Actually the biggest problem with MSAs and patient charges is the
information asymmetry between health care providers and patients.
As I like to say, "We really hope the doctor knows more than the
patient."  Evidence-based medicine means having physicians
combine 1) the best research evidence with 2) their own clinical
expertise (their knowledge of disease and of preventive and
treatment actions they can take), and with 3) the patient's
wishes and priorities.  Patients need to be better informed than
they usually are, but even the best-informed patient does not
have (and typically can never have) as much information as the
doctor.  If they could, why would we need doctors at all?

Most decisions about care (admitting to hospital, medical and
surgical treatments, drugs) are made by doctors, or based on the
recommendations of doctors.  We don't want these decisions made
by patients, unless we have good evidence that patients know what
they need to know to make good decisions.  Actually our evidence
is the other way:  The Rand studies in the US, and Canadian
studies on physician user charges, have shown that patients can
be very poor judges of when they need to see a doctor or which
health care services are unnecessary.  User charges deter both
necessary/effective services and unnecessary/ineffective ones.
Direct charges to patients do not (as advocates hope) selectively
deter unnecessary services - most likely because patients don't
know what these are (either ahead of time or after the fact).
The consistent thing is that user charges deter low-income
patients from seeking care.  MSAs might reduce that problem, by
giving everyone a fund, but low-income people would probably
still be less likely to use the fund, hoping to get the cash
back.  And, MSAs cannot magically give patients the information
they're lacking, and make them better judges of when to seek
care, and what care to "buy".

This is a general problem with applying market-type solutions to
health care; you can't expect markets to produce efficient
outcomes if the buyers lack critical information needed to weigh
the costs and benefits of their "purchasing" decision.  Markets
can be used in parts of health care, where information asymmetry
is less of a problem; "public sector competition" attempts to
encourage efficiency in service provision by letting different
agencies compete to sell health care services to a local health
authority.  But it's essential to be sure the relevant
information on benefits (e.g. treatment effectiveness) is
available along with cost information, otherwise there's a great
danger of lowering quality along with costs.

Given that lack of information is the key, a better way to reduce
unnecessary and ineffective care is to attack the information gap
directly.  Provide 24-hour telephone consultation to patients,
toll-free and without charge, on whether to seek professional
care.  Such services could be provided by nurses and
nurse-practitioners; they would be able to offer reassurance and
information to patients, and help them determine how to manage
the health issue they're calling about, e.g. can it be safely
managed at home, or should they see their family doctor on the
next business day, or do they need to go to emergency or call for
an ambulance right now.  Apparently there are some services like
this being piloted; they make so much sense it's hard to
understand why they aren't universal.

Another source of unnecessary/ineffective/harmful care is lack of
information by doctors.  Sometimes there really isn't adequate
information to help manage a particular patient, and a certain
amount of wasted effort is unavoidable.  But in many cases,
better use of available research evidence would avoid pointless
investigation or ineffective/harmful treatment.  This is what
evidence-based medicine (EBM) is all about - making sure that all
relevant information is used.  EBM can't create perfect certainty
and can't prevent all wasted effort, but it can improve on the
current situation.

MSAs are another trip down the dead-end street of trying to
reduce unnecessary care by charging patients.  Better access to
information for patients and doctors is the real key to reducing
the waste and harm from unnecessary/ineffective/harmful care.


Rebecca Warburton, Ph.D.
Health Economist
Assistant Professor
School of Public Administration
University of Victoria
Victoria, BC   Canada
fax    250-414-4965
email [log in to unmask]
mail/courier address at:
http://dirserv.uvic.ca/dir/DeptMail.asp?DEPARTMENT=PADM





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