The dark side of a consumer-driven health system.

UNCHECKED, PROFESSIONAL sometimes shortchange the rights of patients and interests of consumers and the public. Medical consumerism can help rein in the paternalism and self-interest of professionals. Proponents of medical consumerism argue that it will lead to more responsive organizations and to better quality, service, and prices. Providers of medical care can take account of the consumer perspective, increase information for consumers, and promote patient and consumer choice and participation in decision making. The articles by Julie Morath and Quint Studer show some of the benefits of medical consumerism and explain how consumer-oriented management can improve the quality of healthcare. Elsewhere, I have explained that strengthening the consumer voice is a neglected remedy to promote healthcare change (Rodwin 1997) and looked at the potential as well as the obstacles for the growth of a consumer health movement (Rodwin 1994, 1996, 2001). Consumerism may also help check the conflicts of interest of professionals (Rodwin 1993). Morath, Studer, and I agree, then, that the healthcare system should focus on the individuals who receive or need health services. We also agree that medical consumerism has great value, which is only partially tapped. The perspectives of patients and consumers were neglected for most of the twentieth century. However, over the last two decades the tide has shifted. Health managers and policymakers now generally acknowledge the importance of the consumer in healthcare. The readers of this journal too, I suspect, are either proponents of furthering medical consumerism or are sympathetic to the idea. However, if we adopt a full consumer model for our healthcare system, we will incorporate not only the positive elements of consumerism but some negative ones as well. These negative aspects are often overlooked by proponents, so in this commentary I will explore the dark side. THE CONSUMER METAPHOR When we think of patients as healthcare consumers, we promote the idea that healthcare is a market service purchased by individuals, just like any other. That metaphor works well in some contexts, but not in others. If we forget the limitations of the consumer metaphor, it will distort our thinking about medical care, and we will not be furthering the interest of patients or the public. Healthcare is not solely a matter of individual market choice and personal responsibility. Health is at the core of our social welfare, and it is the product of public policy as well as the private sector. The manner in which we organize our health system reflects our social bonds. How we provide health services can promote or weaken social solidarity and public spirit. Therein lies the rub. Thinking of healthcare as a consumer issue may reduce our sense of social obligation to provide medical services for those who lack means. In the name of promoting consumer choice, we may open up options only for individuals who have ample resources. A consumer model may encourage the idea that healthcare professionals or organizations have little or no obligation beyond engaging in activities that promote their return on investment. We may also forget that when markets do not provide the outcomes we want, we can use public policy and governmental programs to achieve those ends. We need to consider what it is about a consumer health model that we like and whether it is possible to develop these aspects without the less-desirable features of consumerism. There are four aspects of consumerism that I think we should avoid: two address patients, and two speak to providers. These are noted below in the propositions about a consumer model of healthcare. COMPLIANT CONSUMERS If You Don't Have Any Money, You Won't Get Any Service Consumers only purchase what their budget allows, and many people cannot afford healthcare. Should we treat healthcare insurance as an item to be allocated based on ability to pay? …