Last week lecture on health economics was about agency relationship and supplier-induced demand. It discussed it from the point of view that DOCTORS are paternalistic. It might be partly true, at least in England. However, in Canada, there is a clear movement favouring patient empowerment, and medical faculties incorporate patient choice and informed consent to their curriculum form year 1 to specialist training. It's been the case for more than 10 years now, as I had this training myself.
An interesting part concerned the agency relationship between DOCTOR and PATIENTS. I can't still figure how this slide (from Professor Paul Dolan, which quoted Williams, 1988) proved the DOCTOR-PATIENT relationship is an imperfect agency relationship, as the practice here seems so far from reality :
"From theory...
The DOCTOR is there to give the PATIENT all the information the PATIENT needs in order that the PATIENT can make a decision and the DOCTOR should then implement that decision once the PATIENT has made it.
To practice ...
The PATIENT is there to give the DOCTOR all the information the DOCTOR needs in order that the DOCTOR can make a decision and the PATIENT should then implement that decision once the DOCTOR has made it."
In my mind, as a doctor, this is far from how things work. Here's my adaptation of this assertion.
From theory...
"The DOCTOR is there to give the PATIENT all the information the PATIENT needs in order that the PATIENT can make a decision and the DOCTOR should then implement that decision once the PATIENT has made it.”
To theoretical practice...
"The PATIENT is there to give the DOCTOR all the information the DOCTOR needs in order that the DOCTOR can make a decision and the PATIENT should then implement that decision once the DOCTOR has made it.”
To reality...
Information asymmetry exists in the DOCTOR-PATIENT relationship regarding DIAGNOSTIC and THERAPEUTIC information. To proceed to the right diagnosis, “The PATIENT is there to give the DOCTOR all the information the DOCTOR needs in order that the DOCTOR can make a [right DIAGNOSIS]”. This implies specialized knowledge to retrieve the relevant information for DIAGNOSIS, and constitutes part of the information asymmetry. This is in part why the principal (patient) needs an agent (doctor).
On the other hand, the DOCTOR has the knowledge to provide options regarding THERAPEUTIC interventions. “The DOCTOR is there to give the PATIENT all the information the PATIENT needs in order that the PATIENT can make a decision.” However, in practice, the principal is sometimes in a position where the information given can't be assimilated clearly. PATIENTS will often ask the DOCTOR to give their opinion on what they would do (“DOCTOR can make a decision [on behalf of the PATIENT]”). This is part of the agency relationship. Is it perfect or imperfect? Maybe it's imperfect from a theoretical point of view, but relieving patients from their anxiety and fears is also part of this agency relationship... It's called the DOCTOR-PATIENT relationship.
As for the implementation part, both the agent and the principal have different roles. Sometimes, “the DOCTOR should then implement that decision” either “once the PATIENT has made it” or “once the DOCTOR has made it.” An example where DOCTOR implements the decision is when he performs a procedure. Only the DOCTOR can do it. Some other times, “the PATIENT should then implement that decision”, either “once the PATIENT has made it” or “once the DOCTOR has made it.” An example is changing lifestyle to treat hypertension : only the PATIENT can implement such therapeutic intervention. Again, this is part of the agency relationship. "The DOCTOR is there to give the PATIENT all the information the PATIENT needs” to implement the treatment. The agency relationship is dependant on both parties participating in treatment implementation. Does it make this an imperfect agency relationship? Not as long as that's what both parties look for... It's called the DOCTOR-PATIENT relationship.
Medical ethics, opinions from peers, the necessity to maintain a professional reputation and clinical guidelines are all strong promoters of DOCTORS acting in their PATIENTS best interests. Does it restrain their desire for profit maximization? Consciously, definitively. Unconsciously, maybe not. However, supplier-induced demand is not an absolute proof that these measures are inefficient and that the DOCTOR exploit PATIENTS vulnerabilities as ill informed consumer to prefer profit maximization over their PATIENTS well-being. Many hypothesis can be generated that favours DOCTORS acting in their PATIENTS best interest while explaining supplier-induced demand. I shall explore that in a future blog... I'll have to go through this chapter again.
At least, I understand incentives fully now, and I won't let real estate agents sell my house cheap...
This work by
Stéphane Lemire is licensed under a
Creative Commons Attribution-Non-Commercial-Share Alike 2.0 UK: England & Wales License.
2 comments:
Hey Stephane,
Patient empowerment (in Canada):
Yes, some strides have been made for things like consent, etc. however, the patient is still not all that empowered when making a decision. In Canada, a patient still lacks basic information on the type of care he/she could be expected to receive (ie. risk-adjusted mortality rates, infection rates, waiting times, etc.)
For example, in the case of a GP referring to a specialist, you may want the GP to relay info on all of the relative waiting times, and then info on how each specialist performs on given metrics.
For example, if I knew that Dr. X's patients were 2x more likely to get a post-surgical infection I might choose Dr. Y. Alternatively, if the risk was quite low and Dr. X would be less of a wait -- then maybe it's a trade-off I might be willing to make based on my time-preferrence.
Erik
these are all good point... i wonder what the impact would be from a demand-supply perspective?
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