Thursday, August 9, 2012

"Patient Choice".....More a Headache Than a Blessing

One of the main corporo-media and wingnut gripes against the Patient Protection and Affordable Care Act is that it limits "patient choice". Free marketeers and corporate honchos (like Mitt Romney - though he approved 'Romneycare' in MA) also are big on insisting people be given as many choices as possible and then.....let the markets govern the decision. If only......

The true fact is patient choice is overrated, and without a wealth of reliable background information to support that choice, one will more likely repent after making it, or suffer a mammoth case of buyer's remorse. We saw, some 8 years ago, one of the most glaring demonstrations after the "Medicare Modernization Act" was approved and the Prescription Drug Plan known as "Part D" of Medicare came to the fore.

Overwhelmed seniors, faced with a choice from more than 500 different drug plans with differing conditions, co-pays, offerings were simply unable to cope. A good majority had to enlist the help of college grad or Ph.D. offspring - many of who were successful in negotiating the sea of PhRMA choices - but others were lost in that sea, even some with advanced math and business degrees. The situation had become so intractable for many seniors, they had to hire special finance-based services to wade through all the issues and make a decision!

The seniors and their families encountered the phenomenon of  "Over choice" where decisions are nearly impossible to make -especially with the clock running - and a certain "perfectionism" lurks beneath every choice but also renders it replete with regret, and the ever present "buyer's remorse".

The basic assumption of modern free market economic theory and models is that humans are rational agents and, when offered a set of choices - say for a product or service- will end up making the optimum one. But in an excellent book entitled The Paradox of Choice, the author (Barry Schwartz)  showed this isn't the case and when humans are offered a surfeit of choice they punt! They either don't make any purchase, or they opt for the first one that comes to mind or in their field of vision. Schwartz goes so far as to present data to show that a threefold increase in cases of clinical depression can be directly tied to product-service over choice metastasizing since 1910 or so.

As he notes (p. 105):

"There comes a point at which the opportunities become so numerous that we feel overwhelmed. Instead of feeling in control, we feel unable to cope."

The consistent feeling of being unable to cope amidst a society flooded with choices, then leads to stress and yes, depression and paralysis in many. He then cites the case of a survey (ibid.) wherein people were aked if they would like to choose the mode of treatment if they were found to have cancer.  As he notes:

"The majority of respondents said 'yes'. But when the same question was asked of people who actually had cancer, the overwhelming majority said 'no'. What looks attractive in prospect doesn't always look attractive in practice."

WHY the difference? Well, because when faced with choice of cancer treatment (as I have been, since finding out about my prostate cancer) one is literally left in a 'life or death' position for the choice. There are significant consequences vis-a-vis the outcome. It's unlike having to decide between 'Aspen' and Corn Flakes' for breakfast! There may be serious repercussions if one makes the wrong choice, and so many cancer patients don't want to have that burden imposed on them. It's understandable.

When I was asked (by friends and family) why I elected to go with HDR monotherapy treatment for my prostate cancer, as opposed to say radical prostatectomy, I simply said most of the time 'it was the right choice for me'. But when pressed on the issue by a few, I went into more detail, including having much more confidence this mode of treatment wouldn't leave me incontinent and without any sexual function. Nor invite many more possibilities of infection, such as pelvic abscesses, or urinary infections from having a catheter inserted for weeks at a time.

I also had the advantage of having briefly - 3 years- worked for a radiotherapy software corporation which devised the basic system for delivery of the radiation. My wife had also worked with the specific site at which I am to have it done, and she is confident of their expertise and ability. (She actually had to train the staff some 10 years ago in the details of remote afterloader delivery of the Ir192 source  in conjunction with an HDR  'inverse planning" software system devised by one of their own physicists, John Pouliot.)

Hence, my choice could be made based from a superior advantage position of knowledge, experience that many patients would have lacked.  My point is simple: having lots of treatment options is useless if one is unable to intelligently choose between them. Moreover, THIS is precisely what we need to remedy in our health care system - as opposed to simply offering many more patient choices. To that end, instead of offering a vast array of expensive choices, we need to focus on those which are needlessly risky but which medical profiteers may wish to use because of their cost, and profit margins.  Those latter can be effectively eliminated by demanding providers present concrete evidence and safety factors for what they're offering, so we have proof of what works best.

This is exactly what the Affordable Care Act promises to do, pledging $500 million a year by 2014. This is good because the ability to compare various treatments and supporting the most effective will not ruthlessly eliminate patient choice, it will rather help both doctors and patients make better decisions.

As to the privatizers claim that 'doctors know better than the government" this isn't necessarily so, and often found to be false. The hard fact is that most doctors lack the evidence- based data to compare various treatments in any absolute way. Moreover, they're often guided by their own biases which are often money oriented.

The fact is pure patient choice without parameters and guidelines is overrated, and will simply add to the over choice misery now prevalent across the land.

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