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Consumerism And Managed Care Health Affairs, November/December 2005; 24(6): 1477 [Extract] [Full Text] [PDF] [Reprints & Permissions]

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Ignoring The Trimtabs: Shocks, Information, And Money

Rick J. Carlson   ( 12 December 2005 )

Ignoring The Trimtabs: Shocks, Information, And Money 12 December 2005
Rick J. Carlson, Clinical Professor, Policy Programs Department of Health Services, University of Washington Send letter to journal: Re: Ignoring The Trimtabs: Shocks, Information, And Money rickjcarl{at}aol.com Rick J. Carlson	This brief note makes three points about all of the articles on "Managed Consumerism in Health Care" in the November/December issue (starting with the word "Managed" -- see point 3 below). Point 1: It does seem that the rusting but still glittering, chandeliered Leviathan ocean liner that is our health care system will sail on forever, taking on more high-tech cargo but leaving even less health in its wake. And yet all of the contributors here seem to believe that, at most, "consumerism" is a distant clanking sound in the boiler room. This is my first point: They're wrong. Consumerism (just a small wedge of early adopters is needed; see point 2) is more like a midsize iceberg -- maybe not one big enough to sink the sucker, but more than enough to knock the chandeliers loose and cause a few "maydays." Point 2: Policy wonks really need to escape the gamer-type incentive wars they play, which only provide trusses for bottoms that are falling out. Ours is a system about to break down (measured though in years, not months; it IS a very big ship). Using the example of network TV, whimpers are often heard first. In that case, the "whimper" was selling sitcoms for 99 cents through Comcast. That is the "trimtab," a small nudge that moves enormous legacy systems. In the case of health care, a "legacy" system if there ever was one, it's the same: Selling health care directly to consumers through HSAs sounds like a "whimper," but in both cases, although the numbers are small, they don't need to be large. Early-adopting opinion-leading consumers, as with the Internet, shape new markets. This will take MUCH longer in health care, but here are the interacting ingredients -- affordable technology (Internet), money in the game by consumers, shock (just how little is known about what you need and get; a lot of pissed-off fifty-year-olds finding out that Lipitor has about a 50/50 chance of working!), and actionable information (e.g., genome on a chip at $100 in five years). Point 3: The problem is the word "management." In the HMO policy process, we first called HMOs health "management" organizations, and then backed off because, after all, nothing is really manageable in health care, especially consumers with money, information, and moxie (no warm fuzzy family doc memories in this group). Consumerism is NOT selecting one vanilla health plan over another, but picking docs, hospitals, and products on the basis of price and quality (like reliable info about specialists, not golf-buddy referrals; level of MRI, type of "total knee" to replace, the "right" drug for me, etc.). You don't buy a car by just picking a dealer. Do another issue and really dig into this issue, and get some bold contributors who don't find tinkering exhilarating. The idea -- and surely it isn't for me -- isn't to champion consumerism, but to recognize it for what it should be: a whole lot of pushback on value for money. American consumers are trained from birth to do that to systems; let's let them have it!