Sybil is a true story about a woman
possessed with sixteen different personalities spanning the intensely dramatic
Vanessa to the vivacious Marjorie. The
psychiatric term is dissociative identity disorder which is characterized by at
least two identities that alternatively control a person’s behavior. After considerable treatment, Sybil’s
different selves were able to reconcile and Sybil combined them into an
integrated self that relieved her turmoil and improved her well-being.
In
healthcare, we are possessed by different selves that behave in unique ways. These distinct selves include that of
consumer, patient, citizen and customer.
As with Sybil, we need to understand what our separate selves are up to and
evolve an integrated self that minimizes distractions, takes control, and focuses
on a healthy future.
Our four selves in health:
1. Consumer:
America is a shopping nation and we rely on our consumer self when we
buy goods and services. The term “consumer”
comes from economics and is predicated on the theory of choice. The theory states that when people have
choice and information on price and quality they make rational decisions to
optimize their welfare and to stimulate competition to improve efficiency. The theory works well in most industries,
like retail, but poorly in healthcare because the requirements for a healthy
market are distorted: a) There is little consumer choice (employers (mostly)
pick health insurance plans, plans select networks and doctors, and doctors
pick specialists, hospitals, and treatments), b) people pay for things with
other people’s money (insurance and government subsidies), and c) information
for consumer decision-making is either absent, irrelevant, or difficult to
understand. Nevertheless, we persist in our belief that a consumer-driven,
market-based approach produces superior results compared to alternatives including a
government approach.
The latest
example is the health insurance exchanges.
Its primary goal is get more people insured and to make markets work
better by rewarding insurers that satisfy consumer needs better than the
competition. But, there is little choice
among insurers in most markets. The
choice is often among products offered by a single insurer. The
information is limited. Yes, there is
information on prices. But, there is no
information on insurers’ performance in improving health and customer experience
and whether one’s doctors are in the narrower networks offered.
Also, the
lower cost insurance plans conceal hidden costs in the form of much higher
out-of-pocket costs. The “new normal”
deductible is $2500+ for the individual silver benchmark plan. Classic research
from RAND shows that people with deductible plans at this high level use
doctors and prescription drugs significantly less and do not discriminate on the
services they cut, whether effective or wasteful. This has led people to question outlandish medical
charges, which is good, and for some to “take out their own stitches”, which is not.
Peoples’
welfare is improved through the exchanges mostly because insurance is more
affordable due to subsidies and not because their actions as consumers are inducing
more competition to drive down costs and improve quality. So, the consumer self turns out to be an
ineffective role that causes a good deal of frustration and churn and a
distraction from focusing on what matters most.
2. Patient: Our patient self emerges when we
receive medical care. It is defined by
the discipline of medicine which takes a disease orientation that relies on deep
knowledge of the science of diagnosis and treatment to make people well. The expert role of the physician defines the
pact between patients and doctors:
Doctors “know best” and assume an authoritarian role and patients comply
with their doctor’s “orders” and “prescriptions” and assume a dependent role.
There are
two limitations of the patient self. The
first is that the medical model works well when there is a known treatment for
a specific diagnosis. But in many cases,
when the outcomes of alternative treatments are equivalent or equivocal, the
choice of treatment should have more to do with the wishes and tradeoffs of the
person rather than the opinions of the doctor. This is when patients and doctors need to practice
shared decision making. But the medical
model has not relented much to a patient-centered model that truly empowers
patients in decision making.
The other
limitation is that the medical model only works well when people are sick. But the majority of sick care today does not
stem from pathogens or mysterious medical causes. Most is for chronic illnesses that are caused
by individual’s behavior where prevention and self-monitoring are more important than
treatment. And the medical model has not
been very successful in shaping people’s behaviors. For example, the probability that people will
take their medications is 50/50. And admonitions
to eat well and take off pounds do not go far enough. So, the patient self needs to evolve dramatically to be
more actively involved in co-producing health.
3. Citizen: Our citizen self is expressed when we vote to
have others represent our views in the political process and when we
participate directly as a member of a community. It is
based on the discipline of political science and the premise that democracy
leads to improvements in the status quo.
Health care
has certainly been on the political agenda for the last few election cycles and
is positioned for the next. But the citizen self has been relatively passive
and on the receiving end of thunderous propaganda from special interests to garner
support for their positions. A slim
majority votes in presidential elections and far fewer are involved at the
state and local levels.
Although the
citizen self is dormant today, there was a time during the 1960s and 1970s when
it was in full flower. One example was
the Oregon Health Plan which included a great deal of citizen deliberation
about setting priorities for healthcare including what services would be paid
for under Medicaid. The belief was that
the only way to control costs was to understand that resources are limited, trade-offs
are needed, and the political process must activate deep citizen participation
to succeed. This movement reached its pinnacle during the
Great Society era and died off when market oriented approaches to societal
challenges supplanted government approaches in the early 1980s.
The citizen
self has been hollowed out and will be not be resurrected unless the playing
field is leveled and those in power invite genuine participation.
4. Customer: A customer is similar to a consumer in that they both buy
goods and services but is different because of the underlying discipline that
defines it, business. Business relates
to customers in two distinct ways. In
one way, business reveres the customer and keeps them happy with low prices,
high quality, and good service in order to build loyalty and profits. In this view, the customer is always right
and close relationships with them can reveal how to improve products and
services and develop new ones that meet demand.
In the words of Mahatma Gandhi, “A customer is the most important
visitor on our premises…We are not doing him a favor by serving him. He is doing
us a favor by giving us an opportunity to do so.”
In the other
way, business uses marketing and advertising tactics to deceive the
customer. They use intrusive ways to
gather more information about them, without consent, to know them “intimately” in
order to sell more.
In
healthcare, people are seldom referred to as customers. After all, they do not account for much of
the buying. Employers buy from insurers,
insurers pay doctors, doctors determine treatments. In business, leverage comes to those with the
most money in play. People are bit
players and more likely to be on the receiving end which limits the
opportunities for influence and maximizes the likelihood of manipulation.
Our integrated self
Each of the four selves is well-intentioned but does not
live up to its potential to improve health.
They fragment our attention, limit our power, put their own needs above the
rest, and derail us from taking control of our own health destiny. To achieve an integrated self, one must understand
and balance competing demands and align these with an overarching conviction to
achieve our full human potential. This
is not easy. As e.e cummings said, “ To be
nobody-but-yourself--in a world which is doing its best, night and day, to make
you everybody else--means to fight the hardest battle which any human being can
fight; and never stop fighting.”
The good news is that there are developments in three areas that
are converging to make the fight winnable.
In my next blog, I will address these promising solutions.
