Friday, April 22, 2011

I am not a consumer of health care!

And my internist is not a “provider” of health care services. He is my doctor, and I am his patient. Yet politicians, economists, and policy wonks want to turn the intimate doctor-patient relationship into a simple economic transaction between a buyer (consumer) and seller (provider) of services.

Paul Krugman, himself a Nobel Prize winning columnist, writes about this in yesterday’s New York Times:

“How did it become normal” he asks, “or for that matter even acceptable, to refer to medical patients as ‘consumers’? The relationship between patient and doctor used to be considered something special, almost sacred. Now politicians and supposed reformers talk about the act of receiving care as if it were no different from a commercial transaction, like buying a car — and their only complaint is that it isn’t commercial enough. What has gone wrong with us?”

Taking off on his theme, Krugman criticizes plans by House Republicans to “replace Medicare with vouchers” by arguing that “‘consumer-based’ medicine has been a bust everywhere it has been tried.” But not only does he think vouchers won’t work, he thinks, “there’s something terribly wrong with the whole notion of patients as ‘consumers’ and health care as simply a financial transaction.”

Now, let’s for a moment put aside Krugman’s political views and his specific criticism of the voucher proposal. (It isn’t just conservatives who refer to physicians as “providers” and patients as “consumers”—I did a search of how many times the words “providers” and “consumers” show up the Affordable Care Act, and found that “provider(s)” is used 620 times and consumer(s) 190 times, although the law also refers to patient(s) 603 times, and physicians 563 times.)

Doesn’t Krugman’s point resonate with you, regardless of your politics? Isn’t there something terribly wrong with medicine being taken over by the bean-counters and budget analysts who look at health care only as a transfer of economic goods from one person to another?

If a physician is just a provider, why should he or she be entitled to any greater respect or standing than a car salesman? If physicians are just a providers, who can blame physicians when they act like car salesmen, trying to maximize personal gain by selling more services to me, the consumer? If doctors are just “providers” aren’t we inviting the culture that Atul Gawande says he found in McAllen, Texas, “a medical community [that] came to treat patients the way subprime-mortgage lenders treated home buyers: as profit centers.” If physicians are just providers, what’s wrong with them providing more and earning a good living while doing it? And aren’t professionalism and ethics obsolete if medical care is nothing more than an economic transaction between the provider and the consumer?

We complain about doctors that are being squeezed to see more and more patients per hour—but if they are just providers, what is wrong with paying them based on how much care they provide each hour (otherwise known as productivity)?

If I am just a consumer, isn’t it my fault if something doesn’t quite go right with my health and I end up “consuming” more from the system than is my fair share? If I am a just a consumer, I am supposed to be able to shop around for a doctor, right? Just like I did for that new flat screen TV? But that’s not easily done when it’s a sick elderly parent who is admitted for emergency surgery, is it? Or you yourself are facing a frightening illness? Or if I don’t know who is a good doctor or a not-so-good one? And if I am just a consumer, isn’t it all my fault if I didn’t put aside thousands of dollars each year in case my mother might someday end up in a nursing home?

If we look at medical care simply as an economic transaction between “providers” and “consumers” then we shouldn’t be surprised if people act based principally on economic self-interest—the consumer getting as much as he can for as little cost as possible, and the provider earning as much as she can at the highest cost possible. Conservatives might try to alter the economic incentives by making the consumer accept more financial responsibility and letting insurance companies control the supply of services, and liberals might try to do it by having the government control the supply of services through price controls and limits on capacity. But either way, they are missing the point, which is that health care costs are ultimately the very personal and personalized decisions made by physicians and their patients in the examination room or bedside. We need to respect and support that relationship and help doctors and patients make good decisions together, rather than turning them into the equivalent of a used car salesman selling a lemon to a hapless consumer.

Today’s question: Do you agree that “there’s something terribly wrong with the whole notion of patients as ‘consumers’ and health care as simply a financial transaction?”


Brad F said...

If you are a consummate patient advocate, ie, you like your patients and want to help them, with a good demeanor, but are a lousy doctor--does your patient have a right to know?

Vice versa in some ways as well.

You are 100% right with your suppositions, but I feel your essay is unfinished and needs a bit more expansion. Medicine is changing, and there is a commoditization of our profession occurring, like it or not.

Are doctor's ethics always pure; no. Do we put money ahead of other things at times. Yes.

How does that fit into your model? The "Marcus Welby" glass ceiling is breeched and what we have now is not quite provider, nor doctor. A bit of both.

Patients deserve ratings and transparency. We were not always pristine, and if we are rated like goods, what is your term for that?

Something to think about.

Brad F

Chris said...

I agree and blogged about this myself a year or so ago.

ryanjo said...

"Isn’t there something terribly wrong with medicine being taken over by the bean-counters and budget analysts who look at health care only as a transfer of economic goods from one person to another?"

That ship has sailed long ago. The first step was government encouragement of commercial interests to start managing the physician-patient relationship; the rise of the HMO in the '80s. The motivation? As usual, money -- "thar's gold in them hills". Now 1/3 of the health care dollar goes to admin costs, our health insurers are fabulously wealthy, and the average patient can't find affordable care.

The solution we incessantly discuss here? More government regulation and pandering to commercial interests, exemplified by the stepchild of the HMO, the ACA. What better way to solve prior government and commercial excess, than with more of the same?

Clifford Dacso, MD said...

Both this column and Krugman have important points. I would like to add two (maybe) important ones.
1. The physician (and nurse practitioner) is not a "PCP." This term, I believe, arose during the heyday of HMO's. It was an attempt on the part of the managed care industry to de-professionalize the physician. "Provider" does the same. There are some things a "PCP" might do, like providing inferior care, that a compassionate physician would never do.
2. As internists, we have been complicit in this race to the bottom. We chose to go head-to-head in competition with family physicians to become "PCP's" so that we could also become "gatekeepers." This was abetted by the American Society of Internal Medicine, then our business and strategy organization. Many specialists "retooled" (I swear it, that was the word) to become "gatekeepers" because they believed that was the only was to prosperity. Little did they know that they were being played as fools by industry who well knew that we could be manipulated so easily by greed.
I have high hopes about the current new internists. They have great skills and realistic expectations. Medicine has changed irrevocably, as it has many times in the past. We can not let these revolutions change who we fundamentally are, the advocates for our patients and those trying to avoid being patients, in health and in illness.

Harrison said...

I think there is something also terribly wrong with thinking of medicine as being divorced from financial transactions.

There is a new drug that lowers the risk of recurrent episodes of hepatic encephalopathy. It lowers the risk by about 25% in terms of absolute risk reduction. That means it has a number needed to treat of 4. It should be a slam dunk clinical decision. Of course we would recommend it.
But it costs $1300 per month.
So if I'm a patient/consumer I'm thinking that even with a 1 in 4 chance that it will help me, that is a lot to pay for a 3 out of 4 chance that it will be the same as torching over a thousand dollars a month.
And that is a great number needed to treat.
For cholesterol lowering meds the number is around 20.

If we don't think of our patients as also being consumers, and be honest with them about the statistical facts about treatment courses, then we are doing a disservice.


Arvind said...

Bob, where were you about 10 years ago when we (physicians) were labelled providers by everyone including the ACP? It took Krugman to wake you up to this reality?

Is this what makes Krugman get the whatever prize he got? If organizations like the ACP actually listened to their members, they would have heard this complaint 10 years ago.

And if this is such a holy relationship, why did the ACP not stand up to defend it while it was being shredded apart by the ACA?

Water under the bridge my friend.

PCP said...

This issue is long past. The train has left the station, and reached close to its destination and now it takes a left wing economist to wake up ACP from its slumber?
Many of us took offense to this 15 yrs ago when its use became prevalent.

This Doctor-Patient relationship has been systematically weakened by many political, corporate and special interests over the past 15 yrs by everything from price controls by the federal gov't, to DTC advertisements, to 3rd party payer meddling, the assault on Internist primary care by the Proceduralist dominated RUC on the one side and the ANP lobby on the other.
Now finally on its last beleagured legs, we are getting the knock out punch with the ACA and therefore its ACOs and CHC/FQHC modeled Advanced Medical homes.
Somehow this is supposed to bring general IM back from its coma.
The current assumption in DC is that ACOs, AMH, and an expanded role for ANPs, RACs, more Regulations, EHRs etc will lower cost. There is the assumption that if more care is being delivered, it must be because of greed. The certitude that surrounds "these facts" is rather astonishing, and to the extent that doctors had to go cup in hand 3-4 times last year to get sub inflationary adjustment to their fees. Fees which have led to more closures of physician owned practices than openings.
The horrible state of the private practice of medicine is apalling. The insurance oligopoly has just announced stellar results which wall street is cheering sending their stocks soaring and soon their CEOs bonuses will rocket, they boast of their "medical loss ratios" being lowered, all while the extraordinarily generous ratios written not the bill are diluted down.
Yet there is no one, not politicians, not the general public(yet), not the press and astonishingly enough organised medicine standing up for private practice medicine.
I assure everyone reading this board as goes the health of the private practice of medicine, so goes the attractiveness of medicine as a career.
ACP is frankly advocating more for its ideology than its members. Nearly as much has been admitted previously.