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Market Factors

Another limitation on a patient's choice of health care services is the limited availability of market information. Although the Federal Trade Commission (FTC) has eliminated many of the traditional bans on physician advertising, the highly personal nature of medical care makes it difficult to compare prices and services. It is also difficult to obtain a personalized bid for medical services. This lack of information increases the physician's duty to provide the comparative information to the patient that is necessary to make an informed choice of treatment. (This is discussed in detail in Chapter 11.)

Even patients with information about the market for medical services are often financially limited in their ability to choose a physician. These financial limitations stem from attempts by employers and their insurance companies to limit the cost of medical care. The two primary vehicles for reducing costs are health maintenance organizations (HMOs) and preferred provider organizations (PPOs). It is important to recognize that the more the patient's choice of physician is limited, the greater is that physician's duty to protect the patient's interests. If the plan is sufficiently restrictive (as is often true for specialty care in an HMO or PPO), this duty to guard the patient's interests may extend to the administrators of the plan and the employer that selects the plan.

Market models also assume that there is time to collect and evaluate market information, but many serious medical problems arise quickly and must be treated quickly, limiting the patient's choice of physicians to whomever is geographically available. Even in nonemergency cases, the discomfort and risk involved in shopping for physicians severely limit the patient's ability to choose a physician. An equally serious problem is financial limitations. The poor have always been limited in their choices of medical care providers--a limitation increasingly being felt by the middle class.

Finally, market models are based on the fungibility of goods: that ability to substitute one good for another. Patients do not like to treat physicians as fungible. One traditional definition of a profession was that it mattered who did the work, not just the price of the job. While the medical profession does not like to stress the differing abilities of its practitioners, physicians who seek medical care are usually particular about who renders that care. Since it is difficult for laypersons to evaluate professional services, patients usually reward physician fidelity with loyalty.

Physicians who behaved in a responsible manner could assume that the patient would continue to return for care. Acting in the patient's interest might cost the physician profits in the short term, but it led to a stable practice and long-term profitability. The changing nature of the medical care reimbursement system is forcing many patients to move from physician to physician. This destabilizes physician practices and increases the pressure to consider the short-term profitability of patient care alternatives, and it increases the physician's conflicts of interest.

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