Skin in the Game

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Paul Krugman points out that healthcare “consumers” aren’t really consumers at all in the traditional sense of the word:

Medical care is an area in which crucial decisions — life and death decisions — must be made; yet making those decisions intelligently requires a vast amount of specialized knowledge; and often those decisions must also be made under conditions in which the patient is incapacitated, under severe stress, or needs action immediately, with no time for discussion, let alone comparison shopping.

….The idea that all this can be reduced to money — that doctors are just people selling services to consumers of health care — is, well, sickening. And the prevalence of this kind of language is a sign that something has gone very wrong not just with this discussion, but with our society’s values.

But Niklas Blanchard objects that not all of medicine is practiced under life-and-death circumstances:

The actual truth of the matter is that the bulk of medical spending of the average person does not involve death at all…just nagging, often temporary, quality of life issues. In fact, outpatient care (which includes routine and sick visits to the doctor and same-day hospital visits), drugs and non-durables (which includes things like wheelchairs and other medical supplies), and administration account for ~2/3rds of all medical spending in the US.

This is true, but I think it still underestimates just how much knowledge consumers can bring to bear on medical decisions. Take me. By coincidence, the last few months have been absolutely stuffed with visits to the medical-dental-industrial complex. My doctors keep getting worried about things and insisting that I should have some test or other done. On Monday I’ll have yet another — easily the most disagreeable of the lot — and I fully expect that it will show exactly the same thing as all the others: nothing. This has collectively cost thousands of dollars and annoyed me endlessly, especially since I’ve been certain the entire time that there was nothing wrong with me.

Of course, the fact that I’m certain there’s nothing wrong with me doesn’t mean there’s actually nothing wrong with me. I don’t know squat about medicine, after all, and a few days on the internet isn’t really going to make me any more qualified to decide if I ought to get a followup ultrasound to check out those spots on my gall bladder. None of this has been life and death, and I wasn’t under any special pressure to figure out what to do, but that made no difference. As a practical matter, getting a second opinion would have been more expensive than just having the tests done, and trying to otherwise second guess my doctor would have been pretty stupid.

I think there are plainly some areas where forcing people to think harder about medical care (i.e., asking them to fork over some of their own money) can make sense. But it has to be done smartly, since the impact of foregone medical care is often just higher expenses down the road. As an example, we might very well be better off if we not only didn’t charge copays for statins and blood pressure meds but actually paid people to take them. They’re that cheap and effective, and the bigger problem here isn’t overuse, it’s getting people to take the damn things when they’re told to.

So yes: let’s work on incentives, at both the patient, doctor, hospital, and insurance level. But I don’t think we should kid ourselves into thinking that this will affect two-thirds of medical care. More likely, it’s something like ten or twenty percent. For the rest, like it or not, we just have to follow our doctor’s advice.

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