In a great article called The Fallacy of Excellence my old boss and friend Ian Morrison explains what we intuitively know. people don’t understand that more care is not better care. This is going to lead to lots of political problems as we get to righting the Wennberg-illuminated wrongs.
On the other hand, Ian’s lifetime membership in the Paisley Fabian Society will probably be revoked when they find out he’s been watching the Republican candidates debate…..
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Vince, my point is that people can’t even understand enough about cars to work their way through that industry. Isn’t the auto repair industry one of the most complained about, maybe after your cell phone carrier :>). Healthcare is much more complicated and important for the so-called “consumer directed” approach some say will solve what we have now. If you’ve just tuned in you’ll notice I am an advocate of government run, single-pay universal care. That will get us to a better place compared to what we have now but will still allow educating patients about their healthcare decisions. I don’t think we need to be paternalistic, but we need to be realistic about the complex nature of healthcare. A doctor might be able to inform a patient about care alternatives but will the patient really understand enough to make the right decision? I would want as much information as possible but that would just make me feel involved – not necessarily smarter than the doc.
Interesting thread. The premise of Health 2.0 is that better informed patients (and families) will make more thoughtful and healthier decisions, reducing both unnecessary care and unnecessary illness. The parallel theory of consumer directed health plans is that they need a “more skin in the game” incentive to begin paying attention and asking the right questions.
The problem is: will they begin to realize that the incentives and culture of medicine that animate their trusted physicians (and their golfing partners) are not all benign? They are not going to trust the state, the “scientific community” or health plans to tell them what they need. We need a medical equivalent of “Car Talk”, which gently pokes fun at the ripping off (“Now I can buy another boat, etc.”).
Peter,
Let’s back up a bit.
Ian Morrison’s central argument is that we need a national campaign to help people understand that more care isn’t neccessarily better.
I’m supporting his proposition and simply suggesting that analogizing to other everyday consumer decisions would be helpful in simplifying a seemingly complex issue. If you don’t like my car repair analogy, let’s hire a good PR agency to come up with something better.
If I understand the crux of your point, you suggest that car repair is not an area where consumers can make good decisions. Yes?
The logical extension of your point seemingly would be that consumer decisions are so inherently complex and subject to bias that we should just throw in the towel and don’t bother people with decision that they can’t make? …a little paternalistic, eh?
What’s your alternative? Should the “state” make these decisions on behalf of consumers? should we just revert to a socialistic system so that people no longer have to become educated to buy stuff? should doctors just continue to make complex decisions on patients’ behalf?
Educating consumers might be difficult, but that doesn’t lead me to the conclusion that it’s impossible or not worthwhile. I think this should be viewed with shades of gray — consumer decision making can be improved at the margin…and not a black/white issue about whether consumers can or can’t figure out health care purchases.
Vince, how’s this for a closer look at the auto repair industry compared to the health repair industry.
1. Consumers pay about 30% more in labor than is actually done due to the flat rate system. If you doubt my claim try getting a mechanics time sheet for the week and you will find his actual hours worked far less than his paid for booked hours.
2. The oil change industry still markets a 3000 mile oil change interval when new oils and engines can go much farther.
3. The additive industry rakes in millions by marketing mostly useless products with little to no scientific proof as to their real value.
4. Many consumers unknowingly pay for inept mechanics that just perform the R&R approach to solving problems.
5. Most extended warranties are of no value.
6. Can you choose a mechanic any better than you can choose a doctor?
The trick here will be to develop Ian’s suggested “national campaign” in a way that’s understandable to the average person — tricky, but doable.
The best analogy I can think of is one of car maintenance and repair:
* Your car has an owners manual. That manual suggest a list of routine maintence items at specified intervals. Your body also needs routine maintenance at specified intervals.
* When the fix is not routine maintenance, the mechanic should follow the directions in the manufacturers repair manual (akin to following evidence based guidelines)
* Some mechanics will try to sell you more maintenance and repairs than you need…be a wise consumer.
People just need analogies to situations where they already understand that more is not necessarily better.
Americans will have to give up waving the flag every time someone points out weaknesses in, “our system”. Looking inwardly, as we have historically done, won’t cut it any more, whether in foreign policy or healthcare. We need to understand what’s happening across the fence. Ask the auto industry what failure to look past our borders and adapt is like.
But why would Americans not think that more is better in healthcare when their taught that, as consumers, more is always better. We spend more time at Christmas worrying about whether retailers will make their targets than about what Christmas should remind us of what’s really important in life.
What Ian proposes -a “deprogramming” initiative to convince the general public that more expensive care may be lower quality – will require a lot of heavy wonkery- teaching people about Wennberg’s variation work, translating the Rand Corporation data on the spotty adherence to scientific guidelines and the large amount of needless care into 8th grade English, etc. But more than that, the effort will require people to actually believe that the scientific community is not a vast self-serving conspiracy to deprive people of needed care (see the WSJ campaign on access to experimental drugs for an example of the Lou Dobbsian story line).
Trust in the scientific community is in very short supply these days.
Finally, you have to explain to people how healthcare is paid for, and that until VERY recently, hospitals and doctors made a profit cleaning up medical mistakes (because you could either bill private health insurance for the extra services or get “outlier” payments from Medicare), and made big profits by doing stuff that was flat out unnecessary.
Remember that the managed care backlash was about those nasty health plans depriving us of care our doctor (or Aunt Minnie) believed we needed, and that Ian’s propaganda campaign is really about increasing health plan profits (like several prominent commentators on this blog fervently believe). I think most peoples’ belief that more care is better has genetic origins.
Lots of luck, Ian. Write when you get work . . .
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