Thoughts on Health Care:

The Curse of the Patronized Patient

by Roger Bourke White Jr., copyright Feb 2010

In January and February 2010, I participated in a lively discussion thread on health care.

Several points of view were expressed and they were interesting -- few were tiresome cleches. The discussion talked about who should take the leadership role in health care providing, and many points of view were advocated.

But one idea that seemed an axiom of this thread was that patients could not successfully make their own choices.

This insight was an "Ah-Hah!" I had as the discussion went on. The first hint of this axiom came as I proposed switching to a "patient pays" providing system and it was dismissed without much comment. The dismissal was a mystery until I had my Ah-hah moment about patient patronizing.

Why should patient patronizing be so deeply ingrained into the health care system? (Another anecdotal example of this patient patronizing thinking is truism that doctors are difficult patients. By my new insight they are difficult patients because they are partly enfranchised, so they won't always passively go with the flow the way the average patient does, and this is unsettling behavior to those providing.)

Patronizing patients has a long history in the human condition. First, when a person gets sick, they don't feel much like making choices. In Neolithic Village times (the lifestyle for which most of our thinking is well adapted) when a person got sick, the person slowed down, and the health care activity was divided between the patient's extended family and health care providers -- witch doctors and other advice-offering community members.

The modern health care systems have evolved from this passive patient/extended family/health care opinion offerers-roots. In America (but not so much so in East Asia) the extended family part of this system has been eclipsed, so what we have now in the health care arena are just the opinion offerers dealing with passive patients.

This disconnect of patient and family involvement from health care decision making is resulting in fierce turf wars between health care providers, insurance companies, employers (who pick insurance companies), insurance regulators, and health care regulators. That is what we are experiencing in the Obamacare debate of 2009/10.

And this gets us back to this fascinating point we are at today: These turf wars are fiercely fought decisions involving billions of dollars, and all the parties involved claim they are fighting fiercely to protect the patient's interest... but none of these patient advocates is willing to give up their influence to the patient. The thought of doing so doesn't even occur to them, or the patients.

...The patient is disenfranchised and patronized, and everyone involved accepts this as axiomatic... very interesting!

The Roger Fix

I suggest we fix this state of affairs by reenfranchising the patient, and the simple way to start the reenfranchising is by having the patient pay directly for his or her health care.

Yes, enfranchising the patient would be revolutionary, and it would completely upset the current system. Here are a few of the changes I see taking place:

o The patient must accept responsibility for making health care choices -- the old "The devil made me do it."-defense against responsibility when something bad happens must met with a, "No. It's your choice, you live with it." response, at both the community and the legal levels. For the legal system this means tort reform on steroids. The basis for making a successful medical claim becomes fraud in what is offered rather than an unsuccessful outcome. The human body is not a deterministic machine, so we should not expect one hundred percent predictable outcomes.

But, if patients are to be enfranchised, they need to be informed so they have the tools to make choices they can buy into. This means that we as a community must spend time and effort on training everyone to both make good choices, and to accept that they will be responsible for the choices they make. ...This doesn't seem like a bad idea to me.

o The role of regulators changes from prescriptive to advisory. Regulators can suggest good practices, but they can't outlaw anything. They can't outlaw because the choice now rests with the patient.

o Providing good information to the patient becomes much more important. Regulators can take this on as part of their role. They can rate the authority of information that is provided on health choices. But, once again, they can't prescibe the information flow. What to listen to and what not to listen to rests with the patient.

o Insurance should be deregulated. The patient should decide what are good insurance offerings. Once again, good information is important, and the marketplace should offer a lot of ways to rate the value of insurance offerings.

Yes, but... but... but...

Yes, the result is going to seem very chaotic and frustrating to those who want to tell patients what they should be getting in health care.

What is offered will be different. How it is offered will be different. The result is going to have a lot more change over time, offer a lot more variety, and the result is going to be a much simpler relation between patient and provider.

There will be much wailing and gnashing of teeth on the part of those who feel that patients will constantly be duped by faddish-but-ineffectual offerings. My feeling is, yes, this will happen. And it will look like a disturbing amount of health resource gets spent on "worthless or harmful activity" in the eyes of the currently established health care industries and agencies.

"But." I say in response, "If this is what the patient wants to spend his or her money and time on. If this is what the patient feels is the best for him or her... Won't these activities be providing the patient with the greatest satisfaction they can get for their time and money spent?"

And that, as I see it, is the heart of the difference. If the patient buys into the result, then the result, whatever it is, is something the patient can live with comfortably. This is the benefit of enfranchisement. A benefit the current health care debate seems to be ignoring.


May update: A 28 May 10 article in Reason magazine The Rise of Consumer-Driven Care by Peter Suderman suggesting that the combination of HSA plus high deductable will give patients more control over their health care costs. This is a step towards my patient pays concept.

February update: Here is an article in the 25 Feb 10 WSJ, A Better Way to Reform Health Care, expressing a similar view that patients need to be more involved in health care by doing more of the paying.

2013 update: This 7 Apr 13 WSJ editorial, Reflections of a Medical Ex-Practitioner: The glow of the personal relationship with patients is being extinguished by Ed Marsh, covers how this relation has evolved since the 1960's.

2013 update: This 10 Dec 13 Reason article, Health Care's Third-Party Spending Trap by Jeffrey A. Singer points out that "Contrary to 'conventional wisdom,' health insurance—private or otherwise—does not make health care more affordable."


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