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Does the Patient Know Best?

We consumers buy all kinds of things. We read Consumer Reports, read the instructions about how to use things, and we make choices. In medical...

We consumers buy all kinds of things. We read Consumer Reports, read the instructions about how to use things, and we make choices. In medical care, we are not as likely to do as well in our decisions as we do with shirts, cars and auto insurance.

The shirt decision is absolutely clear: We can try it on, see how it looks, know exactly what it costs, and even bring it back tomorrow if we don't like it. The car is sort of like the shirt: Some can even be returned within 30 days, but we don't know how well it was constructed or how long it will last. When we are getting the oil changed in our automobile, we look for the lowest price, or we take it to the dealer or a nationally recognized chain, or we go where our brother-in-law takes his car. Sound familiar? We do the same with medical care, although it often seems like we have even less information than we do for our other day-to-day decisions. In fact, we may not. Do the repair shops post their results for "fixing unknown engine knocks"? Do the car insurers tell you "the percent of claims paid in three days"? The point is we make decisions every day without complete information and on "faith" that the result will turn out well.

Making Decisions about Medical Care

So how are patients going to make decisions about their medical care, and how successful will they be? In the end, they may find that the way they make health decisions may be a lot closer to the way they choose shirts, cars and auto insurance. Consider the following types of decisions:

Personal health care. Patients ignore all kinds of information about smoking and obesity leading to diabetes, despite the fact that they know better. That behavior is not due to a lack of understandable information; more likely it reflects how tough it is to change bad habits. How can patients make good decisions about their health? One important way is to establish a trusted relationship with their physicians so that they get the most appropriate care, understanding that sometimes doing less, based on good evidence, is often the best medicine.

Medical treatments. Too often patients are not informed when making critical medical decisions. Informed patients are better able, when working with their physicians, to "direct" their own care when there is a choice of appropriate treatment. For example, the decision whether to have a wound sutured is not an option, but since the likelihood of long-term survival is similar with different medical treatments when treating prostate or breast cancer, individual preferences should be the deciding factor in the decision.

Choosing a physician. The patient must be comfortable with his or her physician, and when choosing a doctor should have available information that goes beyond a family member's recommendation. Certain facts about the physician, such as board certification and the physician's history of success with certain procedures, will help in the decision-making.

Insurance benefits. Generally, the level of health insurance coverage will depend upon how much health care the patient wants and can afford. The decision can be broken down into the areas of choice, need, risk aversion and cost. Most patients value the ability to choose their physicians, and opt for a health plan that ensures choice. This is particularly true if the patients has a chronic condition and seeks care from many practitioners, although plans with more options and benefits are more expensive. Choice may be less important to the young and healthy who do not think carrying health insurance is important, but a catastrophic plan (at least) will protect them against unforeseen skiing and automobile accidents. However, going without preventive care can cause later problems.

Consumer-Directed Health Care and High-Deductible Plans

Comprehensive coverage is more expensive, and as a general rule, the higher the deductible -- the amount paid out of pocket before insurance starts to pay -- the lower the total premium. Many employers today offer health plans with high deductibles to compensate for escalating insurance costs. Over the last decade, health insurance premiums increased 131 percent, four times faster than wages. Today, one out of five workers is enrolled in a health plan with a deductible of at least $1,000.

Having a high deductible means that patients must make even more decisions about how to spend their out-of-pocket dollars. Most studies have shown that when patients pay for their own care, they skimp on both necessary and unnecessary health care. In these kinds of cases, physicians can guide patients toward receiving appropriate care, but studies suggest that even with physician advice patients will forgo appropriate visits, tests and important preventive care if it is perceived as unaffordable. This is particularly troublesome for those who are low-income or chronically ill, but it affects others as well.

In order to navigate high-deductible health plans and become good health care "consumers," patients need information. Some patients want a lot of information and some want a little. Studies confirm that consumers prefer receiving medical information from their doctors rather than from an outside source such as the Internet, although that may change over time as Web-based and other health information sources become more user-friendly to patients. At the University of Virginia, we have developed a model system that identifies consumers' health information needs, their preferences and the ways in which they prefer to receive health information. Understanding how patients want to receive information about their medical care will lead to the design of appropriate educational materials, which, in turn, will promote better patient decision making.

Health Care Reform and Patient Decision-Making

The proposed health care reforms advocated by the president and members of Congress hold the promise of improving access and coverage for many Americans. In turn, however, patients will have even more decisions to make regarding their medical care. Many of the proposals require Americans to have health insurance and for some to spend more of their income on premiums and other health-related goods and services. Even as the plans provide more health security, they also bring affordability challenges to middle-income Americans who will have to decide how and when to spend their own dollars on health care. This will require health care consumers to take a greater part in understanding the plans, because even plans with the same name may carry different benefits.

To get back to our car analogy, the Web site advocates a "consumer-directed" approach to caring for your car. The site advises that "taking an active role in maintaining your vehicle is the best way to avoid costly repairs down the road." Sound familiar to the advice to get a flu shot or a mammogram, or to visit the dentist? Similarly, many patients will not heed advice about "preventive maintenance" when it comes to their bodies, despite available information. Whether as a result of federal policy or private insurance actions, medical decision-making will continue to be shifted toward an "informed" consumer-patient through mandates and higher out of pocket spending. We must be prepared for the response of the patient who has little interest, motivation, or financial resources to direct his or her health care when needed, and, instead, says to the doctor (as a car owner might say to the mechanic for transmission trouble), "Fix it. Don't tell me how, just fix it."

Arthur Garson Jr. and Carolyn L. Engelhard are the writers of GOVERNING's Health Myths column. They are co-authors of "Health Care Half-Truths: Too Many Myths, Not Enough Reality."
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