Doctors, Patients, or Insurers - Who Will Shape Health Care?

Recently New Yorker staff writers and best-selling authors Malcolm Gladwell and Atul Gawande addressed the question of whether the problem in health care is that patients are too reliant on doctors and don't have the ability to make decisions. In reading between the lines, is that the reason health care is not affordable and care not commoditized or consumer driven like other industries?

At a conference for America's Health Insurance Plans, Gladwell argued that patients or consumers have been unable to be more empowered because doctors, as the intermediary, held the power of knowledge much the same way chauffeurs did for the early days of the automobile and Xerox technicians did in the early days of photocopying. A person was needed to guide and assist the individual to get the job done. At some point, however, the technology became simpler. People began to drive their own cars and make their own photocopies. The mystique of the chauffeur and technician was lifted. Now everyone could drive. Everyone could make photocopies.

Is it possible that for health care and the health care system, which for many people is a system they interact with rarely and in an area (health / illness) where the uncertainty and stakes many be too "high", that individuals willingly to defer the responsibility to someone else? Gladwell hints that might be a possibility:

"A key step in any kind of technological transition is the acceptance of a temporary deficit in performance at the beginning in exchange for something else," said Gladwell. That something else can eventually include increased convenience and lower cost. He offered a number of examples, including the shift to digital cameras where early pictures were not as good as film and the advent of the digital compression of music, which he contends has made the quality of music worse....

The changes in film and music were accepted, he said, in exchange for new opportunities to arrange, manipulate, and personalize our pictures and music. "In healthcare we don't have the same stomach for that period of transition. That's striking to me."

The disruptive innovation that Gladwell is hoping for has yet to affect healthcare. It is possible that as more Silicon Valley start-ups focus on making medical care more convenient, worry-free, hassle-free, more personalized, and more accessible that the majority of individuals won't adopt them because doctors don't approve. The shift to a "temporary deficit in performance" may not be as acceptable even if less expensive and more convenient. As Gladwell notes in the case of dialysis, despite being around for over seven decades, patients in general still don't self-administer treatment, which would be less expensive, but rather continue to go to facilities which are overseen by doctors.

His colleague, Dr. Atul Gawande, countered that other industries, like "teaching, firefighting, and police work" still have intermediaries that do the work on behalf of the individuals. Gawande believes that the real issue is that the care we provide as doctors isn't integrated. We focus on optimizing each part of the health care system without looking across the entire experience of care. Extending this analogy to building the best car and using the best manufacturer for each part, Gawande notes:

building a car with Porsche brakes, a Ferrari engine, a BMW chassis, and a Volvo body. "Put it all together and what you have is an expensive pile of junk that doesn't go anywhere because the pieces don't work together,"

No where was the need for doctors to lead change and think about the entire experience for the patient more clear than a recent New York times piece by health reporter Tara Parker-Pope, titled "Too Much Medical Care". She chronicled her experience as an educated patient and parent of a daughter who suffered an ankle injury at camp. She started first with:

Pediatrician. Initial visit. 
One month later, still not better so she takes daughter to Sports Medicine specialist. MRI ordered.
Referral to Pediatric Orthopedic Surgeon. Another MRI. Blood work.

Slightly abnormal blood work.
Referral to eye specialist.
Referral to pediatric rheumatologist. More blood work. Another (3rd) MRI. Xray of hands.

Five months after original injury, daughter notes that her ankle still hurts. 

Finally, Parker-Pope takes back control. She consults with the sports medicine specialist who reviews the case with the pediatrician. The focus in back on the patient and pain relief. Soon, the daughter is back to resuming her activity.

In retrospect, what is most surprising is how long the entire process went and still the daughter's problem hadn't been solved. Three MRIs for an ankle injury. Four specialists. Three MRIs. Many blood vials drawn. Xray of the hands, though the ankle was the injured joint. It's not that Parker-Pope is naive or uneducated. She is a health reporter for the New York Times and has talked to many doctors and written many stories. The fact that she and her daughter were caught up in the health care system illustrates the challenges facing the public.

Solving the health care crisis will require both points of view offered by Gladwell and Gawande. We need both patient engagement as well as a more coordinated integrated health care system. It is however increasingly clear, particularly based on the New York Times piece, that empowered patients alone won't be able to bend the cost curve. Despite the easy availability of information via the internet and self-diagnosis, there is value to the "expert" in determining the right course of action. As both Gladwell and Gawande note in their previous works there is a need for 10,000 hours of deliberate practice to become expert and that even the experts need coaching for continuous improvement, respectively.

The real problem is whether the "experts" are willing to make the judgement calls that our training provides? When to refer? When not to refer? When to get the MRI? When not to get the MRI? When to prescribe antibiotics? When to hold ground and sympathize when it is a virus? When to comfort, empathize, and heal when it means stopping chemotherapy when treatment is futile? When to do surgery? When to hold off? Are we willing to have others observe us in action so we can be even better? If not, why not?

For health care to be better, doctors must lead the change. No one else can. Insurers and employers have exhausted strategies to make patients more accountable.  Increasing deductibles and co-pays indefinitely won't work. Despite the unprecedented access to information, empowered patients and other patient advocates will never be able to fully close the knowledge gap. That difference in knowledge, as Gladwell points out in his book, Blink, is what allows an expert to distinguish between an authentic piece of artwork and a very good looking fake.

It is also the difference between stopping a number of unnecessary referrals and the cascade effect of subsequent imaging, blood work, and appointments and instead focusing on the patient.

Who will shape health care? Doctors, Patients, and Insurers and in that order.

Or entrepreneurs who partner with doctors to solve our challenges so we can go back to focusing on healing patients.