Do you honestly believe that individuals deserve the right and responsibility to make their own choices about health care? Before you answer, remember, the party in charge of spending the money becomes the ultimate decision-maker. When it comes right down to it, most people say they support patient rights, but only in the context of someone else paying the bill.
Here's why those two issues cannot be separated:
When discussing health savings accounts with employers, I often hear concern that connecting financial factors to health decisions will lead to employees making bad choices (mostly by not getting the care they need). I hear a widespread belief that asking people to take financial accountability for healthcare produces negative outcomes, not positive ones.
Rarely do I hear policy-makers acknowledge that the opposite is also true. Actually, when we remove financial accountability we actually expose people to risk because we encourage people to stay uninformed.1 Economists use the term "rational ignorance" to describe instances where the cost of becoming informed exceeds the perceived value and hence people remain rationally ignorant.
If you understand that all medical procedures — especially those done unnecessarily — contain inherent risk, then remaining uninformed increases the risk associated with healthcare decisions. (For a refresher on why more care is NOT better for patients, review the wonderful work of Fisher and colleagues.2 3)
Rational Ignorance
Because it takes time, effort, and sometimes money to be informed, we choose where to place our energy, attention, and resources. Like any other endeavor, why go to the trouble if the potential benefit isn't greater than the cost? Under normal circumstances, there is much to be gained by being informed:
- Money Saved (by comparing prices of different brands and stores);
- Value Gained (by comparing what we can GET for the price);
- Time Saved (by knowing an option is closer or easier to use);
- Best results (by knowing how to use the item you get — e.g., medicine — appropriately, you have a better chance of it working);
- Personal Control or Preferences (the satisfaction, peace of mind, or other personal preferences that are met when you decide what's best for you);
- BUT — it also takes work.
Two factors ultimately influence whether we decide to become informed about a topic: the value one perceives getting out of it (in the many forms described above), combined with one's ability to influence the eventual decision or situation. If we feel we have no influence, and it doesn't really bring us personal value anyway, why spend the time and energy to be informed? Rationally-we wouldn't. Rationally, we remain ignorant. For example, unless it is a rare topic that affects us in a significant way, few voters invest significant time and energy understanding the referenda on the ballot, because we don't feel like our vote will influence what happens anyway. Why bother?
Think about it: most of us know a lot more about the features on the cars we might purchase (which involve our choice and our financing) than we know about which doctors in our community deliver the best care for the best price.
Compare medical services to other activities and needs in our life:
When Choosing How To Spend Our Money:
When you bought your house, did you look at prices in that neighborhood to see if you were paying a fair price? Did you investigate whether the neighborhood was safe, and have an inspection to be sure the value was accurate?
When Choosing How To Spend Our Time:
Do you read reviews or ask friends about movies or books before you buy them?
On your last vacation, did you research different activities in the area, to best meet your expectations for the trip?
Remarkably, medical care is one of very few services we "select," while knowing almost nothing about the cost, the quality, and without guarantee from the person providing it.
We stay rationally ignorant about healthcare because we know someone else is in control.
While healthcare reform has evoked high emotion and political interest, most citizens are not particularly informed about the specifics. For the most part, under new rules someone else pays for the majority of the cost of care, and that someone else will decide what type of care will be allowed.
Regardless of whether the "someone else" is government or a private insurer, consumers will remain largely uninformed and disconnected from all related information — including price, safety, and quality. Not because agencies won't attempt to make information available, but because the cost of becoming informed exceeds its value. Unless we have great experience, influence or resources, we know we are not in control anyway.
The Ethics of Health Care Reform, published by the Non-partisan Institute for Policy, compared six different models for providing health care, and concluded that none was ideal.4 However, they came to the following conclusion:
"There is only one system that promotes patient choice, and yet still maintains the elements of a well-functioning health care system that ensures access to quality care while keeping costs under control: the consumer driven model" (p. 8). (It was a high-deductible plan with a funded HSA.)
While not using the term "rational ignorance," the report focused on the patient as the rightful decision-maker. "When a third party-government, insurer or employer controls most of the health care funds, that entity eventually becomes the decision maker, not the patient" (p. 4).
Payment Equals Control
The party with the purse strings decides who gets paid, for what, and how much. It's a simple equation. Thus, anyone who truly agrees that the consumer/patient should be the rightful decision-maker must also agree that they should have control over the money spent. Deciding and paying are one in the same.
When we insist that patients should decide about care — but only within the context of a third-party payment system — we create an illusion of patient influence. Patients understand that someone else — a doctor or an insurer — will be granting ultimate permission. This explains why most of us remain ignorant — rationally.
Some will insist that healthcare decisions are far too complex and/or dangerous for patients to make without a doctor acting on their behalf. But the opposite is true. While patients may need or want support in understanding options, that support should come from a person who first and foremost serves the patient. Doctors are humans, influenced by incentives and rules (inherent in the payment mechanism); their advice will reflect who is paying them, and for what. That alone should remind patients that control of payment is an important component of healthcare decisions.
This matters: Protecting people from financial responsibility for healthcare exposes them to risks by encouraging them to remain uninvolved in care decisions. Payment decisions cannot be separated from care decisions because true ownership requires control of both. It's critical that employers understand how plan design can encourage employees to be rationally informed.
References
1 Downs A. An Economic Theory of Democracy. New York: Harper; 1957.
2 Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 1: the content, quality, and accessibility of care. Ann Intern Med. 2003;138:273-87.
3 Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care. Ann Intern Med. 2003;138:288-98.
4 Matthews M. The ethics of health care reform. Institute for Policy Innovation Issue Brief; 2009. Accessed October 22, 2009.
