POLICY: Consumer-Driven Medicine Is Not The AnswerBy Maggie Mahar

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).

Consider, for example, a patient who is diagnosed with stage 1 prostate cancer. Chances are his physician will tell him that there are three possible treatments:

  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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  3. Maggie — Health care solutions must come from all arenas and all parties involved. Your feedback is appreciated…Dr. Shelley
    A New Wellness Paradigm
    How to Fix the United States Health Care System
    We Must Do It Ourselves
    “Problems cannot be solved at the same level of awareness that created them.”
    –Albert Einstein
    Identify the Components: Ones That Work and Ones That Don’t
    The first step to solving any seemingly daunting problems is to break it down into component parts, identify what works about the existing status; and what doesn’t. It’s crucial to learn from the past.
    As a physician and owner of a solo practice (small business) I’ve experienced the health care system from all sides. I’m intimately familiar with how Medicaid, Medicare, and for-profit insurance companies such as Blue Cross, United Healthcare, Aetna, and others work. I am also a consumer of health care services. I’ve had babies, knee surgeries, and other personal interactions with the American medical system. I have witnessed first-hand the extent to which non-citizens are receiving benefits paid for by working Americans. I am a small business owner so I’ve had to decide whether and how to offer health insurance to my employees. I, and others like me, am among the most qualified people in America to help fix the health care system because we have experienced health care from all angles: health care providers, patients, business owners, and tax payers.
    In this chapter we’ll explore what works and what does not work about the existing U.S. health care system. We’ll also address how to fix what doesn’t work and improve upon what does work.
    What Does Not Work
    Big Government Entitlement Programs
    Big Government does not work. Entitlement programs such as Medicare and Medicaid have spiraled out of control, increased our debt, and are a huge burden to existing and as-yet unborn taxpayers. Many people have figured out how to “game” the system and receive benefits they don’t deserve.
    In my county the office that determines Medicaid benefits is populated by some former illegal migrants who are now citizens. Through knowing people who work in that office and are dismayed by current practices, I am aware some staff members are dispensing Medicaid benefits to those who don’t deserve them. We all pay for this. I don’t want my children bearing the cost of the ballooning U.S. entitlement programs, as it will impact their and their children’s standard of living.
    Medicaid “Emergency Services Only” is a perfect of example of an entitlement program gone woefully wrong. Don’t misunderstand me – some of the recipients of this entitlement program truly deserve it. However, this benefit is dispensed to some citizens and non-citizens alike who drive brand new large SUV’s, and reside in single family homes – I’ve literally seen them deliver a baby at the taxpayer’s expense and drive away in a shiny brand new Cadillac SUV. They pay through these luxuries with cash earned “under the table,” not subject to income tax.
    The Medicare Part D prescription drug program is another example of an entitlement program which benefits pharmaceutical companies and wealthy Americans at the expense of middle class and younger Americans. Most beneficiaries of Part D are retired older Americans who did not pay enough into the system to cover this benefit during their working years. As a consequence working Americans and future working Americans as yet unborn will pay for this program. Pharmaceutical companies are guaranteed a “permanent” revenue stream through Part D unless the system is revoked or revamped. As drug costs increase, which they inevitably will, Part D will balloon out of control as has the rest of Medicare and Medicaid and be another source of national debt and excess tax burden.
    Big government does not work because it’s too costly to administer and it is too easy to take advantage of.
    For the first time in U.S. history we are seeing new generations’ standard of living decline compared to the generations that preceded them. This should be a wake-up call to all of us. If you live in the moment and have the attitude, “It won’t affect me,” think again. Your children or your friends’ children, or mother Earth will bear the brunt of our existing behaviors. Examine your motives. Be honest. Do you feel like you need more money or more stuff? Do you really need these things? Or do you need a healthy earth in which you and your children can live sustainably? Now that you’re making a baby it’s up to you to create the best world possible for them.
    Inequities in Wealth Distribution Harm Everyone
    As a species we have not solved the problems engendered by unequal distribution of wealth. The rich getting richer and the poor getting poorer is not simply an economic problem. It’s an environmental and moral one: It’s hard to care about the pollution you create as an individual when you’re worried about how you’re going to feed your family from day-to-day.
    Ostentatious displays of wealth accentuate inequities and engender jealousy. This sentiment leads to the emotion of rage and ultimately to behaviors of radical and violent extremism, terrorism being just one example.
    Dramatic inequity in wealth distribution is a moral problem that engenders social ills such as thievery, violence, and mistaken beliefs.
    National Health Care Administered by the Government is a Bad Idea
    Several countries already have national health care systems in Canada and Europe. This approach has resulted in a two tiered system: A “private” system in which the wealthy can receive any and all healthcare when they desire it; and a “public” system in which the average person must sit on a waiting list for a year or more to have their knee replacement or their heart surgery. Many of these countries have high income taxes on the order of eighty percent to pay for their entitlement programs. The government decides how the individual citizen’s money is spent. Do you think the U.S. Federal Government has proven it is the best entity to determine how your health care dollar is spent? That is the inevitable outcome of a “National Healthcare System”.
    A national health care system already exists in the United States. It’s called Medicare and Medicaid. These programs have failed miserably in several aspects: Lack of coverage: The number of uninsured citizens keeps rising despite the ever increasing money spent on Medicaid and Medicare. Those who are on Medicaid and Medicare are under-insured because these systems reimburse physicians at a rate of roughly twenty cents on the dollar. Most primary care physician practices’ overhead averages forty to fifty or more percent. Thus, physicians lose thirty cents on the dollar for every Medicaid and Medicare patient they see. This necessitates physicians to either refuse to accept Medicaid and Medicare; or to be forced to go out of business through lack of financial viability.
    Entitlement programs charge working Americans twice, and in some cases three times, for the benefits they provide their recipients: through taxes, through cost-shifting of high insurance premiums; and through obligating physicians and hospitals to provide free care to anyone who walks through the door, be they tax-paying citizens or not.
    Just so you’re under no illusions this is a small problem, look at the 2006 statistics published in the American College of Obstetricians and Gynecologists’ newsletter: Seven percent of obstetricians quit delivering babies altogether and another twelve percent curtailed services to accept only low risk clients. The reasons cited for this were declining reimbursement for deliveries and increase financial and emotional cost of malpractice insurance. A large portion of obstetric patients are illegal immigrants who are either uninsured or covered by Medicaid “Emergency Services Only” which pays dismally. This twenty percent reduction in obstetric services in a single year is truly astounding.
    The main reason reimbursement by Medicare and Medicaid is insufficient is because there is a tremendous disconnect between the consumers of these benefits and those paying for these benefits. The payers are middle class working Americans. The consumers are retirees, people below the poverty level, and people who are illegal migrants. There is a complete disconnect between those who pay for the system (middle class Americans) and those who receive the benefits.
    Disconnect between payer and recipient results in over-utilization of expensive services. If you don’t have to pay for something why hesitate to use it? Many people on Medicaid use the nation’s emergency departments like clinics because they don’t have to foot the several thousand dollar bill for an emergency department visit. If people are insulated from the cost of their prescription medications they are likely to use expensive heavily marketed drugs even if they have no proven benefit over older generic drugs.
    Solving the health care crisis in this country requires increasing the connection between the payers and recipients and dispensers (health care providers and organizations) of health care services.
    Profit Incentives…well…raise profits (and cost)
    Why should commercial insurance companies and pharmaceutical companies make billions in profits when there are 46 million uninsured Americans? It just does not make sense. That is the multi-million dollar question. How can, for example the CEO of United Healthcare justify taking home a multi-million dollar annual compensation package when there are children and adults in this country who go without basic health care needs such as vaccinations and access to medical providers?
    Commercial Insurance Companies:
    Increasing Transparency and Evaluating “Managed Care”
    Increasing Transparency
    How do you know you’re getting the health care benefits for which you’ve paid? Do you understand your EOB (Explanation of Benefits) you receive in the mail after you’ve visited a health care provider or pharmacy? Have you checked to see if the insurance company has paid the correct percentage (accounting for deductibles and co-pays) according to your written policy? Have you read your insurance policy?
    The average person (including me) has not read her insurance policy word for word. It’s usually a dense 50 or 60 page document written in legalese. The fine print within this document can contain many exceptions to the summary of the policy, of which you are unaware.
    Does your insurance company pay for “out-of-network” providers in strict accordance with the written policy?
    If you don’t know the answers to all these questions you may not be (probably aren’t) receiving the full benefits for which you are paying. Ask your insurance policy to account proportionally for every dollar of your premium – write to their CEO or CFO. They should at least send you an “annual report” – the company summary they mail yearly to investors. If you can’t get the information by asking, state you’re interested in investing in the company and can they send you an annual report? Money talks and information is power. We can’t do anything about rising health care premiums until we understand where each dollar goes. Once we understand where the dollars go, we can work to control the components eating those dollars.
    Part of how insurance companies have made away with so much of our money is because we don’t demand the information. If we sit passively and complain it accomplishes nothing. Do something! Start by demanding an accounting of where your money goes. You have a right to know.
    If we curtail existing entitlement programs we decrease the administrative burden of the Federal Government. There is a National body, the Joint Commission on Accreditation of Hospital Organizations (JCAHO), whose job is to regularly visit every hospital in the United States to see if they are living up to standards of safety and hygiene. Why not demand a Federal body that does for commercial insurance companies what JCAHO does for hospitals? Given that the largest portion of our national gross domestic product goes to health care it’s only appropriate the insurance companies be held accountable for responsible use of those dollars.
    Evaluating Managed Care
    Managed Care is a model that originated in the 1980’s to attempt to control heath care costs. The original intention behind it was to link quality to cost and use the scientific method to evaluate the merit of various medical treatments. It has undergone much iteration over the past three decades. However, managed care has failed to control cost. Indeed costs have risen hundreds of percentiles over the past three decades.
    Original versions of managed care involved a “gatekeeper” system in which insurance companies dictated patients must see a primary care physician before obtaining a referral to a specialist. Patients also had to jump through hoops to get basic services or tests ordered by the doctor covered. These factors caused great dissatisfaction among consumers of healthcare.
    The present version of managed care involves “Preferred Provider Organizations” (PPO’s): establishing “in-network” and “out-of-network” benefits paid at different levels. The idea behind this is an insurance company negotiates “discounted rates” with a group of physicians or hospitals then drives consumers to use those physicians or hospitals. The advent of PPO’s has also failed to result in controlling health care costs.
    Some of the greatest reductions in health care costs have come from hospitals and physicians themselves. Many physician groups and hospitals have taken the initiative to develop “Disease State Management Protocols” and “Clinical Pathways”. These are tools used to standardize care for common illnesses using evidence-based medicine and proven methods to control the cost of in-patient hospital care. These and similar efforts have produced the most dramatic control of health care costs, while actually improving and standardizing the quality of medical care delivered.
    The FDA incentivizes pharmaceutical companies to develop and market “new and better” drugs because patents on drugs expire after ten years and the drugs can then be produced as generics. Pharmaceutical companies are under minimal obligation to prove their “new and better” drug really is more effective than older, cheaper generic drugs. Pharmaceutical companies aggressively market new expensive drugs direct to consumers on television and to physicians without being required to prove they are more effective than their predecessors. Why? They should at least be required to disclose data about efficacy, just as they’re required to disclose side effects of their drugs.
    Often new drugs are simply old drugs that have been “tweaked” by adding a minor chemical appendage so as to technically make them into new chemical compounds, although they don’t act any differently than their older predecessors. Some examples are “new” birth control pills touted to improve premenstrual syndrome and acne, which are variations on older generic birth control pills. Newer birth control pills sell for about $50 to $60 per month; whereas generic pills sell for about $7 to $10 per month. Both types of pills improve acne and premenstrual syndrome.
    Another example is newer anti-depressants such as Lexapro and Celexa. These drugs are off-shoots of the old stand-by, Prozac (fluoxetine). Prozac is now generic (fluoxetine) and cheap whereas these newer drugs are not. They are touted to have fewer side effects; and they may indeed have fewer side effects. But they have not been required by the FDA to prove it in head-to-head randomized double-blinded, placebo-controlled trials. Are they required to disclose this fact in direct-to-consumer advertising? Why not? Moreover, there are new concerns about all the anti-depressants and increased risk of suicidal or violent behavior.
    What is the logic insurance companies use to determine what they will and will not cover? For example, some insurance companies cover drugs to treat erectile dysfunction but they don’t offer maternity coverage, or coverage for contraception. Or they offer these benefits for additional premium. Why?
    We certainly don’t want to discourage development of new drugs by removing the profit incentive. However, companies should be required to disclose efficacy data in marketing to consumers and physicians. Drug development must become more transparent to consumers so they can make the best choices for their physical well-being and the well-being of their wallets.
    Malpractice Risk Drives Up Cost Via Defensive Medicine
    You’ve all heard the politicians and the media bemoan the fact that malpractice risk increases costs for everyone so I don’t want to tire you with repetition of this other than to summarize. The high cost of malpractice insurance and the emotional toll of malpractice suits cause physicians and hospitals to engage in “defensive medicine”. Defensive medicine is ordering unnecessary tests in order to prove the patient doesn’t have a serious illness and thereby avoid a malpractice suits. There is no evidence that defensive medicine results in better medical care or reduces malpractice suit. The only reliable conclusion drawn by studies of defensive medicine is that it increases the overall cost of health care.
    Malpractice suits have become something of a “lottery” – consumers looking for the multi-million dollar payoff. Defendants (physicians or hospitals) “win” eighty percent of malpractice suits that go to trial – usually after an expensive, drawn out, draining battle. The only people who truly win in these cases are the trial lawyers. Even the malpractice insurance companies take a hit but at least they can pass their cost onto the physician. Guess who the physician passes the cost onto?
    However, if physicians passed on the entire cost of rising malpractice premiums to patients, no one would be able to afford to visit the doctor. Therefore, they only pass on a portion of the increased cost and they absorb the remainder. As malpractice insurance premiums rise, guess what happens to the business bottom line? This is a large contributor to the exodus of physicians from obstetrics: rising malpractice cost and declining reimbursement. If it actually costs you money to get up at 3 a.m. and go deliver someone’s baby, why do it? It makes no sense.
    Money Spent on Extremes of Life
    Ninety percent of the health care dollar is spent on the last six months of life. This often involves intensive care for people afflicted with terminal illnesses who are on life support. They
    may require a tube to breathe, medication to keep their heart rate going and blood pressure normal, a tube for feeding in the stomach, or intravenous nutrition. We often die in hospitals hooked up to machines and being pumped full of drugs. We may not even be conscious. Is this how you want to die?
    Just because we possess the technology does not mean it is best for us to use it. In the past we died with dignity in our homes, surrounded by family members. You should consider how you want to die at a time when you have full mental faculties and can make an advance directive. An advance directive is a document specifying what measures you want taken to extend your life should you not be able to decide for yourself. Don’t leave it up to your family members to make the decision because no one wants the responsibility of “pulling the plug”.
    These extreme measures often consume the final dollars of a family’s savings and are a large component of Medicare expenses. This is money that could go to your children and grandchildren. It could pay for someone to go to college or someone to have a place to live. We have to decide for ourselves how much is enough and how much is too much?
    Okay, so I’ve identified this, that and the other thing that are wrong with our health care system. What is right with it? Well we have access to advanced technology, well-trained physicians and nurses, antibiotics, and the best science money can offer. Too bad such a huge number of people struggle to get basic health care needs met. How do we get out of this mess?
    Addressing the Big Four will “Fix” the United States Health Care System
    In summary there are four big offenders in producing out-of-control health care costs:
    Addressing each of these will decrease the cost of health care while preserving the advantages of technology and science, and increase access for everyone to basic health care services.
    The silent underpinning of many of these problems is risk. So how we manage risk determines the cost of our health care.
    Connecting the Payer with the Recipient
    It is crucial to connect the recipient of health care directly with the payer. The consumer needs to bear the risk of his health care decisions. The consumer of health care needs to directly feel the impact of system utilization in their wallet.
    Eliminating or reducing the scope of entitlement programs would go a long way toward reducing the burden of health care costs for the middle class. Recipients of Medicaid should be required to prove they are U.S. citizens. Non-citizens should not be eligible to receive benefits for free. They should have to pay for their health care just like the rest of us.
    If we do issue driver’s licenses or identification cards to non-citizens, it should be tied to proof of health insurance, proof of auto insurance, and proof of paying taxes.
    We need to decrease the influence of the middle man and limit the role of private health care insurers and the government. One approach to this would be for groups of people to participate in pooled risk plans in which premiums and benefits are determined impartially by an actuarial company. This could be self-directed, for example, by employees of large companies or other pooled risk groups. Alternatively the existing insurance company framework could be restructured so as to decrease the “fat” in the system. This would require government or some outside agency regulating insurance profitability. What justification is there for the CEO of an insurance company making millions of dollars while many Americans go without basic services? Insurance companies would certainly balk at government regulation.
    Consumers must demand greater transparency from commercial insurance companies regarding how their health care premium dollars are spent. Only when we understand where the money goes can we solve the problem of high cost.
    Exert Your Own Cost Control
    You have the power to control your individual health care costs. If everyone reduces her individual costs, the collective cost of health care will decline. Examine your utilization. The most expensive healthcare services are emergency room care, intensive care units (ICU’s), surgery, and advanced imaging studies such as MRI’s and CT scans.
    Examine your utilization of the system. First, if you are ill after regular business hours, decide if you’re sick enough to need to go to the Emergency Room at a cost of thousands per visit; or can your condition wait until your doctor is available during regular business hours for a fraction of the cost?
    Of course for emergencies like chest pain or hemorrhage you should proceed to the emergency room. But if you have chronic pelvic pain and have developed a worsening of pelvic pain the emergency department is not the best place to receive care for this problem. Childhood runny noses and rashes also don’t need to be seen in the Emergency department unless you’re concerned your child may be seriously ill (e.g. have a high fever, or is unable to keep food and water down).
    If your doctor recommends a test, ask why? What is the doctor trying to learn with the test? What are the benefits, risks, and costs of the test? Will this test lead to further testing or surgery? Are you asking for the test because you want to know a certain result? Is the test going provide the information you desire? Will the test give you any useful clinical information to better understand your health? You should know the answers to all these questions before submitting to tests.
    A perfect example of useless tests is “hormone levels”. Women ask me every day to check their hormone levels. If I can’t talk them out of it I usually oblige to satisfy them. However, female hormone tests do not tell us anything your own body can’t tell. For example, if you are having regular monthly periods your hormones will be “in the normal range”. The “normal range” is determined by measuring hormones of millions of “average” people to establish normal values. If you are over thirty, skipping periods, having night sweats, or have stopped having periods, your hormones will be in the “menopausal range” because these values are established by measuring hormone levels of millions of menopausal women. If you are skipping periods before age thirty, you probably have “polycystic ovary syndrome” caused by irregular ovulation. I can test your hormone levels to confirm, but this is usually a diagnosis that can be made by asking questions and doing a physical exam.
    If you are having raging premenstrual syndrome (PMS) I can test your hormone levels. They will most likely be “in the normal range” because hormone levels vary depending on time of cycle, age, and other factors. I can be of much more help by addressing your symptoms and developing a plan to manage them than I can by testing your hormone levels.
    Knowing your actual hormone levels does not help us treat hormonal disorders most of the time because treatment is based on symptoms, not on a number from a lab.
    If you have excess acne or hair growth it is likely your testosterone is high. I can measure it to be sure, but your body is telling me, by producing excess hair and acne that your testosterone level is high. Now if you have these symptoms a hormone level would be useful to exclude a testosterone-producing ovarian tumor. However, testosterone-producing ovarian tumors are exceedingly rare (<1/100,000). I will still recommend the test if I think it’s necessary based on your symptoms and physical findings.
    Be careful of independent labs that offer “saliva tests” for hormones. These are expensive and can be misleading. Saliva levels of hormones can be quite variable from time of cycle and time of day.
    Develop an advance directive while you’re at an age when you have full mental capacity and you can consider these decisions in a thoughtful manner. Write it down. You don’t need an attorney to create an advance directive. Simply writing it down in one page or one paragraph is sufficient. If you want it to be “official” have it notarized. Make sure it answers crucial questions in a clear fashion for your relatives to understand. Advise your relatives you have an advance directive; review it with them; and make sure they know its location. At the end of life do you want to be kept alive with a breathing tube, intravenous feedings, or drugs? To what extent and expense do you want your body to be preserved, possibly with your mind in a vegetative state? Do you want to be resuscitated (brought back to life) if your heart or breathing stops? What would be the criteria you would want established for any of these measures to be taken?
    Require Insurance Companies and Pharmaceutical Companies to Increase Disclosure, Transparency, and Accountability
    We must hold big business accountable for making the most of the dollars we pay them. Insurance companies should be required to present policies in clear, consistent, standardized language to make it easy for the consumer to compare policies. An objective oversight body similar to the Joint Commission for Accreditation of Hospital Organizations (JCAHO) should be established to assess insurance companies and pharmaceutical companies to determine if they hold up to their promises.
    Pharmaceutical companies or an outside agency (don’t we pay the FDA to do this?) should be required to conduct studies of efficacy of new drugs in an objective manner and disclose these results to the public along with the rest of their direct-to-consumer advertising.
    The free market system works: competition encourages innovation and fosters incentives for cost control. We want to preserve the elements of the free market system that function well, while not sacrificing accountability and quality control.
    Doctors Can Impact Cost by Using Evidence Based Medicine and Resisting the Temptation to Practice Defensive Medicine
    Doctors, nurses, and other healthcare providers can dramatically impact the cost of health care by resisting pressures to practice defensive medicine. One would not want to deny access to a necessary diagnostic test or treatment based on price. However, so many tests and treatments are ordered as “cya” measures.
    Often patients request tests that are unnecessary. Usually one can explain the rationale behind testing or not testing and advise the patient to make an informed decision. However, some people are set on the idea that they need this or that test to understand their health. In this instance it is usually counter-productive to try to “talk” the patient out of it, and just go ahead and order the test.
    In order for health care professionals to reduce the habit of defensive medicine, they need relief from the pressures to do so. A revamping of the “malpractice” system in the United States is long overdue.
    Eighty percent of “malpractice” suits are won by the doctor or hospital being sued. This means in most cases that go to trial, evidence of malpractice cannot be found. The stress and cost of malpractice suits is discouraging good people from entering the field of medicine; and causing many to leave medicine or limit their practice to “low risk” disease conditions.
    It has been suggested by consumer groups, physician groups, politicians, and government agencies that it is time to move to institutionalizing compensation for bad medical outcomes. The extent of damage and amount of compensation could be determined by an arbitration group. Funds for this should come from a number of sources: insurance premiums, lawyers, physicians, and consumers. Everyone should have to bear the cost of bad medical outcomes in order to curtail frivolous law suits and keep overall health care costs down over the long term.
    It is much more effective to use a carrot to get people to do the right thing, than to beat them with a stick. For the most part doctors are smart, conscientious – often perfectionist – people who strive to do their best; and if you prove to them certain disease management protocols improve care and reduce cost, they will use these disease protocols. Doctors have studied long and hard to become physicians and it is a life-long learning process that involves accumulating “continuing medical education credits” throughout one’s career.
    Evaluate How We Manage Extremes of Life
    You can maximize your chances of having a healthy term baby by following the advice in this book. You have more control than you may realize. Overall, though, ninety percent of the health care dollar is spent on the last six months of life. Premature babies are expensive and we should strive to reduce prematurity.
    This phenomenon has occurred because advances in technology have outpaced the study of ethics and responsibilities of a society to its members to provide the greatest good to the most number of people.
    We need to decide as a society: How do we want to enter and exit life? Do we want to die hooked up to machines in a vegetative state? Is this the best use of our precious resources? Do we want to risk leaving a legacy of health care debt to our heirs?
    You actually have complete control over this. By writing your advance directive, you remove the burden of your life’s decisions from others and take the initiative. I encourage you to write an advance directive and make your friends and family aware it exists. It doesn’t have to be long – a page or a paragraph. It doesn’t need to be written by a lawyer or notarized. However, if you take the trouble to have it notarized it may increase the likelihood it is taken very seriously.
    You must consider all the possibilities: What if you’re completely paralyzed or brain damaged in an accident? Or rendered into a coma? What type of medical interventions do you want to take place? I urge you to think about these things and write them down: Your family’s lives depend upon it.
    Only by tackling the four major factors increasing health care cost in this country can we obtain a safe, logical, cost-effective health care system. I encourage you to do your part.

  4. I’m just an average American health care consumer and I for one am sick and tired of being out of control of my health care situation. I don’t trust the insurance companies and quite frankly am starting to even question some of my doctors motives because it seems decisions on my health care choices are based on what insurance will or won’t pay for.
    I found this website, http://www.hsaebook.com, can anyone tell me if they’ve purchased this ebook and is it worth it?

  5. Patients don’t know enough about health to decide where to best spend their money. Patients definitely don’t have enough knowledge how to “evaulate” doctors regarding where to best spend their money. To make even one health care decision, let’s say whether to get a mammogram or not would take 3 months of learning/research to come up with a reasonably informed decision.
    I’m a doctor, I’m not a financial guy. I don’t pretend to believe I have the time/knowledge/money to understand who would be the “best” financial advisor for me. It’s not possible.
    Consumer-driven healthcare is for insurance companies to contain costs so they can predictably maintain a certain level of profitability. If costs are predictable, it is easy to setup a system that is profitable.
    Bottom Line: The health of a nation is not a business. Profits always get in the way of Health. It’s not complicated.

  6. I have become a huge fan of consumer diven health care because of the HSA I got at Healthia.com. The price was right. I get information and can shop for doctors. I can go to the doctor of my choice — neither an HMO or the Government tells me who see. What’s not to love?

  7. Maggie –
    I would like to thank you for your thoughtfullness, and for expressing your important message in such clear terms. Please disregard the posts above which seem to be more interested in being confrontational and being heard, than in offering anything meaningful or constructive.
    Your illustration of what a patient goes through in their decision process is exactly correct! If any of the sarcastic commentators above were to be diagnosed with a life-threatening cancer, I can assure you – they would be singing a different song. There is way too much information available for patients to be able to make sense of much of it, and unfortunately, my experience has been that most physicians cannot keep up with the scattered and often contradictory research that is out there, either. The most conscientious of patients come to realize, exactly as you have said, that at some point you need to be able to TRUST your physician to be thoughtful, thorough, and most importantly – to be acting solely in your best interest.
    However – even if the physician isn’t in any way being compensated financially (e.g., Pharma consulting fees, insurance company bonuses, or direct profits) – there is still the crucial issue of whether he is able to make the best decision when the research he has to rely on is so corrupted. (Please refer to others’ work on this issue, such as Marcia Angel’s book). How many physicians believed that they were giving the best advice when writing scripts for Vioxx, HRT, etc? As a cancer patient, I can tell you that the most frustrating and frightening aspect of having your life depend on the best medical advice possible, is realizing that our system of funding and coordinating medical research is SO flawed!
    It seems to me that without addressing the way we pay for and conduct medical research – any debate about health care reform is almost premature. The foundation of our model of health care delivery is being entirely driven by profit, rather than by what makes the most sense SCIENTIFICALLY. Physicians and researchers today have (many of them) become so used to being motivated by the financial incentives available, that to restore scientific purity to the system will certainly be very difficult. Declining insurance company reimbursements for primary care and other areas of medicine are very much a part of the problem. The stress and decline in professional satisfaction for physicians who have to take marching orders re: patient care from low level insurance company employees, certainly also contributes to the problem of physicians seeking ‘additional compensation’.
    Should you ever be faced with a cancer or other serious diagnosis, you will want to be certain that your physician is prescribing a regime that is based ONLY on what will give you the best outcome. But to know that, he needs to be able to rely on research that is totally based on science, which, as we have seen too many examples of recently, is often NOT the case when it is funded by pharmaceutical companies.
    Given the large role that drugs, devices and procedures play in our escalating health care costs, I cannot but believe that an excellent solution would be to vastly increase our NIH budget, and to significantly reform the research oversight process. As we all know, the FDA’s role has become little more than a puppet for Pharma. It should be mandatory that ALL studies, negative or positive, be published. There should be free access to medical research, so that researchers around the world are able to benefit from what has already been done, etc. There should be real efforts at collaboration between researchers, rather than the competition which greatly hinders progress at finding cures. Scientists should set the research agendas based on what looks promising for patient care, not for what will be most profitable for the shareholders of the Pharma stocks.
    If this sounds too idealistic – consider this. Our current system is NOT fulfilling the promise of better health. When twice as much funding (at least) is put towards marketing as towards research, and when those dollars that are spent in research are frequently going towards funding copycat, lifestyle or other unecessary drugs – it should be obvious that government funded and scientist driven research is a MUCH better way to go. We might actually make real headway into finding cures, if scientists were free to collaborate, and build on previous work.
    I would like to propose that the government pay substantial salaries to the people who deserve them – namely, the medical researchers. If they were handsomely compensated, and could focus on doing the best science in collaboration with clinicians, my guess is that we would save substantial in creating drugs that are truly necessary, and that would be available at much lower cost. The majority of costs of drug development are spent on areas other than research. This bloat need not be built into our drug costs. NIH (or a new government funded body) should play an active role in drug discovery and development. Perhaps the government could recoup the cost of paying the scientists’ salaries by selling the drugs to other countries, or private insurance companies, etc. So, they would be saving substantial dollars in lower drug costs for government funded programs such as Medicare, and in addition, could potentially also derive significant income from sales. Most importantly, the research will be much more expeditious, more successful, and it will be RELIABLE (i.e., uncorrupted)!
    For those that worry that without the profit motive, the science won’t thrive as it has in our country – why not offer bonuses to those that directly have a ‘hit’? Surely, we can find a way to make the process of discovery still profitable and professionally rewarding to those who most deserve it – the scientists – and NOT the executives and shareholders!
    I welcome constructive feedback on this post. For those of you inclined to spew more sarcasm, save it for others who may find you clever. I don’t. And may anyone who doesn’t recognize the importance of unbiased research, I will ask you to really use your imagination – pretend YOU have just been hit with a life-threatening diagnosis, and the only drugs available have all had prematurely shortened clinical trials, and were being pumped by ‘ghost writer’ researchers, etc. If you don’t know what I am referring to, please look into this important topic. It is real, and everyone should be very concerned about it. One day your life (or the life of a loved one) WILL be affected by it, and just might depend on it. Maybe then you will share in my concern, and join me in calling for a change in the status quo.
    S. Smith

  8. Maggie,
    Get with it. Stop being such a pessimist. You are right that we will provide care for people who make bad and good decisions.
    However, the “way of getting around it” is to ensure individual accountability for good and bad decisions through tax incentives, health insurance rates, adjustable costs of care, while ensuring access to screeenings, aducation and preventive care for all.
    The savings from the reduction of chronic illness and treatment of diseases not identified until their latest stages would more than cover “end of life” care; our largest single health care cost.

  9. “And when, in the end, we pay for their care, it is usually more expensive than it would have been if they had received preventive care, smoking cessation counseling, etc.”
    I have also heard arguments suggesting that, on average, longer lives are associated with more cumulative healthcare expense over those lives. That is, diseases that might have been death sentences several decades ago can now be managed, primarily with medication, but also with periodic checkups and appropriate tests. Poor compliance with respect to taking medication and/or following recommended diet and exercise regimens might result in premature death and lower cumulative medical cost.
    While it would obviously be nice if everyone with a chronic disease were in perfect compliance with all drug / diet / exercise recommendations intended to manage and control their condition, it is not necessarily the case that non-compliers who develop complications cost the healthcare system more cumulatively if their non-compliance leads to or results in premature death.
    I would be interested to hear if anyone can point to any data regarding cumulative lifetime health spending per person by longevity group. For example, how much healhcare on average do people who live to be 100 or more consume over a lifetime vs those who live to be 90-99, 80-89, 70-79, etc.
    I do not think expecting middle class and higher socio-economic groups to spend, say, $1,000-$2,000 per year out of pocket before insurance kicks in amounts to “letting bodies pile up in the street.” Denying treatment at the ER would be another matter, and no one is suggesting that. The problem is that maximizing compliance with chronic disease management through low deductible comprehensive coverage comes at a cost of lots of overuse and unnecessary care elsewhere in the system. I still think personal responsibility should count for something.

  10. > as a society we’re just not willing to watch the
    > bodies of people who made bad decions pile up on
    > the sidewalks.
    Right. We insist the bodies pile up somewhere out of sight.
    The clash is between two visions of a society: a bunch of individuals being protected from each other, or something more like a family. But families have a head, and this is the nub of it.
    Then there is the question of whether healthcare is owed to the sick by the rest of us. When the answer is in the affirmative, the question then is “what counts as healthcare? What exactly is meant by this?”
    I’ll have more to say about this over on Steve Beller’s wiki.

  11. Barry-
    I agree that many people often spend money foolishly. And if they don’t maintain their cars, no one expects that society should buy them new ones.
    But healthcare is different in this way: as a society we’re just not willing to watch the bodies of people who made bad decions pile up on the sidewalks.
    When push comes to shove, we will pay for the care of people who smoked, drank too much , ate too much, didn’t check out that strange lesion on their leg . . .
    And when, in the end, we pay for their care, it is usually more expensive than it would have been if they had received preventive care, smoking cessation counseling, etc.
    So, there is no way of getting around it (unless we’re really willing to let people die without any care in the final stages) this is a collective problem that requires collective solutions.
    Healthcare and car repair are two very different problems.

  12. With all due respect to the health experts … has anyone really seen one?… I put forward the arguement that we have and are wasting time and resources with the current debate currently in the public domain. If we are actually going to solve the cost-quality problem related to health care, vs. discussing it, we must recognize what the real problem is.
    Maggie’s comments, the related postings, current legislation, and many recent journal articles are quite thought provoking. Unfortunately, they are wasting our time and provide an excellent example of why solutions have and will continue to elude policy makers, providers, 3rd party payors, and the public.
    The debate about consumer driven health care was over before it began. Health care is and always will be consumer driven. Any other discussion or attempt to place responsibility with doctors, providers, policy makers, or payors is an exercise in a failure to understand and ask the right questions.
    Consider that in a free society such as ours each individual mostly chooses their own diet, physical activity and life style. Science continues to show that these choices, along with genetics are the foundation of our individual health.
    Although, we must recognize that outcomes measurements, best practices, clinical guidelines, comparative analysis, health professioanl training, and revising the fiscal burdens of the current health system are all part of the tool box for the future, solutions will ONLY be found when the discussion changes to individual accountability, personal health management tools, multi-cultural education and guidelines, and incentives for each person to accept the consequences of their own health choices. GH

  13. Maggie,
    With respect to your point about patients being just as likely to curtail essential care as unncessary care if they have high deductible health insurance, I see this as more of an individual responsibility issue as opposed to an argument in favor of low deductible, comprehensive insurance. If I don’t change the oil in my car at roughly the intervals recommended by the manufacturer, the car will probably die prematurely or get “sicker” sooner, but I don’t expect car insurance to pay for routine maintenance.
    Many people (especially the young and healthy) who make over $50,000 per year consciously opt to not buy health insurance because they think they won’t need it or, if they do, they can always get treated at an ER. Lots of people spend more than they can comfortably afford for housing beyond their real needs for many reasons from tax advantages to prestiege to a sense of entitlement to unreasonably high expectations as to what constitutes a minimally acceptable middle class life. If supporting this expensive (relative to their income) lifestyle causes them to skimp on healthcare, I think we should view it as their problem, not taxpayers’ or society’s problem, especially if we have collectively gone out of our way to make sure that low income people who can pass a means test receive extra help in meeting the high but manageable (for most people) deductible.
    As a taxpayer, I often get frustrated with what I would call a combination of nanny state and government knows best mentality that assumes that people cannot be trusted to act in their own best interest. I think that, on balance, they can and will. If they don’t, they should be prepared to live with the consequences.

  14. I don’t think people understand this; people don’t even question care that is offered. Patients walk into a place of health care deliver (generic for hospital, doctor’s office, etc…), we allow a provider to dictate what we can or cannot do what we should or should not do and we wait for hours to let them tell us. We must first understand our rights as a consumer, make informed decisions about our care and only at that point will the other components of health care begin to understand that they are going to have to change their way of thinking and doing business. There are so many false affirmations as to the problem in health care and the high cost. There are so many things wrong with health care that we must prioritize, what is the biggest problem? It has to be the unacceptable number of people who die each year due to PREVENTABLE errors. This and the other crimes committed in health care delivery are based on consumer ignorance. How am I and others supposed to care about price sensitivity when MILLIONS of patients are injured while receiving care and TENS OF THOUSANDS die each year?
    I’m sure this has been said before but look at the same number of deaths attributed to commercial airline crashes each year. The IOM report is equal to one major commercial airliner crashing full of passengers EVERY DAY of the YEAR. Other reports suggest and I agree that the number was very low. (many errors that occur in hospitals are not reported, I know of no mechanism to report doctor’s office errors) If this was occurring in the airline industry there would be immediate reform, government involvement. Healthcare does not get the same response, if this was happening in the airline industry and the government did not respond, we as consumers would stop flying. This is the basic principal that must be applied to health care delivery. Consumers must force the change, we must get the information and force change.

  15. > Consumer driven healthcare is providing all patients
    > the tools to allow them to choose the good doctor and
    > not become the victim of the bad doctor.
    Yes — this is a necessary and big part of it. The other bit is about introducing some price-sensitivity back into it and getting people to understand again the “insurance concept”. Kinda like car insurance — lots of people evidently don’t understand that either. But more understand this than medical insurance.

  16. What I believe to be missing is what I consider to be true consumer driven healthcare. Patients are the first to tell you they don’t know what is the best course of treatment. You do not identify true consumer driven healthcare, what I suggest is is where consumers with the right tools have the ability to change healthcare delivery through consumer choice. As things are now consumers are patients and patients only. Patients must act like and be true consumers. If car maker A makes a terrible vehicle and car maker B makes a better one, even if they are the same price I can get the information I need to choose vehicle B. The same does not exist for patients. Consumer driven healthcare is providing all patients the tools to allow them to choose the good doctor and not become the victim of the bad doctor. This goes for all forms of healthcare delivery hospitals, nursing homes, SNF’s dentists, all providers.
    Considering what is happening in healthcare and ALL the failed efforts at reform we cannot wait for nothing to happen. If you and I and all other consumers of healthcare, in very simple terms, see the good doctors and not the bad doctors, go to the safe hospitals and not the unsafe hospitals, consumer driven change begins to happen. The bad providers start to see the impact and either change or get out of the business.
    We can discuss the dollars and cents of healthcare but the real crime is the lack of quality, the risk of going to the hospital for care, the number of injuries that occur during health care delivery and the horrific number of deaths, that we know of, that are attributed to preventable errors. Giving consumers the knowledge is the only hope left to change healthcare for the better.

  17. Great conversation! I would like to point out what Porter points out in Redefining Health Care, the consumer-driven movement is really just another myopic way to shift costs from payers.
    Additionally, nearly all health care consumers are dissonance reducing. And I am not just talking the checkout clerks. In the end, both payers and providers have shifted their patient support obligations to information brokers and patient support services. And to some extent I would much rather have a forward thinking organization like Google managing my health than the bloated, archaic, byzantine and misaligned players that dominate the current system.

  18. > Tom– you ask “who” is recommending
    > consumer-driven health care.
    No, I did not ask who is recommending consumer-driven healthcare. I asked who is saying consumer-driven healthcare is the answer to our health care crisis.

  19. Many excellent points on both side made by intelligent people! Here’s my attempt to reduce the conversation to language Rick and the “checkout clerk” hopefully understand.
    It makes sense for consumers/patients to have information they need to make wise decisions about their own care. If every healthcare provider knew the safest and most cost-effective way to diagnose and treat each patient, if they had the skills and tools needed to deliver that care competently, and if they were rewarded for doing so … then there wouldn’t be having this conversation because care would be delivered efficiently and effectively consistently, and the consumer/patient wouldn’t be into the position of having to make medical decisions. I believe, btw, that is a plausible goal if our country had its priorities straight and implemented sane strategies and tactics, such as defined on our WellnessWiki.
    But since our overly expensive and error-prone healthcare system is being driven by ridiculous policies – where ignorance and secrecy far exceed knowledge and openness, where incentives are misplaced, where strong leadership is lacking, and where destructive games are played to make an extra buck – something new and different must be done to control costs and improve outcomes by breaking the status quo. Consumer-driven healthcare is an imperfect strategy that cannot possibly succeed on its own, but at least it’s an attempt to improve the current situation.
    For any such approach to work, there must also be a sincere and concerted effort bridge the knowledge void, redirect competition; promote consumer-centered , personalized care, support a high fidelity care delivery system, fill the health information technology gap, focus on improving care quality with evidence-based guidelines, and so on.
    If our country has the will to do these things, our healthcare system will evolve into one that helps all people live healthier, happier, and safer lives. Until then, we’re just chasing our tails with no-win, short-sighted, stop-gap measures. So, while Consumer-Driven Medicine ought to be praised for its merits, it is also worthy of much criticism, especially if presented in isolation.

  20. Maggie,
    Re this statement:
    “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.
    Your assertion that its not yet possible to really understand HC quality is patently not true.
    While there’s no question that we’re still at the beginning of leveraging analytical power in health care, a wealth of excellent tools are available to evaluate quality. It is now possible to understand outcomes quickly and accurately through the application of these tools to both clinical encounter data – which typically includes only the experience within a portion of the continuum – and claims data, which are less robust – they does not include lab values or clinical notes, for example – but are embedded with a tremendous amount of clinical information from the full continuum of care.
    I’d urge you to investigate the risk adjuster analytical tools available through Medstat, Ingenix, CareAdvantge, MedAI, TreoSolutions, and D2Hawkeye, to name a few. You also might want to learn about the standardized quality measures that have been developed through the National Quality Forum (NQF), the US Agency for Healthcare Research and Quality (AHRQ), the National Committee for Quality Assurance (NCQA), the Joint Commission for Accreditation of Health Care Organizations (JCAHO), and others.
    Nearly all Fortune 500 firms now use commercially available analytical tools to evaluate the pricing and quality performance of their providers, to identify patients with chronic and acute conditions that need care. These tools are now high credible, have been subjected to extensive review and are in wide use.
    The next step in the evolution of transparency information is the aggregation of data sets with large enough sample sizes to make credible evalations of health system vendors throughout a region. As that information becomes available to every purchaser in a market, it will, for the first time, begin to rationalize the health care marketplace, which has operated until now virtually with no information.
    Finally, it is a mistake to think that the prime drivers of health care change will be consumers. It will be the vendors – the physicians, hospitals, health plans and manufacturers – whose performance is finally on display. That will encourage signifcant adjustments in behavior, under the principles that nobody likes to be seen as a jerk in public.
    Brian Klepper, PhD
    The Center for Practical Health Reform
    904.246.9643, bklepper@cphr.com

  21. I certainly don’t think the patient shouldn’t be the decisionmaker. Quite obviously, the patient should be the final arbiter–it’s their life, after all.
    What I find puzzling is this idea that “consumers” will improve the healthcare system. Consumers are just people who pay with their own savings, right?
    Currently, that’s an option for people. And right now, people who pay from their own savings pay MORE than anyone else does. Why would we think more people paying from their own savings would make the system cheaper?
    And beyond the facts, I fundamentally don’t get the theory here. Why would a rational person expect sick people to haggle with doctors or comprison shop better than huge insurance companies which bargain down and comparison shop for a living, or governments which have the leverage of huge market share? From a pure price standpoint, Wal-mart bargains for flip-flops better than I do, in large part because they buy them by the bazillion. I don’t have delusions I could out-bargain Wal-Mart on flip flops, and by the same token I don’t have delusions I could out-bargain Medicare or Wellpoint for heart bypasses (procedures which, I suspect, have a far more inherently complex price structure than “I’ll give ya a nickel for the blue ones, and six cents for the red ones”).
    Second, what no person has ever made clear to me is why paying their own money should magically make people better decisionmakers about their health. First of all, there’s a wealth of research indicating this doesn’t happen. But even setting empirical facts aside, it doesn’t make any sense. I mean, most normal people don’t want to have unnecessary medical procedures because they’re at best, inconvenient, and at worst, they hurt!
    I’m not deying that people get care they don’t need. It’s a problem, and it needs to be addressed. But why would anyone expect that making patients pay money would address this problem? Seriously, what’s the marginal value of this added disincentive? If you said to me, “pay me $50,000 or I’ll crack your kid’s chest open for no reason,” I’d much rather pay you the money. Most normal humans fear torture more than we fear bankruptcy. So, suggesting that people are suddenly going to become much more skeptical of the necessity of a triple heart bypass because it’s not just a doctor cracking open their chest, it’s a doctor cracking open their chest and a $15,000 payment seems like you don’t understand that when most people are asked, “your money or your life,” they hand over the money. You may also find the cliche “if you haven’t got your health, you haven’t got anything,” illuminating.
    Now, it’s perfectly obvious to me that “consumer-directed health care” can save money–sick people won’t get medical care if they’re poor, and healthy people won’t have to pay for it. I think everyone understands that rationing health care based on ability to pay means the global healthcare costs will decrease. Furthermore, becuase our current system cross-subsidizes the care of many sick people with contributions from healthy people, if we switch over to only cross-subsidizing the care of well-off sick people with healthy people, healthy people will pay less, at least in the short term. That makes a lot of sense to me.
    But while I can see where patient-driven healthcare could lead to real quality improvements, I really fail to see where consumer-driven medicine should be reasonably expected to achieve much of anything beyond making healthcare cheaper by denying it to poor sick people.
    Calling it “consumer-driven healthcare” is putting free-market lipstick on the pig of price rationing. Price rationing has its real merits, but I don’t see why any reasonable human being would think price rationing is going to improve the healthcare system, if we define a “good” healthcare system as one which delivers the best possible care to the most people for the least money.
    Of course, many people define the health care system as one which delivers the best care to ME for the least money spent by ME, and I can see where a subset of such people would find a healthcare system dominated by consumer-directed health care, which rations by price, very appealing.

  22. Let me try to answer a few questions and make a couple of comments.
    Barry– it is admirable that you actually care about the bill even when someone else is paying. Unfortunately; most people don’t pay as much attention to the cost, as long as it is covered.
    But if our goal is avoid waste, and raise the quality of care, higher deductibles and co-pays are not the answer. Studies show that when patients are paying out of their own pocket, they are just as likely to curtail essential care (diabetics not having glucose levels checked, etc.) as unnecessary care (duplicate or unnecessary tests, etc.) (See “Insured But Not Protected: How Many Adults Are Underinsured?” Health Affairs, June 14, 2005.)
    The problem is that most of us are not doctors, and so not in a position to judge whether an MRI is necessary or whether an X-ray would be just as good. (As I noted, often even doctors are nmaking an educated guess).
    And when a patient cuts back on necessary care, in the end, he winds up sicker–and we all end up paying for it.
    Tom– you ask “who” is recommending consumer-driven health care.
    Let’s start with President Bush:”I believe that the more the consumer is involved in pricing, the more the consumer is involved in the decision-making, the more likely it is people will start making rational decisions for their own needs.”
    At the third annual world-wide Healthcare Congress, Bush again talked about turning healthcare into a “consumer-controlled industry” and was seconded by William McGuire, CEO of United Health–he’s the guy who took home all the stock options this year.
    (Peter, by the way, is right, the “Consumer driven” movement, like most of the Bush administration initiatives are designed to maintain the status quo, and allow vested interests to hang onto what they have. The insurance industry is very enthustastic about highly profitable “consumer-driven” health plans which shift both the financial and the decision-making burden to consumers, much the way 401ks–in contrast to traditional pensoin plans–shift risk to the employee/individual investor.)
    Back to the question: who is recommending consumer-driven care as a solution? As I mentioned, Regina Herzlinger of Harvard’s Business School is a leading advocate. See her book “Market-Driven Medicine” on Amazon.com and both critics’ and reader’s comments to get a sense of how this concept initially swept the medical community–and how, now, people are beginning to raise questions about the concept.
    You ask “how many? people are recommending it? Google “consumer-driven healthcare and you’ll find 79,000 references. A quick search of “Factiva” (formerly Dow Jones Informaiton service which tracks newspapers and magazines world-wide, shows 2667 articles talking about consumer-driven healthcare in the past two years
    Tom, I’m not quite sure why you feel a need to be saracastic, but let me quickly respond to a few of your other questions. Why can’t a “resourceful shopper” simply go on line and research doctors and medical treatments?
    First, a little information is a dangerous thing. Information is not knowledge. (As so many investors discovered in the 90s.)
    And that’s what you find online about doctors–a very little information. (On this point, See Dr. Atul Gawande’s article in The New Yorker “The Bell Curve”–you can access it, at no charge, on Google.)
    Again I refer you to the individual investor’s exeperience with 401ks. Many ressourceful investors went online to get information. The result?
    See EBRI (Employee Benefit Reserach Institute) for numbers how much individual investors have made–and lost- on average, over the last 10 years, while investing their own money.
    You point out a seeming contradiction in my argument: While I suggest that patients are not in a good position to find the most competent doctor–or the best treatment– by doing reserach online, I simultaneously suggest that they try to find a doctor who they trust.
    My point is this: You don’t have to go to medical school to recognize someone you trust. This is an intuitive ability that many of us have.
    Put it another way, a friend who recently had a heart attack says that when she walks into some doctors’ offices, she can “hear the cash registers ringing.” But not all of them.
    I think most of us have had this experience, whether dealing with a doctor, a car mechanic, or a contractor who is going to help us renovate our house. Greedy people have a hard time hiding their avarice. Just ask a few questions about how much they will be charging for various services–the doctor who becomes angry, or defensive at the questions (do you have any idea how many years I studied!!) is not the one you want.
    Finally, Tom, I’m dismayed by your assumption that a doctor who sees himself as a professional and puts his patient’s interests ahead of his own financial intersts is an “angelic” ideal. In fact, putting the patient first is part of what he pledges when he takes something called the Hippocratic oath. (I can only hope that you’re not a physician).
    And Eric, I’m sorry I haven’t answerd all of your questions in all of your comments on past posts. But you make so many assertions without specific evidence that it’s hard.
    Here, let me just respond to one point.. You refer to the need “for widespread medical liabity reform.”
    While malpractice insurance is a huge problem for individual doctors in indvidual specialities (like OB/GYN) in individual states, (and has driven some very good doctors out of the profession,),the notion that malpractice ligitation it what is driving healthcare costs sky-high is a myth.
    In fact malparactice awards(in court) and out-of-court settlements equal just .5% (one half of one percent) of total health care spending in the U.S. (See Anderson, et. al., “Health Spending in the United States . . . ” Health Affairs, July/August 2005)
    Of course that doesn’t cover the cost of doctors practicing “defensive medicine.” But what’s interesting (and surprising) is that malpractice awards and settlements are higher in Canada and the U.K. than in the U.S.– and the size of theose settlements and awards is growing faster–by 10 to 28% a year in those countries vs. 5% a year in the U.S. (see same Health Affaris article.)
    So one would think that doctors in those countries would have just as just as much reason to practice “defensive medicine.”
    Yet, we spend twice as much as Canada on healthcare and 2 1/2 times as much as the U.K… .Clearly, given the litigious situation in those countires, fear of litigation does not explain why health care is so much more expensive in the U.S.
    Meanwhile, a recent study in the Journal of the American Medical Association shows that middle-aged Caucasians in the U.S. are, on average, significantly less healthy than middle-aged Caucasians in the U.K. (see google medicaldisclosure.com, 10 June 2006. –
    It’s hard to say why. We’re fatter than they are, but they drink more. Lifestyle factors seem to be a wash. . .
    One would think that by spending so much more, we would be healthier . . . It seems that we’re not getitng much of a bang for our buck.

  23. In cancer medicine, academic hospitals, according to JNCI, “the chemotherapy concession is not held by the individual physician; revenues go instead to the institution.” This kind of phrase in mainstream journals lay bare the economic motivation behind the excessive use of chemotherapy. One proposed solution to this income gap, says Thomas J. Smith, M.D. and colleagues at the Medical College of Virginia, is to make “academic onoclogy practices more profitable and salaries more generous.”
    In other words, academic oncologists should become more efficient billers, prescribing even more drugs and squeezing more revenue out of every therapeutic opportunity. Perhaps they would then be compensated by their universities for the larger bills. I’m sure anyone who has been billed for cancer treatment would recoil at the suggestion. That route might be good for the drug industry, but would it benefit patients? The present system exists to serve the clinical investigators and the clinical oncologists, but not to serve the best interests of the cancer patients.
    Cancer doctors had the financial incentive to select certain forms of chemotherapy over others because they received higher reimbursement. The practice created a potential conflict of interest for these doctors, who must help cancer patients decide whether to undergo chemotherapy or continue if it is not proving to be effective and which drugs to use. The money these doctors make from selling medicine was contributing to the nations high health care bills and adding to the waste and inefficiency in the health care system.

  24. Boy you guys really are all full of yourselves. Tell me how the checkout clerk at the supermarket is supposed to make heads or tails of anything you’re suggesting. Pompous asses, all!

  25. I agree mostly with Peter — the so-called Consumer-Driven approach without symmetrical information or accountability I think is supported especially by physicians because it maintains their traditional position in the doctor-patient relationship. They will not have to face a knowledgeable buyer.
    Consumer-Driven mechanisms can in the context of a thoroughgoing reorganization of the industry a la Enthoven be useful to inform patient (or even physician) choices at the margin. Without a reform in place, these mechanisms might cause some patients to educate themselves about the nature of insurance, might cause them to demand a better information, and might induce some price sensitivity for common “technical” procedures. These are important things, and if we are going hard down the path of incrementalism make some sense. But mostly I think it will maintain the status quo.

  26. If anyone wants to read the money statement, it is this:
    “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…In other words, what we need isn’t ‘consumer-driven medicine,’ but ‘patient-centered medicine.'”
    Thus, your argument against encouraging patients to be consumers and doctors to be business people is that patients are not consumers and doctors are not business people. I think you are merely stating your personal preference for a patient-driven system vis a vis a consumer-driven one. And that’s fine. But it makes your argument little more than a long-winded personal lament that medicine is modernizing to become a free market economy based on capitalistic principles rather than command and control style economic planning reminiscent of the defunct socialist and communist economies of the last century. Which, again, is a fine lament for you to make.
    But it doesn’t speak against consumer-driven health care as “the” answer; it just tells us that “you” don’t like it. And, in a free society, it’s your right to make that known.

  27. Maggie- well written, even if I disagree with most of it!
    Respectfully, you have dodged all of my questions during the week– and followed the wonderful medical student and resident trick of “don’t answer the question you’re being asked, answer the one that you know”.
    You lay out a whole host of reasons why the patient cannot possibly be equipped to make his or her own medical decisions and then say that they want to understand their options and even get second opinions.
    You also lay out some very severe criticisms of the concept of ‘pay for performance’: ” 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. ” Yet the ‘medicare for all’ approach you favor is on the verge of going to the system you say cannot possibly be accurate.
    The medicare for all proponents also conveniently leave out any widespread medical liability reform that would actually protect doctors (and others) if they are simply doing their best in uncertain situations.
    I am sorry, but none of your arguments this week have gotten beyond the pie in the sky stage— I presume you wish the rest of us to ‘trust you’ to have unelected wise men and women figure out the details later, in an environment that I’m sure will not be subject to lobbyists, interest groups, or personal biases.

  28. Those trying to solve the growing crisis by proposing consumer driven healthcare, given that the present providers even want that and will allow it, are really trying to keep the present system, at least for themselves, and are not really interested in substantial reform. I think this “consumer driven” solution is a subversive campaign by the present players trying to hang on as long as they can to a failing system that works for them but not for patients.

  29. > Consumer-driven medicine is seen,
    > by many, as the answer to our health care crisis.
    Really? How many? Who are they?
    And then there’s this sharp bit of analysis…
    First Mahar says:
    > 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.
    I see: pretending. So it is evidently unreasonable to expect resourceful people to differentiate doctors in an information-rich world. Hmmmmm. OK. Let’s go with that.
    Then she says:
    > 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.
    So how the deuce is the patient who was just a few lines ago incapable of finding a good doctor supposed to find a such a mensch as this: a professional who will put his patient’s interests ahead of his own financial interests—to give the best possible advice? Does Mahar pretend that all physicians are created equal, and that all are so angelic, obviating entirely the need for a search? It is clear from the study of practice variation that they are not.
    Maybe this explains it:
    > 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.
    Does she think that consumer choice must be made at the level of an individual doctor or treatment? Or at even at the level of an individual hospital? It need not.
    But presuming I must choose a doctor myself without assistance, how shall I find a doctor to trust? Mahar says I can’t use data: no! That’s just a rating on “somebody’s” system. And I couldn’t possibly trust “somebody” to rate doctors. Which leaves me by her lights with what? My “feelings”? Feelings are a poor guide to truth.
    In the end, she has offered us nothing but the status quo: go find us an affable guy who may or may not be keeping up and, unless he does something egregious, is not accountable. To anyone. And Maggie Mahar after three years’ research thinks this is just hunky-dory.
    No thank you.

  30. I keep thinking of an eBay type of situation, where doctors are the “sellers” of service, possibly rated on various measures by past or current patients, while patients are the “buyers”, shopping for docs who best fit their style or their specific medical problem.
    Or, perhaps, maybe more like one of those online matchmaker services, like eHarmony, where it’s a bit more of a two-way matching process. A patient provides info on how they like their doctor to interact with them, humor, seriousness, paternalism, etc, as well as stuff about themselves; docs (and other health professionals) provide info on their qualities, fees, likes/dislikes (eg, “I am always on time for appointments… if you can’t be on time, please find another doctor”). Patients can see how other patients rate providers on these qualities. Then there is a matchmaking function, eventually resulting in a date (appointment).
    I mean, why not?

  31. As one who has been through 6 surgeries (including CABG) in the last 12 years, while earning my living in the money management business, I think I can speak to this issue from both a medical and a market perspective.
    First, I agree that medicine is a very imprecise science with plenty of uncertainty, subjectivity, and judgment calls. Also, it is important to find a doctor that inspires trust and confidence and who can communicate treatment options with clarity. Having said all that, it is also not unreasonable, I believe, to make it clear that I care about costs too even if insurance is paying most of them. If I need a CAT scan or an MRI and there are several perfectly good imaging departments I can go to, it would be nice to know which one is cheapest and go there. If I need cardiac bypass surgery and I can get it at one of three hospitals, all of which have the appropriate equipment, it would be helpful to know if one is $15,000 or $20,000 less expensive than the other two. If I need to take a drug for blood pressure or an ACE inhibitor, it would be helpful to know if there is an effective generic that would save me money vs a branded drug.
    In short, I think there is plenty of room to both trust the doctor and enlist his help, if necessary, to insure that I receive cost effective treatment rather than just blindly go wherever he sends me without anyone even caring about cost. It is this blank check mentality that got us into this mess. High deductible or consumer driven health plans could help to counteract this attitude. Perhaps there should be a course or two on cost effectiveness taught in medical school. If there isn’t any such training already, there certainly should be.

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