What if payers required all health consumers to take a one-day "Healthcare 101" class every five years? Especially when they're eligible for Medicare, the age when the need for healthcare services dramatically increases.
Qualified instructors would explain the importance of patients asking questions about their care, and who should answer them. Students would learn about how to measure quality of care, and where to check for it. They'd learn a few current concepts, like accountable care, incentive payment, discharge planning, hospital-acquired harm, and evidence-based medicine.
They'd see the difference between a hospital marketing campaign and what's right for them.
Yes, there would be a test. And they'd have to pass. And their providers could see their scores.
Nanny state
I know: "That sounds silly, awfully nanny-state." So offer people $200 off their health insurance premium, and I'll bet they'd volunteer. They could even take the course online.
After all, everyone has to take a class to get a driver's license. And incentives are common: a few years back, after I was ticketed on the freeway and lost my appeal, I had to attend a course for two days to avoid a hefty fine. (I chose "Comedy Traffic School," taught by a nightclub standup, to at least get a few laughs out of the experience.) Come to think of it, my car insurer said I could get a $50 credit on my premium if I took Geico's class in defensive driving.
Heck, I was even told that I couldn't operate the high-end quilting machine I coveted unless I took a course held by the manufacturer, Bernina.
Healthcare is surely a more critical and complicated issue than quilting, and it's certainly as important as driving a car.
This "Healthcare 101" thought came as I browsed through a survey published this week by the Institute of Medicine, Kaiser Permanente, and Consumer Reports, which partnered on a project regarding the state of physician-patient communication.
The thrust of the report, Communicating with Patients on Health Care Evidence, is that patients must demand a much greater role in making decisions, in cooperation with their providers—but that providers need to step it up to make that happen.
Que sera, sera?
For example, the report says four in five consumers surveyed want their doctors to listen to them, but only three in five say that the providers do. Four in five patients also want to be told "the full truth about my diagnosis, even though it may be uncomfortable or unpleasant."
But here's what amazed me from this survey: one in five people don't seem to care.
There's more. For one in four people, it isn't essential that their doctors tell them about risks associated with each healthcare option.
One in three don't need to know how various options would impact their quality of life. Half of the respondents don't even want their doctors to offer them choices, or to discuss the option of forgoing tests and treatment altogether. More than four in five say their providers should only offer options that their providers think were right.
It’s a "Que sera, sera" approach to diagnoses.
But there's a big disconnect with how healthcare really happens.
Doctors and hospital providers complain all the time that they shouldn't receive reimbursement penalties if their patients don't do what they're advised. They say if patients would just get off their duffs and become active directors of their healthcare rather than passive recipients—or victims—then much of the need for their services might disappear.
Think about it: Making consumers share responsibility by learning how to manage their choices might just get this process going.
The accredited patient
I ran the concept by John Santa, MD, MPH, director of Consumer Reports Health Ratings Center, publisher of hospital ratings. "It’s an interesting idea," he says. "It sounds like you think folks should have to get a healthcare license to get healthcare."
Yes, in a hypothetical, modest proposal sort of way, that's where I'm heading. An accreditation process for the patient.
Santa then started to play off the idea. "Imagine if a health system or a government organization asked you: In return for a better benefit, we want you to understand how the system works. Look at this booklet. Take a drive through your healthcare system to make sure you understand what to do in an emergency. How do you prevent disease."
Some of this activity might happen through the soon-to-be-launched healthcare insurance exchanges. "Do you want to drive on the health exchange highway? Well, you need a license," Santa jokes.
The difficulty, he says, is that when he was in medical practice in Oregon, he realized many of his patients "are more comfortable placing their total faith in their doctor...They say 'I don't want to think about anything but that I have the best doctor and he or she is doing the best thing, and this will all turn out well.'"
The truth is, I think, that patients don't feel competent to learn what they should, or they just don't feel up to it.
The other concern, of course, is that many doctors paternalistically think many of their patients can't absorb this information, and they don't have time to explain it anyway. Maybe it’s a version of the phrase spoken by Col. Nathan R. Jessep in A Few Good Men: "You can't handle the truth."
What the course should teach
There's probably some truth to that argument. But I argue back that we should try to fix this.
In my hypothetical Healthcare 101 curriculum, there'd be sections on licensing and certification credentials so patients would understand competency differences—say, between a nurse practitioner and a registered nurse.
There'd be a brief section on how the Patient Protection and Affordable Care Act is changing payment incentives, which is changing the way hospitals and doctors provide care—imposing penalties for readmissions, infections, hospital-acquired infections, and other conditions, and establishing core measures of care. I'd spend time on rating systems, like those offered by Consumer Reports and Leapfrog Group, so consumers are more likely to shop for quality.
They'd see why these things are important and how many dollars are associated with performance. And that health consumers play a critical role in that process.
And they'd learn that doctors shouldn't provide healthcare through instinct alone because there is science and rules to what constitutes proper care. They'd hear why an antibiotic will do nothing to cure a viral cold, and the difference between clinical trial evidence and what a relative swore about herbal therapy or high colonics. (It continues to amaze me that even some of my most well-educated friends don't get this at all.)
By the course's close, patients would better appreciate how healthcare is a fast-paced business where the services that a doctor wants them to have—say a test or a drug or a procedure—may not be what they need or want, especially if they knew the alternatives and potential downsides. The phrase "informed shared medical decision" would become part of their lexicon.
They also might come to appreciate how smoking or being overweight increases their chance of requiring expensive, acute care and an early grave. It's far less "que sera, sera" and much more about choice.
What do you think? The accredited patient. It has a nice ring to it. Class dismissed.