Can Consumers be Trusted with Their Own Health Care?

Some consumers want more control over their health care, while others are happy to leave the "experts" in charge. Why can't we have both? John Quelch advocates for empowering consumers to have a range of choices.
by Dina Gerdeman

Consumers today have more control than ever over the way they choose goods and services—from browsing freely at grocery stores to managing their own financial assets.

Perhaps consumers should also have a greater sense of empowerment when it comes to their health care.

That was the essence of a presentation given at the fifth U.S.-China Health Summit at Harvard Medical School in September by John A. Quelch, the Charles Edward Wilson Professor of Business Administration at Harvard Business School and Professor in Health Policy and Management at the Harvard T.H. Chan School of Public Health.

“I’m going to make some humble suggestions. I’m not a doctor and I don’t play one on TV either. I have very little credibility here,” he joked. “But I do know something about consumers and consumer behavior.”

Quelch recalled how different grocery shopping was in the 1950s when he was a child tagging along with his mother at Sainsbury’s in England. Back then, shoppers visited different counters to request various foods, paying for cheese at the cheese counter, fruit at the fruit counter, and so on.

Years later, self-service became the norm, with consumers pushing their own carts around the supermarket, stopping to linger as long as they wanted or moving as quickly as they wished.

A one-size-fits-all approach to health care doesn’t work. ©iStock/AndreyPopov

“There is more choice available to the consumer than ever before, and choices are within an arm’s reach of desire,” Quelch said. “You don’t have to go through an intermediary to access these choices. Some people would contend that the consumer has more control.”

Similarly, consumers can have a greater say over how their financial assets are managed—from opting for a low-cost system of self-management with a company like Vanguard to spending more money to hire a firm like Merrill Lynch that has people actively managing their stock portfolios.

“Neither one of these approaches is better or worse than the other,” Quelch said. “They cater to two different types of consumers.”

The Varying Needs Of Health Care Consumers

So what do groceries and stocks have to do with public health?

Quelch believes, for one thing, the market for public health could learn an important lesson from these other markets: There’s no such thing as a one-size-fits-all solution, largely because different consumer segments have different preferences.

The problem in the health care industry comes partly from a clash of interests. Doctors are passionate about addressing the individual needs of each patient, while regulators and policy makers are intent on having one piece of legislation that covers everyone.

What we don’t have, Quelch said, is a middle ground of different strokes for different folks. “Different segments of consumers need to be dealt with in different ways to achieve improved outcomes.”

Meanwhile, health care consumers want different combinations of what Quelch calls the “five Es:” expertise, empathy, efficiency, economy, and empowerment. The preference for the precise mix of these elements differs from consumer to consumer, depending on patients’ individual needs.

“It probably also differs according to the situation, if it’s an emergency or it’s discretionary,” he said. “I’m convinced every consumer has a different profile and a profile that varies by situation and according to the patient’s life stage.”

Patient Empowerment Taken Too Far?

As an example of patient empowerment—and a glimpse at its potential problems—Quelch talked about taking the 23andMe test, a saliva-based direct-to-consumer personal genome test that reveals a person’s genetically based health risk across dozens of disease categories.

23andMe test results showed one patient at higher risk of liver and bowel cancer—and that made sense, given family history. The patient  discussed the test results when he next visited his doctor, who pointed out that he had had two negative colonoscopies, so the risk suggested by the genetic analysis was mitigated substantially by the reality of those two tests with healthy outcomes.

“The question is always and legitimately raised by health care professionals: When is empowerment too much? When are you engaging the patient to the point that she may take action that is not in her best interest?” (The American Cancer Society in October pushed back its age for recommended mammograms in part because they can lead to false positives and unneeded treatments.)

And what would consumer empowerment do to health care costs? Quelch noted that in the cases of the grocery retail market and the financial services market, higher empowerment typically leads to lower costs because more of the work is shifted to the consumer. He said there’s a pressing need for more research to find out whether higher health care empowerment would lead to better outcomes and lower costs.

“In the world of health care, maybe the curve goes in the other direction, as I suggested in the 23andMe example,” he said. “If you empower consumers, they start asking a lot of questions that eat up a lot of time from providers who are already stressed in the health care system.”

Quelch argued, on the other hand, that it was fun to get those test results, and he hadn’t heard of anyone who took the test and immediately sought major unnecessary medical interventions.

“I’m coming at this from a consumer point of view. Nine times out of 10, I trust the consumer to do the right thing,” he said. “(But) if you’re a regulator, and the consumer does the wrong thing one out of 10 times, that’s 10 percent, and that’s too much for a regulator to tolerate. There’s a disconnect between the regulatory standard and the market standard in terms of the way these two groups think about how much empowerment is safe to have in our system.”

Yet Quelch believes consumer empowerment has the potential to save the system money, deliver greater consumer satisfaction, and ultimately lead to better outcomes.

“No one knows more about her health or the way she feels than the consumer,” he said. “While not every consumer is able or willing to take on responsibility for their health, most are.”

In many ways, some patients already have a great deal of decision-making power—choosing, for example, which insurance plans they buy, when and where to seek treatment, whether to stick with medications, and whether to change their lifestyles according to doctors’ recommendations.

But patients vary tremendously in their desire and ability to be empowered. Quelch said health care consumers fall into four different segments:

The “Fitbitables”: These are the “worried well,” he said, who are involved in their own health care, are staying healthy, and are taking preventative action.

The Invincibles: These are the folks the Affordable Care Act had trouble pulling into the health insurance system. They are mostly young and healthy and not especially interested in health issues or paying for medical insurance.

The Improvables: These are people who have become sick. They may not have been involved in their own health care earlier in their lives, but they are now committed to improving their health.

The Incapables: These folks are chronic sufferers and tend to eat up a large share of the health care budget; while they may represent only 20 percent of the patient population, they account for 80 percent of the total cost.

The Incapables represent an especially big challenge. Effective patient empowerment requires three things, Quelch said: the patient has to desire empowerment, the patient has to have the ability to take on the responsibility of empowerment, and the patient needs a support mechanism, such as family members or providers to help. Incapables may fall short on one or more of those counts.

“Not everybody has these three things,” Quelch said. “We have to take care of the people who don’t have these three things as well as the people who do. We don’t have to worry much about the incapables in financial services, but in health care, we do.”

About the Author

Dina Gerdeman is a senior writer for Harvard Business School Working Knowledge

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