14 replies »

1. Rbaer – we are exactly on the same page. It is a cultural issue, and it is beyond the reach of our health system alone. However, I think our health system needs to be integrated into the cultural shift. Two points here – physicians are not properly incented to aggressively practice proactive/preventive medicine. Our reimbursement model does not support this. This reality is showing up in our medical institutions. A good friend, Dr. David Nash at Thomas Jefferson University in Philadelphia laments about the challenge of filling slots at the medical school for internists – the front line docs. Specialities – they are turning people away, but primary care – there is no interest. (And why would we be surprised – it is an impossible lifestyle – 2000 – 3000 patients, the healthier ones don’t see you until they have a problem, constantly battling with insurers about claims, worrying about possibly missing some early signal from any of these patients – it is a very difficult life.)
   The second point – where the intersection of healthcare and consumerism needs to occur – I believe – is we have to help “people” get there. In other words – health is the ultimate personal issue. Yet for each of us – it is almost like we invent the wheel as we go – like no one has ever aged. Things start to feel different as we age – we learn as we go. It does not have to be like this – we have the knowledge to tell people in advance exactly what is going to happen as they age – what signals to look for, and how to optimize health. Additionally – for the average person – “health” is overwhelming. Turn on the news any day and you’ll likely hear about something new to worry about. So for an individual with many competing distractions and a take for granted mentality about their health – what should they worry about – cancer? Heart disease? Diabetes? The latest flu strain? So for the most part, they just tune out and hope for the best. Maybe try to watch what they eat and exercise.
   As an example – statistically – we know that in this country one out of two people will die of cardiovascular disease. Wouldn’t it be nice to know if you or the person sitting next to you were the “one”? Wouldn’t that give you some focus on what you – personally can do to optimize your health going forward? If you didn’t present the appropriate risk factors you could pretty much tune out to all the advertising, all of the news stories and statistics and worry about heart disease? But maybe you find you have a high risk for a particular cancer – so now you can focus your attention more narrowly and effectively on managing your risks.
   Medicine and technology have advanced to the point that we can help people understand their individual risk factors. This information can then be used by consumers to take action on a focused basis. This could be a good first step to engaging people beyond the healthcare system. This will only get more precise in the near future with advances in genomics and ultimately personalized medicine.
   But we need to begin conditioning people today to understand their personal health status, with personalized programs to help them optimize their health. Yes – this is probably the intersection of medicine, government, business, I’d even add entertainment to the list – no one said that good health can’t be fun.
   Now – my good friend Peter – yes I agree financial incentives/disincentives will likely be necessary. (We give discounts for good drivers, for taking proactive steps to safeguard property – why not reward people for proactively managing their health. Obviously, we can’t penalize people for health conditions – but we can reward them for either staying healthy, or effectively managing existing health conditions.)
   My point – I think we need to develop more effective tools and products to help people better understand and manage their health.
   BTW – I am not a physician – just a very highly motivated consumer/business person. I did have every parents worst nightmare interaction with the healthcare system about eight years ago when my then eight year old son was diagnosed with cancer. (He was successfully treated and is the pride of my life today – but this interaction did give purpose to my life. Hence – I’m attempting to bring my life of experience in building new products and markets to the world of healthcare. No one should ever take their health for granted.)

2. Taxing unhealthy habits and using that money to fund healthy habits over the long term would change mind sets. Brian, I suggest, “The Omnivore’s Dilemma” by
   Michael Pollan as a good place to start for understanding how we got here and why we continue to get sick.

3. Thank you, Dr. Baum, for your comments. I don’t want to keep the last word at all; the following is just a thought that I forgot to write about in my above post, and that Dr. Baum just mentioned above, namely the issue of prevention (versus sick care).
   I do think that most countries, esp. the US, could benefit from better prevention. While I think that the healthcare system could be much more supportive of prevention (some ideas below), I think it is wrong to place the burden of making prevention happen on the healthcare system only.
   I personally think it is a culture- and values question and not so much due to lack of knowledge (similar to the perspective on educational problems in the US, by the way; I do think that most US Americans think that excellence in learning comes exclusively from excellent schools and teachers, while students’ and families’ attitudes are neglected). Most people already know the basic ABC of staying healthy (exercise, low weight, no smoking, varied diet). They do not pursue all this due to behavioral issues (unrealistic goals, social habits – group drinking, smoking, eating, lack of motivation) or simply because they lack time and money to change deeply rooted misbehavior (e.g. time and money to do enjoyable sports, money for better food). If you want to change this, I think a campaign sponsored by government, physicians and employers would work best. Another idea would be to reward a healthy lifestyle (e.g. normal weight, successful blood pressure reduction, smoking cessation, good blood sugar control) with financial incentives, such as reduced premiums or copays. These are old ideas that are not to popular with most market libertarians (at least the former) and probably neither with the general population … but if Dr. Baum has better ideas for promoting a healthy lifestyle, I would be extremely curious to hear about them.

4. I have definitely enjoyed the dialogue on this thread. To provide a bit more context on where I’m coming from – I have traveled the country speaking mainly to employers – of all sizes, providers – both docs and health systems, the occasional “consumer”, and representatives of states and the federal government.
   A very common theme has emerged in virtually all of these discussions – “our total healthcare system – defined as providers and consumers – must do more to keep people healthy.” In other words – once someone presents with a chronic illness – they are on a new cost trajectory. They become one more statistic of high consumption/high cost of care.
   As spencer – commented – “the only way we can reduce health care costs is to focus on improving the public’s health.” Here in lies the essence of my thread. The question is – how do you engage the public, or individual consumers in managing their health before they become seriously ill? I once met with Senator Tom Harkin and he commented that “if it were only as easy as mandating good health, we could truly impact long term healthcare costs.” In our follow on discussion, we agreed that somehow, someone – must organize products and services that engage consumers and create demand for “good health”.
   The more I’ve read through the comments posted on this thread as well as others – I’ve observed a tendency to lump all of healthcare into the sick care model. Yes – once someone is diagnosed with a potentially life threatening disease – “consumerism” has a very different meaning. At best an individual may research their condition, may pursue second opinions, may ask questions of their care team and may even investigate success measures from one doc to another or one facility to another.
   What I’m looking at is where/what is the experience for the 80% or so of the population that is pre-symptomatic and considers themselves healthy? This is our opportunity population. Dr. Jim Fries at Stanford published the compression of morbidity theory back in 1980. With due respect to his work – I would net it out to say – the optimal living condition is to live a long and healthy life and “drop dead”. This is optimal from both the “consumer” perspective and the provider perspective and probably from society’s perspective as well. Wouldn’t the majority of us want to live a long life – at near full capacity – high quality of life and then without extensive pain and suffering and years of intensive medical intervention – simply “pass away”?
   I’ve gotten much deeper then I anticipated when I started this thread – and don’t want to get into debating McCainCare, ClintonCare or ObamaCare; and certainly don’t want to get into the much deeper debate over life and end of life issues – so I’d like to just stick with the basic proposition – would it not be desirable to keep people healthy?
   If that premise is accepted – then how do we accomplish that? In our current model of care – I don’t see how a motivated “consumer” can take decisive action. They don’t have the tools, the information, access to the resources to fully understand their own unique health situation – health risks and a path to manage those risks.
   As rbaer correctly stated I did not specify the “product” or source of the product – because I don’t believe it exists today. Perhaps it could be an insurance product, perhaps it could be a provider product, or perhaps it is something totally new. A consumer oriented product that integrates the front line doc, but also brings together a broad array of both health assessment tools and programs to manage specific risks. Here I blatantly refer to “consumerism” because it can’t be purely a clinical product – no one will participate. So in our packaged world – and service oriented economy – there seems to be a void for someone to step in and fill.

5. What’s up with consumerism in health care? The only way we can reduce health care costs is to focus on improving the public’s health. The Zaftig Redhead blogs about this issue in the context of McCain’s healthcare plan.
   http://thezaftigredhead.blogspot.com/2008/05/mccaincare-bad-medicine-for-consumers.html

6. Actualy Brian Jiffy Lube’s business became possible when service stations could no longer offer oil changes just for the price of the oil and filter and you had to wait longer as well. Premium pricing allowed higher profit margins which enabled Jiffy Lube to exist as a one service shop. BTW dino oils don’t have to be changed every 3k either – as a consumer did you know that?
   Consumers are only as good as the information they can not only get but analyse. The causes and effect of disease are so complicated that it’s hard enough for even doctors to diagnose properly without some trial and error. I’ve had more misdiagnosis from docs (8 years + of training) than correct diagnosis – or at least presumed causes and treatment plans. As with choosing a mechanic or buying a house consumers have just about as much real knowledge of what they’re doing as with healthcare because they aren’t allowed all the information needed to make good analysis, it’s pretty much hit’n miss . Even if they had the info do they have the time to wade through the differing opinions? I wouldn’t want my ability to search for answers outside the medical profession to be restricted, but my searching and possibly finding the right answer will have little to no effect on our present healthcare delivery system. There’s just too much money to loose by vested parties.

7. BB and, apparently much more so, F. Timmins want to perceive that buying health is an ordinary act of consumption care (“To a man with a hammer everything looks like a nail”).
   First, they both fail to identify the product that they talk about: is it the insurance coverage? The provider? A healthcare system? Each individual diagnostic or therapeutic step the provider suggests? If HC consumerists can clarify this, we can deepen the discussion.
   Now, is purchasing any kind of healthcare product, whatever it is, comparable to buying a car (BTW, the claim that car buyers are “extremely informed and sophisticated buyers” is arguable at best looking at all the Hummers and overpowered cars on the roads)? Well, I think that I enjoy a nicely mixed practice experience re. my patients’ economical and educational level. I can tell you that there are few patients that really use the available information to their advantage (most don’t get much outside info at all). Actually, I get the feeling that the smarter patients first hear what I have to say, ask intelligent questions and reconfirm my advice/opinion with internet info or, if it’s a bigger thing, with a 2nd opinion. Patients that have set ideas what they want are often unrealistic and easily misguided.
   Consumerism (“I want this MRI scan”) is also not totally disconnected from cost- and coverage issues.
   Mr. Timmins wonders about “the bog of traditional assumptions”. I claim that it is him who has preconceived notions, namely the credo of the free market:
   1. virtually all problems can be reduced to market phenomena
   2. virtually all problems can be solved or reduced with the power of the free market
   3. government involvement or other regulation strangulates the free market and makes things worse

8. Ok – I’ll grant you “Jiffy Lube” may not have been the best example. However, the origins of Jiffy Lube do date back to pre-synthetic oils when oil changes were a bit more frequent. Additionally, they filled the void left a very long time ago when “full service” gas stations regularly checked fluid levels, (and doctor’s made house calls). The point – people didn’t necessarily know what routine maintenance was required on their cars. A service industry evolved to fill the overall void.
   I think we’re in a situation where the average consumer knows more about the maintenance schedule for their car then their own immunization schedule or personal risk profile for cardiovascular disease, let alone specific actions they may take to lower their risk profile.
   I’m not sure Peter if in your concluding comment “long live consumerism – consumerism is dead” which side of the fence your coming out on. Or if you simply advocate a return to a time when we just kick back, hope for the best? Unfortunately for many individuals – that is their perspective of healthcare – do nothing until they are faced with a diagnosis. Fortunately, I believe there is a growing segment of the population that wants to do more, wants to be involved, but is not totally sure what to do. The question – who or what will fill this void.

9. “Just as Jiffy Lube created a widespread mentality that every three thousand miles you need to change the oil in your car, how can we get our society to look at managing their health in the same proactive manner?”
   I’m not sure Jiffy Lube “created” the mentality but they capitalized on the misconception carried over from the early years of automitive oils and engine technology. This is a concept based on profits not proper engine care. If this example doesn’t highlight the problems of consumerism in relation to our present health cost delivery system I don’t know what would.
   Jiffy Lube’s business model of 3K oil changes pads it’s bottom line by consumers changing their oil way too often. That’s certainly fits with the overuse of healthcare by consumers and providers and adds to the costs we won’t be able to afford much longer.
   Long live consumerism – consumerism is dead.

10. Well first, thanks for the comments back on my article. I wanted to respond to several points of view expressed. I would categorize the comments in three buckets – 1. the issue of health insurance, 2. the definition of an “informed health consumer” and 3. the existing “free market” in health care.
    On the first point – insurance – insureds vs. uninsureds – who pays for care, etc. This is obviously a substantial issue, and I’m sure we can expect to hear a lot about it in the coming months as we move to the general election this fall. The point of my article was not to address this issue. Simply put, if somehow we did close the coverage gap – provided universal coverage or mandated coverage for everyone – reached that “promised land” and breathed a collective sigh of relief – every American is insured – I would suggest that still leaves us far short of addressing the long term cost of care. We will have accomplished nothing in changing the fundamental cost dynamics of health care consumption. With 78 million aging baby boomers rapidly approaching peak health consumption years – if we can’t engage “people” to become active participants in managing their own care – then we are destined for some disastrous financial implications as we wait for each of those 78 million people to become chronically ill.
    The second point “how do we define an “informed health consumer”? Is it nothing more than providing information? Quality rankings for providers, cost information for care options, so that a “consumer” can make an informed decision? The now “informed consumer” will turn to their appropriately ranked physician and assume their work is done? They now have someone – a highly ranked physician that assumes responsibility for their care and well being? There are at least two flaws with this assumption. First, generally individuals that consider themselves healthy – don’t often visit a physician. It is a priority that exists and is easily postponed if a schedule conflict arises. Second, with all due respect to my many physician friends – the days when the patient obediently “follows doctor’s orders” are long gone. Moreover, that is probably a good thing. An informed consumer should be an active participant in their care – asking questions and engaged.
    The third point – frustration with the existing free market in healthcare and the failure of a market system to provide adequate care. Perhaps we need to define “adequate care”. The current system of care is largely a “sick care” model. That’s probably why we continue to refer to the consumer of healthcare services as a “patient” rather than a “consumer”. What I was initially proposing was to look at the delivery of care through a different lens. Shifting from passive care to active care. We cannot simply look to physicians to make this change. There are not enough physicians, they do not have the time and they are not adequately compensated to practice aggressive proactive care. Even if all of these issues did not exist – the “consumer” must be engaged in the process.
    For a consumer to be engaged – they have to be motivated, they have to see tangible value in the outcome. Unfortunately, we can say to the 20 year old male – if you do all these things, your quality life expectancy “may” increase from 78 to 85.
    So what am I proposing?
    As an example. I’ve worked with Dr. Steve Klasko – Dean of the University of South Florida Health organization. He and I discussed the challenge and opportunity that exists on college campuses across the country. As students descend on campuses for their very first “on their own” experience – their health is generally one of the last things on their minds. Yet, couldn’t this be a unique opportunity to establish a lifetime pattern of health maintenance/health consciousness? Could a service, an “experience” be created to address the needs of this population? Moreover, what parent wouldn’t be interested in a product like this? Clearly the “product” could not be a distillation of the age old – eat right, don’t smoke, don’t drink, no sex, sleep enough, etc. But in a facebook, xbox world – can’t we come up with something that would be engaging, entertaining and yet quite helpful relative to managing this very critical transition in a young adult’s life as they begin to take responsibility for themselves? Perhaps the proposed outcome would not be to live a longer life – but to enjoy “peak performance now”. The peak performance could relate to sports performance, academic performance or that other activity prevalent on college campuses.
    The long term outcome – if we engage the 20 somethings in active health management – what might happen to them as they age and begin raising their own family? (Rhetorically – perhaps they will continue to be an active health consumer.)
    The question – who would create and provide such a service? A primary care doc? Each university would create their own? The federal government? Or for better or for worse in our creative “free market” environment – an aspiring entrepreneur that sees a better way. Creates a product that is appealing, packaged, transportable – from college on to the next phase of life and integrates with clinical care so that information can be shared.
    This is just one very basic example – but I think it is a different way to look at healthcare. Not at a macro level, but at a level that addresses life stages and specific health needs. The point – we’ve got to engage people if we are to break the cycle of passive healthcare.
    Just as Jiffy Lube created a widespread mentality that every three thousand miles you need to change the oil in your car, how can we get our society to look at managing their health in the same proactive manner?

11. It’s funny how most people seem to forget that we’ve had a ‘free market’ in healthcare for over 100 years – with it’s concomitant market failures – that has resulted in the patchwork system we have now.
    Heck, Medicare came about because – surprise! – insurance companies don’t make money covering the old and sick who need a lot of care. And you don’t have access to our healthcare system without insurance. Market Failure = government steps in.
    The simple fact is too many people are making too much money off the current system for it to change anytime soon. And having ‘pricing information’ on a website doesn’t change the fact that you can’t afford it in the first place.

12. My comment is more in response to the “MSG’s View” than the article by Mr. Baum. Of, course “some” healthcare expense is beyond the financial ability of most of the populace. This is a separate issue with separate solutions. Insurance, insurability, or lack of either is not really what I perceive this article is about. The discussion is whether or not “Third Parties” can determine both the effectiveness of healthcare services and its cost better than the individual involved.
    The second paragraph at least addresses the pertinent issue. I find the argument that presumes average people are incapable of learning enough of the healthcare system and their own bodies to be able to function as reasonably intelligent buyers is most depressing (and terribly regressive). Instead of using the analogy of buying an “electricity substation” (which would require special engineering training and expertise), perhaps it would be more useful to compare healthcare purchasing with buying an automobile. While there is much high tech engineering involved in the product (that few understand), there is apparently little problem in the public becoming extremely informed and sophisticated buyers. The difference? Information is readily available to educate the automobile buyer (to the extent that the buyer needs to be educated in order to make the purchase). The same is becoming more true everyday with healthcare. Not so with the marketing of electricity substations.
    Let’s not mire ourselves in the bog of traditional assumptions without examining the validity of those assumptions.

13. My comment is more in response to the “MSG’s View” than the article by Mr. Baum. Of, course “some” healthcare expense is beyond the financial ability of most of the populace. This is a separate issue with separate solutions. Insurance, insurability, or lack of either is not really what I perceive this article is about. The discussion is whether or not “Third Parties” can determine both the effectiveness of healthcare services and its cost better than the individual involved.
    The second paragraph at least addresses the pertinent issue. I find the argument that presumes average people are incapable of learning enough of the healthcare system and their own bodies to be able to function as reasonably intelligent buyers is most depressing (and terribly regressive). Instead of using the analogy of buying an “electricity substation” (which would require special engineering training and expertise), perhaps it would be more useful to compare healthcare purchasing with buying an automobile. While there is much high tech engineering involved in the product (that few understand), there is apparently little problem in the public becoming extremely informed and sophisticated buyers. The difference? Information is readily available to educate the automobile buyer (to the extent that the buyer needs to be educated in order to make the purchase). The same is becoming more true everyday with healthcare. Not so with the marketing of electricity substations.
    Let’s not mire ourselves in the bog of traditional assumptions without examining the validity of those assumptions.

14. I think that those of us with a certain degree of wealth and education have trouble recognizing how different the world is for people without savings or discretionary income, without in-depth understanding of healthcare and the healthcare system… While this review is very interesting, it fails to understand that the populace cannot afford our healthcare system today. Over 20% of the country does not have an insurance product at some point during the year (largely due to cost) and it is likely that the only reason why this number is as low as it is results from employer sponsored health insurance. So, the idea that more consumer products to buy is the solution fails to recognize the underlying economics of our system.
    The other surprising omission in the review is that through most of the phases of decision making, a certain amount of understanding about how the product will work is required. For instance, I am not capable of buying an electricity substation – I’m not an engineer and I wouldn’t know what criteria to assess alternatives against. Biology and physiology are much more complex than an engineered product – they work in a standard way, with the exception of the billions of genetic customizations that make us all unique. Physicians are there to interpret our healthcare for us – potentially giving us choices. But oftentimes, we have as much chance to critically assessing these choices as a hail storm hitting Costa Rica! Real consumerism requires consumer intelligence about the service provided at a sufficient level of detail for consumer engagement to make a difference. I hold out little hope for this to realistically take place in our (or any) healthcare system.
    Thus, if we want consumerism, we need to center on those things that everyone is capable of engaging in – the level of financial risk we take, the choice of provider/physician (potentially around quality, but probably around meeting other intrinsic needs like affability, comfort, convenience), and our own responsibility for healthy behaviors. If we can incent around these attributes, without creating spillover effects into the outcomes of other individuals, then consumerism can survive and thrive.