Saturday, February 21, 2009

I Agree, But Can't Comply

I received a thoughtful response to my recent over-the-top post about the difference between "consumers" and "patients" from a gentleman at He raised some good points, but I am afraid that neither he nor I will get to see our ultimate vision of consumer- or patient-centered health care in the future. Here are a few snippets of what he had to say:

This is becoming one of those "get over it" moments for healthcare professionals. You can resist the notion all you want; the fact is patients more and more see themselves as consumers, and that's not necessarily a bad thing.

.....When it comes to my health, I have to do my own homework and make my own decisions. When it comes to my kids, I end up getting the best help and useful information from teachers and non-physician providers. The tired notion that as a patient I have some special connection with a physician who partners in my health is an alien concept. I don't blame physicians for this; it's just the way the system has evolved. As a result, I have no choice but to be a conscientious healthcare consumer.
I agree wholeheartedly --- it is important to be a conscientious healthcare consumer, and it is not necessarily a bad thing for patients to see themselves as consumers. But let's look at what a true provider of services-consumer interaction entails. Right now, my son is at swimming practice, and after spending the last hour catching up on paperwork, I am doing a little blogging. Where did I go for a cup of java and wifi access? I could have gone to Corporate Coffee Central; I like their coffee. I could have gone to my favorite coffee shop; it's pretty long drive, however. I chose instead to go to another locally-owned franchise, because it was convenient, has wifi, and serves a pretty good cup of joe.

I chose. Pretty simple concept in a capitalist society.

We had a simple cash exchange, a couple of bucks for a big, black cup of mud, and then a couple more for another cup. I had a menu of options to choose from, knew the price, and had the option of getting extras, such as a pastry that would make even Fat Bastard add a few inches to his waistline. Before I ever got here, I had seen advertisements for this and other places I could choose for coffee, all of which proclaim that they have the best tasting stuff. Some of them are running special discounts, which is really cool if you are a caffeine fiend like myself. If I became unruly, or refused to pay for my coffee, the shop owner can run me right on out the door, with no repercusions. If I ran a coffee shop, I would do all of these things --- advertise, make sure I offered the best product at a reasonable price, try to meet the desires of my customers, etc.

However, as a physician, I am not allowed to do these things. I cannot set my own price for providing care to patients ---- the government mandates what I can and cannot charge, with a list of rules that is so long it mirrors the tax code. I think that there are things that I do pretty well, and that I am caring and compassionate and very competent. However, I cannot advertise that I provide better care than my competitor across town ---- this is partly due to ethical standards, and partly due to the issues surrounding patient privacy. I cannot run a "special," giving patients a Mardis Gras discount for laparoscopic cholecystectomy ---- if I did so, Medicare or their insurer would demand repayment for the difference in price for all of the other cholecystectomies I did in the last three years. And if I have a patient who is rude to my staff, refuses to follow instructions, and doesn't pay his bill..... I still have to take care of him.

Realistically, Mr. Johnson and I are talking about two sides of the same coin --- or, more accurately, about two individual squares of a Rubik's cube, as there are many dimensions to this issue. Physicians are not allowed on the same playing field as other small businessmen. As a result, patients are not given all of the potential information that they may desire to be conscientious healthcare consumers. This problem will only worsen if we head to a single payer or totally government run healtcare system.

If Mr. Johnson and those at really believe in the consumer model of healthcare, then they must be at the forefront of the effort to prevent our headlong dash towards socialized/government run healthcare. How responsive are the folks at the DMV? The post office? How much help or information do you get from the DMV, and how much time does it take you to get it? Do you really think that the system that runs government offices will generate a more consumer-friendly, transparent healthcare system --- when they will have absolutely no competition? The answer is less government involvement in healthcare, with a decrease in the Byzantine set of regulations we deal with. This would allow physicians to negotiate with hospitals, labs, insurers, employers, etc., to form more efficient and integrated models of healthcare delivery. Then both Mr. Johnson and I would be happy, because he would be better able to get the data needed to make informed healthcare decisions, and I would have more time to devote to patient-centered care.

I do have one other question, though. At 2AM, when you are sick as a dog and need an emergency laparotomy, how are you supposed to be a conscientious healthcare consumer unless you have spent a considerable amount of time in preparation, studying all of the available surgeons in town?