Maybe Martin Luther King was right: the arc of the moral universe bends toward righteousness. Maybe the arc of history favors democracy. I hope so, but lack that optimistic certainty. Indeed, I hesitate to predict where this country’s election mania will bend the arc: will we emerge more compassionate, more equitable, more tolerant? Or will electors opt to retreat to a nativist, conservative, Darwinian time?
But, whatever the arc of politics, the arc of cyberspace favors the market, empowering all of us consumers with the transparent knowledge that would make Adam Smith giddy.
Transparency undergirds any working market: buyers must know what sellers offer, must see the range of products, must be free to choose what they want.
In medicine, cyberspace has made patients into consumers. The Internet has dissipated the force-field of “doctor knows best,” specifically, my doctor knows best. Patients now can click and click to learn about their diseases, piercing the once-mystic aura of professional expertise. Consider prostate cancer. There is no one uniform medical consensus on the benefits of PSA testing, surgery, radiation, or wait-and-see. Doctor X may advise one course; doctor Y, another. In the not-very-distant past, an insured patient might seek a second opinion (assuming the insurer would foot the tab); an uninsured patient would trust the clinic physician’s wisdom. But without a consensus, or if minority opinions challenged the majority wisdom, most patients would not know. The same holds for breast cancer: we have a range of treatments, a range of drugs. And to some extent a physician’s choice will depend not just on the patient, but on his/her training and experience. Today a patient who knows how to click can discuss options.
The government has weighed in, challenging “golden rules” of practice. How often should a woman have a mammogram? How often should a person, with no history of colon cancer, have a colonoscopy? If a person has one clear colonoscopy, how long before a second one? Is the annual Pap smear essential – or can it be biennial? Does a woman’s age influence the answer? Who needs bone density tests? Who needs annual physicals? Amassing mountains of data, expert panels have offered their wisdom – wisdom that often challenges the status quo.
Patients are consumers, not purchasers: their employers, government, and insurers pay. And, thanks to a cyberspace-fueled explosion of data, purchasers at last can bargain, considering the value of a treatment or test, its cost-effectiveness vis a vis alternatives, and, finally, the different providers of care.
So if one treatment is less effective than another, given reams of data, insurers can urge patients to try the more effective one first. If that is the least expensive, insurers can be insistent. If data suggest that a biennial test should replace an annual one, insurers can pay for the former, letting the patient pay for the latter. If data suggest one treatment is ineffective, insurers can refuse to pay (though irate patients may take their case to insurers’ appeal boards). Physicians have their own practice patterns: if data suggest one physician is an “outlier,” doing more surgeries than the norm, insurers can make that a discussion point in negotiating with that physician (or can drop the physician from its network). As for charges, hospitals vary widely: generally, hospitals charge “private-paying” patients the most (‘private-paying” is generally a misnomer since the “private-paying” patient is often uninsured, ends up as an “account receivable”). Even charges to insurers vary, depending on the insurer’s clout. In the not-so-long-ago past, those charges were shielded, but the era of transparency has erased the shield. Insurers now shop for prices. In a not-too-distant future, the Exotic Marigold Hotels may become commonplace, as insurers refer patients overseas, for cheaper hip replacements.
Pundits said that the Internet spurred revolutions in the Middle East, crediting Twitter and Facebook for the Arab spring. Maybe. And maybe the arc of history is truly bending, even after the post-spring violence.
The Internet, though, is bending the evolution of health care, towards a more efficient, market-driven system.
Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email firstname.lastname@example.org.
From The Progressive Populist, September 1, 2012
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