Consumer-driven medicine is seen, by many, as the answer to our health care crisis.
Put the consumer in the driver’s seat, we are told, and patients will drive down costs by insisting on the very best value for their dollars.
The movement goes hand-in-hand with health savings accounts and high-deductible plans: Force the patient to spend his own money, and he will be motivated to comparison-shop.
“When consumers pay directly, innovators respond to their needs—that’s how a market works,” declares Regina E. Herzlinger, a leading consumer advocate, in Market-Driven Healthcare. (Writing in 1997, Herzlinger somewhat optimistically held out the American automobile industry as a prime example of an innovative industry that has responded to consumers’ needs. )
What Herzlinger ignores is the “uncertainty” that is intrinsic to health care. In my recent book, Money-Driven Medicine: The Real Reason Health Care Costs So Much I quote Dr. Atul Gawande, who rightly identifies “uncertainty” as the “core predicament” of medicine– “the thing that makes being a patient so wrenching, so difficult, and being part of a society that pays the bills so vexing.” (Complications: A Surgeon’s Notes On an Imperfect Science).
a)”We could just keep an eye on it,” the doctor might say.. “Since you’re 67, and this is a cancer that grows very slowly, it’s quite likely that it will never catch up with you. “We’ll just have you come in every six months so that we can monitor its progress, but hopefully, we’ll never have to do anything.. This course of treatment is called “watchful waiting.”
b) “Alternatively, we could try radiation treatment. This will have side effects that you won’t like. About one half of patients become impotent within 2 years. Some suffer side effects like rectal bleeding. And there is a possibility that the tumor will come back.”
c) “Surgery. This is the most certain remedy. If all of the cancer is removed during surgery (and if course this is always an “if”) —you are probably cured. But of course you face the risks of surgery—you could lose a lot of blood during surgery. And afterward, you could be impotent or incontinent—or both. Most people don’t suffer severe incontinence, but about a 1/3 while find that they leak urine when they cough or laugh. . . “
Then, if your doctor is very honest, he will tell you—“We can’t be sure, but I think that in your case, ‘a,’ or ‘b’, or ‘c’ is the best course of action.” (Though these days, a doctor who believes strongly in consumer-driven healthcare and patient autonomy may say, “I can’t tell you which treatment is best for you. That’s something you have to decide.” )
Given the ambiguities, how can patients hope to comparison-shop the way they might shop for a computer?
While Consumer Reports can rate mid-priced refrigerators briskly and clearly, in a way that makes comparisons easy, it is all but impossible, even for physicians, to be positive of the relative benefits of a great many medical procedures. The product is opaque; you can’t compare two treatments the way you might compare two cars. This is not just because the human body is so complex, but because each body is unique—what worked on one patient may not work on another.
Granted, today both physicians and patients enjoy access to more information than ever before. But, as anyone who has ever been seriously ill knows all too well, the more one learns about a disease and the odds of success with possible treatments, the more ambiguous the situation can become. (And most of our healthcare dollars are spent on serious and chronic illnesses.)
As researchers noted in a 2004 article in Health Affairs, “much of medical practice remains in gray areas . . . and is likely to remain so for quite some time.”
“Outcomes research”–which compares outcomes for similar patients exposed to different treatments, drugs or procedures– is still an infant science. In-depth analysis of outcomes requires long-term, risk-adjusted clinical trials. It will be many years before we have enough clinical data to create useful guidelines for “best practice” when treating most chronic and serious diseases. (In an excellent article in The New Yorker, Dr. Atul Gawande describes how over a 40-period one physician painstakingly learned how to establish what appears to be “best practice” for just one disease—cystic fibrosis. )
In the meantime, there is a real danger that quick comparisons of .how patients fare under different regimens will turn into an entrepreneurial industry that produces Instamatic “report cards.” Such snapshots of medical data can be misleading, warns Mark Fendrick, a professor of medicine at the University of Michigan. In a letter to Health Affairs, he paraphrases sports announcer Vin Scully: “The utility [of such ‘report cards’ on quality] resembles the benefit a drunk derives from a lamppost in the dark, ‘support not illumination.’
Returning to the consumer’s dilemma, to make his situation as a shopper all the more difficult, when it comes to healthcare he knows that there are no warrants or guarantees. The patient cannot return an unsuccessful operation. And if he winds up unhappy with the outcome, he may find himself stuck with something far worse than a bad haircut.
No wonder patients are reluctant to bargain-hunt—even in cases where they can get clear price information to make comparisons. This is not an industry where consumers are going to bring prices down—even when spending their own money.
A sick patient isn’t looking for a bargain, he’s looking for the highest quality. But when it comes to comparing healthcare providers, it’s extraordinarily difficult to measure quality. As one hospital CEO told me, “our patients know whether they like the rooms, the food, the service—but they have no way of knowing whether they are getting the best possible care.”
Even after the fact, the patient can never be sure—would his condition have cleared up on its own if he hadn’t had the operation? Would another, less expensive or less painful treatment or drug have just as good a job, with fewer side effects?
Some pundits claim that mortality rates will tell you how good a hospital or a doctor is. But the truth is, a hospital with high mortality rates may simply be one that takes the most difficult patients. When they are being “graded” on mortality rates, many hospitals have been known to “game” the system by refusing the hardest cases. Adjusting for the difficulty of the cases that a given doctor or hospital takes is a very tricky business.
The consumer-driven movement tries to shift the burden of ensuring quality to the patient—pretending that, by just going online, the resourceful health care shopper can become his own expert, and learn to choose the “best” procedures, doctors and hospitals at the best price. A few years ago, a Wall Street Journal article suggested that in this new era of consumer-driven care, “New rating systems around the country are staring to make it possible for people to shop for a hospital the way they shop for mutual funds.” (“Shopping for Hospitals,” May 1, 2002)
Did we learn nothing from the nineties?
Just as most people are not cut out to be their own money managers, the majority are not well suited to becoming their own physicians. In the 21st century we have instant access to a world of information—but information is not knowledge. All of the mutual fund rating systems in the world could not save the small investor if he bought a five-star high-tech fund at the market’s high. And if it is difficult for laymen to avoid the hype while chasing hope on Wall Street, consider the dilemma of a seriously ill patient facing the mysteries of his own mortality.
Patients need to rely on their doctors—doctors who are professionals and will put their patients’ interests ahead of their own financial interests—to give them the best possible advice. Some of that advice will be based on what the doctor has read and learned, some on what he has experienced. Much of that experiential knowledge will be intuitive knowledge that is hard to put into words—knowledge that a patient can’t pick up on the Internet.
Certainly, today’s patient wants to be included in the decision-making process. The days of “Doctor Knows Best” are long gone. Patients want to ask questions, to have their options laid out for them. Often, they want a second opinion. But while they don’t want to be kept in the dark, once they have been informed, most want their physicians to help guide them toward the course of treatment that the physician has reason to believe (even though he often cannot be certain), will yield the best result.
In an essay questioning the whole idea of consumer-driven medicine, Robert Berenson, a physician and former top Medicare official, quotes health economist Victor Fuchs, noting that Fuchs “understands that the patient/physician relationship is very different from the one we accept in the commercial marketplace because it requires patients and health care professionals to work cooperatively rather than as adversarial buyers and sellers.”
In other industries, “caveat emptor” always applies. The savvy consumer must take care that the seller does not cheat him. He must demand the best product at the best price.
But healthcare is different from other industries. The buyer is not a “consumer”–he is a patient. And the seller is not a businessman marketing a commodity—he is a physician practicing his profession. Insofar as a patient “shops” for healthcare, he needs to shop— not for the least expensive doctor, nor for the doctor who advertises that he has the highest ratings on somebody’s rating system– but for a doctor whom he trusts to act as a professional, and put the patient first.
In other words, what we need isn’t “consumer-driven medicine,” but “patient-centered medicine.”
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