Years ago, when I was less inflexible, I took up Pilates. My instructor, Jim, a charming chap with an infectious laughter, was a 911 truther. I’d egg him on to hear about his conspiracy theories. Jim believed that 911 was concocted by Bush and Haliburton so that the U.S. could invade Iraq to capture their oil. He thought that United Flight 93 never took off. Whatever happened after 911 became the motivation for 911. He was the sort of person who would have concluded that Mahatma Gandhi plotted the Second World War to free India from British rule.
I began to suspect that Jim was, to put it charitably, nice but dim. But he wasn’t that dim. He corrected me when I once, innocently, underpaid him. He was also smart at advertising and when he met my wife, he told her that she should join me for Pilates because it would strengthen our marital bond. My wife politely declined the bond strengthening. He was also very cued up with the nutritional sciences and warned me, without leaving a trace of irony, “don’t believe everything you read about diets.”
That we are experiencing a “consumer revolution” in healthcare is a durable meme in the media and in policy circles just now. When you hear the word “consumer”, it conjures images of someone with a cart and a credit card happily weaving their way through Best Buy. It is, however, a less than useful way of thinking about the patient’s experience in the health system.
A persistent critique of our country’s high cost health system is that because patients are insulated from the cost of care by health insurance, they freely “consume” it without regard to its value, and are absolved of the need to manage their own health. In effect, this view ascribes our very high health costs to moral failure on the part of patients.
Market-oriented policy advocates believe that if we “empower”patients as consumers by asking them to pay more of the bill, market forces will help us tame the ever rising cost of care. If patients have “skin in the game” when they use the health system and also “transparency” of health providers’ prices and performance, patients can deploy their own dollars more sensibly.
This concept played a major role in the otherwise “progressive” Affordable Care Act. The 13 million people who signed up for coverage this year through the Affordable Care Act’s Health Exchanges opted overwhelmingly for subsidized policies with very high deductibles and out-of-pocket cost limits. The “skin in the game” argument has also heavily influenced corporate health benefits decisions. More than 30 million workers and their families receive high deductible plans through employers.
Susannah Fox, CTO of HHS, shares how she is fostering patient empowerment and engagement through technology. Matthew Holt, Co-Chairman of Health 2.0, had the opportunity to personally chat with Susannah and learn more about the democratization of healthcare!
Matthew Holt: Matthew Holt here, delighted to be on with a really wonderful amazing person in healthcare who is not only my friend but also the CTO of HHS, Susannah Fox. Susannah, thanks so much for joining us.
Susannah Fox: I am thrilled to be talking with you.
Matthew Holt: Well, so those of you who don’t know — Susannah originally was a journalist at U.S. News and World Report and spent many, many years at Pew Research, and is basically leading the survey research understanding the patient experience — probably in healthcare as a whole but studying the patient experience with the use of technology. She happens to be the first proper keynote speaker we ever had at a Health 2.0 conference back in 2008, attended Health 2.0 in many different places with us, and has been a great friend and colleague.
Recently I wrote about the problems with Maintenance of Certification requirements. One of the phrases I read repeatedly when I was researching the piece was “the patient as customer.” Here’s a quote from the online journal produced by Accenture, the management consulting company:
Patients are less forgiving of poor service than they once were, and the bar keeps being raised higher because of the continually improving service quality offered by other kinds of companies with whom patients interact—overnight delivery services, online retailers, luxury auto dealerships and more. With these kinds of cross-sector comparisons now the norm, hospitals will have to venture beyond the traditional realm of merely providing world-class medical care. They must put in place the operations and processes to satisfy patients through differentiated experiences that engender greater loyalty. The key is to approach patients as customers, and to design the end-to-end patient experience accordingly.
Except for one thing. Patients are NOT customers.
The definition of a “customer” is a person or entity that obtains a service or product from another person or entity in exchange for money. Customers can buy either goods or services. Health care is classified by the government as a service industry because it provides an intangible thing rather than an actual thing. If you buy a good, like a car, you voluntarily decide to shop around and get the best car you can for the price. Even a vacation, especially a vacation package or a cruise, is a good. A nice dinner, while a good in the sense of the food, is also a service. You buy the services of the cook and servers.
Here is why the patient shouldn’t be considered a customer, at least not in the business sense.
1. Patients are not on vacation. They are not in the mindset that they are sitting in the doctors office or the hospital to have a good time. They are not relaxed, they have not left their troubles temporarily behind them. They have not bought room service and a massage. They are not in the mood to be happy. They would rather not be requiring the service they are requesting. Which leads to number 2:
2. Patients have not chosen to buy the service. Patients have been forced to seek the service, in most cases.
3. Patients are not paying for the service. At least not directly. And they have no idea what the price is anyway.
4. Patients are not buying a product from which they can demand a positive outcome. Sometimes the result of the service is still illness and/or death. This does not mean the service provided was not a good one.
5. The patient is not always right. A patient cannot, or should not, go to a doctor demanding certain things. They should demand good care, but that care might mean denying the patient what the patient thinks he or she needs. The doctor is not a servant; she does not have to do everything the patient wants. She is obligated to do everything the patient needs.
6. Patient satisfaction does not always correlate with the quality of the product.A patient who is given antibiotics for a cold is very satisfied but has gotten poor quality care. A patient who gets a knee scope for knee pain might also be very satisfied, despite the fact that such surgery has been shown to have little actual benefit in many types of knee pain.
BOSTON, Ma. — It was Christmas Day. I was on call at the hospital and was waiting for my wife and 6-week-old son to come so we could eat lunch together. She was bringing kimbap, sweet potatoes, and avocados. But then my pager buzzed.
On the phone was a hospitalist physician.
“Is this ID? We have a new consult for you,” she said. “This man has a history of dementia. For some reason he has a urinary catheter to empty his bladder. We gave him an antibiotic, but now his urine is growing a resistant bacteria.”
I sighed. Yet another catheter associated urinary tract infection.
I walked up the stairs to his hospital room. He was bald, thin, and sitting alone in bed. The peas and fish on his tray were untouched. There were no gifts or tree in his room. I washed my hands, put on gloves and a yellow isolation gown, and introduced myself.
“How are you?”
“Ok, I guess,” he replied.
“Do you know where you are?”
“I’m not sure.”
“You are in the hospital. Do you know what day today is?”
He’s a middle-aged man with diabetes. This kind of thing is a “red flag” on certain patients. He’s one of those patients.
“When does it happen?” I ask.
“Just when I do things. If I rest for a few minutes, I feel better.”
Now the red flag is waving vigorously. It sounds like it could be exertional angina. In a diabetic, the symptoms of ischemia (the heart not getting enough blood) are atypical. It’s the pattern of symptoms that is the most important, and to have exertional shortness of breath which goes away with rest is a pattern I don’t like to hear.
What he needs is a stress test – more specifically in his case, a nuclear stress test (because his baseline EKG is abnormal). But there’s a problem: he has no insurance. A nuclear stress test will cost thousands of dollars.
I can refer him to the hospital, but I know the financial situation he and his wife face. They have no money because of a chronic pain problem he has. He hasn’t worked in several years, but hasn’t ever been able to get disability either (“I tried, but was denied three times”). Without insurance he’s not able to get his problem fixed, so he’s disabled. But he can’t get disability, so he can’t get insurance to get his problem fixed and no longer be disabled.
But the problem on hand is this: he needs a test he can’t afford.
There are many folks out there in this same situation. It may not just be the people with no insurance, and it may not even be people who don’t have money. In fact, my own family is facing this same problem. Multiple family members (myself included) need dental work done. Some need it done badly, yet we don’t yet have the money to pay for it. So we wait for the money to show up while the problems gets worse.
At 6:30 AM, I kissed my 14-week-old son Joe on the forehead and headed off to work at the hospital. By 3 PM I was back in bed with a hacking cough and a fever. I had influenza.
As a doctor training in infectious diseases, I knew that the flu can be dangerous in vulnerable populations like little babies. I had visions of Joe being admitted to the pediatric intensive care unit, as I swallowed a pill of oseltamivir (brand name “Tamiflu”) and shivered under the covers.
Should I also give my little boy Tamiflu to prevent him from getting sick? The answer should be clear to an infectious disease physician-in-training, right?
I felt competing instincts. Paternal: to “do something” to prevent Joe from getting the flu. Medical: “do nothing,” as the rampant overuse of antibiotics in children has had negative consequences and the same might be true for antivirals.
As I researched the question further, I learned that the decision to give prophylactic Tamiflu is anything but simple.
Close contacts of people with the flu (including babies) can receive Tamiflu if they are at high risk for influenza complications. One Greek study of 13 newborns found that the drug was safe but did not address its effectiveness. Moreover, the number of babies who would need to receive Tamiflu to prevent one serious case of influenza is unknown.
For the second year running, more women than men have signed up for coverage in health insurance marketplaces during open enrollment under the Affordable Care Act. According to the Department of Health and Human Services, enrollment ran 56 percent female, 44 percent male, during last year’s open enrollment season; preliminary data from this year shows enrollment at 55 percent female, 45 percent male – a 10 percentage point difference.
What gives? An HHS spokeswoman says the department can’t explain most of the differential. Females make up about 51 percent of the U.S. population, but there is no real evidence that, prior to ACA implementation, they were disproportionately more likely to be uninsured than men – and in fact, some evidence indicates that they were less likely to be uninsured than males .
What is clear that many women were highly motivated to obtain coverage under the health reform law – most likely because they want it, and need it.
It’s widely accepted that women tend to be highly concerned about health and health care; they use more of it than men, in part due to reproductive services, and make 80 percent of health care decisions for their families . The early evidence also suggests that women who obtained coverage during open enrollment season last year actively used it. Continue reading…