June 10, 2005

Therapeutics
Delivery Technology Paves Way for RNAi Therapies

Neuroscience
Gene Clue to Brain Asymmetry Revealed on Right Side

Social Medicine
Gun Violence May Be Viewed as Contagious

Neurology
Fetal-cell Transplants Reverse Parkinson’s in Two Patients

Clinical Research
Discord Found in Clinical-trial Contracts

Health Care Policy
National Mental Health Survey Shows Mixed Results on Progress

Genetics
Disease Mutation Tracked Down, Ending ‘Curse’ for Colombian Families

New Books
The Spring Bookshelf

Education
HMS Teaching Awards Presented for 2005

Accolades
Students Laud Gardner as Champion of Humanism in Medicine

Medical Ethics
Debate at HMS Frames Ethics of Online Organ Donation

Brain Chemical Serotonin Linked to Left–Right Patterning of Embryo

Rising Leaders in Minority Health Research Turn Data into New Directions

New Chairs Honor Federman and Egan Family

Honors and Advances

In Memoriam

Let Consumers Drive Progress in Health Care Quality

Front Page

Let Consumers Drive Progress in Health Care Quality

Photo by Patrick Ladapo Joseph Ladapo

Five years have passed since the Institute of Medicine released its landmark report on medical errors. Their claim that 98,000 people die each year from hospital mistakes provoked serious consternation and catalyzed a national movement toward improving health care quality and safety. This movement has largely been led by government and private agencies. But the leaders should make room for the group with the most to gain—patients.

Last month, Lucian Leape, an adjunct professor of health policy at HSPH, and Donald Berwick, an HMS clinical professor of pediatrics and health care policy and an HSPH professor in the Department of Health Policy and Management, two distinguished researchers in the field of health care quality, published an assessment of U.S. health care safety in the Journal of the American Medical Association. Noting the mobilization of both public and private organizations in the quality improvement campaign, the authors stressed that “the groundwork for improving safety has been laid,” and noted a “growing patient safety movement is afoot.”

The authors’ list of major stakeholders shaping the future of health safety includes the Agency for Healthcare Research and Quality (AHRQ), the National Quality Forum (NQF), and the Leapfrog Group, a consortium of corporations that buy health care for their employees.

But what about the patients? Could they play a role, too?

The omission of patients from the roll call of key stakeholders is no accident. It reflects the reality of who the major players are at this moment and suggests a widely held view among health care professionals that patients may be too uninformed to play anything more than a passive role in shaping health policy. The sea of knowledge that divides patients and medical professionals may be too vast.

One thing is certain: the old paradigm of consumers taking a passive role while health care leaders unilaterally decide the direction of health care is anachronistic. Medical care is too expensive and too valuable for this to continue.

But just because patients do not know enough does not mean that they can’t. In fact, a growing number of people believe they can. These people are championing a new model for health service delivery in America—consumer-driven health care (CDHC).

Dollar-based Decision-making
Consumer-driven health care is a loose term for health plans that place more of the responsibility for health decisions on the patient. Leape and Berwick turn to national agencies to improve health safety because the market will not do so. The market will not because—for now—patients apparently don’t understand the problems.

The key to consumer-driven health care is that patients with high deductible insurance plans pay for health care through personal accounts they own, often called health savings accounts. No more $10 copays. Patients pay the true price for their services.

The advocates of this increasingly popular model believe that patients who pay for their services will think harder about their decisions. Quality, safety, and cost-effectiveness suddenly become more important, and the market responds. Rather than AHRQ and other organizations setting the pace for health policy, patients become the gateways to change.

According to Regina Herzlinger, the Nancy R. McPherson professor of business administration at Harvard Business School and a leading advocate of CDHC, this model “will improve health care quality by inducing competition among providers that respond to consumers’ needs.”

She believes patient consumers are “bright people, especially when they are spending their own money.” The history of consumer empowerment buttresses her assertion.

Consumers Lead, Health Care Follows
Is this the way forward for improving health care quality and safety, controlling costs, and achieving other pressing health care objectives? It would seem that the current system of insulating patients from medical utilization decisions is a paradigm whose time has passed. We live in an information-rich age, and information is constantly creating new markets, opportunities, and empowerment.

Are there relevant threats to the CDHC path? The answer here is also yes. A phenomenon called adverse selection is the biggest risk. Well known to economists, adverse selection occurs when healthy people selectively leave an insurance risk pool. The price of insurance in this pool rises because there are fewer “good risks.” Healthier people leave as premiums rise, the premiums rise more because healthier people have left, and a downward spiral ensues.

The fear is that healthy people will select CDHC plans. This concern is real but not insurmountable, and early research is ambiguous. One thing is certain: the old paradigm of consumers taking a passive role while health care leaders unilaterally decide the direction of health care is anachronistic. Medical care is too expensive and too valuable for this to continue.

The formulation of quality and safety policy illustrates a fundamental problem with our health care system. The primary stakeholders, patients, have tacitly surrendered their ability to actively shape the process. Yet it is hard to believe they do not want a voice. They do, and they won’t be heard until both power and purse are put in their hands.

—Joseph Ladapo is a fourth-year medical student at HMS
and a PhD student in health policy.

The opinions expressed in this column are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.

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