Sunday, January 18, 2009

JAMA Commentary on Consumer Driven Health Care: It's Time to Give Healthcare Consumers a Chance

In the latest (January 21 and not on line yet) issue of JAMA, physicians Robert Berensen (of the Urban Institute) and Christine Cassel (of the American Board of Internal Medicine) argue that consumer driven health care may not be what patients need. Briefly, they argue that this kind of approach – in which consumers have full access to information on price, quality and services and get to choose accordingly – places patients at a huge disadvantage. It also discounts the proven and long standing value of physician professionalism. According to Drs. Berensen and Cassel, the knowledge needed by the consumer is too complicated, the relationship with the health care system too asymmetric and patients are too vulnerable to making bad choices. Compared to your physician healthcare system tour-guide where your doctor can act as an advisor, fiduciary and advocate, the medical marketplace is a lousy option.

The Disease Management Care Blog doesn’t entirely buy this at several levels.

While physician professionalism is an ideal, physicians are also:

Humans who carry their own bias and agenda into their patient encounters.

Vulnerable to economic factors when framing patient options.

Even when salaried and even when in premier academic settings, may belong in organizations that are monopolistic, predatory and not acting in their patients’ interests.

Drs. Berensen and Cassel also fail to distinguish between preference sensitive and insensitive care. The former involves healthcare services that are subject to patient choice (for example, a total knee replacement for progressive osteoarthritis), while the latter involves services are not readily optional (for example, a total hip replacement following a fracture). The DMCB accepts the notion that women in labor, men with heart attacks and grandmothers with hip fractures generally cannot exercise the usual laws of economics in a medical marketplace.

However, persons with chronic illness – such as osteoarthritis, prostatism, diabetes, high blood pressure and coronary artery disease – generally do have the ability and the time to get involved in determining much of the content of their care. This includes the outcomes they want from treatment and the amount of money and effort they are willing to expend to get there. There is plenty of great commentary and reviews that show that consumerism is an untapped force in healthcare.

The DMCB has lived through decades of physician professionalism and isn’t all that impressed. While it’s a great notion, relying on its routine applicability to day-to-day medical practice, while attractive, is at best na├»ve and at worst the last refuge of the status quo. It's what the doctor ordered, not what patients need.

We can work on expanding and improving the profesionalism but it’s time to give the consumers a chance when it comes to health care choices for chronic illness.


Brady Augustine said...

CDHC is just not yet ready for prime time, so to speak. The economist in me believes that the more direct the relationship between supplier and demander, the better our health care market will work. But as many smarter persons than I have pointed out, health care is not a well-functioning market.

CDHC basically started at the end-point and expected all of the other pieces to fit into place with minimum pain (see President Bush's Executive Order of Aug 22, 2006).

It is kind of like installing democracy in a country without first ensuring stable institutions are in place (courts, protections on private property, human rights, etc). In the case of health care, this means public health, coordinated systems of care, measurement, payment incentives, etc.

As QI folks would say, a good outcome is not necessarily the result of good processes but good processes lead to good outcomes.

Until systems are organized, simplified, transparent, and accountable, CDHC will operate at the fringe and most models will favor more of a shared approach (e.g. value-based insurance design).

Hopefully, CDHC will have a larger role in the future but we have to fix the processes so that CDHC follows logically, not force risk onto the people who are least likely to manage it well because of imperfect information. ~BAA

Jaan Sidorov said...

You raise an excellent point Brady!