Your consumer powers when choosing a hospital

An excerpt from Doctor, Your Patient Will See You Now: Gaining the Upper Hand in Your Medical Care (Rowman & Littlefield).

The casual attitude people demonstrate when choosing doctors incurs a steep price. Let’s direct our attention to your consumer powers when choosing a hospital.

The imperative ‘caveat emptor’ (let the buyer beware) carries the most consequence when you purchase health care. When it comes to hiring a hospital’s services, it’s more caveat empty than caveat emptor.

It’s time to impart the same lessons for hospitals as we did for doctors. All hospitals are not the same. Each is its own unique brand. We, a nation of shoppers, are obsessed with brand names that tout their distinctiveness. In reality, most consumer products in any given category are all but indistinguishable from each other.  We think we can see the smallest pixel a human brain can process on a video display. We taste the figs and peaches in a $9 bottle of wine. We claim the sensory hyper-acuity possessed by dogs, dolphins and nocturnal predators.

Few use these consummate consumer skills when choosing a brand of hospital. “Aren’t they all the same?”  Imagine the consequences if 1 in 500 of you died as the result of using HD-DVD over Blu-ray players. Rather than the three-year war for your loyalty, HD-DVD would have suffered an extinction event within seconds. Yet, 1 in 100 of you will die or be damaged by preventable medical error when you lie in your hospital beds that were so casually chosen. For many surgical procedures there is a 30% greater chance of dying at “your” hospital than at a carefully researched facility that may be only a few minutes or hours away. The choice between Sony and Samsung is a minor one. Not so for St. Sony or Samsung General. Let’s show you how to choose the right hospital in the certainty that you will, one day, need one.

It’s a jungle

Yes, it is confusing out there. Hospitals are variably touted for their safety, high-volume, elevated-ranking, report cards, or their home on some publication’s list.

Some “top” hospitals are not on the list of “safe” hospitals. Aggressive clinics are not all high-volume institutions. US News and World Report (USNWR) hails hospitals that HealthGrades (HGs) and the Leapfrog Group (LFG) ignore. You would think that all of Forbes’ largest and safest top 10 hospitals would find a home somewhere on USNWR’s 170 ‘Best Hospital List.’ Only half did in 2008.   For USNWR in 2009, “…more than 40% of non ranked hospitals had better performance than the average top ranked hospital in a cardiovascular composite measure.” And finally in 2010, there is little concordance in hospital rankings across report cards.  Only 8 hospitals rank in the top 50 of both USNWR’s “America’s Best Cardiovascular Hospitals” and the HealthGrades’ Best Hospitals”. What does this all mean?

Finally, how about that familiar old pile down the street? That’s right, your local hospital, St.Wutsisz. It’s on no one’s honor roll. It’s not a designated “Hospital of Distinction” or a “Center of Excellence.” It missed the cut of USNWR, HGs, LFG, Reuters and Consumer Report by a country mile.

Maybe you tried investigating hospitals but surrendered, stymied by the bewildering varieties and numbers of hospitals vying for your business.  Perhaps your nascent consumerism was nipped in the bud by skeptical media reports shrilling over the flaws and frauds associated with the hospital rating systems.

In light of all this, very few of you go shopping for a hospital. In 2008, fewer than 15% of the population referred to hospital ratings or report cards. Most people have never seen one. 70% don’t know they exist and a mere 1% actually use them when making healthcare decisions.

The features the public do value most, cost and convenience have the least predictive value for survival when you are hospitalized.

The public remains passive recipients of their healthcare, relying on friends, family, familiar doctors and, alarmingly, their medical insurance company’s websites. Nobel Laureate Paul Krugman sums it up best when he offers two pieces of advice about health insurers.

1) Don’t trust the insurance industry.
2) Don’t trust the insurance industry.

People follow the path of least resistance, staying with familiar hospitals that are close to home regardless of the problems they or their hospitals suffer. It is astounding that many would sooner die (and do) than leave their neighborhood for better care when it’s needed.

In a study published in 1999, patients were asked to imagine that they had a resectable pancreatic cancer. They were given the option to choose between local or regional care – a four hour car ride from home. If the risk of operative death were doubled at the local hospital compared to the regional institution, 45% of the study population preferred to stay close to home. If the local risk was quadrupled, 25% would still stand pat.  How about six times the risk compared to a regional center? 18% of local die-hards (or more accurately die-easys) wouldn’t pack a lunch and gas up the Buick. As the odds of death increased, there remained a significant number of stalwarts who remained stalled at home. Finally, under the promise of certain death, a 100% local operative mortality (compared with 3% regional hospital death rate), 10% accepted their fates and would march off to their hospital qua abattoir without complaint.

Attention Darwin Award Committee! So stunningly counterintuitive are these results they might be thought of as a poorly designed outlier with aberrant statistical anomalies gleaned from an unrepresentative patient population. Nope. A clinical survey in 2000 by the Kaiser Family Foundation and The Agency for Healthcare Research and Quality (AHRQ) concluded that  “Personal recommendations and familiarity are so important that they often outweigh more formal indications of quality … people are more likely to choose a hospital that is familiar (62 percent) over one that is rated higher (32 percent).”

In the past, the need to choose a hospital was unnecessary. You were lead in tow to the hospital where your family doctor practiced. There was no choice. “It’s the doctor, stupid.”  With the rise of the hospitalist movement your doctor may not work in any hospital. The ‘where’ becomes your choice.  Let’s work out a simple, but rigorous, plan. A plan for routine hospital care, another for emergency regional backup, and a strategy to find a national center when all else has failed and you are told nothing else can be done.

Steven Kussin is a gastroenterologist and author of Doctor, Your Patient Will See You Now: Gaining the Upper Hand in Your Medical Care.

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