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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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ShelleyMarkEMRhelpDavidS. Smith Recent comment authors
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Shelley
Guest

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… Read more »

Tom Leith
Guest
Tom Leith

> I’m just an average American health care consumer
> I found this website, http://www.hsaebook.com
Liar.
Mark Lundberg
Principle
HSASuccess.com
Web Site = http://www.hsasuccess.com
Contact Details = Mark Lundberg

Mark
Guest
Mark

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?
Thanks,
Mark

EMRhelp
Guest
EMRhelp

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… Read more »

David
Guest
David

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?

S. Smith
Guest
S. Smith

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… Read more »

Warren Kolber
Guest

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.

Barry Carol
Guest
Barry Carol

“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… Read more »

Tom Leith
Guest
Tom Leith

> 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… Read more »

Maggie Mahar
Guest
Maggie Mahar

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,… Read more »

Great Healthkeeping
Guest

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,… Read more »

Barry Carol
Guest
Barry Carol

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… Read more »

Safe Care First/Andrew
Guest
Safe Care First/Andrew

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… Read more »

Tom Leith
Guest
Tom Leith

> 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.
t

Andrew
Guest
Andrew

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… Read more »