How patients decide
Kaiser has released a survey showing that most people don’t comparison shop for health care (pdf), which gives Niko Karvounis at Health Beat a chance to explain how sick people make decisions:
In a weird way, it’s actually more efficient to use social networks to help find a doctor than it is a third party ranking system, because the former reflects you as a person to a greater degree than any organization can. Moreover, when many of us look for doctors, we’re sick—and thus probably worried or scared. When emotions run high, we want comfort, and comfort means familiarity, not abstract rankings.
He gets that part right, but along the way manages to paint sick people as ‘tards:
Ultimately, patients’ health care priorities aren’t entirely rational—and so relationships, and not rankings, are important. [...]
In the end, our health care priorities are highly subjective, influenced by emotion, familiarity, and perception
I get what he’s trying to do – argue against the consumerist fantasy of health care – but I’d be grateful if he could do so without impugning the mental capacities of sick people along the way. Yes, these decisions often get made under extraordinary pressure, but that doesn’t make them irrational. Searching through a social network is an entirely rational way to go about finding care, especially if it’s demonstrably more efficient. So what Karvounis means is that these decisions aren’t easily quantifiable, which is not the same as rational.
With one exception – which I’ll get to – I don’t often use these tools, and I consider myself more rational than most patients. Some of this is simply timing. Four years ago when I was hired to my job, I did compare the various health plans offered. Since then the plans haven’t changed much, and I’ve been satisfied with my choice, so I have no reason to comparison shop. On slightly different lines, when I was in the hospital and needed a surgeon’s advice, I didn’t have access to the internet to look up my options.
Another part is location. Shopping for health care is not simply a matter of going to CVS and picking out the Consumer’s Digest “Best Buy” from the shelf. Doctors and facilities can be widely distributed geographically, and that’s an entirely rational factor. In my case, I chose my current gastroenterologisy largely because he was close enough to my work that I could duck out for appointments easily. The hospital where he has privileges is also easily accessible by mass transit from my house, so I don’t have to drive there or back when I’m at my worst. That’s not something captured by most comparison tools, but it’s still entirely rational.
Yet another reason I chose this doctor is that the referrals clerk at my PCP’s office suggested I see him. I had asked for another gastro in the same practice, but the clerk told me that my current doctor was better for Crohn’s disease. (It also makes coordinating care easier if you know your PCP already has a working relationship with a specialist.) Similarly, I’ve found another good way to find or compare surgeons is by asking nurses when I’m in the hospital. They know whose patients recover quickly, and whose suffer needlessly. What else do I need to know?
These are all reasons why I don’t pay attention to health care rankings, but the biggest reason is that nobody else in the system seems to care, either. I don’t see any evidence that doctors, hospitals, or insurers are the least bit influenced by any of these rankings. If they don’t take them seriously, ain’t I fool to?
To get back to that exception I mentioned: two and a half years ago I had surgery. It wasn’t an emergency, but urgent and serious, so I did the research to find out where I could get it done best. As it turned out, the surgeon I knew from my hometown ranked higher than the local surgeon who was insisting on the operation. Also, the former could do my procedure laproscopically, instead of cutting me wide open. Also also, it turned out that my insurer’s own internal comparison tool ranked the hometown hospital at about 80% of the price of my local hospital, and everybody was in-network. Better outcomes, less cost, and familiar hands – this was a win-win-win situation, right?
Wrong. My insurance company fought me for weeks. They had already approved the operation, they just didn’t want me to go home to get it done, for reasons I still don’t understand. I begged, cried, yelled, and called and called and called until I finally convinced them to take their own data seriously. I had to pretend to be wholly irrational to get them to be just a little bit rational.
The experience taught me that these tools are essentially irrelevant to my life as a sick person. I’m still waiting for the study that proves otherwise, but until then I’ll keep making decisions as best I can. Just because wonks and journos don’t understand that process doesn’t mean it’s irrational.
2 Pings