Asking the wrong people
Tuesday, April 28 2009
Ezra Klein posts a rundown of a new Kaiser/NPR poll (.pdf) on health care, from which he concludes:
This, I think, gets back to the need to change the behavior of doctors rather than consumers. 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. But their underlying tendency is to want everything done, no matter the cost, no matter the evidence. A conservative would say that that’s because they don’t feel the cost. If they did, they’d be quicker to demand the evidence. 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.
Though we agree on the politics, Ezra’s a bit off base on what this survey tells us about patients – reason being, this is not a survey of “patients”, but “a nationally representative sample of 1,238 randomly selected respondents”. And that means we can expect only about forty percent of the people surveyed to have a chronic disease, a fact not reflected in the survey itself. The only indicator of potential illness is the chart I grabbed above, counting number of “doctors or other health professionals seen in the last two years”.
Why is this a problem? The picture that emerges from this survey doesn’t reflect a typical “patient”. It reflects an average American, who may or may not be a patient in any meaningful sense. And by meaningful, I mean the sort of person who has an substantial need for ongoing health care. It would be a mistake to draw conclusions as to what patients will do based on what Americans would do; most Americans aren’t patients. And indeed, one of the few charts (see below) that breaks down answers by doctor count shows that intensive users of the system encounter – surprise – more problems.
Why is this important? People with chronic illness – “patients” proper – account for about 75-80% of health care spending. Understanding how patients think about the health care system is a crucial step in health care reform. Yes, in some cases health care decisions get made by worried parents trying to save a sick daughter, but this scenario also presents something of a “ticking time bomb” fallacy. The fact is, a lot of important, expensive health care decisions concern non-fatal, non-urgent chronic illnesses over extended periods of time, in contexts that extend well beyond the hospital walls.
In terms of cost, Ezra is generally right: the people most equipped to make effective decisions about costs are doctors. But he’s still a bit too dismissive of patients’ decision-making on health care; it’s not that patients “offload” these decisions, but that we’re not permitted to make the decisions. Patients should be more skeptical of their doctors, and they should be able to check their doctors’ work, but many doctors resist that sort of active participation from their patients. An adequate version of health care reform might focus solely on the cost problem, but a better – and more effective – version would help equip patients to play a more active role in their care.
This isn’t an endorsement of the sorts of conservative proposals Ezra is arguing against, which in any case aren’t about patient empowerment so much as forcing sick people to bear the burden of their contingent circumstances. But it’s also not an endorsement of Ezra’s view, which seems to be that doctors should be given all the tools and authority to make the important decisions. Instead, I would like to see health care reform that helps patients take better care of themselves, in part by increasing their access to care, but also by increasing their access to evidence and information that might encourage better decision-making. And in the meantime, it might help to see some surveys of what patients – people who need health care – actually think about the system we have.
“How many different doctors and other health professionals have you seen in the past two years?”
Wow, my answer would require much more than 6+ to be an effective representation. Just think about the dentist and dental hygienist – that’s already TWO health professionals. Optometrist. PCP and her nurse. Rheumatologist and her nurse. Neurologist, Nurse Practitioner, and infusion nurse. OT (for RA) and PT (for MS). Podiatrist for custom shoe inserts. MRI technician. Phlembotomist. Mammographer. And the psychologist who helps me manage at times.
Doesn’t sound like too many health professionals, do you think?