Paul Krugman: Partially right

Filed Under: Costs, Health plans, Patients

I hate to disagree with Paul Krugman, the stellar New York Times economist, but I must.

In a column a few days ago, he wrote that it is wrong to refer to medical patients as consumers, and that the giving and getting of medical care “can be reduced to money” is “sickening.”

While I generally agree with the thrust of the column, I have to take issue with his points on this topic.

“Here’s my question,” he writes. “How did it become normal, or for that matter even acceptable, to refer to medical patients as ‘consumers’? The relationship between patient and doctor used to be considered something special, almost sacred. Now politicians and supposed reformers talk about the act of receiving care as if it were no different from a commercial transaction, like buying a car. … What has gone wrong with us? …

“That’s why we have medical ethics. That’s why doctors have traditionally both been viewed as something special and been expected to behave according to higher standards than the average professional.  … The idea that all this can be reduced to money — that doctors are just ‘providers’ selling services to health care ‘consumers’ — is, well, sickening.”

I think he misses the point: the problem is that in many cases the patient-consumer is unable to make decisions that are in her financial interest, partly because our health-care system is so opaque.

For example, you’re in an in-network hospital for an emergency appendectomy with an in-network surgeon — but the anesthesiologist and the pathologist are out-of-network, meaning that unless you are conscious and able to ask, you have to pay extra. It happens. A lot.

Are you a patient in this case? Or are you being fleeced?

Your doctor recommends an MRI, and you take his recommendation on where to have it, an in-network provider, incurring a $500 co-pay — but you could have had the procedure for $450 with no insurance. You just didn’t realize it, because in this case you were being a patient and not a consumer.

Or you have to make unpalatable decisions about paying for insurance (or not), paying for a prescription (or not), choosing a generic, arguing about an overcharge — because while you thought you were being a patient, the system thought you were simply a consumer, and an uninformed one at that.

I do think he’s right in one regard, though, that the current move toward “consumer-driven health care” has an unhealthy aura. That feels to me like someone’s description of a plan in which more and more of the payments are the consumer’s responsibility.

From the comments on Krugman’s pre-column blog post on this topic, there’s this view, from “jimherb”: “This whole idea of ‘consumer-driven’ health care baffles me. I take what the doctor advises. I am not trained in medicine-that’s why I follow the doctor’s advice. I am not demanding tests, drugs and services beyond medical advice (as much as the TV ads would have me do.)”

And this one from “ken”: “Who should make the call? Doctors? Government? Insurance companies? Who? If you think doctors, let me disabuse you of the notion that their primary motivation is love of their fellow man. It is a distant third behind their personal accountability and monetary remuneration. Very distant. Government? Well let’s put it this way; you could pay the medicare bill for everyone in America for the next ten years for the amount of money that has been stolen from Medicare and Medicaid. The amount is so staggering one might say the programs themselves actually encouraged fraud and abuse. Insurance companies? I won’t even go there. The only way you will get cost effective treatment is through a hybrid system with a public option, in which the public option is an hmo whose cost must be managed in the aggregate. With the private market to keep it honest cost versus care will yield an effective return i.e. the best care for the dollar.”

And this one, from “ZA”: “I agree wholeheartedly, however, I would add that, for me, this all fell apart at the point that someone decided that healthcare could be a ‘for-profit’ endeavor.”