Free-market enthusiasts encouraged the transformation of patients into consumers, expecting consumer-patients to lower the costs of care. If the cost of computers could plummet as savvy shopper shopped, why not the cost of mastectomies? Or hip replacements? A fee is not immutable, but marks negotiation between purchaser and seller. HMOs that negotiate for ever-lower rates from hospitals understand that principle.
Yet ultimately consumer-patients did not seek the cheapest care. You might want to drive a clunker to spare your budget. Nobody wants a clunker of a new hip, inserted by a bargain surgeon at a third-grade hospital. Besides, savvy shoppers have to feel up to the task, and sick patients generally don't feel energetic enough to price-shop. So bargain-rate health care didn't take hold. The price-sensitivity lay in more optional services, like lasik surgery.
But if the consumer frenzy did not transform patients into shoppers, it did transform them into "demanders." In the Marcus Welby era, patients saw doctors as wise benevolent sorts. Patients did what the doctor ordered.
That mind-set is long gone.
First went the presumption of benevolence. The last 20 years of HMOs' gag rules, incentives and gatekeepers have made patients skeptical of their physicians' Hippocratic leanings. If a physician says that a patient with a migraine doesn't need to see a neurologist, today's patient wonders: Has the HMO limited the symptoms that merit referral to a specialist? Do the HMO "incentives" translate into lower pay for referrals? The same goes for prescriptions. When a physician prescribes drug x, is he remembering the drug company's CME (continuing medical education) cruise to the Caribbean? Is the physician bound by a restricted formulary? When a physician lays out the options for treatment, is he omitting a therapy because the HMO wouldn't pay for it -- the "gag rule?"
Next to go was the presumption of wisdom. Thanks to the Internet, patients probe the arcana of diseases. On-line support groups share not only miseries and cheer, but advice. Popular magazines feature the avatars of empowerment: patients who challenged their physicians and prevailed, insisting upon treatments that ultimately worked.
Today's patients have become the best arbiters of what they need. Not surprisingly, in an ultra-technological universe, today's patients need technology, drugs, experimental treatments. And vocal patients have turned their needs into demands.
Here are a few examples.
In May the Food and Drug Administration voted not to approve Provenge, a drug for prostate cancer. The FDA wanted more evidence of safety, as well as efficacy. Patients subsequently threatened the physicians who voted for caution. ("Cancer Experts Threatened After Opposing Drug," New York Times, June 4). The FDA is caught in a bind: on the one hand, this consumer-nation wants safe, effective, economical drugs -- a hard trifecta. On the other hand, desperate patients and their families want easy access to anything that looks promising in early-stage trials.
Michael Moore's movie SiCKO includes a patient whose HMO denied a treatment. That story is now commonplace. For years the media focused on women with breast cancer whose HMOs wouldn't pay for bone marrow transplants, considering them experimental. The "women-as-victims of HMO cheapness" stories garnered sympathy -- and occasionally spurred the HMO to renege. Years later, the media barely reported that the clinical evidence supported the HMOs.
Legislative noise has revolved around Big Pharm's influence over physicians; indeed, a few states ask physicians to disclose the perks, from dinners to stipends, they receive. Yet it is not just physicians who push up usage. Patients share some of the blame. Consider antibiotics for ear infections in young children. Some infections are viral. The recommended treatment is "observation." Yet in a survey of 200 physicians (Pediatrics, August 2007) two-thirds of physicians who prescribed antibiotics did so because of "parental reluctance" to "observe." The parents wanted the drug. The over-use of antibiotics has spawned antibiotic-resistant infections.
"Doctor knows best" was not a useful maxim. Often the doctor doesn't know best, but needs to work with a patient who asks questions, who probes the wisdom-via-the-internet, and who wants second opinions. Yet "doctor knows nothing" is not useful either.
Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email firstname.lastname@example.org.
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