4 ms·

The problem with asking patients to shop based on price is that the penalty for making the wrong choice is much more devastating than with just about any other

The problem with asking patients to shop based on price is that the penalty for making the wrong choice is much more devastating than with just about any other good or service. I did a ton of research when I bought my car, but even then the price of making a sub-optimal decision was limited to a substandard experience or waste of money. When choosing a surgeon, however, the cost of a wrong decision will be perceived to be much higher—shoddy work there could be life-altering/ending. Of course, shoddy workmanship on my car could also have devastating results (and safety was a big part of my decision process, especially since my father might not have died in his car accident if he had side curtain airbags), but it's not considered with the same level of urgency. Also, I'm extremely wary of pricing schemes that disincentivize preventative care and early interventions. Many illnesses are much more treatable—at much lower cost—if they're caught early. While we also need to be careful to avoid unnecessary expense, we don't want to discourage people from seeking care at the early signs of trouble. That being said, I do agree that transparency in healthcare costs is very much needed. However, we need to be careful in considering how market forces impact personal healthcare decisions.

msandford 11y ago
You make some good points regarding quality, but there are a great many things where that doesn't matter. Yes if it's a major medical issue where a life hangs in the balance quality matters tremendously. But a huge range of medical care is about quality of life or other more minor things. I also think that if prices were available to people they might choose the preventative care themselves versus waiting until things are so bad that a major and costly intervention is needed. People talk about externalities as if they're the devil when it comes to climate change, but when it comes to medicine nobody bats an eye. Right now the consequences of people smoking, eating poorly, drinking too much, etc are generally externalities for individuals because either their insurance eats the cost or the public does. I'm not suggesting that people should be forced to bear that cost entirely on their own without insurance, but with no pricing available GPs have one less tool to "scare straight" their patients. I think what's especially galling is that the hospitals do have all the pricing information available in a database that they use to turn patients charts into bills. It's just not published publicly so patients can't make a slightly more informed decision on the front-end, they only see it AFTER care has been provided.
- VLM 11y ago
  > I also think that if prices were available to people they might choose the preventative care themselves versus waiting until things are so bad that a major and costly intervention is needed. Insert analogy with car maintenance here. I'm just not seeing it in practice given the car maint example, although it sounds nice. Clearly, based on the car example, you can't motivate people merely with $$$ or inconvenience or some responsibility guilt trip. I'm thinking pain might work. "The total pain experience of a root canal is Y% vs flossing at a total pain experience of Z% make your choice..." Then again people seem impervious to pain, or impervious to learning from pain. "lets have another kid" "lets go on a fifteen mile hike in brand new boots" "hold my beer and watch this" If $, inconvenience, and guilt trips don't work, and pain also fails, I'm not sure whats left as a possible motivator.
  - msandford 11y ago
    Pain, cost, inconvenience, etc are all marginal motivators even if they don't have the 100% effect on people's behavior that you'd like. Some people are going to be dumb full stop. But for everyone else, giving them more information is probably going to be useful and on the whole, will move things in the right direction. Keep in mind that I said "might" not "definitely will for sure 100%" so that's in line with my above comments re on the margin.
    - VLM 11y ago
      I think our disagreement might fundamentally revolve around you seeing "might" and I'm observing "almost always does not". I'm still interested in the idea of listing and evaluating motivators, so we've listed four of varying opinions of effectiveness, it would be interesting to identify a fifth (or more) of equal or better effectiveness. Thinking of what PR people like to use, there's sex appeal, I suppose that could be used in public service TV commercials as a new fifth strategy. I have no idea how to sell "preventative EKGs are sexy", but I'm no marketing guy, and somehow they sell cars and junk food with sex appeal, so its probably possible to sell EKGs and immunizations and diabetic glucose test screens under the same strategy... somehow. This sounds like such a bad idea, I hesitate to declare it a serious fifth strategy idea.
bmelton 11y ago
There's a balance to be struck, for sure, but cost transparency as an alternative to complete and total cost opacity is a move in the right direction. My daughter fell at lacrosse practice and hurt her wrist. We had an x-ray, which proved inconclusive with the swelling, another x-ray after the swelling subsided, which also resulted in an inconclusive result, followed by an MRI which indicated a bad sprain, for which we ended up getting a very cast-like splint. This is basically the same as what we thought from the initial x-ray, as even then the doctor was advocating for a splint in the absence of an obvious break. If costs were more apparent, we probably would have had an x-ray once, and then gone with the splint, but price opacity and insurance obfuscated the costs enough that we naively opted for the more diagnostic approach, which proved to cost a lot more than just having gone with the splint initially. As a developer, I'm inclined towards the "know what you're fixing before building patches" approach, so the diagnostic approach was logical to me, but had I known that the end result was basically the same either way, I could have saved myself the cost of an x-ray and MRI and just skipped to debugging.
- VLM 11y ago
  If you turned the tables on your "free market" anecdote, what is the market value of that ER doctor or radiologist as a software developer? I'm not even sure how to account for emotions, I'm pretty dispassionate about unit testing frameworks, but if my daughter might be crippled for life I'm fairly certain I wouldn't be a rational market participant. Its highly likely that your trying to practice medicine without a license holds the same market value as a doc trying to be a software dev, that being somewhere between 0 and a modest negative number. You could extend the analogy by taking printouts of the pricing plans for github(tm) and visual source safe(tm) and waving them in front of the er doc to ensure the er doc makes the wisest possible free market decision when selecting a source code repository. This is only a fair analogy if the ER doc knows absolutely nothing about software development other than if he gets the decision wrong his life will be ruined. As a somewhat more neutral analogy, waving prices for github vs VSS in front of my mother quite frankly holds negative value for all participants, its a Potemkin show that merely wastes labor hours. Pretending to provide a market where none can possibly exist is wasting labor time putting on a show. My mom has some skill in real estate law so she should be making decisions in her area of expertise, and software professionals should be making decisions in their areas of expertise. My mom does not walk up to random people on the street and insist they make life changing decisions in minutes about the right legal strategy to provide clear title to real estate or WTF exactly she did before she retired, "well in that county a title search costs $X but title insurance and hoping for the best costs $Y unless we take it to court then it costs $Z..." etc. See you can "make a market" in a campy going-thru-the-motions sense by having a semi-monopoly provider declaring an arbitrary list of prices on a chalkboard then calling that a free market. But making a functioning efficient market is a whole nother kettle of fish that requires a calm rational meeting of equal minds at a similar level of training and education to dispassionately trade interchangeable identical commodities, with the goal of all participants minimizing the spread between price and value. That's pretty much the opposite of good medical care.
greggman 11y ago
I don't understand how paying directly or not has anything to do with choosing a surgeon. Plently of socialized medicine system you get zero choice. Some 1/2 socialized, you still have to pay if you want a choice in surgeon. I'm not against socialized medicine I asking how do you think not having "market forces" fixes the problem you're suggesting
fluidcruft 11y ago
One problem is that medicine is very counter-intuitive in terms of evaluating practitioners. Metrics that consumers think they would want to look at are very deceiving once you start digging into what's really going on. The reality is that often the best doctors work on extremely challenging cases that have both high costs and poor outcomes. Some doctors build practices that filter to select the easy cases (i.e. those with a large mismatch between allowed charges and actual resource needs). This allows them to push discounts do their patients aggressively because of the overall pool of cases they've selected. I haven't seen of any reasonable way of handicapping metrics that actually works, and frankly I would be extremely wary of anyone that claimed to have the answer. Honestly, I have no idea how you go about evaluating this situation as a consumer.
- dredmorbius 11y ago
  There are some attempts to do severity adjustment, though these typically rely on diagnosis codes, which can themselves be gamed. A fairly strong heuristic is simply experience: the number of procedures performed is highly correlated with quality. Facilities often have strongly uniform outcomes determined by senior staff.
protomyth 11y ago
"The problem with asking patients to shop based on price is that the penalty for making the wrong choice is much more devastating than with just about any other good or service." Yet we do it with our sight when choosing laser surgery. I get the feeling that better institutions would win out and care would improve. I think preventative care is a separate issue. The government, instead of passing that horrible bill (and yes, I read every page and cussed at every will be decided later line) could have just subsidized a yearly examination, 2 teeth cleanings, expanded health saving accounts, and attached a "disaster clause" to all insurance where the government picks up any cost for an incident over $100,000 (changes the cost of insurance by providing a cap).
- dublinben 11y ago
  Laser eye surgery is a completely elective procedure. It can't be compared at all to the non-elective procedures that contribute most to healthcare costs.
  - protomyth 11y ago
    You need to correct your vision in some way (glasses, contacts, surgery). It is the surgical variant of the correction. It demonstrates how the market for surgical procedures works when considering pricing. Its all markets, its just who gets to decide on what you value.

msandford 11y ago

You make some good points regarding quality, but there are a great many things where that doesn't matter. Yes if it's a major medical issue where a life hangs in the balance quality matters tremendously. But a huge range of medical care is about quality of life or other more minor things. I also think that if prices were available to people they might choose the preventative care themselves versus waiting until things are so bad that a major and costly intervention is needed. People talk about externalities as if they're the devil when it comes to climate change, but when it comes to medicine nobody bats an eye. Right now the consequences of people smoking, eating poorly, drinking too much, etc are generally externalities for individuals because either their insurance eats the cost or the public does. I'm not suggesting that people should be forced to bear that cost entirely on their own without insurance, but with no pricing available GPs have one less tool to "scare straight" their patients. I think what's especially galling is that the hospitals do have all the pricing information available in a database that they use to turn patients charts into bills. It's just not published publicly so patients can't make a slightly more informed decision on the front-end, they only see it AFTER care has been provided.

VLM 11y ago
> I also think that if prices were available to people they might choose the preventative care themselves versus waiting until things are so bad that a major and costly intervention is needed. Insert analogy with car maintenance here. I'm just not seeing it in practice given the car maint example, although it sounds nice. Clearly, based on the car example, you can't motivate people merely with $$$ or inconvenience or some responsibility guilt trip. I'm thinking pain might work. "The total pain experience of a root canal is Y% vs flossing at a total pain experience of Z% make your choice..." Then again people seem impervious to pain, or impervious to learning from pain. "lets have another kid" "lets go on a fifteen mile hike in brand new boots" "hold my beer and watch this" If $, inconvenience, and guilt trips don't work, and pain also fails, I'm not sure whats left as a possible motivator.
- msandford 11y ago
  Pain, cost, inconvenience, etc are all marginal motivators even if they don't have the 100% effect on people's behavior that you'd like. Some people are going to be dumb full stop. But for everyone else, giving them more information is probably going to be useful and on the whole, will move things in the right direction. Keep in mind that I said "might" not "definitely will for sure 100%" so that's in line with my above comments re on the margin.
  - VLM 11y ago
    I think our disagreement might fundamentally revolve around you seeing "might" and I'm observing "almost always does not". I'm still interested in the idea of listing and evaluating motivators, so we've listed four of varying opinions of effectiveness, it would be interesting to identify a fifth (or more) of equal or better effectiveness. Thinking of what PR people like to use, there's sex appeal, I suppose that could be used in public service TV commercials as a new fifth strategy. I have no idea how to sell "preventative EKGs are sexy", but I'm no marketing guy, and somehow they sell cars and junk food with sex appeal, so its probably possible to sell EKGs and immunizations and diabetic glucose test screens under the same strategy... somehow. This sounds like such a bad idea, I hesitate to declare it a serious fifth strategy idea.

bmelton 11y ago

There's a balance to be struck, for sure, but cost transparency as an alternative to complete and total cost opacity is a move in the right direction. My daughter fell at lacrosse practice and hurt her wrist. We had an x-ray, which proved inconclusive with the swelling, another x-ray after the swelling subsided, which also resulted in an inconclusive result, followed by an MRI which indicated a bad sprain, for which we ended up getting a very cast-like splint. This is basically the same as what we thought from the initial x-ray, as even then the doctor was advocating for a splint in the absence of an obvious break. If costs were more apparent, we probably would have had an x-ray once, and then gone with the splint, but price opacity and insurance obfuscated the costs enough that we naively opted for the more diagnostic approach, which proved to cost a lot more than just having gone with the splint initially. As a developer, I'm inclined towards the "know what you're fixing before building patches" approach, so the diagnostic approach was logical to me, but had I known that the end result was basically the same either way, I could have saved myself the cost of an x-ray and MRI and just skipped to debugging.

VLM 11y ago
If you turned the tables on your "free market" anecdote, what is the market value of that ER doctor or radiologist as a software developer? I'm not even sure how to account for emotions, I'm pretty dispassionate about unit testing frameworks, but if my daughter might be crippled for life I'm fairly certain I wouldn't be a rational market participant. Its highly likely that your trying to practice medicine without a license holds the same market value as a doc trying to be a software dev, that being somewhere between 0 and a modest negative number. You could extend the analogy by taking printouts of the pricing plans for github(tm) and visual source safe(tm) and waving them in front of the er doc to ensure the er doc makes the wisest possible free market decision when selecting a source code repository. This is only a fair analogy if the ER doc knows absolutely nothing about software development other than if he gets the decision wrong his life will be ruined. As a somewhat more neutral analogy, waving prices for github vs VSS in front of my mother quite frankly holds negative value for all participants, its a Potemkin show that merely wastes labor hours. Pretending to provide a market where none can possibly exist is wasting labor time putting on a show. My mom has some skill in real estate law so she should be making decisions in her area of expertise, and software professionals should be making decisions in their areas of expertise. My mom does not walk up to random people on the street and insist they make life changing decisions in minutes about the right legal strategy to provide clear title to real estate or WTF exactly she did before she retired, "well in that county a title search costs $X but title insurance and hoping for the best costs $Y unless we take it to court then it costs $Z..." etc. See you can "make a market" in a campy going-thru-the-motions sense by having a semi-monopoly provider declaring an arbitrary list of prices on a chalkboard then calling that a free market. But making a functioning efficient market is a whole nother kettle of fish that requires a calm rational meeting of equal minds at a similar level of training and education to dispassionately trade interchangeable identical commodities, with the goal of all participants minimizing the spread between price and value. That's pretty much the opposite of good medical care.

greggman 11y ago

I don't understand how paying directly or not has anything to do with choosing a surgeon. Plently of socialized medicine system you get zero choice. Some 1/2 socialized, you still have to pay if you want a choice in surgeon. I'm not against socialized medicine I asking how do you think not having "market forces" fixes the problem you're suggesting

fluidcruft 11y ago

One problem is that medicine is very counter-intuitive in terms of evaluating practitioners. Metrics that consumers think they would want to look at are very deceiving once you start digging into what's really going on. The reality is that often the best doctors work on extremely challenging cases that have both high costs and poor outcomes. Some doctors build practices that filter to select the easy cases (i.e. those with a large mismatch between allowed charges and actual resource needs). This allows them to push discounts do their patients aggressively because of the overall pool of cases they've selected. I haven't seen of any reasonable way of handicapping metrics that actually works, and frankly I would be extremely wary of anyone that claimed to have the answer. Honestly, I have no idea how you go about evaluating this situation as a consumer.

dredmorbius 11y ago
There are some attempts to do severity adjustment, though these typically rely on diagnosis codes, which can themselves be gamed. A fairly strong heuristic is simply experience: the number of procedures performed is highly correlated with quality. Facilities often have strongly uniform outcomes determined by senior staff.

protomyth 11y ago

"The problem with asking patients to shop based on price is that the penalty for making the wrong choice is much more devastating than with just about any other good or service." Yet we do it with our sight when choosing laser surgery. I get the feeling that better institutions would win out and care would improve. I think preventative care is a separate issue. The government, instead of passing that horrible bill (and yes, I read every page and cussed at every will be decided later line) could have just subsidized a yearly examination, 2 teeth cleanings, expanded health saving accounts, and attached a "disaster clause" to all insurance where the government picks up any cost for an incident over $100,000 (changes the cost of insurance by providing a cap).

dublinben 11y ago
Laser eye surgery is a completely elective procedure. It can't be compared at all to the non-elective procedures that contribute most to healthcare costs.
- protomyth 11y ago
  You need to correct your vision in some way (glasses, contacts, surgery). It is the surgical variant of the correction. It demonstrates how the market for surgical procedures works when considering pricing. Its all markets, its just who gets to decide on what you value.