12 May 2008

Consumer-Driven Health Care

Dr Wes has a nice rant about the myth that is consumer-driven health care. I couldn't agree more.

Consumers are not in the position to make informed decisions regarding their health care. In many cases they have no options at all: once you are admitted to a hospital you are under the care of a slew of hospital-based physicians who are the ones "on service" at that time and if you don't like one or more of them, well, you're SOL. Worse, when you are really ill, your ability to make value-based health care decisions goes rapidly to zero: Which ER is this ambulance taking me to? Is it worth it for me to spend that extra day in the ICU? The surgeon standing next to my bed telling me I need an emergency operation seems too expensive -- is there a more reasonably-priced surgeon available? And maybe I don't need a quadruple bypass -- can you see if we can get away with a single-vessel job?

It's ludicrous.

Yet conservatives continue to contend that consumer-driven health care will provide a solution to the crisis in health care as costs continue to escalate. The claim is that consumers who bear significant out-of-pocket costs, or as they charmingly put it, consumers who have skin in the game, will make rational decisions regarding their health care which will lead to lower costs.
Nothing could be further from the truth. Some "skin" might be a good thing -- Jeebus knows I've seen enough medicaid patients misuse the ER that I can see the undeniable value of a copay in driving good resource utilization. But the more "skin" in the game, the more likely patients are to defer necessary care, and the less control patients really have over the way the money is spent.

So when McCain and his henchmen extol the virtues of "market-based" solutions to the health care crisis, remember this and the intellectual bankruptcy of their misleading and dishonest health care plan.


  1. There is a fundamental difference between emergency care and routine medical decision making. Emergency and most inpatient care is, I agree, not amenable to personal decision making cost improvements. However cost of outpatient meds, screening labs and tests, and etc. may be amenable to patient decision making. As it stands now the only one who has "skin in the game" is the insurance company whose sole motivator is to pay for as little as possible.

    Furthermore, as a critical care doc I feel that maybe we'd see a lot less 85 y.o.'s on pressors, CVVH, and the vent if there were even a $50/day ICU copay. If I never hear "do everything" one more time it'll be too soon.

  2. wealthandtaste5/12/2008 3:05 PM

    You're right, patients should just blindly accept the dictums of anyone wearing a white coat, without regard for cost or the chance of adverse outcomes.
    The physician is now the philosopher-king, and his will shall be done. The patient's intellect be damned!

  3. W&T --
    Don't be a jackass. When a patient is lying in a gurney in the ER, or in the hospital with a serious illness, they are really not in a position to acquire the information to critically evaluate the doctor's advice. Especially when it is time-sensitive. A good doctor will explain the risks and benefits and alternatives so that the patient can be confident that the proposed treatment is sound, and if the patient has questions or reservations, a good doctor with take that into account and tailor the proposed treatments to match.

    But unless the patient happens to have significant knowledge of medicine, or the time to acquire it, it's not reasonable to expect that they will be capable of "directing" their own care.

  4. Most medical care isn't provided in emergency departments and isn't particularly time sensitive.

  5. Shadowfax-
    Thanks for the mention. One of the overriding themes in my post is the confusion between the term "consumers" of healthcare and patients. Are they the same? Patients might think so, but to policy wonks, they are VERY different. Today, irrespective of co-pays, etc., I would argue that patients have NO skin in the game of policy formation for the future of healthcare, rather it's the "consumers" (defined as Big Business, Insurers, hospital associations, and even Uncle Sam) that are shaping healthcare of tomorrow. Yet it is our patients who pay directly for the Wonder Boys of healthcare policy (those with the money and lobbyists from BOTH sides of the aisle) for the unproven websites extolling the virtues of their initiative with press releases rather than science. The IBM initiative was for the State of Georgia - one state in 50, at the tune of $5.2 million for a website that costs what, $300,000? It promised to bring all of the information for patients under one electronic roof - while similar websites already exist for tons of other companies, insurers, and states. Scores and scores of websites. All with the same goal. All reporting to be better than the last without any evidence that these effect actual patient interactions with their healthcare system. None of which evaluate how confusing they are for patients to utilize.

    Was this the work of conservatives? Liberals? Party affiliation is not the point. Rather, clarifying who the "consumer" of healthcare really is when it comes to developing policy and websites - I fear we've lost the focus that it's really about the patients anymore.

  6. The whole 'consumer' vs 'patient' thing drives me up a wall. My mechanic has the common courtesy to tell my his hourly rate and give me a cost estimate before he starts work. How much will my diagnosis and treatment cost? Is it gauche to even think to ask that of my doctor? If I don't ask, is it my doctor's responsibility to tell me? Does he or she even know? How can one be an intelligent consumer when nobody can tell you what your bill will be prior to treatment? And will that total change if you pay cash or via insurance? I won't even get into the realm of sorting out what insurance will and won't pay for. "Tell us what you had done and what it cost and we'll tell you what we'll pay for (and keep in mind that if you don't tell us in the way we prefer, we'll arbitrarily not pay for it...)"

    If I'm having a mole removed or my pectus excavatum dent pulled out, sure, I can comparison shop to my heart's content. If I'm pissing blood or having a stroke I'm in no state to hunt for a goddamn bargain like Adam Frigging Smith. Let me hazard a guess that the loudest of the "Let The Market Sort It Out" Kool-Aid drinkers have never been on the losing end of that situation.

    Am I a Communist if I suggest that for-profit health care is a great way to ensure that no more than seventy cents of each dollar spent on health care actually goes toward treating the sick and injured? I don't expect doctors, nurses, lab techs, et. al. to work for minimum wage, but shareholder profit is pure friction.

    I can't speak to W&T's relationship with his/her/its physician, but I'd like to believe there's something more to it than their relationship with their mechanic.

  7. Scalpel is right. The argument that people can't be "consumers" while on an ER gurney is a classic straw man. The vast majority of health care decisions involve more or less routine care.

    The "progressive" argument against CDHC always comes back to the medical equivalent of "the white man's burden"--people are just too dumb to make their own health care decisions.

    The Health Insurance Experiment, the only serious study of actual patient behavior as it relates to this issue, proved that to be paternalistic hogwash.

  8. Personally, I believe the argument of "patient" vs "consumer" is extremely valid. Consider The Patient.

  9. my favorite reading is the detailed bill of my wife's hospital stay for our 3rd child....she is an rn at the hospital, so much of her stay was free, but the prices listed and the actual amount the insurance company(final consumer) paid was crazy. 30-50 per cent discount!!!...I wish i could get that at the pump or grocery store for beign a loyal, repeat customer...

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