propaganda

[tim]

So there's a meme going around that it's not doctors or hospitals (you know, the ones who get richer by providing unnecessary care), but rather, patients who are to blame for the rising cost of health care, because they demand too much medical treatment.

Do you think so? Have you ever demanded care that was above and beyond what you needed? Have you known anyone who went out and got health care just for fun?

Or could it be that convincing people to blame themselves is a powerfully politically disempowering tactic?

I'm listening to an NPR program at the moment talking about how things would be better if people would just trust their doctors, who are currently cowed into submission giving patients the unnecessary and potentially harmful care they demand because insurance won't reimburse them for spending extra time explaining to the patients that it's not necessary, and due to fear of malpractice suits.

But why should you trust someone who puts their fear of losing money ahead of your welfare?

Comments

[badasstronaut.livejournal.com]

I'm sure I've said this somewhere recently, but there's a huge problem of GPs prescribing antibiotics unnecessarily because patients apparently demand them, and they just cave because they can't figure out what else to tell them. But the responsibility for prescribing inappropriate phramaceuticals belongs to the prescriber.

[tim]

Exactly! I have no sympathy for someone who swears they'll do no harm and then screws over the patient (and everyone else, when it's antibiotics) because they're too weak to say no.

[asrabkin]

I actually do have some sympathy for them.

First, because there are a lot of doctors out there, and patients will go doctor shopping. So it's easy to rationalize saying "yes" on a gray case when the patient is insistent. And second, because if it was bacterial, and your diagnosis was wrong, and the patient's condition gets sharply worse, the physician can be vulnerable to really serious malpractice and reputation penalties.

In general, people tend to be excessively cautious in avoiding low probability catastrophic risks. We maybe ought to try to restructure the incentives we give physicians to avoid this.

[luinied]

Or could it be that convincing people to blame themselves is a powerfully politically disempowering tactic?

It's not quite blaming themselves, though; it's blaming presumably richer (or at least better insured) people who are acting foolishly and wastefully. Which is really powerful; I'm assuming it's because people who believe in Good Old Republican Values generally aren't allowed to think poorly of those above them, so when a chance comes - be it celebrity heiresses or trial lawyers or whatever - the rage is ridiculously strong.

[wkfauna.livejournal.com]

I read a book about this recently called _Crisis of Abundance_. The thesis was that when monetary incentives are removed from the equation, people and doctors don't make enough of a cost-benefit analysis when deciding what tests or treatments to get. For example, if someone has low back pain and the doctor thinks an MRI may, but is very unlikely to, show something interesting, they may prescribe the MRI if it's covered by insurance but not otherwise (and the patient may demand it or not based on the same considerations). So it's not so much a case of getting patently absurd care, more that if you don't have to pay for it anyway you may be more likely to get care or tests that have a very low chance of helping.

At Microsoft I had an incredible health insurance that basically covered almost everything I could think of ever needing. In a spoof video at work a coworker called it "communist utopia". I know I went to the doctor more often and bought prescription meds that were more expensive and less likely to work than when I had to pay for part of my costs.

[asrabkin]

There's a lot of people who get seen by physicians when a physician's assistant or nurse practitioner would be as well qualified to see them. E.g., sore throats, minor infections, etc. Does that count? As someone below pointed out, there's a lot of test inflation and gratuitous use of antibiotics.

Unfortunately, there are a bunch of other cases where "too much" is in the eye of the beholder. End-of-life care is very expensive. How much is it worth to extend someone's life by six weeks, or to improve their quality of life for a bit before the end? It's hard to measure and hard to even define.

[etb]

There's a lot of people who get seen by physicians when a physician's assistant or nurse practitioner would be as well qualified to see them. E.g., sore throats, minor infections, etc. Does that count?

Sure, if it's in response to patient demands ("I want to see a real doctor"). Otherwise, no: the patient didn't set up the state's health care licensing framework, negotiate contracts and fees, etc. Similarly, one can try to blame patients for going to emergency rooms instead of walk-in clinics, as if people have an innate preference for the former, when it's really that there is no walk-in clinic or it's not open at the right time. (Or you're in Quebec, and the walk-in clinic doesn't accept out-of-province medicare, but the emergency room does.)

[asrabkin]

Lack of cost-sensitivity can be more subtle than "I want a real doctor." The default social assumption in much of the US is that everybody has a primary care physician, and that they go to that physician with routine complaints. If the health insurance plan has that assumption built in, patients have no incentive to go looking for cheaper providers for routine issues.

But I do take your point that often there are real legal barriers to non-physicians dispensing routine medical care.

[anemone.livejournal.com]

patients have no incentive to go looking for cheaper providers for routine issues.

There are also very few providers of cheaper alternatives. I think this is a shame, not just from a cost-saving standpoint, but from a consumer-convenience perspective. I do not want to have to make an appointment with my doctor when I have a sore throat that I think isn't just a cold. I'd like to be able to go to walk-in clinic open at convenient hours.

The other problem is that it's difficult for consumers to make cost decisions, since health care billing is so bizarre.

[asrabkin]

I agree with everything you're saying. Though I suspect there's a circular dependence here. If consumers had stronger incentives to look for non-MD alternatives for things like sore throats, then those alternatives would become more common.

[miang]

Both: convincing people to blame themselves is powerful; but yes, this does happen sometimes. There's a phrase for it at our hospital -- "the pink liquid." As in, parents bring their kid to two or three different GPs/clinics and then two or three different hospitals, because they're dissatisfied with the answer they get ("your kid has a cold, take them home and give them bed rest and soup"). What they WANT is the magic pink liquid that they can give their kid to fix everything, and they're convinced that the doctors are holding out on them. I wouldn't be at all surprised that adults in charge of their own health care do this with much more expensive visits and tests. Consider how entitled (some) people are about everything else in life -- why should medical treatment be any different?

For what it's worth, I also take great issue with the idea that doctors and hospitals are the ones getting rich off the system, but that's a whole separate discussion. AFAIK, most hospitals have non-profit status (ours does) and frequently operate at a loss.

[asrabkin]

Mmm. Many colleges and universities are staggeringly inefficient at delivering education, though they're nonprofits too -- and frequently operate at a loss.

warning, woman talk

[anemone.livejournal.com]

I agree with the general premise that there's lots of unnecessary care, but I wouldn't say it's the consumer's fault.

But I've certainly gotten care I think is unnecessary. I've had two ultrasounds for my current pregnancy. Perhaps the first was justified to date the pregnancy (though the fact that I had a good idea when act that led to conception occurred and two pregnancy tests a week apart, one negative one positive, and it correlated with my cycle-tracking).

The second, which I got because my measured date from ultrasound #1 (which matched my estimated data within a day) was week off the last missed period, was a complete waste of everyone's time and money. I tried to protest, but it became clear that it was just easier for everyone to get the unnecessary ultrasound.

The end of my last pregnancy was filled with pointless tests, too. The high cesarean rate in the US does not benefit women or babies, but does add to our health care costs.

My daughter has had repeated ENT visits recommended by our doctor. Some of these were justified, but not all of them.

Also, some provided in unnecessarily expensive ways that also happen to be inconvenient. An annual quick-check physical should take ten minutes while you're in walmart, not a trip to the doctor and waiting in the room, and blah-de-blah blah. I find it annoying how difficult it can be to get a sore throat checked it. This should be cheaper total cost (post insurance it's cheap enough as it is) and easier.

[juli]

Did they give any information on how to cow doctors into submission? Hasn't been my experience on things where I am right and where it really matters that I am right that it comes easily.

[tim]

Seriously! I've gotten "Did you look that up on the Internet?" with an accompanying sneer, because it's obviously a shameful thing to think for yourself and take responsibility for your own health.

[juli]

Knowledge disempowers the doctor, which is bad for some legitimate reasons, but sneering is probably also a meme handed down from snake oil salesmen and other good nineteenth-century ancestors of the modern western doctor.

[gailg.livejournal.com]

Assuming you were talking about This American Life, I believe the point of the whole program was that there are many causes of high health care costs: patients, doctors, insurance companies, etc. Last week's episode, More is Less (http://www.thislife.org/Radio_Episode.aspx?episode=391), contained segments about doctors, patients, and the insurance industry. It was a really interesting show. This week's episode, Someone Else's Money (http://www.thislife.org/Radio_Episode.aspx?episode=392), which I haven't heard yet, is a deeper look at the insurance agency. Considering that out of two shows, only one part of one hour concerned how patient's are responsible for health care costs, and more than one hour is dedicated to how health insurance companies are responsible, I think it's unfair to imply that the show only blames patients.

[tim]

It was a Think Out Loud program, actually (a show I despise, but I... can't... stop... listening).

[gailg.livejournal.com]

Oh that show! Okay, I apologize. That show gets on my nerves a lot. Occasionally they have an interesting topic and/or interesting guests, but most of the time it's agonizing to listen to. Please consider my post as a recommendation for better shows to listen to on the same subject.