What about the patient?

The reform debate has been so focused on economic disequilibrium created by providers and payers (mostly payers, as of late) that an observer could be forgiven for forgetting patients are also part of the equation. Yes, something definitely needs to be done about the high costs of medical care and health insurance, but is the typical patient just a helpless pawn in a game controlled by two powerful players that only care about their own profits? Can problems of cost, quality, and access be solved solely by reforming the business practices of hospitals, physicians, and insurance companies?

I spend a lot of time interacting with providers and payers, and they make a convincing case that the typical patient is also part of the problem. For example, physicians report that patients frequently demand a drug or a test that isn’t appropriate, but writing the order is less of a hassle than taking unbillable time to educate the patient about the risks of overmedication or running the risk of losing the patient altogether as s/he goes down the street to another doctor who will provide what the patient wants. Powerful public outcries against scientifically sound proposals to formalize evidence-based medicine and reduce the frequency of screening mammography offer further evidence of patients’ contributions to the high costs of care. These problems deserve at least as much consideration as the cost-increasing impact of defensive medicine.

Democrats’ final, frantic push for reform-cum-insurance overhaul is highlighting supply-side market failures without saying anything about the expenditure-increasing impact of excess demand. I believe that providers and payers absolutely must make major improvements in the way they do business, but I am frustrated by reform proposals that do not expect patients to improve their health behaviors, too. Providers and payers are way ahead of Congress in addressing this problem through medical homes and care management programs. Purchasers (employers who provide health benefits) are also taking steps in the right direction by with innovative programs that shift insurance from entitlement to engagement.

I am disappointed that these impressive efforts to promote appropriate, cost-effective care don’t get the same political attention as stories about people who can’t get insurance. A lot of Americans with insurance coverage are squandering resources that could be allocated to those without it—assuming that we can find the political will to balance the right to health care with the corresponding responsibilities. Taxing Cadillac plans might transfer income, but it doesn’t align rights and responsibilities. Do you think reform should look more carefully at patients’ contribution to the problems and participation in the solutions? If so, how?