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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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discounted football jerseycoetseeRandy KarprbarYaj Recent comment authors
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Guest

In my opinion you are not right. I am assured. I can defend the position. Write to me in PM, we will discuss.

coetsee
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coetsee

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Nate
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Nate

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… Read more »

Margalit Gur-Arie
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Margalit Gur-Arie

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… Read more »

MD as HELL
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MD as HELL

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.

Barry Carol
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Barry Carol

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… Read more »

108DAYS
Guest

Margalit, Your posts seem to allude to the assumption that your patients can’t comprehend the clinical aspects of your care treatment. What makes you think you’re right all the time? What are you basing your clinical decisions on? Do you listen to your patients? As a “consumer” I can tell you I’ve encountered a lot of attitudes like this, and these attitudes are why we think physicians are so arrogant. They have no faith in their patients and think everything they do is right. In a hospital setting, often, they physician has very little notion of what’s actually happening at… Read more »

Yaj
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Yaj

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… Read more »

Margalit Gur-Arie
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Margalit Gur-Arie

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… Read more »

Yaj
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Yaj

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… Read more »

Randy Karp
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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… Read more »

rbar
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rbar

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.… Read more »

Yaj
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Yaj

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?… Read more »

Nate
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Nate

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… Read more »

Ma
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Ma

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,… Read more »