A decade ago, while I was working for Vanderbilt University Medical Center, we secured funding from the Agency for Healthcare Research and Quality to conduct a national study to explore the core beliefs that anchor how consumers view our health system. We conducted 16 two-hour focus groups in San Diego, Chicago, Teaneck, N.J., and Columbia, Tenn., recruiting in a cross section of America ranging in age, health status, income, ethnicity, insurance status and political leanings.
After reviewing the videotapes of these groups, we concluded that seven core beliefs anchor the public’s view of our health system. They are:
- I believe medicine is too complex for me to understand and prefer that my physician to tell me what to do.
- I believe good medical care is about getting access to a doctor when I need him/her.
- I believe health care is better for some than for others.
- I believe health care should be available for all, but not under government control.
- I believe health costs are high, but there’s not much I can do.
- I believe the profit incentive in the health system is strong and care is compromised.
- There’s not much I can do.
Our report concluded: “Consumer attitudes reflect personal experiences with the system, primarily interactions with doctors, hospitals and insurance companies. Therefore, the context for understanding health care consumerism is [found in] the deep-seeded beliefs about the health system, not attitudes about specific problems, concepts, ideas, organizations or policies. Beliefs do not change easily: When they do, the change is transformative. The belief system of health care consumers is highly personalized, built from personal experiences and powerful emotions. For the vast majority, these experiences are negative, and particularly for those in minority and uninsured groups.”
A decade later, after the passage of the Affordable Care Act and the spotlight that’s been placed on our system of care, it seems to me that these beliefs are unchanged. They’re strongly held and deeply personal.
But the irony is this: In spite of the avalanche of health websites, report cards and media coverage about health care, the majority of Americans are confused and ill-informed. Why? There are probably two explanations:
First, it’s because the health system is complex. Each day, roughly 80 peer-reviewed articles are published in journals that announce findings about new diagnostics and treatments. During the four years a medical student is in the classroom or a clinical rotation, 40 percent of the underlying body of science will change. And equally complicated, our payment system: The ICD-10 coding scheme is seven times denser than the IRS code. It’s aptly called a “complex adaptive system,” though some would challenge how well it actually adapts to changing market needs and values.
Second, it’s because it’s easier for the health system to operate if patients are dependent on the system to make their decisions. For 75 years, those of us who operate inside the system have assumed that its complexity exceeds the capacity of most individuals to understand or navigate it effectively. That’s why we prefer to call them patients. We value their trust and confidence and bristle from structures, policies, procedures, regulations and outside parties that lean toward engaging them as active consumers. And segmentation studies and behavioral economists have demonstrated that the majority of consumers prefer to be treated as patients, reflected in core belief No. 1.
Patients respond to the information and incentives they’re given. Research has shown that when consumers are provided understandable treatment options around a health problem, they opt for more aggressive interventions than what their professionals might otherwise recommend. When consumers are made aware of the out-of-pocket costs for services they’re directed to use, they choose more wisely.
When consumers have access to data about the factual differences in the performance of their local physicians and hospitals, they change the providers they use.
When health insurance plans offer narrower networks or restricted coverage, consumers choose a plan that aligns with their own desire for convenience or access. And across the board for millennials, Gen Xers, and boomers, price sensitivity to co-pays, deductibles, out-of-network penalties and premium increases are sparking consumer pushback.
The core beliefs of U.S. health consumers haven’t changed dramatically in the decade since the study, but it’s likely they will. Four trends are driving the transition from patient to consumer:
- Employers are shifting more financial responsibility to the 160 million among us whose coverage is through our employment, and that’s prompting consumers to become watchful buyers.
- Medicare and private insurers are tying provider payments to patient adherence and satisfaction via bundled payments and accountable care organizations.
- Technologies that attract investors are leading a digital revolution in health care that’s disintermediating physician-patient relationships with distance medicine, e-visits and scripts, etc.
- And growing numbers of patients are becoming activists themselves, prompting greater access to alternative health and legislation that expands the scope of practice for nurses, pharmacists and other professionals whose careers are limited by traditional rules.
In health care, the pace of our clinical innovation is accelerating at lightning speed; by contrast, the pace of our transition from patient to consumer is lethargic at best. Let’s face it: Many prefer the old rules, and most patients are content to follow.
British philosopher Alfred North Whitehead wrote, “It’s not ignorance, but ignorance of ignorance that is the death of knowledge.” Ignorance about how our health system works creates what is, perhaps, our greatest challenge. The seven core beliefs of health care consumers haven’t changed much, but there’s no doubt they will.
Health care organizations that seize on the shift from patient to consumer will win in the market. People's core beliefs are changing slowly, but certainly. They are neither patient nor patients; they’re consumers.
Paul H. Keckley, Ph.D., does independent health research and policy analysis and is managing editor of The Keckley Report. He is a member of Health Forum’s Speakers Express; for speaking opportunities, please contact Laura Woodburn.