We the Consumers

We the Consumers

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There has been much talk lately about the Consumer movement in health care. The health insurance industry has given us the Consumer Driven Health Care (CDHC), which has gained much traction in the marketplace in the form of high deductible insurance plans, where the Consumer, having “skin in the game” now, is expected to make informed decisions on how to spend his or her money on health care services. The Consumer is empowered and in control of health care expenditures.

And then there are the various Consumer advocacy groups demanding an end to the paternalistic approach to the practice of medicine. Doctors should relinquish control to the Consumer. Consumers should actively manage their care by obtaining and controlling their medical records. Consumers should be informed by the medical establishment of the latest evidence-based best practices, timely research and costs of treatment. The Consumers will then make an informed decision aided by a myriad of peer and professional information available on the internet.

That’s a lot of new responsibilities for most of us who have no idea how much a visit to the doctor costs and even less of an idea whether or not we need that stent, assuming that we even know what a stent really is. Well, since we are Consumers now, not just passive patients, let’s see how we stack up to our brand new responsibilities.

As part of the work of the Commission to Build a Healthier America, the Robert Wood Johnson Foundation released an issue brief in September, titled Education and Health. It turns out that 16% of us over the age of 25 never completed high school and 30% of us have no schooling beyond high school. The percentages are of course much higher for those of us who happen to be black or Hispanic. If that’s not enough, RWJF also found that 3% of college graduates, 15% of high school graduates and 49% of those that did not complete high school  posses “below basic” health literacy, which renders us rather ineffective in making decisions related to medical care. Since there is a strong correlation between parents’ educational attainment and their children’s predicted level of education, the future doesn’t bode well. “The United States is the only industrialized nation where young people currently are less likely than members of their parents’ generation to be high-school graduates.”

Moreover, it seems that health status is directly proportional to educational attainment. The RWJF study finds that those of us that never graduated from high school are twice as likely to report being in poor health than college graduates. The “good news” is that the uneducated seem to have a shorter life expectancy – about 5 years shorter than our educated brethren.

How do these numbers relate to our brand new Consumer status in the health care field? When it comes to CDHC, it’s pretty simple. Since lower education is, of course, associated with lower income, we will not spend any money on doctors until we find ourselves bleeding to death and having to go to the ER. We, the not so educated Consumers, know better than to spend $5000 we don’t have on fancy doctors. We should be able to save a boatload of GDP this way.

When the inevitable happens and we get that heart attack, assuming we survive, there will be decisions to make; educated and informed decisions. The doctor will hand us literature explaining the options we now have, and maybe refer us to some websites where we can get more information. We’ll have to decide whether to stick with what the dudes in the JAMA article are recommending or go with the NEJM study published just this week (lucky us), but first we need to read that 50 page pamphlet from the American Heart Association, so we understand the basics of our condition. Sounds great doc, we’ll be sure to read all of this stuff later, but if you were in our shoes, what would you do doc? Yeah, that’s what we were thinking too, let’s go with that.

To be sure, many of us did go to college and even graduate school, maybe even medical school. Most folks leading the Consumer empowerment efforts in health care are very well educated. They are thoroughly able and willing to direct their own care and that of loved ones. They will make sure that the government’s investments in technology and electronic medical records translate into better quality of care for the educated Consumer. How about the not so educated Consumer — will we benefit as well?

In essence Consumer empowerment in the health insurance space amounts to shifting a certain amount of financial responsibility and risk from the insurer to the Consumer. Some of us are able to shoulder this new burden. Many of us are not.

Consumer driven medical care translates into shifting some of the professional and moral responsibilities from the physician to the Consumer. Some of us are fully capable of taking these new responsibilities on. Most of us are not.

But do we really want to? Are we ready to absolve the medical profession of the need to make compassionate and morally charged decisions? Are we ready to transform our doctors into providers or “sellers” and ourselves into “buyers” or consumers in a “free market” where both buyers and sellers are solely motivated by their own selfish interests? Are we willing to trust that the “invisible hand” will actually materialize and create optimal efficiency? And above all, will these efficiencies benefit all Consumers, or just the usual, wealthy and educated suspects?

Speaking of efficiency, from Overcoming Obstacles to Health, also published by the RWJF in 2008, it seems that instead of looking for change under the sofa cushions, maybe we should be looking at fixing disparities in our society. There seems to be $1 trillion to be gained annually, with half of it directly linked to health care cost, if we just increased the education levels for all of us who never made it to college. And while we cannot dispatch one third of our population to campus overnight, it seems ill advised to concentrate solely on the symptoms of our national problems and ignore the underlying malignancy.

We the People are not ready to accept palliative care for ourselves and our Posterity.

Margalit Gur-Arie is former COO at GenesysMD (Purkinje), an HIT company focusing on web based EHR/PMS and billing services for physicians. Prior to GenesysMD, Margalit was Director of Product Management at Essence/Purkinje and HIT Consultant for SSM Healthcare, a large non-profit hospital organization.

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34 Comments on "We the Consumers"


Guest
bev M.D.
Nov 7, 2009

Good post. When our hospital (way back) tried to implement a policy calling patients “guests” instead of “patients”, I bitterly resisted, feeling that it is critical to giving care that we think of sick people as “patients”. Unfortunately, things have now gotten completely out of hand with “consumers”. All I gotta say is, you get what you pay for in our consumer-driven society. I think we are living that now. Personally, I would prefer to be treated as a patient when I am sick.

Guest
MarkS
Nov 7, 2009

Good post and points, Margalit! I agree fully.
Actually, the situation is worse than you describe. I am a physician and presumably well qualified to make good decisions but I can imagine the following scenario:
I have chest pain and go to the ER. The cardiologist (who is still big on putting in stents since the evidence against them is “new” and he also makes big bucks to support his boat, etc.) tells me that the ECG looks a little odd and I really should have a cath and stents.
I know that there is little benefit (and there are possible complications) from the procedure but I am sitting there in pain, anxious and worried and the doctor is telling me that I need this procedure. Do I have the courage to go against my doctor, refuse the procedure, upset him, cite the latest research, etc.? I don’t think so…

Guest
Nov 7, 2009

Patients just need to have rights, and the option to make choices. For too long the medical mafia has lorded over and mistreated patients. I have a different description of consumer-driven medicine, words like accounatibility and transparancy come to mind. Did you guys see this Sunday’s NY Times? There’s an excellent piece “Making Health Care Better”
http://www.nytimes.com/2009/11/08/magazine/08Healthcare-t.html?_r=2&pagewanted=1

Guest
Nov 7, 2009

Thanks- But who wants to grow up?
Most of us would much prefer to remain infantalized by an exceedingly paternalistic health care system who “will take care of us”
Education and the democratization on information through the internet helps. But most of us when we are sick regress to childhood pretty rapidly
GROW UP AMERICA!
Dr. Rick Lippin
Southampton,Pa

Guest
robert
Nov 7, 2009

Excellent post.
I agree with what you say, and will go as far to say that CDHC contains a strong element of class-based elitism.
I deal daily with patients who have no education, no transportation, and no access to prescribed pharmaceuticals. I see children in the hospital with preventable illnesses because there was no support for them to get the routine vaccines. I see old people in the hospital because they stopped their meds when they reached the donut hole, and when that wasn’t enough, they stopped buying groceries.
And then I come to this web-site and find people whining that they they can’t go on-line at 3 AM and find out what their CRP was 8 years ago.
What are our priorities?

Guest
Jean Esdrace Charles
Nov 7, 2009

I certainly am looking for a good result out of this whole healthcare issue. We definitely need a reform done in this system to some degree at least. The most important is what to include and what not to include.
I can agree with you on that too.

Guest
Robert Carl Parisien
Nov 7, 2009

Health care reform is crucial to the overall economy here. I have patients that cant afford care. These people are not poor people. The benefit structure is horrbile. Carl Parisien Natick MA

Guest
propensity
Nov 7, 2009

Dream on. All consumers are advised to have someone with them 24/7 when hospitalized, and question every test and pill. This is triply more important if the hospital has deployed POE systems. Mistakes facilitated by POE are widespread and the advocate may keep any from reaching the patient.

Guest
Nate
Nov 7, 2009

nice job ducking reality and avoiding the obvious there Margalit. You couldn’t find 3 lines to discuss the more praticle aspects of CDHPs? Less then 50% of the population have more then a couple hundred in healthcare expenses in a year. Only 20% have any significant amount of claims. You completly duck the experience of 80%+ of the population and focus on what a fraction of the 20% experience.
Lets look at some of the real outcomes Margalit doesn’t find significant enough to matter;
uneducated person told there is a generic exactly the same as the brand they have been paying 10 times as much for, since it is now their money under their CDHP they should consider changing. Can they hadle that Margalit?
Going to Wal Mart you can get a 90 day supply for $10of the exact same drug CVS is charging you $100, can we trust they can find Wal Mart on their own?
Going to the doctor urgent care or Drug Store clinic is a fraction of the cost as going to ER and waiting hours for basic illnesses. Can we expect them to schedule their time better to more then cut their cost in half?
I could go on all day with examples of basic situtions that happen thousands of times a day compared to your scare tatics that happen only once or twice.

Guest
robert
Nov 7, 2009

Nate:
Sober up and get your acronyms straight. Margaret was talking about CDHC, not CDHPs.

Guest
Robert Waugh MD
Nov 7, 2009

Part of our obligation as doctors is to explain the options to patients in language that they can understand. I resent the implication that I’m going to make a recommendation to a patient based on my upcoming boat payment. I also don’t think it’s fair or appropriate to suggest that poorly educated patients can’t understand options presented to them in plain language. As a sub-specialty surgeon trained in the inner city, I have had thousands of conversations with patients about their surgical options that have included descriptiosn of very complicated procedures. Just because people are not educated doesn’t mean they’re stupid.
It’s our job to break treatment options down and explain them to our patients. There simply isn’t any other way to make this happen, and we shouldn’t try to mandate “good” choices or somehow legislate how patients will decide what to do.
I agree that the “consumer” model for patients is a bad one because the obligation of the “seller” is different. The guy in the stereo store is payed to upsell his product, I am payed to help people make the best choice for them. Believe it or not, there are those of us out there that take great pride in getting a patient through an injury without an operation where we could just as easily recommend one.

Guest
MD as HELL
Nov 7, 2009

Good luck

Guest
Nate
Nov 7, 2009

lol your not very bright are you robert? Insurers don’t sell CDHC they sell CDHPs which are CDHC. And yes she was specifically speaking of CDHPs
“Consumer Driven Health Care (CDHC), which has gained much traction in the marketplace in the form of high deductible insurance plans, where the Consumer, having “skin in the game””
What do you think a high deductible insurance plan is?

Guest
Gary O.
Nov 7, 2009

Margalit,
The problem is not the analytic ability of the average consumer, it is the abject lack of data to analyze. How can the consumer make an informed decision without any knowing the track record of healthcare providers, based on proven results or quantifiable data — data which rarely exists? Most care sites have little or no data. The individual health care business entities that do have data generally keep their own data to themselves. …[M]ultiple studies have shown that there are actually huge variations in care delivery performance levels between sites, providers, care systems and care teams. …Mammography interpretation skills vary significantly. So do surgical outcomes, as do actual survival rates from various care teams for various procedures and conditions. …Even more alarming, the knee surgeons and oncologists and mammographers who have the worst outcomes have no way of knowing that their own care outcomes are not as good as they could or should be. –George C. Halvoson, Health Care Will Not Reform Itself, pg. 46.

Guest
Barry Carol
Nov 8, 2009

I’ll throw my two cents worth in here.
First, there are large chunks of medical spending where price and, to some extent, quality transparency exists and is obtainable fairly easily. I’m thinking about dental and vision care, nursing home and in home healthcare, durable medical equipment, and, importantly, prescription drugs. The cost of administration, public health initiatives, research and development, and investments in structures and equipment (about 15%-16% of healthcare costs combined) is not relevant to this discussion.
With respect to hospital charges and physician and clinical fees, which together, account for 50%-55% of healthcare spending according to CMS, there is enormous room for improvement with respect to price and quality transparency. The theme of the excellent NY Times article in its Sunday Magazine section this weekend by David Leonhart which focuses on Intermountain Healthcare in Utah and Idaho is that we need to be able to measure results if we are serious about trying to figure out what works and what doesn’t in which types of patients. In other words, we need better and more complete information. With better information and robust, user friendly price and quality transparency tools, referring doctors should be in a much better position to recommend the most cost-effective specialists, drugs, imaging centers, labs and physical therapists.
I also think you way underestimate the ability of people without a lot of formal education to understand and process information if communicated to them in clearly. A relative who spent his career with the VA tells me that the vast majority of the poorly educated clients that he interacted with understood very well what benefits they were entitled to and how to apply for them. I’ve known plenty of people over the years who did not go to college or even finish high school but who have plenty of common sense and can navigate real life issues including healthcare matters quite well, thank you.
Finally, as Nate points out, in any given year, relatively few people have significant healthcare costs. Even within the Medicare population, in any year, 50% of the 65 and over population (22.5 million people) account for only 4% of Medicare’s program costs or less than $1,000 each on average. For the under 65 population, Harvard Pilgrim tells us that 9% of their members account for over 60% of their costs. They are not the same people from year to year. A woman could give birth one year and have essentially no health expenses the next. One could have a heart attack and then recover and be well managed with medication for years to come. The percentage of the population, excluding those in nursing homes or assisted living, who incur more than $5K in health expenses year in and year out is probably tiny. I would guess less than 5% but perhaps Nate has better data.
The bottom line is that CDHP health insurance plans can make enormous sense for much of the population, especially those in the top half of the income distribution whether they went to college, finished high school or not. Even for those with lower income, a CDHP may work fine if they have the savings to absorb the higher deductible in a particular year. Insurance should be about assuming the actuarial risk associated with catastrophic and high cost events. It should not be expected to cover the equivalent of oil changes for our car which most people seem to be able to pay for without insurance quite well.