Consumer-Driven Health Care: The Changing Role of the Patient
Table of Contents
Why Patients Are Managing Their Own Care
Whether they like it or not, patients are likely to manage more of their own care in the future. This is the result of several trends.
Patients Can Access More Medical Information. With the advent of the Internet and the ease of access to medical information, patients no longer have to rely on physicians to answer every question. They can obtain medical information directly. The growth of the Internet and the vast amount of information it makes available are leading to dramatic changes in information delivery.8 About 80 percent of adult Internet users (estimated at 93 million people) have searched for health information online.9 Estimates vary, but by most accounts there are approximately 20,000 health-related Web sites.10 These activities constitute a sharp break with the tradition of doctors as the sole source of health related information. In the past, much of the medical literature was available only at large libraries, medical schools or by subscription to expensive scholarly medical journals. Now, much of this literature is readily available to anyone with Internet access.11
According to a recent survey of patients visiting an internal medicine practice, more than half (54 percent) had used the Internet to gather health information. Of these, about six-in-ten (59 percent) rated the information “the same as” or “better than” information they got from their doctors. An equal number (60 percent) did not discuss the findings with their physician.12
Another way patients find out about medicine is direct-to-consumer advertising, which is mostly about drug therapies. Drug advertising benefits patients because it educates them about new treatments and often prompts them to seek care for previously untreated medical problems.13 In 2000, drug manufacturers spent $2.5 billion on direct-to-consumer advertising; about $1.5 billion dollars was spent to promote a mere 20 drugs.14
“Federal tax law subsidizes third-party payments.”
There Are More Treatment Options. Medical science has made enormous advances in the past few decades, increasing the range of therapies available to patients. Prescription drug therapy is an area where consumers have the most choices. For example, U.S. companies developed 370 new medicines within the last decade alone, according to the Pharmaceutical Research and Manufacturers of America.15
Take heart disease, for example.16 Most experts suggest patients reduce the risks of heart disease using behavior modification involving diet and exercise.17 Patients with high cholesterol may select from any number of cholesterol-reducing drugs from a class known as “statins.” Patients with hypertension can use beta-blockers, calcium channel blockers and angiotensin-converting enzyme (ACE) inhibitors to lower blood pressure.
When patients develop heart disease they often can choose between invasive surgery or various drug treatments. For instance, heart disease may be treated with surgery, such as angioplasty with stents to open clogged arteries or coronary bypass grafts where arteries are too clogged to reopen. Drug treatments include virtually all of the same drugs use to prevent heart conditions. In addition, most cardiac patients are prescribed diuretics and a small daily dose of aspirin to reduce the risk of heart attack.18
“Having more choices, patients want to make more decisions.”
Having more choices available, patients increasingly want to participate in decisions about which treatments they receive.
Doctors Can’t Manage Patients’ Care. In the past, many patients had a “personal” physician who met most of their health needs. In addition to examinations and treatments, doctors also were responsible for patient education.19 The ongoing relationship between the physician and patient was an information exchange, in which patients told their doctors about their symptoms and doctors provided diagnoses and recommended treatments.20 This trusting relationship has changed for a number of reasons. Among them: 1) Increasing medical specialization means that no single physician can provide all the information patients need, and 2) Physicians do not have enough time to give their patients complete information on their health. As medical knowledge has grown, an increasing proportion of doctors have specialized so that no individual physician can provide all the care a patient may need. Even within their specialties, doctors have trouble staying current in their field. About 10,000 clinical studies occur every year, and by some accounts, medical knowledge doubles every 42 months.21
“More than three-fourths of patients think medical errors could be reduced if physicians spent more time with patients.”
All specialty boards in the American Board of Medical Specialties require their members to take periodic exams to maintain their certification but most experts admit it is not enough to keep physicians current in their field. Many older doctors are exempt from periodic testing and don’t stay current.22 There is also a problem in the allocation of the physician’s time. A recent study in the American Journal of Public Health estimates that physicians would spend seven hours a day providing preventive care counseling to patients if they followed all of the recommendations of the U.S. Preventive Services Task Force.23 Although the average time physicians spend with individual patients has not fallen significantly, because of the increasing amount of information to be conveyed, and preventive and treatment measures to discuss, the proportion of physicians saying they do not have enough time to spend with patients rose nearly 24 percent between 1997 and 2001, from 28 percent to 34 percent of doctors surveyed.24 Patients are less likely to trust a diagnosis made by a specialist who spends only a few minutes with them.25 According to a recent article in the Journal of the American Medical Association, patients usually want more information about their medical condition than they receive from their doctors. For instance, during a 20-minute office visit physicians spend less than one minute discussing planning and treatment, on the average. Doctors discuss options and help patients arrive at a treatment based on their preferences during fewer than one in 10 office visits. About half the time, doctors fail to ask patients if they have questions.26
“Physicians spend less than one minute per office visit, on average, discussing planning and treatment.”
A Harris Poll found that even when physicians offer to answer patients’ questions, 60 percent of patients forget some of the questions they mean to ask.27 Moreover, patients retain only a fraction of the information they receive from their physician during an office visit.28 People think this lack of communication affects the quality of patient care. For instance, more than two-thirds of the public (72 percent) thinks “insufficient time spent by doctors with patients” is one cause of preventable medical errors, and three-fourths (78 percent) think that the occurrence of medical errors could be reduced if physicians spent more time with patients.29 [See Figure III.]
Physicians will always serve an important role advising patients about their medical needs. But patients need other options. Patients seeking medical information on their own are partially substituting for the service of physicians.30 A few hours spent on the Internet may substitute for a costly face-to-face office visit.
Managed Care Created Distrust of Insurers. In the 1980s and 1990s, employers began replacing fee-for-service health plans with managed care in an attempt to reduce their health care costs. Managed care organizations tried to hold costs down by negotiating deeply discounted fees with providers and by limiting access to services they deemed unnecessary. They often limited doctor discretion and replaced it with protocols for managing patient care. In many cases physicians were directly employed by health insurers and given financial incentives to withhold or limit access to types of care the insurance companies considered wasteful or costly.31 Even today, nearly one-third (31 percent) of U.S. physicians report they sometimes do not discuss useful treatments that are not covered by insurers.32
Practices like these led to a consumer backlash in the 1990s, as patients saw managed care as a threat to their health and well-being.33
“The number of people with health savings accounts could grow to 18 million by 2012.”
Employers Are Requiring Workers to Share More Costs. Employers are increasingly shifting health care costs and risks to employees.34 For instance, during the period from 1993 to 2004, the average annual deductible workers with conventional health plans had to pay before insurance began to pay rose an average of 86 percent from $222 to $414. For family plans, the deductibles rose by 74 percent ($495 to $861).35 Over the past 10 years PPOs with higher deductibles have been replacing first-dollar HMO plans.36 PPO coverage has risen from 27 percent of all covered employees to 58 percent. PPO plans have higher deductibles and 31 percent of PPOs used by small employers now feature in-network deductibles of $1,000 or more.37
More employers are offering consumer-driven health plans, which usually include high deductible health insurance coupled with personal health accounts which workers use to pay for their incidental medical spending.38 A recent Milliman employer survey found that almost all (98 percent) employers are considering offering high deductible health plans, whereas in 2003 less than half (48 percent) considered offering them.39 In 2002, only about one percent of workers (1.5 million people) had health plans featuring personal health accounts.40 According to a new estimate by Forrester Research, the number of people with health savings accounts could grow to 18 million, with $35 billion in assets, by 2012.41 [See the sidebar “Personal Health Accounts.”]