of facts when they are uniformed proves nothing. People have lots of opinions, so what.

2. The health care issue consists of two sectors: those who need expensive care and those who need routine care. Lumping them together distorts things.

The experience of, say, a cancer patient faced with $100K per year chemo-therapy is much different from a person with an aliment that costs $1000, yet both might say that their insurance company gave them a hard time. Obviously the outcome from this refusal is going to be vastly different.

A sensible poll would ask groups about their experiences separately and stay away from speculative questions altogether.

The UK has a system where effectiveness figures into payment and treatment decisions and has had pretty good results from this, but I doubt one in a hundred in the US knows that this exists or how it works. Yet they are free to express an opinion on what sort of oversight panel they favor.

What's the point of such poorly designed polls?

Who do they mean by "my doctor"? Aren't most expensive tests etc. prescribed by specialists? I think of "my doctor" as my primary care doctor.

I have MS, and I have had a couple specialists try to squeeze extra billable testing out of me - successfully, I later decided in 2 cases, but I wasn't in a position to judge at the time.

My insurance company has been quizzing me about this, but I don't want to answer them. Some doctors I trust, some I don't. There need to be guidelines in place, set by people who know what they are doing, and an appropriate system of compensation. Um, duh.

A liberal would say that people don't worry about cost when they're dealing with an uncomming heart bipass even though they are seldom better than let invasive treatment. They largely offload decision-making to the doctor,

the problem with wisewon's position

Given that what Virginia wrote in no way resembles my position, how about humoring me and telling me what you think my position is.

Either that, or read my posts more carefully. All I said here is that information on the quality of care from providers should be available for people to review to help choose their doctors and hospitals. That, along with the fact that patients know more than they did a decade ago, and increasingly seek out information about their health conditions.

So its not clear to me what "problem" you have with my "position."

Conservatives think that patients are in control, liberals think that doctors are. Both positions are correct....to a point.

As a patient, I do have control over certain things--using a generic or even going OTC, really assessing whether I am sick enough to go to the doctors office or to the ER. But in the big scheme of things, this is little spending in the health care world.So I would argue conservatives are right--consumerism works in this small sliver of spending. This would be an argument for not having very rich benefit provisions, especially in those areas where I can be a consumer.

Once I end up in the hospital, or needing some outpatient surgery, all that questioning, all that choice, goes out the door. At that point all you want to do is get better, fast. And you agree to whatever the "system" tells you needs to be done. Here, consumerism fails, and here, having high deductible health plans does not change spending patterns, it just shifts cost. So for these services I would argue for richer benefit provisions.

I do think that the Internet has helped patients become wiser. This seems to be especially borne out in the chronic condition space where you can double check what your doctor is saying rather than just assuming he/she knows everything. But you still do not know if a test is not needed, and you have no idea in many instances if the doctor has a financial interest in the testing facility.

Lastly, it was mentioned above and is very true. Polls in this area are very difficult to decipher what you are really learning.It is one thing to answer a poll, it is yet another to deal with a sick child at 2:00 a.m.

All I said here is that information on the quality of care from providers should be available for people to review to help choose their doctors and hospitals.

What Virginia said is that negotiation and discussion with doctors is difficult even for informed and educated patients.

And all I'm saying is that your fixation on league tables serves the same social demographic that already takes advantage of its time, money and mobility to get their kids into the "right" public schools.

As such, it really doesn't address the big basic problems of access and cost, making it at best a garnish to sell structural reform to those middle-class types who rotisserie-league their lives.

We've also seen an early example of what a little learning (or at least a little data) can do, courtesy of Google Health. (Extended post here.)

I'm not sure how to even respond to this, its so off base.

This directly addresses the waste issue. It forces doctors to practice better medicine, as patients will be looking for doctors who practice it. It leverages Wennberg's findings on quality and cost.

Your viewpoint has an amazing Bush-like ignorant quality to it. I'm looking to to provide information on high quality/low cost care to everyone, as an important tool in health reform. Not the only one. It doesn't address access, for sure. Its only one part of reform. You are arguing that it would be better for people to not know if their doctor practices quality medicine. Its stunningly ignorant. Their is wide recognition that people don't know if their providers are really qualified. There is good literatute, that the Leapfrog Group has publicized, that show there are certain basic indicators that highly predict high quality/low cost medicine. Things like "sufficient volume on procedural cases on an annual basis." In other words, that the doctor sees enough of a given problem that he truly knows what he's doing. You're arguing that it would be better for patients to not know if their doctors are qualified to handle the most important issue in a patient's life. So I'm just stunned. Less information is better for you. Better for patients to continue to go blind. Faith-based medicine I guess. Damn the quality movement-- I guess you know better.

PS I've read your links in the past. This stuff does suck today-- that's the exact reason we need the government involved. It'll take forever to get this right solely in the private sector for a variety of reasons. A coordinating body that looks to ensure the right information is provided to patients is exactly what's needed.

It forces doctors to practice better medicine, as patients will be looking for doctors who practice it.

Aren't you assuming that patients can accurately distinguish between better and worse medicine? If they could do that, what are all the homeopaths and reflexologists etc. doing still in business? To say nothing of the antivaccination movement?

The Internet can spread both information and misinformation and most consumers are ill-equipped to sort them out without professional expertise in the field. Yes, consumers seek out information, but what they find is truth, lies, mistakes, misleading weaseling, and irrelevancies all mixed together.

Chris,

I'll just repeat myself:

This stuff does suck today-- that's the exact reason we need the government involved. It'll take forever to get this right solely in the private sector for a variety of reasons. A coordinating body that looks to ensure the right information is provided to patients is exactly what's needed.

PS Its like this:

www.hospitalcompare.hhs.gov/

But a lot better. Both the website and information provided are pretty poor. But its a first step in the right direction.

Except that like many things in health policy that are "self evident", "volume improves outcomes" is often shown to be untrue. For example, the recent study showing that "centers of excellence" in gastric bypass surgery have a high volume and spend a lot of extra money meeting guidelines... for no better outcome. Or the variety of previous studies that have shown the same point in different types of surgery. The fact is that "quality guidelines" are being pushed into use well before the data support it.

And otherwise I'm amazed that "liberals" don't seem to get basic facts about doctor/patient interaction. The #1 #1 #1 thing people want is the knowledge that the doctor is completely in their corner promoting their interests. Attempting to make the doctor a cost analyzer weighting grandma's needs versus the cost to society is guaranteed to promote a rebellion against any "reform" that includes it. Just like last time.

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