Commentary in GAMA Reports on healthcare reform most often begs the question, presuming solutions will emerge from government regulation and convoluted tinkering with current systems. Few writers delve into the role of the marketplace, the lack of competition in the insurance industry, and the advent of the 21st century healthcare patient, who is increasingly engaged in "participatory medicine" through a broad array of resources to pursue health education, decision-making, and therapeutic options in tandem with their physicians.
Scant imagination seems in play as talk obsesses about sustainable growth rates, Medicare trust fund, tort reform, skyrocketing healthcare costs, corruption (waste, fraud and abuse) and without fail the uninsured as if they were a homogenous group in dire need of services.. .right now... all of which culminates in a rigid mindset that invokes government as the central problem solver.
After observing for decades the flaws inherent In government sponsored programs like Medicare and Medicaid, why would practicing physicians imagine government as the source of or inspiration for healthcare reform? Time and again, government shows a greater propensity for worsening complex problems, not solving them. Recently, we have been exposed to the fiscal impossibility of a universal government sponsored healthcare program that promises to expand access and hold down costs.
Government provides a key oversight role as do professional medical organizations in establishing standards, but these institutions are not the essential players in the world of healthcare. Our critical attention should instead focus on the two players with the only starring roles: doctors and patients-notwithstanding the conventional wisdom assigning the "rich uncle" role to government, the "devil you know" to insurance carriers, and the "devil incarnate" to trial lawyers.
That these other supporting actors strive for leading roles in the ongoing healthcare drama should be informing us about the deep moral hazards built into our current systems. These hazards above all else weakened doctor-patient relationships by diminishing our patients' decision-making capabilities towards their own health. Nobly, while the Current insurance structure started out with good intentions and fostered phenomenal advances, its premise is counterintuitive: take money out of clinical encounters by using insurance reimbursement, and the doctor-patient relationship would thrive; whereas, if money were in the equation, the relationship would suffer and compromise medical care.
This premise, now a quasi-religious belief, dominates our attempt to understand healthcare delivery systems. Yet, in the real world, we witness aging and maturing adults making more prudent decisions about the food they eat, the budgets they keep, and the cars they drive. Why then is it unimaginable that patients would develop their own cost-conscious health judgments as well? Such smarts evolve through decades of shopping, that is, knowing what and when you can afford something. But, shopping is not promulgated in current healthcare delivery and consumption.
Which leads to a disturbing question: do we physicians believe the vast majority of our patients are too ignorant, stupid, or ill-equipped to scrutinize their own healthcare costs? Do we honestly think they could never learn to make rational, budget-informed decisions with the assistance of their providers? Forgive the jargon, but that attitude seems so....20th century! In the emerging context of participatory medicine, numerous patients have begun the appropriately self-serving process of budgeting healthcare dollars, selecting compatible physicians in and out of mainstream medicine, recognizing value in various treatment approaches and most importantly showing greater engagement and commitments to their treatments.
Patients use the Internet to become better informed about their health and how to improve it. The reputable Delotte survey in 2008 showed nearly 75% of adults want direct access to electronic medical records, email capabilities with physicians and interactive electronic scheduling. The meaning could not be clearer: patients want information to participate in their healthcare. Even lower Socio-economic classes with supposedly less Internet access polled greater than 50% interest towards electronic access. Remarkably, 25% of adults are willing to pay for interactive services.
We do not know as yet how much patients will pay out of pocket in the emerging model of participatory medicine. What drives participatory medicine now is a sizeable proportion of patients who are dissatisfied and frustrated with inefficient or ineffective aspects of traditional healthcare delivery. This new paradigm will reach a tipping point once the market exerts greater influence on the business of healthcare delivery. In the simplest terms, imagine astronomical deductibles that cause doctors and patients to work under new sets of rules. Most health care decisions (excepting emergent and some urgent ones) will unfold via a natural buyer-seller experience, and prices will drop. Physicians will perforce post fees. Doctors who deliver higher quality care will benefit accordingly. Patients will show greater savvy, finding ways through Internet or other resources to conscientiously prepare for doctor's appointments, the result-better care, better outcome, and better price.
Strengthening ways in which physicians and patients must communicate with each other will neither solve all healthcare issues nor eliminate the need for insurance coverage (both public and private) for emergency or catastrophic illness. But over time, this market- informed, doctor-patient relationship offers enormous potential to enhance patient self-efficacy, capitalize on preventative medicine, drive down costs, avoid wasteful spending, limit corrupting influences, and ultimately create innovative and less expensive opportunities for access. Am I dreaming? Sleep doctors have that tendency. Still, if we are unwilling to embrace this patient-centered potential I fear we will miss a transforming moment in the history of medicine, leaving us to suffer another government managed nightmare.