Here’s a thought experiment presented a recent conference on healthcare consumer advocacy. Let’s say that you’re told you need surgery of your knee. It’s an elective surgery to repair a torn knee ligament, the ACL. Your insurance covers part, but not all, of the cost. How do you choose which hospital to go to?
At the moment, there is very little information for you to make such a decision. Many people will choose the hospital they normally go to or that their doctor is affiliated with. For the purposes of this thought experiment, let’s say that the following information is available to you:
- type of hospital (large academic hospital versus small community hospital versus orthopedic specialty hospital)
- number of ACL surgeries per year
- rate of infection and complications
- length of stay
- patient satisfaction
- total cost to system
- total out-of-pocket cost to you
What factors would be most important to you in making your decision?
Healthcare choices are highly personal, and it’s not surprising that participants at the conference came up with widely different answers. Many said that they would rely on recommendations. Citing that user-originated online ratings of hospitals are not yet widespread, they stated that they would ask for feedback from family and friends.
“These are the people I trust, so I trust their judgment and experiences,” several groups said. “If I ask a stranger, their values may be different from mine.”
Some looked at the potential negative consequences.
“Hospital-acquired infections and complications are bad, and I want to avoid those at all costs,” a participant said.
It’s not clear, though, whether data will be granular enough to provide specifics that are helpful in the comparison. What if hospital-acquired infections for the hospital overall are high, but complications for that procedure are low? Are there certain complications that are worse than others—maybe you’d put up with pneumonia, but not if your wrong knee were operated on?
Others tend to value the potential positives. Some like the idea of going to academic centers, which are seen as “better” than community sites; some others like orthopedic specialty hospitals because of their brand-name appeal. A higher number of procedures connotes confidence, as does greater patient satisfaction.
Interestingly, cost was much lower in the decision algorithm. Nobody cited cost to the system as a factor. This was not surprising, but what was surprising was that cost to individual was also not a major factor. As one participant put it, “I don’t want a discount surgeon.” There still seems to be the belief that the more expensive is better, or at least that no expenses should be spared when it comes to health—at least for those middle-class conference participants.
Finally, many would not even make the choice at all. They would go based on the recommendation of their doctor. According to multiple participants, asking their doctor about the possibility of a hospital different from their recommendation was difficulty.
“How do I even go about addressing it?” they asked asked.
This exercise underscores an important realization: in the movement to empower patients, we must keep in mind that healthcare is not transparent, and not a true market. There is a difference between shopping for a TV and shopping for a surgeon. This is not to say that more information isn’t better; it is important for us as patients to get more information so as to make a better decision.
But we must also be cognizant of the type of information that is available. Even in this information age, little is currently available to make a decision of what doctor or which hospital to choose. Ultimately, it will take time to develop trust in a source enough to rely upon it to supplant word of mouth and personal experience.
Leana Wen is an emergency physician who blogs at The Doctor is Listening. She is the co-author of When Doctors Don’t Listen: How to Prevent Misdiagnosis and Unnecessary Tests. She can also be reached on Twitter @drleanawen.
