Consumer-Driven Health Care

One of the many problems facing health care delivery in the United States is the performance of unnecessary procedures. This contributes greatly to a health care economic model driven by the supply of a particular provider, as opposed to patient need or demand, and which in turn ratchets up cost. The underlying logic is complicated, but for now it's enough to now that fraud is rarely a factor.

A -- not "the" but "a" -- recognized driver of this  is a tendency on the part of employer-insured patients to request (and get) care and procedures that they don't need simply because the cost is invisible to them: They show their insurance card, make a co-pay, and leave the rest to their employer and the insurance company. Consumer-Driven Health Care is a conservative response to this problem aimed at righting the supply-demand relationship, making the patient more prominent and responsible for health care decision making, and reducing the role of the employer so that insurance becomes portable.

Generally, this involves an individual or family establishing a Medical Savings Account (there are a number of different types) paired with catastrophic health insurance. The individual contributes pre-tax dollars to the account (some plans permit an employer match) that incur tax penalties if spent only on anything but health care. Unspent dollars roll over to the next year and the account belongs to the individual: Even if an employer matches it or sets it up as part of a health coverage plan, an individual changing jobs take the account with him or her.

Criticisms of the plan take aim at its lack of utility for the chronically ill, unsuitableness for low income people who might quickly use up their medical savings and repeatedly hit the gap between the account and the insurance policy, the issue of health literacy, and the real possibility that the pendulum will swing too far and create a situation where people don't get care that they do need. In my mind, though, none of these objections are necessarily insurmountable. (Health literacy is a complex issue that I don't deal with here.)

But I believe that the real Achilles Heel of CDHC lies elsewhere, and that if it becomes the dominant health care financing paradigm -- a real possibility -- it will if anything exacerbate the problem it is designed to solve.

It's a curious thing that when experts on left and right debate health policy, they conduct the debate from an Olympian perch that ignores one of the most important commercial forces in American life, and that has certainly happened here. When the aggregate dollars in the various accounts reach a certain level, they will attract the attention of a marketing and advertising apparatus. This apparatus will labor mightily to separate that money from the accounts and transfer it to the interests they represent. And the apparatus is very good at what it does. People will be told that they "need" certain procedures and that they should not "forget" to get a regular this or that, none of which they will actually need, at least at the pace recommended by the various advertisements.

The campaigns will work well enough that the health care system will wind up performing just as many or more unnecessary procedures. We'll be right back where we started from, except that the health care system will have deprived people of their savings and turned hospitals, clinics, and group practices into racketeers. I don't think that that is the kind of doctor-patient relationship that Hippocrates or Galen had in mind...

One of the most important ongoing health care projects is the Dartmouth Atlas of Health Care. Dr. John Wennenberg, the genius behind the atlas, discovered and first documented the phenomenon of unnecessary care driven by provider supply in a particular area. Unnecessary procedures do not affect health outcomes in a given area. For example, it's possible for heart surgeons in one area to install twice as many stents as heart surgeons in a different area but resulting in no discernible difference in overall cardiac health. In this case, we would say that the difference in the number of procedures may have been unnecessary. Use the atlas to find out which procedures in your area may be performed at an unnecessary rate...