-Loralie Ma, M.D.
Information Asymmetry and the Role of the Patient in the Healthcare Marketplace
Much has been written on information asymmetry by economists – a transaction where one party has more, or better, information than the other. In business, this leads to an imbalance of power in transactions, which can sometimes cause transactions to go awry.
In healthcare, information asymmetry exists due to lack of patient information about the healthcare marketplace (its players and limitations). Patients may also have difficulty determining the quality of their caregivers, and may also have differing definitions of quality of care. As an example, most patients have an incomplete understanding about the different types of health care providers, their level of training, and their scope of practice. Physicians typically require four years of graduate education for their medical degree, as well as internships and residencies ranging between three and seven years. The total number of hours of clinical training of physicians averages approximately 12,000 to 16,000 hours.
Nurse Practitioners typically require 2 – 4 years of graduate education, no required residency or fellowship training and 500-720 hours of patient care hours. Their clinical training allows patient evaluation and treatment on a basic level, but may lack the high level of knowledge and practice gained in physician training.
Physician Assistants typically require 3 years of graduate training and 2000 hours of clinical rotations before practicing. Their role is typically that of a physician extender, allowing the performance of evaluation and procedures under physician supervision.
Naturopaths typically require 4 years of graduate training, no required residency or fellowship training and 720 – 1,200 hours of patient care before practicing. Their practice is not that of traditional medicine but has some overlap with traditional allopathic/osteopathic medicine.
Patients seeking healthcare may not be fully aware of the differences in training in their healthcare providers. In some cases, this lack of understanding may lead to delays in diagnosis or optimum care for certain illnesses. Patients may also not understand, within their state, what medical procedures or prescriptions their healthcare providers are allowed to prescribe.
For example, a patient recently came into one of our radiology offices with a prescription from a Naturopath who prescribed a CT scan of the chest and abdomen to look for an aortic aneurysm. The patient is a woman in her early 40s and the Naturopath felt a pulsatile mass in the lower abdomen. In Maryland, the Naturopath cannot order a CT scan, but is allowed to in Washington D.C.
Of course, an abdominal ultrasound would have been the preferred examination and less costly to the patient with no exposure to ionizing radiation. However, the patient will not know that. This example of information asymmetry is pervasive in the healthcare arena, as, even within physician groups, there is often more than one type of healthcare provider present.
A second issue is quality of care. Quality of care may have different meanings to different people:
- To the patient, quality of care may mean getting an appointment quickly, being able to talk with their healthcare provider, and getting the treatment or test they think they need.
- To the physician, quality of care typically means adequately assessing the patient’s medical situation, diagnosing the disease, and treating it successfully.
While these definitions should be aligned, they are often not the same, and this creates friction in a patient’s assessment of their physician. Patients may feel their interaction with other healthcare providers is more convenient, and that they are more willing to have a conversation, and do not always understand that their clinical outcome is the most important determinant of quality.
The Internet also plays a role in information asymmetry. While the Internet is a vast repository of information, that information is often not vetted for accuracy and validating data is not often available for the patient. Much of the information on the Internet is marketing-based, with patients having access to information, but often do not get the entire story when it comes to their healthcare.
For patients to be optimally aware of their practitioners training level, as well as the adequacy of that training for the type of healthcare needed, we should better educate our patients about these differences.
To address this information asymmetry, the medical community must do two things:
First, the medical community needs to educate the patient about the importance of diagnosis and treatment. Second, the medical community should try to respond to these important needs of their patients, whether through the use of physician extenders, or hopefully in the future, through the use of technology, to free the physician for these important conversations.
Unfortunately, at this time of transition in healthcare, technology often decreases the physician’s ability to interact with their patient, due to hours spent in documentation and insurance paperwork, which are not adequately compensated.
Hopefully, the House of Medicine can work to educate patients about the importance of correct diagnosis and treatment, and educate patients about the level of expertise needed to do so. As physicians, we should work to address the patient’s many needs in their healthcare interactions, in addition to diagnosis and treatment, to inform them about their own health and our role in protecting that health.