Patients as Consumers in the Market for Medicine: Bedside Manner > Survival Probability

Young and Chen, 2020: Consumer-driven health care is often heralded as a new quality paradigm in medicine. However, patients-as-consumers face difficulties in judging the quality of their medical treatment. With a sample of 3,000 U.S. hospitals, we find that neither medical quality nor patient survival rates have much impact on patient satisfaction with their hospital. In contrast, patients are very sensitive to the “room and board” aspects of care that are highly visible. Quiet rooms have a larger impact on patient satisfaction than medical quality, and communication with nurses affects satisfaction far more than the hospital-level risk of dying. Hospitality experiences create a halo effect of patient goodwill, while medical excellence and patient safety do not. Moreover, when hospitals face greater competition from other hospitals, patient satisfaction is higher but medical quality is lower. Consumer-driven health care creates pressures for hospitals to be more like hotels. These findings lend broader insight into unintended consequences of marketization.

It doesn’t surprise me that consumers respond much more to nice nurses than to survival probabilities. Nice nurses are observable by patients but survival probabilities can only be estimated from sophisticated statistical models. I do wish that patients paid more attention to the outputs of sophisticated statistical models when choosing doctors and hospitals, as I think this would improve quality, but mostly they don’t. As a result, competition increases patient satisfaction but less clearly increases medical quality and medical excellence. The authors, in fact, argue that competition reduces medical quality but that part of their paper is weaker than the former and the bulk of the economic literature indicates that hospital competition also increases quality albeit not strongly and with some mixed results.

Hat tip: Kevin Lewis.


Hospital competition and quality of care. The finding, that they are inversely related, could be the result of (1) the division of the best physicians among the competing hospitals, (2) the segregation of patients among the competing hospitals, with the sickest disproportionately admitted to one hospital, (3) the competing hospitals spending more on what makes patients happy rather than on what makes patients well. My observation: hospitals are hiring physicians as full-time employees, replacing the old model in which physicians were independent contractors. More than 50% of physicians are now employed by hospitals. Does this new model improve the quality of care? I can make an argument that it doesn't. For example, younger, less experienced physicians are more likely to be hired, in part because of the preferred lifestyle of this generation and in part because they demand less compensation. At the other end of the age spectrum, physicians in the twilight of their careers are more likely to choose employment at the hospital as compared to busy physicians in the prime of their careers. We would like to believe that hospitals adopt models and engage in practices that produce the highest quality of care. We would like to believe that. Medical economics is a growing sub-specialty, but much of the work medical economists do is focused on the quantity of care rather than the quality of care, in part because the latter is difficult to measure (as compared to the former).

Do you have any video of that? I'd love to find out more details.

Our daughter is a nurse. While she really likes helping people, she doesn't really like talking to them. So now she works in the operating room, where everyone is safely unconscious. This seems to be working out well for her.

That's funny. Years ago I asked one of my physician clients, an ob/gyn, why he chose that specialty. He responded that he initially was in training for a different specialty but came to realize that he didn't like being around sick people. As an ob/gyn, most of his patients are well, just pregnant.

Years ago, as a *very* young expectant mother, the doctor sent me off to a tour for parents of the hospital floor where we would deliver our babies. "Pregnancy is a state of health!" was their mantra, and accordingly, they had tried to make the surroundings as pleasing and mauve (a color in its end-stage of popularity at that time) and spa-like as possible. [The neo-nates were very nearby as well, though, and there was nothing spa-like about that environment!] They urged us to come back and take childbirth classes. (I did not.) They showed us the showers they'd installed in the birthing rooms, the idea then being current - for all I know, still is - that you might wish to give birth standing up while being doused with water.

A few months later, I showed up on a very cold midnight to give birth. I was gotten into a hospital gown. The nurses assessed me, then told me to dress and go home as it would be some time yet before the birth - I had driven there prematurely, and pregnancy is a state of monstrous good health even in a girl with about as much notion of birthing babies as Prissy. So I returned in the middle of the night to my ill-heated "garage apartment" (so we called it but in fact it *was* the garage, not over it), somewhat disappointed. And then about four or five hours later retraced the route to the hospital, a little more convincingly pregnant, and a couple hours after that, gave birth.

It was all fine, excellent care, efficient nurses and anonymous "Stork" summoned over the PA in place of my doctor who was not available; but I do indeed remember the customer-service aspect of being sent home more clearly than the rest of it.

"where everyone is safely unconscious": towards the end of my last operation I wasn't. I treated them all to some strong language, but only blasphemy, no obscenities. It really was a wee bit sore.

+1, the imitation of what distinguishes this from sight.

Let me tell you about a subject I am pretty enthusiastic about: healthcare. Like you and I, Mike is appalled by the fact America has lower life expectancy and higher infant mortality rates than the other developed countries. It is not right at all. We put men on the Moon and we surely can do better by our countrymen. Mike will:
Create a Medicare-like public insurance option
Improve and expand enrollment in Affordable Care Act plans
Cap health care prices and ban surprise medical bills
Lower drug costs
Protect access to care in rural area
Mike will get it done!

How I think we should all respond to electioneering comments (see second 51 or so):

Are you one of those St. Petersburg trolls pretending to be a Bloomberg supporter?

I don't think there are any St. Petersburg trolls. It is more like a myth, like Biden's electability.

Maybe you prever Bolshevist agitator Senator Sanders.

Boris, is that you?

Trolling for Trump?

I think Thiago is an amateur, who gets his kicks this way. But there are legit concerns

Fake News! Actually it was. Indications that the Russians wanted to influence, but no Trump.

Then came this:

Putin wants Trump in office, sowing discord in the Democratic Party helps to accomplish that.

You might notice that Bernie didn't fire the career analyst who gave him the news and publically call it a hoax. Bernie wont be a useful asset like Trump, but trolling the Democrats certainly makes it more likely Trump will be able to continuing kowtowing to Putin for four more years.

As always, the Fake News Brigade cant see past the moles on their nose.

I don't think the Russian government has any interest in keeping Trump in charge.

Yet, Democ-rats keep insisting on this mad hoopla.

You may recall that we had a mole who saw the papers on Putin's desk in 2016, and plenty of people still refused to believe it after that.

We must sadly downgrade our expectations, and hope that not everyone gets it, but enough people do.

-50 across the board for taking Thiago’s bait

-10 to anonymous for derailing a thread about healthcare to engage in conspiracy mongering

Skeptic tips his hand. The official positions of the US intelligence services are conspiracy theories? Only if you are a Russian agent, or a true Trumpian.

We might be killing ourselves with kindness.

Let me pose this example:

A friend of mine told me how he quit smoking: When he was 17, he told his doctor he had begun smoking.

His doctor grabbed him by the shoulder and began yelling at him. Telling him he would die if he continued, and scaring you know what out of him.

Today, would the doctor have received a high satisfaction score after that interaction? Would the doctor have even dared to do this, even if it were effective?

Perverse incentives matter.

And in an affluent society, keeping good habits (diet, exercise, alcohol, drugs, tobacco, general safety) matter more than choosing a provider.

Any doctor or hospital is providing a last ditch effort.

"...consumers face difficulties in judging the quality of..."

Fill in the blanks. It's pretty much all true for the average consumer. This phenomenon is not limited to the medical market.

I do wish that patients paid more attention to the outputs of sophisticated statistical models when choosing doctors and hospitals

But do we actually have good statistical models of providers and hospitals that properly adjust for patient sickness and demographics? Something like prevention of hospital borne infections seems simple enough to measure, but patient outcomes seems much tougher.

"prevention of hospital borne infections " might be a pretty good proxy for all-round competence.

Prevention of hospital borne infections is an excellent measure. I wonder if when you call your local hospital they will provide that information.

Yes, if the operator or patient relations individual can find it.

More efficiently you can use:

Which reports rates for HAI and other metrics from medicare patients. The data is skewed by the normal stuff: types of care in which the hospital specialized, patient payer mix (Medicaid patients are just more likely to get infections), and demographics (e.g. how many SNIFs and the like escalate patients to this hospital).

A better option than infections, which reflect not just how sloppy your care is but also how aggressive are the bugs coming into the hospital, would be more specific measures like central line infections. Even here if you treat primarily healthy folks with good insurance you are going to have much better results than treating a bunch of homeless Hep C/HIV IVDUs whose immune systems are shot. And of course if you have a large psych-med population numbers will tank.

Let's look at this way: How large is the difference in survivability? And how accurate are those statistics? We think of statistics as hard facts, but we all know they can be games. So if the outcomes aren't that different, who wouldn't prefer spending time with nicer people?

Medicare's numbers typically show a couple of percent difference in 30 day mortality. Something like 9.1% at one hospital verses 12.3% at another is not uncommon. The real question, as always, is who are the hospitals treating. Large academic hospitals typically are treating sicker, poorer patients and have much worse compliance with follow-up. So though they have a 25% greater chance of mortality, I am less worried going to any of the local ones because I know that having only that much excess mortality with their patient populations is insanely good.

There are other datasets that track further out, but the 30 day mortality Medicare one is the most accessible and has a bit more apples to apples comparison going on.

I’ve also seen hospitals play hot potato with dying patients.

On the margin, bedside manners are so bad, while survival is already decent, that they plausibly matter so much more

Bedside manners are so good that the standard rankings bin it based upon did you get a perfect score or did you not. The vast majority of patients report that their physicians are kind, compassionate and caring. Slightly smaller margins apply for nurses and other care givers.

Things I have seen dramatically increase patient satisfaction scores over time are not about the quality of care or even the bedside manner but:
1. Increased nursing ratios, having more nurses per patient makes patients happier that the call button works faster.
2. Private rooms. They are much less efficient for most bog standard care, but patients vastly prefer them.
3. Short stays. Patients will typically accept a couple of days in the hospital, but once they have been there for a while there is a secular trend lowering their satisfaction. Getting patients home quickly, particularly having the staff to manage evening discharges, improves satisfaction.
4. Better food. Almost always less healthy, but better tasting food goes a long way. Having all the standard fast food available for the family also improves scores.
5. Free, no-hassle parking.

Most of the cost drivers in medicine are either because we are more effectively treating diseases in a progressively sicker population or because patients demand them.

Heck, the times I've been in hospitals (as a visitor) I've been amazed at how the staff deprecates quality and quantity of sleep. They simply do not believe (or do not care) that sleep aids in healing.

"Most of the cost drivers in medicine are either because we are more effectively treating diseases in a progressively sicker population or because patients demand them."

So the number one cost in medicine is the patients. Who knew?

Good post.

Competition, obviously, is a good thing.

difference being between noncompetition and antimonopolistic behavior.

At some point acknowledging health care is not an appropriate market-driven good is required.

"Hospitality experiences create a halo effect of patient goodwill, while medical excellence and patient safety do not. ...Consumer-driven health care creates pressures for hospitals to be more like hotels."

The same can be said of colleges and universities: student goodwill generated by less academic rigor and more fun and pampering yields more alumni donations.

Medical care in the US will improve greatly when analysts and policymakers finally acknowledge that NOBODY CARES WHETHER OR NOT IT IS EFFECTIVE. It's all about ritual and appearance. Robin Hanson articulated this very clearly in "The Elephant in the Brain", which I highly recommend.

The best way to make Americans happy is to radically deregulate medicine. If you want to go to an AMA doctor and get evidence-based treatment, that would be your choice. If you want to go to a practitioner of Chinese medicine or voodoo, that would also be your choice. But for the market to really work, consumers would have to accept liability for their choices, and suffer the consequences themselves if they made the wrong one.

My wife is on her 5th $M in HC billings since 1/17, and one major reason I am a recently retired Internist. So having been at her hospital bedside as her primary care doc, 50% of the last 3 years, I have had to deal with the terrors of observing and then having to intervene with her hospital care many times for many potential errors. Over 3 long term hospitalizations at a major tertiary center, her care deteriorated over time. And much of that IMO was due to the inexperience of new hires.
The last admission I constantly asked myself: My god, how do non-medical people deal with this? Or are they just oblivious to this? I think the latter. I am not optimistic.

Scary--and very credible--testimony.

Comment by an airline CEO years ago: "People judge our engine maintenance by how clean the tray tables are. It's just the way it is."

I judge them by how skinny their stewardesses are.

Maybe we should just give people what they value, though.

From the abstract: "However, patients-as-consumers face difficulties in judging the quality of their medical treatment."

This is simple arrogance telling consumers that they don't know (or can't figure out) what they REALLY want, but the authors know better than they do. While assuming consumer ignorance or confusion might be true at times, the better first-approximation explanation is that people simply have different definitions of "quality."

People like to be (or FEEL to be) cared for (e.g. the Hansonian medicine referred to in another comment). Who are we to tell them this is the wrong priority?

Most patients don't know the medical standards of care. So in the hospital they might receive for instance the wrong IV, not the best medication for them or some useless testing. And yet still heal and come out alive.

Must be another Kevin Lewis, as this one is not excellent.

But then, possibly Dr. Tabarrok has no position (or manifesto) on excellence ready to share.

Looks like selection bias.
I get the feeling that deceased patients aren't filling out many satisfaction surveys.

Came here to say the same thing!

"I do wish that patients paid more attention to the outputs of sophisticated statistical models when choosing doctors and hospitals, as I think this would improve quality, but mostly they don’t."

Yeah, sure, dumb patients.

Tell me - how WOULD a prospective patient realistically go about assessing this? Where is the data? What are the controls on the data? Not generalities - specifics! I recently had a colonoscopy - not pleasant. Couldn't really assess the risks (of the procedure) ahead of time to my level of comfort. Didn't even think about how I might go about assessing the (out-patient) facility or the doctor (s?) in question - would have almost certainly be a hopeless undertaking.

Take something that is FAR more uniform - the impact of educational institutions on their student populations. How much does attending Harvard, vs. merely, say, Emory or Univ. of Alabama, improve educational and life outcomes for the typical person who has that choice available to him (i.e. a strong student). It's VERY difficult to disentangle treatment effects (what does Harvard, and the Harvard environment) teach/confer, vs. the population differences between the median Harvard/Emory/Alabama student. Same thing at the K-12 level. Yet the differences here are probably smaller than the differences among hospitals, the data is more public, and the sample sizes larger (at least, against high risk medical treatments).

If you've got concrete advice about how a savvy prospective patient can ACCURATELY choose among prospective providers, let's hear it. If not, then perhaps those patients who at least appreciate being well treated are not total morons.

(FWIW, the "bedside manner" of my outpatient colonoscopy wasn't great. But it was outpatient, and I seem to have come through it with no lasting ill effects of note.)

Diving slightly deeper on my education analogy:

This is a topic of IMMENSE interest to students and parents, also to the educational establishment. There is deep data available, and it's attracted the interests of economists. And yet, for all that, it's pretty hard to come to firm, data-driven conclusions about the value-add of an elite university vs. a near-elite, a state flagship, or something below that.

Parents, and students rely in large part on various secondary/tertiary signals of quality, and, when the cost difference is substantial and finances are constrained, make subjective guesses at the value of the pricier option(s). And this for a field that's subject to a lot of national analysis (Not only kids/parents from Massachusetts are interested in the value of Harvard, but also those from Missouri, Michigan, Montana, and beyond). In a field where folks make mostly local choices (medicine/hospitals), trying to find good data - not easy...

Relatively objective information is available for those willing to look. E.g.

Ask a doctor that you know and respect, and ask who they go to!

That reminds me of Gigerenzer's tale about mass breast cancer screening. German doctors are happy to send patients for that screening. But for themselves or their wives - no. More harm than good comes from it.

I wonder if (and how, and to what extent) this dynamic shapes the kind of advice doctors and nurses -- and maybe others, like lawyers -- give.

Don't doctors and hospitals have some sort of fiduciary responsibility to patients to take account of costs of alternative treatments that pushes back against the demand for more costly services?

Of course not.

The legal standard employed is "standard of care" which means that as a doc you are protected if you do what everyone else is doing. You are free to go off the reservation, but you open yourself up to malpractice claims. Lawyers have, successfully, argued that docs pushing back against costly interventions are liable for adverse outcomes.

The classic example is C-sections. There are a number of cases for which a C-section is absolutely indicated (e.g. placenta previa) and there are a number where they are possibly wise (e.g. fetal distress). If an Ob/Gyn has a marginal case (e.g. concerning decelerations), they cannot be faulted for going back to the OR as everyone else does that. If they opt to discourage a costly treatment, they can be held liable, even for outcomes that had nothing to do with labor. And of course, if you opt to buck consensus, you are absolutely screwed if you made any sort of human error (e.g. misread a tocometer).

Once everyone does it, the law places physician duty solely on the side of following consensus regardless of cost, likely patient outcome, or any other factor. This works most of the time, but if you want docs to aggressively buck business as usual to merely save money you would need a complete rewrite of tort law.

If this is right why is this not mentioned more when discussing increases in health care costs? And this kind of tort reform ought to be pretty easily bi-partisan. You could even put it into an ACA or Medicare/Medicaid funding act.

The mapractice lawyers give heavily to Democrats. Trial lawyers as a whole dumped something like $40 million on Clinton and basically nothing on Trump. They have been funding Democrats aggressively for decades and as they are opportunistic they are very potent for giving to swing seats.

One of the most famous practitioners of this sort of flim flam was John Edwards, also known as the 2004 Democratic vice-presidential nominee. Which again, makes it hard to completely undercut this sort of business when they are, personally, power brokers within the Democratic party.

So we are stuck with Republicans. Taking on this sort of Tort reform is basically a no-win for them. Physicians do not actually get hurt by having a "standard of care" bar to clear. We get paid the same regardless. There is no groundswell among docs to change this because the vast majority are safely ensconced in a system that does them no personal harm.

Instead the real beneficiaries would be the malpractice insurers. Republicans changing the law so that insurers save money? Yeah that has all the lift of a lead balloon. As long as Democrats can successfully tar the Republicans as shills for insurance on this, the whole idea is DOA.

Instead Republicans talk about sky high pain and suffering awards because those poll better. There the message is simple and broadly popular. Having to get into the weeds about which metrication rule to use in court cases in hopes of changing prescribing patterns? Way to far into the weeds.

Or put it another way: Democrats are bought off and Republicans are scared.

When I did my training during the 1970's, we might jokingly tell a 70-year-old patient that their warranty had expired! Meaning after about that age we might want to ease back and not pursue more aggressive and expensive medical treatment. Most of the time the patient sensibly and willingly agreed to pursuing a course of cheaper, less risky or complicated treatments. Today that age is about 80 or 85. And as disease frequency increases dramatically with age, so does our health-care spending.

Yes, making health decisions based on proper statistical analysis is a rational way to go. However, obtaining valid statistics or even data for your analytics is near impossible.

I had a decision of that type on cardiac ablation and using, google and my other doctors looked up what I could on the Dr. options. However, most of the data were impressions and opinions of other "experts". My final pick was the one with the most readable scientific publications and it worked out OK but wasn't rational.

Comments for this post are closed