Health reformers fail to hold patients accountable for health costs

Health reformers fail to hold patients accountable for health costs

To cut costs in our health system, reformers target the massive of waste.  One way to reduce waste is to change the way doctors are paid.  The fee for service payment system, they say,  encourages doctors to prescribe more expensive care, which lines their pockets and drive up the cost of care.

To combat this trend, reformers often have providers in their crosshairs, introducing new payment models like accountable care organizations which, in theory, will keep costs down by paying doctors for the quality, rather than the quantity, of care.

The jury is still out on whether holding down costs this way will be successful.

I do agree there is tremendous waste in our system.  I’m on board with the Choosing Wisely movement, the attempt by professional medical societies to educate physicians and the public about unnecessary tests.

A variety of factors explain why doctors are incented to order expensive tests.  The rise of the relevance of patient satisfaction, for one.  The pervading mentality among physicians that more tests can shield doctors from malpractice lawsuits, for another.  Most reformers dismiss these reasons, but talk to any doctor: these factors often hover over medical decisions.

I want to focus on another reason, however.  The role of patients.  Health reform generally shields patients from the responsibility of rising health costs, but perhaps that should change.

In a recent study from Health Affairs, patients don’t want costs to be a part of medical decision making.

Researchers asked a focus group of patients and found that they “did not generally understand how insurance works and felt little personal responsibility for helping to solve the problem of rising healthcare costs. They were unlikely to accept a less expensive treatment option, even if it was nearly as effective as a more expensive choice.”

Worse, patients often felt vengeful towards insurance companies — which reformers have worked hard to vilify in the public arena — and because of this, patients “seemed to be motivated to choose expensive care out of spite.”

Doctors are being pressured to consider costs when prescribing care.  But holding costs down needs to be a shared responsibility between the doctor and patient.  Yes, the fee for service payment system needs to be abolished, and reformers are right to introduce new ideas to replace that flawed way of paying doctors.

But reformers ignore the patient’s role in controlling costs.  I didn’t see this particular Health Affairs study being covered in Wonkblog or the New York Times’ editorial page, for instance. Doctors can spend all the time they want going over the risks and costs of expensive tests, or explain why a generic medication is just as good as a brand name equivalent, but it’s a two way street.

Patients also play a role in cost control.  It’s time that reformers acknowledge that.

Health reformers fail to hold patients accountable for health costsKevin Pho is co-author of Establishing, Managing, and Protecting Your Online Reputation: A Social Media Guide for Physicians and Medical Practices. He is founder and editor of, also on FacebookTwitterGoogle+, and LinkedIn.

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  • southerndoc1

    For-profit insurers.
    For-profit pharma.
    For-profit medical equipment.
    For-profit hospital chains.
    All dedicated to maximizing return for executives and shareholders.
    Yeah, it makes sense to blame doctors and patients for out-of-control expenses.

    • Guest

      You are free to start your own insurance, pharmaceutical, medical equipment company and even hospital and run it not for profit if you think they would be successful.

    • Mike C.

      You are free to start your own insurance, pharmaceutical, medical
      equipment company and even hospital and run it not for profit if you
      think they would be successful.

      • buzzkillerjsmith

        I doubt that southerdoc is greedy or vicious or antisocial enough to do that. Medical school grad, not business school.

        • Mike C.

          So instead point fingers and complain, but do nothing to change things.

      • southerndoc1

        All I was saying was that, if you’re concerned about how much we spend on health care, follow the money. It ain’t going to patients or physicians.

        But you knew that.

        • Mike C.

          I know that most physicians make a fair wage and every patient has the same opportunities in life as physicians do. They’ve made their choices, while other people have made their choices to front the money and build medical complexes and provide many people with an opportunity to make a decent living and help people.

          I also see hospitals helping many people who don’t pay anything for that care, while others pay more than their share. If you think it is unfair, then there are other options, other choices you can make.

  • drd

    You know what would be interesting. Where is a study of where health costs are coming from?Who are the largest contributors to rising healthcare costs? It’s interesting I would have to search far and wide to find an article like that. Agree fully with southerndoc.
    You notice articles like that never come up to make a logical argument of accounting for costs? Hum…Interesting. How then can you make an informed decision? Just guess?
    Articles of this sort that pick on doctor’s pay, patients parts, immigrants causing costs to rise. All true. But are these the major players? I often wonder if the industries mentioned send out lobbyists propaganda to get folks mad about immigrants for example, to detract from where the majority of costs are coming from.
    I don’t doubt patients contribute in these ways, but I guess I just wonder what they are reacting to?

    • southerndoc1

      Cokely’s study in Massachusetts (I can’t speak to how well done it was) identified inflated fee schedules negociated by large hospital corporations (non-profit in name only) as the single largest contributor to rising health care costs.

      • drd

        thank you. I’ll have to look at that.

  • Tracy Caisse

    One third of our population is over weight or obese. People have deplorable eating and drinking habits and refuse to exercise. This is not the responsibility of medical care providers. People should pay a percentage of their medical care based on their fitness levels and BMI. 10% overweight=10% of insurer responsibility mandated to be paid by the patient. Let people have to pay for being fat and unfit.

    • Kristy Sokoloski

      Yes, many people have deplorable eating and drinking habits, and refuse to exercise. However, no one can make people do the things that they should to better their health (see the blog entry that got posted several weeks ago that talked about holding patients accountable for their actions). Making people pay a percentage of their medical care based on their fitness levels and BMIs is not going to change a single thing. As for making 10% of insurer responsibility being mandated to be paid by the patient won’t change things either. In NYC the mayor tried to put a ban on the purchase of soda drinks that were bigger than 16 oz, and a judge overrruled it. The reason? Because you can’t force people to change their habits if they don’t want to.

      • Tracy Caisse

        No, you can’t “make” anyone do anything, but you can incentivize. If the fatter you were, the more you had to pay for your own care, you might reconsider that next donut. When the cost of cigarettes went through the roof, many people quit, and I am sure, many others rethought the decision to start. It could work if we had the backbone to create limits.

        • C.L.J. Murphy

          But the point is that come 2014, it will be illegal to discriminate, price-wise, on all aspects of lifestyle choices and pre-existing conditions (except tobacco use). In other words, in all health and behavior except smoking it will be illegal to incentivize customers to adopt a healthier lifestyle. Insurance companies have historically priced for risk – including weight – but they will no longer be allowed to. In 2009 it was still legal to charge an unfit obese drinker more than a fit healthy teetotaler, and most insurance companies did. No more.

        • Kristy Sokoloski

          “If the fatter you were, the more you had to pay for your own care, you might reconsider that next donut” is a rather interesting statement. Unfortunately, the people that choose to eat their donuts and their high fat diets will still find a way to do so. And they will continue to do so no matter how high the cost just like has happened with cigarettes. The prices of cigarettes went through the roof but that still didn’t stop the majority of smokers that choose to smoke to keep smoking. The minute you start putting limits on what people can and can’t have the more it becomes easier for them to not be compliant with health and dietary recommendations. And if the people don’t want to do it oh well. Plus, by trying to limit them then you will hear an outcry of taking away a right to the freedom of choice.

          • Jane Berg

            Socio-economic status is a confounder to how people live and eat as well. Obesity, heart disease, and excessive drinking are not limited to our poorest or middle class people. It exists even among our wealthiest. Greed from insurers and inefficiencies in claims processing are also confounders to the problems.

          • Kristy Sokoloski

            Jane, I agree with you about that obesity, heart disease, and excessive drinking are not limited to our poorest or middle class people, and that it exists even among the wealthiest. It’s because of this being the case that I said what I did about that no matter how high the cost to try and discourage the continuation of behaviors that contribute to bad health if someone wants to continue those behaviors they will find a way. They will find a way to continue to do what they are doing no matter how high the cost is. Doesn’t mean that the choice that they make to continue this is ok because it’s not, but it’s their choice.

    • C.L.J. Murphy

      Obamacare makes it illegal for insurance companies to penalise customers for poor health choices – with the one exception of tobacco use.

      It did used to be the case that an insurance company could charge higher premiums for an unfit morbidly-obese 30-year-old woman with a fatty liver who drinks heavily; than they did for a fit athletic 30-year-old woman with beautiful organs who rarely drinks, and only socially.

      Of course that takes away one incentive (lower premiums) for lazy fat alcoholic couch-potatoes to change their ways. It also means that the conscientious fit athletic 30-year-old is going to be penalized with a hike in premiums, because now she’s going to be subsidizing all the lazy fatties’ premiums so that they can get the increased level of health care they will have brought upon themselves from an insurance company who is no longer allowed to charge them more.

      With socialized medicine, individuals are LESS accountable for their actions and resultant health costs than they would be in a free market system. I agree with many aspects of Obamacare but wish they hadn’t banned carrots & sticks when it comes to patient accountability.

    • Caitlin Peebles

      Just out of curiosity, would all of you “MAKE THE FAT PEOPLE PAY!” folks be just as vociferous in demanding that AIDS patients similarly be punished for their largely self-inflicted diseases? Or poor single mothers? Or patients with STDs? Or anyone who fronts up with a sports-related injury?

      There are many medical conditions which could have been prevented had the patient lived a safer, more cautious, more “holy” lifestyle. Why should the overweight person be shamed and singled out to pay for their own knee replacement when the professional athlete is not?

  • Ben Green

    The tipping point for driving down costs will occur once most patients have skin in the game for their care decisions. High deductible health plans will drive this movement and docs will need to be accountable to cost decisions of their patients. Imagine if insurance companies bought your groceries; you also would favor the more expensive option. But alas that is not the case and consumers make educated decisions on groceries based on cost, taste, health factors, etc. Healthcare is moving in this direction.

    • Margalit Gur-Arie

      Yep. It is moving in this directions, where people without money make “educated decisions” to forgo healthy food, or to beg at food banks for canned ravioli, so that they and their children can become malnourished or obese, or both. While rich people have educated conversations on the subject over their hor d’oeuvres.
      Oh and by the way, the cashier at 7-11 is not accountable for the dietary decisions of her customers. Tipping point is almost here….

      • C.L.J. Murphy

        In many countries, the poorest citizens are the thinnest and if you see a fat person you can safely assume they are affluent. The modern Western world has turned this on its head. Ah, “progress”.

        • Margalit Gur-Arie

          The let them eat cake lady was ahead of her time…

          • Tracy Caisse

            Only the “Cake” that Marie Antoinette was referring to was whole grain, dark bread, not the refined white garbage the rich could afford. We would be healthier for the fiber, protein and unprocessed nutrients in this “cake” if only people would eat it.

  • Healthcare worker, NON MD

    Patients abuse the system. They go to multiple doctors for the same issues so the left hand doesn’t know what the right hand is doing. They go to the ER for the same issues they are being treated for by their PCP’s and specialists because they didn’t get a call back from the doctors office when they call in at 4 pm on a Friday afternoon.

    Everyone is responsible here, NOT just doctors. Doctors make way LESS money treating these patients than the administrators at the hospitals who are churning that dollar mill. Working MD’s in clinical practice went to college for a LONG time and have a huge responsibility and they take care of US. Why is everyone always blaming the doctors?

    Doctors order expensive testing because if they don’t, people will SUE. I see patients on a dally basis abuse the ER. They order that way to protect themselves.

    • Suzi Q 38

      You are generalizing, but your frustrations are understandable.

  • James deMaine

    As you may be aware, TIME magazine recently devoted a full issue which “follows the money” and shows how broken our insurance system is. See –,9171,2136864,00.html

    • Kristy Sokoloski

      I read this article and it was very interesting. I also had to do an assignment for one of my classes for school about this article. It was very interesting.

  • buzzkillerjsmith

    This is the tragedy of the commons that we all read about in Sociology 101. People do what they perceive to be in their own short-term interest even if their actions hurts the very system they depend on. Failure to take steps on global warming is a prime example.

    A few ways to deal with the situation, at least partially:

    1. Make people pay the full cost for their decisions. This is hard row to hoe and it defeats the whole point of insurance. Some people would get less care than they should have, as is the case now of course.

    2. Have the insurance companies or the government or doctors or someone else say no to people who ask for more than they should have. Good luck with all that.

    3. Quit whining about HC costs and get out the checkbook, America. You ate it, you pay for it.

  • Bonnie Modugno, MSRD

    How will we grapple with patients who use “free” medical care for companionship and community?

    • Kristy Sokoloski

      Bonnie, would you please explain a bit further what you mean by this? This is one I have not heard of before.

      • Bonnie Modugno, MSRD

        I see a good number of elderly clients and their appointments with providers fill the calendar and their need for attention and socialization. That also holds true for those who seem fairly awkward socially and are lonely. Some are candid about it with me.
        There has to be a better way to meet these needs, but there are good reasons why a medical appointment is safe or works

  • JPedersenB

    I see doctors saying this over and over, that patients demand the most expensive care. My own experience is that the doctors that I have interacted with are the ones insisting on all the tests for the annual “fishing trip.”
    I agree with southerndoc that the for-profit parts of the medical business are really what is driving costs…

    • kevinmd

      Sure, some doctors go on the fishing trip.

      But some patients do too, according to the Health Affairs study:

      The point is, cost savings need to be a shared responsibility. Health reformers need to acknowledge that.


      • Homeless

        I have been paying insurance premiums for 25 years and you criticize me for healthcare spending?

        • Suzi Q 38

          I was accused of this until it was discovered that I had spinal stenosis with possible MS.

          I was complaining about various unusual and weird symptoms, that came and went for about a year, then escalated with additional and more persistent symptoms in the last 6 months before diagnosis.

          The first year and a half, the doctors thought I was a litigation seeking hypochondriac.

          I challenged them to ask my insurance company what my medical record had been in the last 5-10 years prior to my hysterectomy and subsequent problems.

          Very little activity, other than seeing a PCP twice a year with yearly labs. Maybe a GYN for a PAP smear.

          IF you go back 15 years, you will find my knee surgery.

          Other than that, not much.

          We decided to have PPO for the last 15 years. Thank goodness, it all started with my son and a retinal bruising from an eye accident that rendered him blind in one eye. He was 14 at the time. The doctors did everything they could for him for a month. After his initial surgery, I had him at the of the best teaching hospitals in Los Angeles within 2 days of
          the accident.

          That has cost us $850.00 a month for the privilege.

          If I need 4 MRI’s (Cervical, head, thoracic, and lumbar) to determine why I have had troublesome neuropathies for the last year and a half, so be it.

          You would want some answers too. Sometimes, they are necessary. For a year and a half, my neurologist did not think so. Why? My symptoms kept changing, as neuropathies do. I am convinced he thought that I was making stuff up.
          What I didn’t know was that I was paralyzing and leaving it to rest, or alone, was making the paralysis permanent for me.

          SAVE money????
          Who are you saving it for? For the insurance company???
          For someone else? Why do you think that I have sacrificed monetarily for the last 15 years or more for PPO insurance? For some doctor to sit on his hands and wait, and ignore my glaring symptoms?
          I was one that needed the tests.

          I like the idea about saving money. Try that same principle when you treat your own family with serious conditions.

          Go with your gut feeling. If it sounds serious, especially neurological. Get me the definitive tests, before the signal changes on the spinal cord render me permanently disabled.

      • JPedersenB

        Agree, Kevin. There is so much wrong with medicine and costs that it is going to take a Herculean effort just to sort things out!

    • Suzi Q 38

      I am just the opposite.
      I needed an MRI of my head and spinal cord (cervical, thoracic, and lumbar..all w and w/o contrast) for fairly serious neurological conditions (legs weakening and neuropathies in hands and feet, back pain, stress urinary incontinence). The neurologist hesitated on day one of my complaints. He just ordered the lumbar spine MRI.
      It wasn’t until I had gone through two rounds of PT (the PT director feared that my weakening was serious, but neurologist did not agree),
      and my symptoms came and went for about a year. One thing remained constant, though, my legs were getting weaker and weaker, ever so slightly each day.
      I was going to leave the teaching hospital several times to get a second opinion, but I was discouraged by staff each time.
      They asked me to be a “patient” patient; that UC whatever hospital was way too big, and that I would get “lost” there.
      Anyway, I stupidly allowed them to see if my symptoms would magically “go away” for about 3 4 month intervals.
      I asked for more tests; the neurologist did not think that I needed them.
      My symptoms got worse and worse. I kept asking for an MRI and nerve tests. The answer was a resounding “no” from the neuro.
      Ironically I improved a little for a couple of months. By then a year had passed.
      My symptoms got even worse, and i was ready to leave the teaching hospital again, for a larger teaching hospital. I was hoping that a different set of “eyes” and attitude about my condition would give me some answers and treatment.
      Lucky I told the gastroenterologist of my plans, and he asked me to repeat all of my symptoms again. He told me that the problem was in my upper spine, and to tell all of my doctors that “He said so.” He was Chief of Staff.
      I booked another appointment with the neuro and told him what the gastro said. I told him that I was about to leave his facility, and if he didn’t run to tests I had been asking for for about 8 months for, I was going to take it to patient advocacy.
      Wow, he finally ordered all the tests I had been asking for and more.
      Discovered the spinal stenosis…light spots on my cord, nerve damage in both hands and feet, etc.
      When their neurosurgeon saw me, he was livid. I told him the “Reader’s Digest” version, and he placed some angry phone calls.

      Anyway, I got apologies and my MRIs’, but the insurance company wanted me to go with a cheaper off site MRI place.
      I didn’t know I had spinal stenosis at the time, so I said “You want to save 66%? Great. Tell me where to go.”

      I also routinely carry my lab results with ordered by my PCP at home to my specialists visits.

      I asked for a consult by an endocrinologist. She was O.K., but I realized that I didn’t need her. She wanted me to return in 3 months, but I told her that since I couldn’t take HRT, due to cancer
      that I would let my PCP take it from here. She had checked out my thyroid and hormones.

      I figured out that I actually got sicker under the care of all of these highly credentialed specialists that could only treat one area of the body. The reason was that they didn’t talk much to each other.
      There was not NP or PCP in charge of me to make sure everyone followed up with me.

      Not all of the patients want to go cheap, but I tried to contain costs, and it almost got me in a wheelchair.

  • Charlene Jebens

    I couldn’t agree with you more. I have started a small company to work with individuals to help them to improve their understanding of the health care system including the insurance product they purchase. We teach them to be better, more informed consumers of health care and to manage their health and wellness in a way that keeps them healthly. Thank you for this article.

  • mgeuchre

    As a former paramedic (also worked 3 years in
    Hospital ER’s/SICU) who spent 11 years since in cardiac and orthopedic surgical sales here is my perspective. I stand against declining reimbursements for physicians. The reimbursement for giving up most of one’s 20′s, student debt, bureaucratic regulations, malpractice insurance and legal paperwork is already
    low- especially primary care MD’s.

    Patients also get the shaft in ways they have no idea about. The entire system is funded through health care insurance premium
    dollars and self-pay. An example for the point I am trying to make- That drug commercial repeated on TV is a $250 million marketing campaign. The expense of this marketing is reflected in the cost of the drug. 30-40% of medical company capital goes sales/marketing/administration. Since the beginning medical
    companies have been 100% responsible for educating doctors on what technologies are available. The cost to health care? $50 Billion annually. This cost is spread over all health insurance premiums.

    Then there is the Health care GPO, what a shaft this is, to the tune of $37.5 billion, all in the name of cost control. Here’s an independent study everyone should know (google it): Do Group Purchasing Organizations Achieve the Best Prices for
    Member Hospitals? An Empirical Analysis of Aftermarket Transactions

    These are the two most corrupt segments in health
    care which patients have no say in or control over. I could list half a dozen more with little effort. In modern reform efforts the solutions always involve more bureaucracies, regulations, work and inefficiencies. If we made this simple and efficient, players such as physicians and patients could take a more active role. How about physicians controlling when and where they receive
    medical technology information and only in segments where they are actively seeking new and better solutions? And finally, yes, I am part of a solution looking to reform through efficiencies. A platform that makes it easier for physicians to be involved then to sit in the current systems. Not asking them to do more, inviting them to do less (how novel). Medical marketing is our first target, GPO’s are next, and then a swing at the other unnecessary, inefficient and corrupt cost drivers killing our health system.

    It’s not physician reimbursement, folks.. or patients. We could cut $80 Billion of waste while improving efficiencies without blinking an eye. These entrenched money grabbing systems will not go
    down without a fight.

  • Doug Capra

    This is great! Those really making all the money in health care can just sit back and laugh as most doctors, and most nurses, and most patients (the responsible ones) point fingers at each others and fight it out blaming each other for everything. I’m sure they’re getting a real kick out of conversations like this.

  • drjoekosterich

    You are correct Kevin. As the ultimate consumer of services and products the patient must take some responsibility. If the money came out of their own pocket they certainly would. Everyone wants the most expensive when someone else pays. This is the same in food cars plane travel and … health

  • shiriegale

    Much of the money spent in this country on health care is spent fixing what people have done to themselves. That’s where the patient is responsible. We are all responsible for keeping ourselves as healthy as we can.

  • MightyCasey

    Sorry, but I’m not buying this. Looking at the Kaiser and HealthAffairs links, I don’t see info on what the study details are (n of what? population?), which makes me wonder who was actually studied.

    I can say, from my own observation and experience, that patients have not been encouraged/enabled/empowered/educated to understand how to determine *value* in healthcare. We’ve also been instructed that the newest/best/highest-priced treatment option is best, thanks to relentless advertising and marketing for pharma blockbuster drugs and robotic surgical suites.

    Pricing has been hidden in healthcare for decades. Now patients are to be told to grow up and stop whining? Help us understand. Make pricing more transparent. Make outcome measures visible down to the practice level. Help us figure out *value* as part of shared decision making. Don’t just call us spoiled brats for not understanding how the system works.

    • kevinmd

      We’re on the same page here. Better price transparency is essential if both doctors and patients want to make value-conscious choices.


      • MightyCasey

        Delighted to hear that (and I already knew you were) – I’m endlessly frustrated, though, by the rising tide of noise about patients being the problem when it comes to cost. If we’re kept in the dark – and we have been in Mushroomville since time immemorial, or at least since insurance became the standardized payment method – we have to be educated on a better way to make healthcare choices. That message is a core part of my mission, and one of my own most frequent writing topics …

  • Lisa Boesen

    I would be interested to know the cohort mix of those consumers who don’t want cost to be part of the medical care equation. My personal experience has been in transitioning to a high deductible health plan, costs because very evident. As we transition to the consumer paying more out of pocket, consumers may become more accountability for the health to lower out of pocket costs as well begin to learn how to ask questions and be a partner with the physician in lowering healthcare costs through alternative tests.

  • Beverly Tchang

    Do you think a greater development in patient responsibility can lower healthcare costs? I’m envisioning a cultural shift where patients do feel more empowered to solve health problems themselves with the advice of a physician, using phone appointments or better education about diseases.

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