Editor's note: First of two parts.
In 2002, when Dr. Adrienne Boissy was an intern at the Cleveland Clinic, she was responsible for a vivacious young woman in her early 20s—not that much younger than Boissy herself. The young woman, a jet-ski instructor named Emily, was bubbly and active, all blonde hair and youthful energy.
Emily (whose name has been changed for this story) arrived at the hospital with some numbness and tingling in her legs. During that first visit, she was diagnosed with multiple sclerosis. The clinical team that Boissy was a part of gave Emily the medical run-down: Multiple sclerosis is a chronic demyelinating disease. We're going to treat you with IV steroids, and that should help you feel better.
The traditional word to describe people like Emily is "patient." But in the midst of evolving attitudes about how to both provide and pay for healthcare, there are many who would call her a "consumer." Now the chief experience officer at the Cleveland Clinic, Boissy thinks of her experiences with Emily as a lesson about the assumptions that clinicians have about what patients need from them—but at the time, she found herself unprepared for what happened next.
Boissy didn't have any direct responsibility for the big decisions in the young woman's care, but she rounded on her each morning and the two spent some time together. They got to know each other. One night when Boissy was on-call, she received a page to talk to Emily. She grilled the nurse: What did Emily want, exactly? What could she tell this girl that the rest of the staff hadn't already said? Worse, what if Emily asked a question for which Boissy didn't know the answer? The thought that perhaps she had done something wrong crossed her mind.
Boissy ran to her textbooks in the call room, a cramped and bare-bones space. She studied feverishly and tried to prepare herself for what Emily might ask.
By the time she approached Emily's bedside, she knew everything a young doctor would want to know about MS: Its pathophysiology, its expected outcomes. She felt prepared for any question that Emily might ask her about her disease.
"I sat down," Boissy recalled years later. "She said to me: 'I've been thinking a lot about what’s been going on.'" Boissy asked her what questions she had.
"You know," Emily said, "I have this boyfriend."
Boissy did know. The boyfriend was a little older than Emily and very handsome.
"I'm wondering," Emily asked, "if you think that I should marry him so that when I can't walk anymore I will have someone to take care of me?"
Boissy's heart started racing. Beyond the obvious pathos of the moment, it was a request for which she was totally unprepared. This was the moment that Boissy now uses to describe clinician assumptions about patients needs, but at the time, she was at a loss for words.
Transactionally, Emily's medical team did everything they should have for a consumer patronizing the Cleveland Clinic's renowned facilities. They informed her of her diagnosis, gave her medication and made her feel better physically. Yet, at the moment of medical crisis, those services were not top-of-mind as she thought of her future. Was Emily a "consumer" of healthcare, or was she a patient?
Providers across the country are leaping feet-first into consumer-driven medicine, restructuring their business models despite widespread concern that this change in taxonomy creates a model that will ultimately break down—with drastic impacts on both providers and patients.
Healthcare Dive looks at the controversial evolution of the "patient" into the "consumer" and how it continues to fundamentally change the business of providing healthcare in ways that are both positive—and incredibly risky.
What do patients want?
The conceptualization of today's "patient" as a consumer of healthcare is a premise that, fully established or not, the healthcare industry at large is organizing itself around with all the zeal and determination of a tent convert. The federal government has decreed it, redefining the term in its manifesto for the future of the nation's healthcare system. Insurers are rolling out consumer engagement programs from wearables to coupons to popular food chains.
Care providers are moving in the same direction: In New Jersey, the Ripa Center for Women's Health and Wellness at Cooper University Health Care offers yoga, fitness classes, cooking classes and art programs in addition to their OB/GYN and cardiology services.
"There's not anything more important today in healthcare than this undeniable focus on the consumer," Jesse Cureton, the executive vice president and chief consumer officer of Novant Health, told a panel in March.
"I'm using that word intentionally," Cureton said.
The business model of providers is shifting. Although more physicians are turning to hospital employment, unable to cope independently with the costs and administrative complexities that have come with the ACA's wide-reaching requirements, urgent care clinics are thriving. Here's a statistic that neatly and powerfully sums up the positioning of healthcare as a consumer good: As of January, more than one in three walk-in retail clinics were in strip malls or shopping centers. Pick up your groceries or your new plasma TV, and stop in to have that cough checked out.
Widely considered to be at least one of the solutions to expensive overuse of hospital emergency departments, these clinics have grown 20% since 2009—numbering 9,400 as of 2013. Regional chains like City Practice Group of New York and national ones like Concentra treat patients on a walk-in, as-needed basis, luring consumers with fast, efficient care.
Although it's a bonanza for some providers—the approach also opens room for subscription clinics like One Medical to thrive—hospitals are a trickier case.
Some hospitals, like Henry Ford Hospital in Michigan, have gone the luxury route. Henry Ford has its own restaurant that serves fresh and healthy foods, much of which is grown on-site. A former executive of the Ritz-Carlton hotel chain designed and runs the $360-million facility with an approach that calls to mind the old adage that "the customer is always right."
Financially, it's a strategy that appears to be working: CEO Nancy Schlichting told CBS News that the costs of running the facility are offset by low re-admission rates and high recovery rates. "Our goal is always to have the most efficient, high-quality care, so a lot of people will come and it'll make a very cost-effective model for the industry," Schlichting said.
The business case for consumerist healthcare is a no-brainer. Shift more of the cost of care to individuals through higher deductibles, and provide consumers with quality ratings to allow them to compare services and providers, and voila—the system is now incentivizing smart shopping. That, in turn, decreases costs. At first blush, it's a very neat solution for a complicated social service.
However, it also assumes that consumers of healthcare behave rationally and unemotionally, and that the only imperative they have is affordable wellness. That may make the model untenable.
"The irony is that this turns out to be an industry where, the better you do at making it consumerist, potentially you lose other positive aspects of the experience that people have to come to cherish," Dr. Barron Lerner, a bioethicist and internist at New York University's Langone School of Medicine, told Healthcare Dive.
The first "positive aspect" that gets lost in the mass-market delivery of consumerist healthcare is the inherently personal relationship a patient has with his physician, Lerner says. The industry already refers to hospitals and physicians as "providers" of healthcare. For some patients/consumers, the days when a primary care physician treated the same person throughout her entire life, remembered birthdays and acted as a trusted family advisor are a thing only found on Turner Classic Movies.
By treating medicine like a commodity, that relationship has been irrevocably altered by its new transactional nature. Some worry the pendulum may swing so far towards patient autonomy that physicians lose any sense of personal investment.
The industry has already experienced the fallout from that loss—and tried to correct it.
In 2013, 40% of physicians reported that they had burnout. In 2015, that number was up to 46% of respondents, according to the Medscape Physician Lifestyle Report survey. Since the 2013 survey, the top three reasons for physician burnout have remained constant, with No. 1 being too many bureaucratic tasks and No. 2 being too many hours at work—both of which interfere with the stated purpose of the physician: caring for patients.
Burnout also makes physicians more prone to errors and reduces their empathy, perhaps the most critical component of a successful doctor-patient relationship.
This matters to providers. Errors, outcomes—both are now being measured and reflected in Medicare reimbursement. Patient experience matters to the bottom line (although none of the major ratings systems are in agreement on how to adequately measure this, and it doesn't necessarily reflect outcomes.)
This is both the irony, and the future, of healthcare consumerism: The more the healthcare market adopts a consumer-first attitude, the more regulation it's going to invite. That's exactly the opposite of more traditional consumer markets.
On the federal level, the FDA recently ordered the commercial genetic testing company 23andMe to stop marketing its personalized health reports, which the company claimed told customers if they were genetically predisposed to over 250 diseases or medical conditions. In New York, the state's public health council is demanding tighter regulations and more transparency for the rapidly-proliferating urgent care clinics. These kinds of clinics are not inspected as regularly as hospitals or surgery centers, making it much more difficult for their customers to find updated safety records and quality of care ratings. New York won't be the only state to turn a critical eye on these commercially oriented providers.
In the IT space, healthcare consumerism battles violently with consumer protections. Stark and other anti-kickback protections are intended to protect consumers from providers who determine referrals by studying profits rather than the best interest of the patient.
But the unintentional consequence is that it prevents the kind of low data interchange fees that other data-reliant industries—like banking, for example—use to incentivize (and pay for) interoperability. Instead, it's up to the federal government to demand, cajole and legislate unfettered flow of consumer data.
Yet for large vendors, the possession of that data is a competitive advantage—it helps keep clients in-network. Eventually, this likely will shift as cloud-based vendors gain more market share, but the evolution appears to be slow.
All of this begs the question: Do patients even want to be consumers? Many physicians report that the answer is "no."
They note many patients want trusted guidance. Perhaps the only reason the demand for price transparency evolved is not because patients have an inherent urge to shop, but because the bills were simply too high to seem legitimate.
"The idea of someone being empowered enough to make a decision is good," Lerner told Healthcare Dive. "But for the vast majority of decisions, most people don't want to pick between blood pressure pills or decide whether they need to go for a test. Most people are glad—if they trust the doctor—to be told what to do."
You could argue that's just good customer service. Or, you could argue that it's a fundamental breakdown in the consumerist model.
The evolution of the patient into the consumer occurred in two distinct waves, according to Carolyn Engelhard, a health policy expert at the University of Virginia School of Medicine. The second, more recent wave is about the selection of insurance coverage, and the availability and accessibility of care with that coverage. But originally, the term meant something much more fundamental—a sometimes-bloody debate over human rights that in some ways is still being fought in exam rooms across the country.
Read Part II: A look at what happens when the consumerist model breaks down.
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