Health Reform and the Big “D”

When it comes to my health, money is no object

Milton Berle, American comedian, 1908 to 2002

Ask experts what health reform is all about, and they will say,” Cost, Access, and Quality,” generally in that order.

They seldom mention the Big “D” – Demand. It drives the other three.

I am thinking of these health reform factors because I’m in the process or organizing a book, tentatively named, The Perfect Reform Storm,” based on some of my 1586 blogs. The book will include blogs from March 2010, when the Accountable Care Act passed, to the present when talk of its repeal is in the air. A Republican-dominated House is about to assume power, and the 2012 Presidential campaign will soon be underway.

Writing on demands for care is not politically correct. To do so shifts attention and responsibility to health consumers and patients. Conventional wisdom says patients are relatively helpless when faced with doctors with superior knowledge. This is sometimes called "information asymmetry."

Doctors, in other words, control patients’ health, cost, and outcomes destinies. This may be true in certain situations, such as the use of expensive technologies to treat cancers when less expensive and equally effective treatments are available (Medinnovation Blog, December 9, 2010,“Costs Rise When Patients and Specialists Embrace a New Technology for Treating Prostate Cancer”). Patients are often equally responsible for their health, sometimes more so if they do not change behavior, follow doctors' orders, and do not become health literate.

Larger forces are at work that foster increase health care demand.

• The most inevitable and biggest of these is simply aging populations which demand more medical resources for treatment of chronic diseases.

• Second are life-saving and life-style improving technologies . Cancer drugs and treatments, cardiac stents, joint replacements , and cataract surgeries spring to mind.

• Third is media-spread and Internet-disseminated news and information of medical “breakthroughs,” be they weight loss products, botox injections, erectile dysfunction corrections.

• Fourth is our litigious society which compels doctors to practice “defensive medicine," to ward off malpractice suits or a future day in court.

• Fifth is third party coverage of health care, with no upfront costs or small co-payments, which make patients unaware or insensitive to true costs.

• Sixth is the “entitlement mentality,” which perpetrates the belief that health care is a universal “right” and that all care ought to virtually free to all individuals, no matter what their socioeconomic status.

I do not decry these fundamental realities of human nature. They are part of our society, our mental mindsets, and our belief in egalitarianism, which we preach but seldom practice. They contribute to the quantity of services delivered. They affect quality and outcomes. In general, they increase costs if providers are not allowed to compete on price or design and packaging of services.

They are impossible to regulate totally. No amount of bureaucracy or number of protocols can stem the demand tide. When the demand exceeds the supply, e.g. the number of physicians available, the government or the market will in the end do the right thing by increasing the supply, but decreasing the demand is an altogether different and more difficult thing.