Patients need help to navigate the health care system

The New York Times recently ran an op-ed by Paul Krugman with the intriguing title, “Patients Are Not Consumers.”

Here’s an open letter to him:

Dear Dr. Krugman,

As a comparative effectiveness researcher, I agree with many of the arguments that you are making in your most recent article. However, I disagree with your main point that patients are not consumers.

I understand your sentiment and agree that patients are more than consumers just as doctors have more obligations than their own (financial) good. However, it is not just House Republicans, as you seem to suggest, that favor “consumer-based” medicine. Business economists Michael Porter and Elizabeth Teisberg base their entire theory to shift competition from health plans (you mention the failed Medicare Advantage idea) to individual clinicians and facilities based on the patients’ informed decisions in the market.

Patient-driven medicine is also more than just vouchers for seniors. Just look at e-patients like Dave or the Society of Participatory Medicine or former hospital CEO Paul Levy who rightly point out that patients are the most under-utilized resource in medicine and that health care process should not just be patient-centered but patient-driven.

Clinicians’ help to patients to navigate the health care system is essential. Patients will often be guided, for instance, in referrals to specialists by their primary care physician, if they happen to have one. America’s health care system, unfortunately, is so fragmented that in reality patients often need to find their information on their own, at least at some point along the way, or through families and friends.

I feel strongly that patients should essentially be engaged and empowered and have access to a wealth of information, from medical conditions to outcomes of individual medical providers or facilities.

Comparing and selecting providers of clinical services (yes, I would call doctors and others that) even if they might not pay the entire bill is an essential feature of engaged and empowered consumers.

Nevertheless, health care will never be a perfect market. Patients need to put difficult-to-digest information into context to be able to make use of them. A discussion with the clinician of your choice is most often invaluable and often cannot replace other ways to interpret information. Since you, Dr. Krugman, are an economist, I am wondering why you missed out on naming the imperfect condition in question: information asymmetry.

Yours sincerely,

Ben Geisler

Benjamin P. Geisler is a comparative effectiveness researcher who blogs at Health Care Value Strategies.

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  • Steven Reznick

    Just the fact that someone can list their profession as a comparative effectiveness researcher is proof enough of just how dysfunctional our health care system is. Another professional intertwining themselves between the doctor and patient and picking their pockets of the limited health care dollars available and intended for patient care is not necessarily what is needed. 

    Smart well educated patients need a doctor who is their own and who can sit down and review the problem and discuss the research they have done and guide them through the health care system. It is as simple as that. Decades will go by before the bureaucratic and government encouraged use of computerized systems is able to deliver meaningful data that can be reviewed and interpreted and provide consumers with information in a manner they can digest and understand. I just read an op ed piece in the Wall Street Journal on ” transparency” in health care data. It was written by a cabinet level administrator and a Stanford academic physician and promoted use of Medicare and insurance company billing data to obtain the info needed and research effectiveness. What baloney. Medicare and private insurance billing data is garbage. Health care providers at all levels have multiple diagnostic choices to make when filling out a fee ticket. They pick the non fraudulent one that will get them paid. It often is tangential and peripheral to what the patient actually complained about and has ( Patient comes in with a cough, sore throat, nasal congestion, fever and malaise. Do they choose viral upper respiratory tract infection or any of the symptoms as the final diagnosis?  They choose the one that gets them paid for the visit and chest x ray).

    Patients need a well trained doctor who becomes their family physician and will review and discuss options and choices with them.. In the long run and the short run that is the best option for having patients be educated health consumers. 

    • Anonymous

      “Medicare and private insurance billing data is garbage.”

      So true. That anyone thinks billing data is of a quality that it can be used to guide medical care indicates a degree of disconnect from reality that is truly frightening. Coding for dollars does not give us reproducible results.

      The quality of this data will become exponentially worse once ICD 10 is in place.

    • Anonymous

      how many people, most days, most weeks, most years, really need a doctor to “sit down and review” any problems they may have? Steve, you wring your hands over big gov’t meddling in transactional health care (not really the point of most datagathering/sharing initiatives); I remain concerned over physicians who stubbornly continue to practice as if it were the 1880s; as if everything worth knowing about patient treatment were between their own two ears; as if their hands-on ministrations were not likely the least important aspect of any person achieving optimal health.

  • Steve Wilkins

    Which came first..empowered health consumers or a broken health care
    system with too few, overworked primary that unilaterally decided to
    push more “responsibility” onto the patients and call it “patient

    I happen to believe that it is the latter with notable exceptions.
    People like e-patient Dave and the organizations like the Society
    mention in your post are certainly becoming more visible.  But it is a
    very nascent movement and by no means constitutes a majority of
    patients. Look at e-patient Dave’s background and he like me and many
    “empowered patients” were “well connected” with top notch providers
    before he ever need one…a luxury most patients don’t have. Claims by
    consumers to have “gone online to look for health information” as often
    quoted by surveys conducted by PEW and others do not necessarily equate
    to empowerment.  Before the internet people turned to traditional
    material for the kind of health information they now find on the web.
    Sure patients can talk to “Like” patients but when they walk into to the
    doctor’s office the “empowerment” we ascribe to often patients

    As as health care professional  and a patient and spouse of a lung
    cancer patient it is imperative that “navigators” be available to cut
    through the red tape and miscommunications that is today’s health
    system.  If my wife had not had me to fight through the system she would
    be dead today. 

    Patients need all the help they can get as Dr. Geisler’s post title states.

    Steve Wilkins  

  • marc

    Of course people need to be engaged and empowered, but this is not the same as consumerism, which is about low-level transactions. Healthcare is a profession that requires regulation and yes, comparative effectiveness research. All patients should expect a high (gold) standard of care, and that should be mandated by professional bodies and government. Shopping around for a doc you like should not mean one you don’t like is going to give you the wrong treatment. 

  • Anonymous

    So as a consumer, I theoretically have access to information on medical conditions and I can research the best options for my particular situation.  So why do I need a doctor’s opinion?  Oh, it’s because of the information asymmetry. The doctor knows more and is in a better position to make the best decision.  So what’s the point in spending all that time researching that medical condition only to default to the expert?  Oh, it’s because I should make my own consumer based decision.  So why do I need a doctor’s opinion?

    • Ben Geisler

      I would definitely say that there’s differences between finding information (that e_patients might not know about, since it’s just appeared on PubMed or EmBase or ClinicalTrials.Gov or Cochrane or at as an oral presentation at a conference or wherever), interpreting it (not  just the results, but also whether methods were appropriate, all option were compared etc., the study populations applies to your condition etc.), and making the decision (a decision could be entirely made by you, the e_patient, or jointly — “shared decision making”). So does it hurt to get a second opinion (your doctor’s) or if your condition is grave even a third one (second doctor), and go back and forth while making the decision? If everything is crystal clear, get it over-the-counter.

      • Anonymous

        Well, theoretically, I don’t have the expertise to know if my search was exhaustive, whether I interpreted the information correctly, or whether I missed that new Cochrane review.  So if I don’t know whether the information I have is flawed, then how do I know whether it’s safe to treat OTC?

        So the idea that I am a consumer, can make consumer based decisions on my research seems to contradict that I am really a patient, who doesn’t have the expertise to make a diagnosis or an appropriate treatment plan unless it’s simple enough to treat over the counter.

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