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Key Problems for Report Cards

I found our conversation with Bobby Yeh extremely stimulating (Ep. 19 Public reporting: necessary evil or harmful fake news?).

It’s not often that I get outflanked by Anish on the question of regulation and health policy!  But I was persuaded by Bobby’s argument that refining outcome measures can be helpful to mitigate the damages that might otherwise be inflicted.

Yesterday, Bobby brought to our attention that US NEWS has just released its own rankings of all US hospitals for a number of surgeries (e.g., coronary bypass surgery, aortic valve surgery, colon cancer surgery, etc.) and conditions (e.g., congestive heart failure, chronic obstructive pulmonary disease, etc.).

The US NEWS report card includes not only publicly-reported clinical outcomes, but also a variety of the measures such as length of stay, nurse staffing ratios (number of nurses per patient), and patient satisfaction surveys.

There are two problems worth highlighting, as far as I see them:

First, scorecards in healthcare never categorize according to price.  This is very different from, say, ratings for restaurants on Open Table or ratings for hotels on Trip Advisor where price obviously matters.  In the healthcare system, as we all know, price has been rendered completely meaningless.  But not rating according to price, implies that it doesn’t matter how much things cost, or that healthcare is not a scarce resource. Which means that institutions are expected to act as if they were all luxury restaurants or resorts!

Second, including a bunch of variables into a composite score raises the question of how to weigh the different variables. How much importance should the ranking protocol allocate to “length of stay” as compared to “survival” or to “nurse staffing”?  There is an element of arbitrariness, especially since some patients may actually prefer longer hospital stays, and other patients may only care about survival and not care a whit about “data transparency.”

The main problem here is that “quality” has inherently a subjective component and ultimately has to do with integrating the various components of the whole enchilada: We can comment all we want on the sauce, on the texture, or on the taste separately, but at the end of the day the question is “is it worth eating or not?”  Putting all the pieces together is not a calculation but a decision.  And a decision is a judgment, i.e., an act of the will.

Ranking various arbitrarily weighted objective variables without any reference to price cannot realistically help patients answer the question that ultimately matters.


  1. Anthony Perry, M.D on 08/20/2018 at 1:55 AM

    You 2 guys are a real asset to the medical discussion. Here’s a little encapsulation of how I see the issue.

    The only legitimate judge of the quality of a medical service is the recipient of the service. This is because the patient is the only one who knows what he values. (It’s the principle described in Von Mises “Human Action”). The idea that patients do not know enough to make such decisions is nonsense. They get information from various sources including magazine reports, or their doctor, etc. But the only reason there is a medical interaction in the first place is because someone is moved to obtain what he values. Anytime anyone decides to seek something he is doing it with limited information but the seeker is the one who is moved to make the choice based on what he wants and he will seek no further unless he gets what he values.

    And of course taking price out of the decision is foolishness in the extreme since the consumer will then accept anything that is not painful or troublesome as long as he gets what he values in the event.

    • Michel Accad on 08/25/2018 at 9:25 PM

      Thank you, Anthony. Medicine operates as if value is objective, a notion which belongs to the dark ages of economic theory. The problem is that most economists also believe in making medicine an exception to the subjective theory of value. (Sorry for late posting of your comment).

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