Patient or consumer? The evolving role of the purchaser of health care services.

• Author: Kennedy, James J., III
• Position: Florida

The only important thing was to end her suffering. I knew I was breaking the law but there seemed to be things more important than the law, at least to me in my private tragedy."[1] The words of a convicted murderer. Hardly a poster child for the rights of individuals needing health care but, for many, the trial of Rosewell Gilbert in a Broward County courtroom more than a decade ago captured the usually unspoken pain of disease. His wife of 50 years lay suffering in his arms day after day and Mr. Gilbert chose to end that pain. Few would argue that this man loved his wife. Many would contest the legal or moral grounds of his chosen cure.

In the decade that has passed since Mr. Gilbert's conviction, the health care delivery system has been awash in change. Managed health care, "gatekeepers," hospital mergers and consolidations, and the rise of the investor-owned hospital chains are all now a part of the health care landscape. The business of health care delivery has changed quickly and dramatically, with this past decade seeing a revolution in the human intangibles of health care delivery. Perhaps in response to cases like that of Mr. Gilbert or, perhaps, as a natural consequence of an evolution in societal norms due to an aging population, an explosion of legislative and judicial recognition of living wills, health care powers of attorney, and health care surrogates has occurred in the last 10 years. We recognize the picture of Dr. Jack Kevorkian on the news every few months, and, on November 4, 1997, the citizens of Oregon again overwhelmingly affirmed their desire to permit physician-assisted suicide in their state.

As the business of health care has changed, so has the role of the patient. No more simply the passive and compliant minion of the family doctor, the patient has become 58 THE FLORIDA BAR JOURNAL/APRIL 1998 a savvy consumer who wants more input, more choices, and more autonomy when making health care decisions -- especially end of life decisions. Yet, as the business of health care has grown, many patient/consumers believe their choices and privacy are eroding. Where does the patient/consumer fit in this new order of health care delivery? This article addresses several of the safeguards established for the benefit of the patient/consumer in 1998.

By all accounts, the patient/consumer is the asset most coveted by the insurance industry, the health maintenance organizations, the hospitals, physicians, and all the other myriad of health care providers. Patient days, covered lives, risk pools, and capitation rates are all economic measuring sticks for the business of health care delivery, and each is contingent upon enrolling patients in a particular plan or with a particular provider. Yet, in today's health care marketplace, the perception of the patient/consumer often is that he or she has no individual voice in the system despite collective economic clout. In large part because of increasingly complex reimbursement methodologies and delivery systems, the patient/consumer needs an advocate so that he or she can gain full access to the specific provider or course of treatment that the patient needs or desires. Frequently that advocate is the patient's health care provider. The patient/consumer looks to his or her physician or local hospital to interact, lobby, and advocate with the gatekeeper of care or the payor of services. Unfortunately, today's patient/consumer often cannot freely choose his or her physician or hospital. The individual's employer (or its health plan) makes that choice. The employers likewise feel trapped when they desire to offer flexible and generous health coverage to employees and dependents in a cost-effective way. However, in order to gain cost savings, they often must limit individual choice, and the consequence is the formation of an economic bond between the hospital/ physician and patient/consumer. The patient/consumer perceives the provider as having the economic leverage, influence, and expertise to assist with meaningful access to quality care.

Moreover, the hospital and physician share a community of interest with the patient/consumer, and are inclined to assist the patient/consumer for several...