Managed Care Matters

I don't see how consumer directed health care as presently conceived is going to work ("work" defined as significantly reduce health care cost inflation). Among other problems with the concept, most of the dollars are spent by folks with chronic or very expensive acute conditions that have costs far above their deductibles eliminating any incentive for these folks to worry about costs.

But I’ll suspend logic for the moment to consider another issue. If consumer-directed health care is going to work, consumers will have to know what their health status is, what their health status means in terms of potential morbidity, and what health care (for those conditions) might cost them. Then, if they want to be "educated consumers," they will need to have current, accurate information on the costs and outcomes of health care providers in their geographic area who treat their specific conditions (or potential conditions).

The first two aren’t too tough, at least on a population basis. Health risk appraisals have done a pretty good job of forecasting future health conditions…for the general population. And epidemiology has evolved into a reasonably accurate science for prediction of population-based morbidity and associated trends.

The last two are also not too tough, again on a population basis (seeing a trend here?). Case-mix adjusting physician outcomes can produce a fairly accurate picture of individual physician and/or facility outcomes. If you have a large enough sample size and if the diagnoses and other data are accurate, consistent, and complete. Rather big ifs…

(I apologize in advance for denigrating the rather significant issues inherent in case-mix assessment and analysis and ignoring the wide variation in practice patterns across specialties, geography, and physician. I’m making a huge generalization to make another point.)

The big breakdown is our individual uniqueness - we are each a population of one. And that’s where "consumerism" blows apart.

We each get treated as individuals, not as populations. We have unique combinations of co-morbidities, allergies, pre-existing conditions, quirks, differences, nuance, needs and fears. Some of us know a lot about medical stuff, and most of us don’t know much at all. And some patients think that “quality care” is getting in to see the doc within a couple of days, while others view it as a clean waiting room with lots of interesting magazines, and still others want a doc who is warm and smiles, while another group wants to see case-mix adjusted statistics on outcomes.

This "a plus b plus c plus d..." is what makes each patient unique, a population of one.

And docs have to treat individuals, not populations. So, each patient gets treated a little differently.

Patients need to take responsibility for their health, and play an active role in their care. No debate there. But in an increasingly specialized world, with physicians unable to keep up with the growing library of medical knowledge, individual expertise getting deeper and narrower and an educational system which is hard-pressed to adequately educate many Americans on some rather basic subjects, it is not only irresponsible but incredibly naïve to expect or demand individuals have all the knowledge and experience required to effectively “manage” their own health care.

The bright-eyed, textbook-quoting academics and theoreticians citing both obscure economic theory and Adam Smith see consumerism as the cure for health care’s ills. Boy are they clueless.

Oscar Wilde’s oft-quoted " ...a cynic is one who knows the price of everything and the value of nothing" also applies to these "health care economists."