Ian Morrison

“The health care consumer needs to have skin in the game” is a phrase you hear frequently in health care. For those of you who don’t play poker, it means we consumers ought to pay at the point of care, which will motivate us to make more informed, value-conscious choices. Every health plan CEO I know, and almost all large employers, see this as the big new theme for health care. Consumer responsibility for payment will be sold to us consumers bundled with choice and couched in terms of empowerment. (Remember, when you hear the word empowerment, it’s code for “you’re on your own, pal!”)

At the same time, we have increasing variation in health care. A recent Institute of Medicine report calls attention to the huge disparities in care based on race and socioeconomic status. Physician John Wennberg’s research over the last 30 years has pointed to enormous variation in medical care across the country and across very small geographic areas. The patient safety and quality measurement gurus tell us that there are enormous differences in the quality of care between institutions and within institutions. Efforts to standardize care have been thwarted by a lack of enthusiasm among providers. Indeed, practice guidelines and evidence-based medicine are viewed by most doctors as one step away from communism.

How will the newly empowered, value-conscious consumers make out in this highly variable world?

If I go to that happy place inside (or listen to my most optimistic colleagues at the purchasing coalitions and health care foundations across the country), I can imagine the value-motivated consumer forcing a recalcitrant provider community to work on the big problems of clinical redesign and process improvement. We consumers, armed with new performance data at the provider level, will have the information and incentives to kick clinical butt and make choices that keep providers on their toes and take the American health care system to a new level of quality and accountability. But when I allow my natural Scottish cynicism to rise, I hear myself saying: “Most costs are incurred by the sick or the unconscious. They are not in a good position to kick anyone’s butt, let alone their doctor’s. And we Americans already have more skin in the game than anyone else in the developed world, with little measurable improvement in the value of health care we receive.”

In truth, both of my inner voices are correct in their own way. Fine-grain performance metrics in the hands of motivated consumers will have positive effects on the way care is organized and delivered. Providers should not resist such metrics, but embrace them. At the same time, the most disadvantaged among us-the poor, the elderly, the uninsured (or underinsured) with chronic illnesses, or just those of us who are medically illiterate-will struggle mightily because they haven’t the resources, knowledge, or support to navigate through this new world.

Ian Morrison is an author, consultant and futurist based in Menlo Park, California. This column was published in the October/November 2002 Health Forum Journal.