Monday, April 25, 2011

Patients ARE Consumers...Except When They Aren't

Do you shop the health care the way you shop for, say, a new mattress? Well, in the case of the unfortunate patient to the left, probably not. There are plenty of situations where medical care is an urgent case of life-and-death, not a consumer choice. But there are also many situations where our purchasing decisions are made with the same cognitive tools that we use to choose any other service or object.

Paul Krugman disagrees. In a column last week, Krugman resoundingly declared that patients are not consumers...that was even the headline if his point was in doubt. Let's look at his argument in a bit more detail:
Here’s my question: How did it become normal, 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.
Certainly that vision of the medical experience as somehow removed from the normal way we buy is appealing: it's nice to think we will be taken care of without any consideration of our wealth or even our personal decision-making: just put yourself in the hands of your physician and all will be well.

But Krugman acknowledges, a few paragraphs later, that we're only having this conversation because of the current political moment, where people on both sides of the aisle are trying to figure out how we can afford our entitlement programs without bankrupting the country. So, at some point, money is going to come into the picture as a factor. And that's where the idea of talking about patients as consumers comes into play. The conservative theory is that bringing consumer-like behavior to health care (in other words, letting individuals try to go out and get the best value for their dollar) will slow the exploding health care costs that are hamstringing our economy. Referring to patients as consumers is not to minimize the emotional, human aspects of medical care, but to describe a certain rational, value-seeking behavior that conservatives hope to bring to the industry.

Krugman doesn't think patients can be wise consumers of health care. But he is dramatically oversimplifying. The trauma patient in the picture up top is not a consumer: he's not going to come back to consciousness to demand the ambulance drive him over to Memorial Hospital, where they charge 10% less for blood transfusions. But a patient with diabetes, dealing with a chronic condition, is going to make dozens, if not hundreds, of consumer-ish decisions about what drugs to take, what physicians to see, and which diet plans to attempt. If they were more personally responsible for those economic decisions, they would (in the aggregate) make better decisions about how to balance cost and care quality.

That's why it makes sense to move towards a system where the costs of catastrophic care (like traumatic injuries or heart attacks) are socialized to some degree, but to expect individuals (either on their own or through private insurance) to cover the costs of chronic care, physicals, and the like.

We want to believe there's a way to treat everyone "fairly", but what we really mean is that we don't want to hear tragic tales of system failure that make us sad for the victim and nervous for ourselves. We want to believe we and our loved ones and, perhaps, "the deserving" will always be cared for. And that we don't have to make tradeoffs between how good our care is and how much it costs. But we do. We can either wash our hands of the decision and ask the government to decide, for all except for the most wealthy, who gets what care, or we can embrace our role as consumers and make the best decisions we can for ourselves and our families.

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