Fixing Health Care By Altering Patient Behavior
Economists have long said health care, as a market, is a strange animal. A large part of this is because patients don't act like regular consumers.
Imagine you walk into a Target store. You stroll through the aisles and see all the regular stuff. Just one thing is different — nothing has any prices.
Now imagine that as you're checking out, your boss is there saying, "Let me help you out with that." In most cases, our employers pay for a large part of our health care.
Patients are a strange sort of consumer. We don't know what anything costs, and even if we did, it does not matter because we are not covering most of the cost.
This is not necessarily wrong. It simply means that as consumers, we are not very involved in containing costs. There is debate about whether this should change, with economic arguments on both sides.
Transforming Patients Into Consumers
David Goldhill, a businessman who wrote the article "How American Health Care Killed My Father" for The Atlantic magazine, argues that patients need to act more like consumers.
Goldhill's father died from a hospital-borne infection. While sitting in the hospital, he says, he noticed all the ways in which a hospital does not act like a normal business.
"I thought about all the things I had seen while accompanying my father in his time in the hospital that made absolutely no sense to me," he says.
On several occasions, he says, his father was taken for procedures intended for other patients. What's more, the hospital's investment in information technology was less than what he's seen at his own dry cleaner: "And this is an industry where information literally is a life-and-death matter," Goldhill says.
Goldhill says the problem is that health care costs are hidden from us. He says that over the course of your lifetime, you and your employer spend $1.7 million on your family's health care.
"Let's take all the money we're spending on insurance, give it to the patients and have the patients spend much of it directly," he says. "Let's have catastrophic insurance for the worst cases — the truly rare, major, unpredictable events. And the rest, let's rely on the consumer. The key is that the patient is actually getting the bill."
Goldhill's proposal is what many economists call a consumer-driven model. Individuals would be required to buy some sort of catastrophic plan. Only expenses over, say, $50,000 would be covered. That's a high deductible, but you would have $1.7 million over your lifetime that you currently do not see. That amount would be built up slowly in what is often called a health savings account.
The Unique Nature of Health Care
Richard Kirsch of Health Care for America Now, an advocacy group pushing for affordable health care, hates the idea of a consumer-driven health care system. He says you can't compare health care to a typical business. It is different from shopping around for a car or a pair of shoes.
Kirsch offers this example: You look down at your arm and see a growth there. You're likely worried that the growth might be cancer, but you're also scared.
"If now you have to go into a bank account or have financial barriers to getting that care, you may not go to the doctor and see if that growth is a problem or not," he says. If you go to the doctor and find out that it's not a problem, then that's good news. But, he adds, what if you didn't go and it turned out to be a serious melanoma that caused a lot more expense and became a serious health risk later on in life?
"We don't want health care consumers making decisions based on finances," Kirsch says. He also makes an economic argument. Markets, he says, need good information to work. And the patient — the consumer — doesn't have enough information.
Goldhill agrees that patients do not have the information they need to make the right choices now. He argues, though, that if we controlled more of the money, businesses would pop up to help us choose doctors and hospitals. That is how most consumer economies work, he says. We all benefit from Walmart's low prices, even if we don't shop there.
"You're not going to shop for health care if you're hit by a bus," Goldhill says. "That's not the point. The point is, you're served in a health care system that has been tightened up, both from cost and quality point of view, because some consumers for many procedures are shopping around."
Kirsch sees that as a lot to ask of patients. He points to places like the Mayo Clinic that provide good care at a low cost as an example of how the system can work well without saddling patients with hard financial decisions.
There are some data from the nonprofit Rand Corp. on this question that Kirsch and Goldhill are debating.
One answer is that they are both right: If you make patients more like customers — force them to chip in more with co-pays for drugs, doctor visits and procedures — that does seem to eliminate waste. On the other hand, it also means some people won't go to the doctor when they need to.
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NOAH ADAMS, host:
Speaking of health care, when you go to the doctor, you probably don't think about this, but you are a part of a massive economic system, a system that wastes a lot of money. And one reason, among many, for all that waste is you. Economically speaking, you're a consumer, but you don't really act like one.
NPR's David Kestenbaum and Chana Joffe-Walt have this story on why that is and whether it should change.
CHANA JOFFE-WALT: David, we're going to start by imaging something strange.
DAVID KESTENBAUM: Go ahead.
JOFFE-WALT: Okay. Imagine you walk into a Target store. And everything is there on the shelves: all the shoes, the toasters, the guys in those red vests, but all the stuff on the shelves, nothing has any prices. That is what being a patient in our health care system is like.
KESTENBAUM: You mean because we have insurance. Yeah, this is a weird thing number one. You want to get your knee fixed? Fine. You want to stay alive another six months? Fine. You want that drug you saw on TV? No problem. It's covered.
JOFFE-WALT: No prices. And even weirder, when you get to the cash register at Target, your boss is there saying, hey, let me help you out with that.
KESTENBAUM: That's weird thing number two. Most of the time our employer pays a large part of our health insurance.
JOFFE-WALT: Right. We don't know what anything costs and even if we did, it doesn't really matter because we're not paying for a lot of it. Now, none of us is necessarily bad. It's just unusual in economic markets and it does mean that we as consumers, we don't have a strong incentive to keep costs down.
KESTENBAUM: And this is a big question for people who think about trying to fix our system. Is that okay that we patients are not involved or is it a problem? Maybe the problem. Of course, the answer depends on who you ask. We asked two guys.
JOFFE-WALT: Well, actually we asked a lot of guys and women, but we were most fascinated by these two because they're both business-minded people, but they completely disagree on this question.
KESTENBAUM: The first guy, David Goldhill, started by describing his devastating hospital experience. He wrote about it recently in The Atlantic. His father died from an infection he got in the hospital. Goldhill says, as a business guy, the whole experience seemed really wrong.
Mr. DAVID GOLDHILL (Businessman): I thought about all the things I had seen while accompanying my father in his time in the hospital that made absolutely no sense to me. The fact that my father several times was taken for procedures intended for other patients. The hospital's minor investment in information technology - less than I, frankly, I saw at my own dry cleaner. And here is an industry where information literally is a life and death matter.
JOFFE-WALT: For Goldhill, this made it very clear that patients need to be acting more like customers, asserting their right to spend their money here or take it elsewhere.
Mr. GOLDHILL: Let's take all the money we're spending on insurance, give it to the patients and have the patients spend much of it directly. Let's have catastrophic insurance for the worst cases — the truly rare, major, unpredictable events. And the rest, let's rely on the consumer. The key is that the patient is actually getting the bill.
KESTENBAUM: Goldhill calculated this amazing number. He says, if you look over the course of your lifetime what we and our employers spend on a family's health insurance, it is $1.7 million. So, his proposal: instead of making that invisible to us, let the patients control it. Require that every person buy some sort of catastrophic plan. Only expenses over, say, $50,000 would be covered. Less than that you're on your own, but you would have that $1.7 million.
JOFFE-WALT: Richard Kirsch hates this idea.
KESTENBAUM: He's our other guy.
JOFFE-WALT: Yeah. So, Kirsch works for a group called Health Care for America Now. And we sat the two of them down, and he says, no, it may seem like we're consumers, but health care, he argues, health care is different from shopping around for a car or a pair of shoes.
Mr. RICHARD KIRSCH (Businessman): Let me start with, let's say you look down at your arm and you see a growth there and, you know, you worry that growth might be cancer, but you're also scared. If now you've got to go into a bank account or financial barriers to getting that care, even if the money's there, but you're not sure how long it's going to last, what you need it for, you may not go to the doctor and see if that growth is a problem or not.
And you - so you go and turns out it's not a problem, good. Was that a waste? But what if you didn't go and it was a serious melanoma that cost a lot more expense and was a lot more serious to your life later on? We don't want health care consumers making decisions based on finances.
KESTENBAUM: Kirsch makes another economic argument. Markets, he says, they need to have good information to work. And the patient, the consumer here, does not have enough information.
Mr. KIRSCH: And that's like when my wife was in the hospital, the gall bladder surgery recently and it was an emergency procedure and she was going to shop around and see, is this the best surgeon? Is this the best hospital? Is that exactly the right procedure? Are we going to trust this doctor or not?
Mr. GOLDHILL: No, that's not how…
Mr. KIRSCH: Again…
Mr. GOLDHILL: Excuse me, but, again, that's a misunderstanding of how consumer economies work.
KESTENBAUM: They went back and forth on this.
JOFFE-WALT: There is some data on this question they're debating: an answer. And it is…
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JOFFE-WALT: Unfortunately, they're both right. If you make patient more like customers, you force them to chip in more, co-pays, for drugs and help pay for doctor's visits and procedures, that does seem to eliminate waste, but it also means some people don't go to the doctor when they really need to.
KESTENBAUM: Richard Kirsch and David Goldhill, they do agree on one thing, though, the system we have now - that system - it is definitely not working.
I'm David Kestenbaum.
JOFFE-WALT: And I'm Chana Joffe-Walt, NPR News.
ADAMS: And you can hear more of that debate on the Planet Money podcast at npr.org/money. Transcript provided by NPR, Copyright National Public Radio.
