We the Consumers

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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32 replies »

  1. Anyone experience anything about the easy google profit kit? I discovered a lot of advertisements around it. I also found a site that is supposedly a review of the program, but the whole thing seems kind of sketchy to me. However, the cost is low so I’m going to go ahead and try it out, unless any of you have experience with this system first hand

  2. fixing education is simple;
    1. Stop allowing the bottom class of their world countries to immigrate here, we don’t need any more gardeners and nannys. We have college educated professionals waiting a lifetime to enter legally while we allow uneducated and skilless people to enter at will. Poor uneducated people tend to have poor uneducated kids.
    2. round up NEA and other teacher union bosses and execute them for what they did to public education and our kids
    3. outcomes are not equal and never will be, basic opportunity is. Take every liberal “fix” to our education system and throw it out. cross town bussing where kids spend as much time getting to and from school as learing out, social advancement out, electives and feel good crap they love to push out, english as a second language out.
    4. if you fight, skip school, and are disruptive your out, I rather 10% of the kids be uneducated dumpasses I need to lock up when they turn 18 then 50% of all kids be dumpasses becuase we taught down to the 10%. Life is full of failures, we need to identify and fail them so the rest can advance.
    Personal responsibility will fix most problem, education and healthcare included. Until the liberals got this stupid idea called Medicare 83% of all of us had no problem paying for healthcare. Healthcare didn’t become unaffordable until Congress tried to make it affordable.

  3. Barry, I agree with everything in your post. I think there may be only one fine point that is worth mentioning. The ultimate responsibility for cost effectiveness, I believe, belongs to the physician. I guess I am not ready, or willing, to transfer this burden to the consumer who by and large is lacking the tools.
    As to education, I hope to have the same national level of attention that healthcare is getting devoted to education some day. I’m not optimistic….
    108, I am not a doctor. I am just a citizen that has no desire to become Jiminy Cricket for the medical profession.

  4. If people can manage their own healthcare, then managing their own social security should be a snap. Yet there was no way the feds were going to let go of their power over the retirement money. Just more data and people should be able to lose their investment advisor and beat the market year in and year out. It is much simpler with real data than with the vagaries of medical decision making.
    Good luck.

  5. Margalit,
    I think the issue of trust between doctor and patient is a critically important one. To me, trust means the following: First, I want to have trust (and confidence) in the doctor’s clinical skills as well as his communications skills. I also want to trust that he will practice cost-effective medicine especially after I make it clear that I am one of the comparatively few patients who wants good value for money even when insurance is paying the bill. If I tell him that, short of something egregious like wrong site surgery, I’m not going to sue if I have a less than perfect outcome I want to be treated as though I’m a member of your own family and the bill is being paid with personal funds, not insurance money. If he needs to refer me to a specialist, I want to trust that he is tied into a network of competent doctors who also practice cost-effective medicine, not CYA defensive medicine or money driven medicine.
    Second, regarding your comment about the need to reduce poverty by investing in education, we’ve been doing that for decades but the results are disappointing to put it mildly. In my state of NJ, average primary and secondary school spending per pupil rose from less than $1,500 in the mid-1970’s to about $18,000 today (2nd highest nationwide) while the Consumer Price Index during that time rose “only” fivefold. Due to a landmark court case in the late 1970’s called Abbott vs. Burke, we have 31 special needs districts (out of about 600 in the state) that receive massive state aid of over $4.5 billion per year altogether. One of those, Asbury Park, now spends $35,000 per student and the results are still lousy. At the same time, the National Education Association and its local affiliates staunchly oppose school vouchers, it resists creating more charter schools, it opposes merit pay, it defends tenure, protects the incompetent and refuses to allow its members to be held accountable for student performance. All the union cares about is sustaining its monopoly power along with its members’ generous salaries and ultra generous pension and health insurance benefits. This, in large part, accounts for why NJ residents pay the highest property taxes in the country and have the highest or 2nd highest overall state and local tax burden. Like healthcare, there is already plenty of money in the public education system. Also like healthcare, it just needs to be spent more effectively which requires systemic changes which are extremely difficult to bring about because powerful entrenched interests benefit from and aggressively defend the status quo.

  6. Sorry for the oblique post there, Margalit – but being educated and all I figured that you’d read my post and understand that I was making the point that people who have legal problems and lack the legal training necessary to completely understand the law and effectively use it to
    advance their interests in court…hire attorneys.
    They don’t hire attorneys that they don’t trust, and if they have occaision to lose their trust in their integrity, expertise, etc they can and frequently do…hire a different attorney. The fact that they selected the attorney, and the attorney knows that they will stay hired only as long as they retain the confidence of their clients leads to more trust in the attorney, not less.
    The principal arena in which this trust is either non-existent or profoundly compromised as a matter of course is in those cases where the defendant only has access to a public defender assigned to him and paid for by the government. This is the model that has its closest analogue in the model of the physician-patient model that you are expounding.
    Again – feel free to opt into the medical equivalent of the public defender’s office for your health care if you wish, but I’ll continue to exert myself in an effort to preserve my right to opt out.

  7. Nate,
    Those folks that decide to smoke and drink and not avail themselves of preventive care, what do you think causes most of them to behave that way? Are they evil? Do they have some inherent flaw? I don’t think so. If you read the articles, you’ll see that there is a very good correlation of this sort of behavior and lack of education.
    So all I am trying to say here is that people would be able to better participate in their care and make better decisions if they had more education. We need to fix education in this country. It is as important as healthcare, even if we fail to see the immediate consequences. What exactly doesn’t make sense here?
    This consumerism phenomena is going to backfire if physicians are going to be put in a position where they have to retract the “care” element from healthcare. My contention is that the people that will be most damaged by that are the ones that need it most.
    That is of course not to negate a patient’s right to be informed and be able to take an active role in his/her care if he/she so desires. It should be the patient’s choice, Yaj. You may choose to “hit the stacks in the local law library”. I may choose to trust my doctor, or seek a second opinion from yet another doctor. I want to be able to trust my doctor, therefore I would prefer that in your quest for consumer rights, you leave this relationship alone .
    Another thing that is already happening is what rbar is concerned about. There are always those that will demand inappropriate and mostly more expensive treatment. The more people have access to all sorts of information on the internet, the more they tend to diagnose themselves with horrible diseases and in turn demand expensive tests to rule out their worst fears. I have no idea how to stop that.
    And have you noticed all the pharma ads on TV these days? Have you noticed how they all bypass the physician and advice the consumer that they “owe it” to themselves to ask their doctor for the particular drug? From what I hear, these campaigns are working very well.
    As to the free market assumptions, I figured you would be an avid Adam Smith admirer.
    Anyway, there are plenty socially responsible companies out there, like Ben & Jerry, but when it comes to buying ice cream, they’re in it for the money and you are in it for the ice cream. You won’t get any ice cream if you state your burning needs for ice cream. You will get the ice cream if you address Ben & Jerry’s concerns and give them money and that’s exactly how it should be in a free market.
    Of course the government can intervene and make Ben & Jerry give you ice cream because you really need it, but have no money, and there goes the free market out the window… 🙂

  8. Rbar:
    The answer to your question is definitely “no.” That’s because it’s impossible to construct a set of metrics that objectively characterizes such decisions as smart or dumb outside of each individual’s subjective preferences.
    One of the other major unstated premises at play here is that there are no possible mechanisms by which consumers who are confronted by complex problems requiring expertise that they don’t possess can get the help they need to make informed choices.
    If we apply Margalit’s model to an another complex domain like the law, we can see that the consumer with a difficult legal problem has no choice but to hit the stacks in the local law library and take their chances. Given this reality, it’s clearly crazy-talk to imagine professionals with extensive formal training and formidable expertise assisting with complex medical decisions for a fee.
    With regards to risk pooling, it’s clear that at some level third parties are going to have to enter the picture at some point – but unless you accept the premise that such parties can reliably know what’s in your best interest, and will be willing to do so even when it conflicts with their own – it seems to me that the optimal system is one in which they have as little influence as possible over as many medical decisions as possible.
    People that feel differently, like Margalit, have every right to enroll in systems that are based on the assumption that they are both stupid and incapable of determining what is in their best interests, but they don’t have the right to force everyone else into such a system – at least not until the current legislation is signed into law.
    ts, but having to simultaneously confront that while

  9. Countless lives have been ruined or cut short by Misinformation. We need to chase the right bandits before we can hope to solve the crimes. Your total cholesterol level for example, is a lousy predictor of heart disease. Handing over the responsibility of managing our lives to others isn’t working very well.
    The next time you’re advised to commit to a course of action that could endanger you, ask to see a human study that supports it. The next time a mulit-level sales person tells you about the next “miracle ood” , ask them to proove ( not with anecdote or headlines news, or studies on three blind mice…but with human study).

  10. yai,
    Are you implying that people make actually SMART decisions about these things that you mentioned (partner choice, career … and somehow you forgot to mention all these financial choices)?
    Anyway, I personally have nothing against consumer driven health care … as long as it is the consumer who pays, not a 3rd party. I don’t want “consumer” patients in my risk pool (i.e. insurance) who decide that they need an MRI for an ingrown toe nail. Of course I am facetious, but in reality, people with this inclination do exist in varying degrees, and they tie up substantial ressources. Again, OK with me if they pay OOP for unreasonable consumer choices.
    And let’s face it, in todays’s world, knowledgeable docs facing a competent patient DO discuss reasonable options. It may have been different with many of the older docs, but nowadays, anything else is rather the exception.
    And finally, let’s not forget what many actual patients want: especially older patients almost invariably ask me, when I confront them with several reasonable options: Well, doctor, what would YOU do? Of course that does not negate that these folks should be given the choice (or the chance to choose) to begin with.

  11. What a nauseating mish-mash of logical fallacies (argument from personal incredulity), egotism, and conceit masquerading as an argument.
    How on earth do people who lack formal academic training possessed by the author manage to negotiate *any* of the complexities of every day life. How do they figure out what careers to pursue, who to marry, whether to spend their money or save it, what neighborhood to live in, or what brand of toothpaste to use without the likes of Margalit to hold their hands and let them know which of their subjective preferences are objectively superior to the others.
    Trust? Nothing inspired that like HMO compensation algorithms that rewarded doctors for withholding care.
    The end is nigh…

  12. tracking our data while the 20% are not exactly the same people every year a large portion of them stay the same. While there are acute cases like a pregnancy or one time event those are easily insured and managed. Those are perfect example sof why CDHC works, save money the 4 years you are healthy so the one year you need it your covered. It’s the 5-10% with cronic conditions that need identified and managed, something the liberals in congress are making illegal.
    Low income people that forgo routine care are more ignorant then bad consumers. If they spend $500 a year more in premium to cover $300 in routine care we need to send them back to middle school math not worry about their health insurance. Its not the insurance plan that is causing the low participation. If they can’t afford the routine care how could they afford the premium for higher benefits? Those same people that supposedly can’t afford routine care are also more likly to smoke and drink. Your falling for propoganda not research.
    Check out Patient care which John Alden gives for free to all its members, they get price and outcome explained to them for free, what info are the consumers supposedly missing or do nto have access to? It is all there they just choose not to access it. Just like the myth of the crisis in employer premiums yet most employers won’t even take basic steps to lower their cost. The crisis in private insurance is a myth, all proganda to garner support for reform to save Medicare and Medicaid which really are in crisis.
    “The basic axiom of a “free market” is that both buyers and sellers are acting in their own best interests and are totally and completely devoid of compassion and any regards for the well being of the other.”
    You have to be joking, how brainwashed are you? You apparently have no ability to even grasp the concept of free market without applying your liberal coloring. Where do you learn such hogwash as free market lacks any and all compassion let alone it is a basic axiom? Many times the buyers best interest coinsides with the sellers best interest further still it is an accepted and proven marketing strategy to build an entire business around compassion. Where do you lefty nut jobs come up with this stuff? Would you say Ben & Jerry’s lack compassion? The Red Marketing campaign by Amex? Google and their philanpatry. Do you just regerertate this stuff or do you really believe it?
    MA you forgot to share what you paid in taxes back home versus what you pay here.

  13. There is another facts that I want to comment in relation of what I said about healthcare in Brazil. I am not saying that is perfect but people has more possibilities there. When you is hired by your Company and they provide the health insurance to their employees, you need to wait 3 months as a grace period, that’s it. If after three months you need to do a surgery, they pay everything, 100%, there is no such thing as bill the patient. I needed a surgery and they paid everything, an excellent hospital, doctors, everybody. On the other hand, before the surgery I had to go to the ER (I had stones in my kidneys), when I had a crisis, I went to the government hospitals, received free assistance, injection to cut the pain and they didn’t charged me one cent. Although I have private health insurance the ER of the gov was close to my house. My mom needed a surgery for catharat and they did in one eye and after a certain time in the other eye. The medications we could afford to buy but we also had the option to get free in the government advance posts. The vaccination of children in Brazil is also FREE and is national day, every singe state MUST take their children to be vaccinated with no charge. It is not perfect as I said, because if you want to be cared by government hospitals and post, you need to stay in a queue, waited to be attended, it is incovenient but it is free, you need to have patience to stay at the hospital waiting your turn. The government improved a lot the attendance in public hospitals lately. There are also a Hospital Schools, also free, all treatment and visit are monitored by professionals and they also call the students of Medicine to help them and learn the profession at the same time. Also there free government universities that treat your pet, it is free, they do surgery and also procedures not only in emergency cases but in routine examinations.
    The healthcare in Brazil needs a lot of improvement but at least there is no co-payment, co-insurance, deductibles and such scam that the Health Insurance Companies use here. The government stablish a limit to Health Insurance when they increase their rates. The factor “pre-existing conditions” is still a nightmare, but like I said, it is much cheaper than here to do a surgery there, if it is expensive it is because a lot of equipments are imported from other countries.
    I hope that people here really protest against such insane plan of health that they are to put on us. I hope that in this country we can have a third party, that we options to vote directly to the presidency, this is democracy, this is supposed to be in a country like USA.

  14. Margalit,
    The critical decision point for medical consumers is not “when you are clad in a big paper towel and the ‘seller’ is about to perform a rectal exam on your persona.” It is at the point where you choose your health care provider. To quote from Halvorson’s book again:

    Mortality rates for breast cancer surgery patients vary by up to 60 percent depending on which hospital does your surgery. Mortality rates for coronary artery by-pass surgery can vary by over 900 percent between adjacent hospitals. If you are a heart patient, your personal chance of dying from that surgery is hugely different based on the hospital and surgery team you pick.
    Your chance of getting a bloodstream infection after the surgery also varies by factors of 4 to 10 between comparable hospitals in the same community. Bloodstream infections probably caused 70,000 deaths in California hospitals last year — and consumers don’t know which hospitals do the best job of keeping those infections from happening. (pg. 120)

    The point that Halvorson makes in his video interview (linked in the right hand column of this page) and his latest book is that consumers currently do not have information on which to base informed decisions, because data is not collected or shared, or both.

  15. I am a naturalized citizend, my husband was born in USA.When I came to US more than 10 years ago, I thought that the system of healthcare here would be much better than one in my country. I was so disappointed when I got my first job here because I was told to pay part of the health insurance and there is other “co-payment” everytime you go to visit the doctor. In my country, the Companies pay 100% of the health insurance plan, there is no such thing as co-payment. The Companies that provide health insurance to the employees receiving high discount in their taxes. On the other side, people that can afford a private health plan or do NOT have an employer to cover them, they can use the health insurance of the Government that is FREE. I said FREE, surgeons, visit to doctors, treatment and the medications are free also distributed by what we can Health Advance Posts (there are doctors and nurses in such offices that attend the population of low income). Why the government provide free healthcare, because people that works, everybody that works contribute with a certain percentage to the government, every month is discounted in your paycheck. This amount is not too much, it depends on your salary and it is not heavy for the workers, the Company has the obligation to collect the total amount and send to the government, for this reason the medical care is free. Even the workers that has private health insurance paid by their Employers can use the free assistance, free hospital, free emergency room. This country is Brazil, my sister pays R$400/mohth (about 225 dollars per month)because she prefers to have a private insurance. This premium include everything, if she needs surgery, if she needs physical therapy, etc. This plan of the American government that is passing to the Senate, this would be the most outrageous, you are obligated to have and if you don’t you pay penalties. Definitely, this Country has just a mask of democracy, the true face is a didactorship.

  16. What’s going on with the text formatting? Seems weird and the comments entry box is acting strange…..

  17. First of all, here are the links to the two RWJF articles (not sure why they didn’t show up in the original post)
    Education and Health – http://tinyurl.com/ygt8gsz
    Overcoming Obstacles to Health – http://tinyurl.com/yf88rxp
    Nate, as Barry mentioned, the 20% folks that have major problems is not the same 20% every year. Most everybody has problems at one point or another and the 20% is ever changing (I think we discussed that before).
    People with high deductibles and low income often choose not to get routine care until it’s too late (there were several posts to that extent in previous threads).
    Barry, catastrophic event has different definitions depending on your income. For a family of four making $50,000 per year, the $5000 deductible is catastrophic enough and doesn’t even come close to the price of a couple of oil changes. It doesn’t take much to reach that $5000. A set of braces for the kid would put you well over.
    Dr. Waugh, I do agree that physicians should explain procedures and treatments as best they can and I don’t think that people are stupid. However, the degree to which a patient is capable of making decisions, doing more research, seeking other opinions is highly dependent on their level of education. It is true, as Barry writes, that there are folks with no education that can manage the financials related to health care rather well. My concern is the clinical aspect.
    The issue I’m having with this notion of consumerism is that it creates an adversarial relationship between the doctor and the patient. The basic axiom of a “free market” is that both buyers and sellers are acting in their own best interests and are totally and completely devoid of compassion and any regards for the well being of the other.
    It is hard enough to act the “buyer” part when you are clad in a big paper towel and the “seller” is about to perform a rectal exam on your persona. Having no analytic skills to fall back on and replace the fear and perceived humiliation with cost efficiency considerations, makes it even harder. I just don’t see how you go through a typical doctor/patient interaction that is totally devoid of trust, and if trust is a required element, then you cannot have a free market populated by buyers and sellers.
    Whether we like it or not, the current body of knowledge in medicine is not advanced enough for physicians to make clean cut decisions. I am not sure it will ever be, certainly not in our lifetime. To presume that even after careful explanation in laymen terms of the intricacies involved, will allow a lay person to actually make a clinically sound decision, particularly if they function at a fourth grade literacy level is a bit of a stretch, I believe. Couple that with the fact that, as Gary wrote, not all doctors have all the information and if even if they did it is rarely conclusive and the patient is in fear of his life, and you are pretty much guaranteed a large percentage of bad decisions.
    Besides, if the doctor is the “seller”, how do I even know that what he is explaining to me in “layman terms” is in my best interest? Would he even care if I make a bad decision? Is this the final institutionalization of “money driven medicine”? Where do I go from here, to the support groups on the internet?

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

  19. Margalit,
    The problem is not the analytic ability of the average consumer, it is the abject lack of data to analyze. How can the consumer make an informed decision without any knowing the track record of healthcare providers, based on proven results or quantifiable data — data which rarely exists?

    Most care sites have little or no data. The individual health care business entities that do have data generally keep their own data to themselves. …[M]ultiple studies have shown that there are actually huge variations in care delivery performance levels between sites, providers, care systems and care teams. …Mammography interpretation skills vary significantly. So do surgical outcomes, as do actual survival rates from various care teams for various procedures and conditions. …Even more alarming, the knee surgeons and oncologists and mammographers who have the worst outcomes have no way of knowing that their own care outcomes are not as good as they could or should be. –George C. Halvoson, Health Care Will Not Reform Itself, pg. 46.

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

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

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

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

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

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

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

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

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

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

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