In the United States prior to World War II, healthcare delivery was a private affair between the patient and the doctor. The doctors delivered the best care possible and the patients paid the doctor with the best means they had at the time, often resulting in the old bartering system. Then along came insurance companies to step in the middle of that relationship and remove the payment from the service. In its simplest form, the patient bought health insurance, and the insurance company paid the physician for services rendered to the patient. What was meant to remove the act of paying directly for healthcare services, ultimately removed an important layer of the doctor-patient relationship. Now patients could request whatever healthcare services they needed, and the doctor could administer whatever services deemed necessary for the well-being of the patient, with almost no regard to the cost of such services (fee-for-service model). With soaring healthcare delivery costs, insurance companies tried different models to contain these costs, such as staff-model HMOs, and PPOs, in other words, “Managed Care.” Then came a wealth of intermediaries to try and “carve out” their piece of healthcare delivery, (Dental, Eye Care, Pharmacy Benefit Managers, etc.), but the unintended consequences were to increase the cost of healthcare delivery, not reduce them.
Today, we see a very complex healthcare delivery system in the United States with large insurance companies, new delivery models (i.e. Accountable Care Organizations, Patient Centered Medical Home, etc.), and new Organized Provider Networks. The intermediaries are still attempting to carve out their portion of the healthcare delivery dollar, and costs of healthcare continue to rise each year. New integrated delivery networks are certainly attempting to be more efficient and effective in providing services, but costs continue to escalate annually. Since the sky is NOT the limit when it comes to healthcare dollars, we are drifting into an area of rationalized healthcare as a means to get costs under control. As the Rolling Stones song so succinctly put it, “You can’t always get what you want!” That is to say, there has to be a limit to what people, employers, and governments are willing to pay for healthcare! Everyone is beginning to ask where the value is for the services received, and how much is needed to achieve optimal results. When is a surgical procedure, a drug, a diagnostic test, or a procedure simply not worth it? And who gets to make such decisions?
When people see rising co-pays and greater out-of-pocket expenses for healthcare they begin to take more of a vested interest in their healthcare services and well-being; they begin to look for optimal outcomes and a cost-benefit to such services. In this Age of Transparency, we now have access to more information than ever before about the cost of healthcare, such as the quality measures of doctors and hospital, the cost of new medications and procedures, and the outcomes of medical interventions. And while the pre-War doctor-patient relationship has not yet been re-established, we now see a return to concern for costs on both sides of the relationship. Patients now have a greater say in the delivery of their healthcare services, and can begin to challenge the value of a blood test, an X-ray, a new procedure, a prescription, or even a doctor visit. To be sure, healthcare delivery is fast becoming more of a shared responsibility, on both the clinical and economic side of the healthcare business.
Now, let’s return to the rationalization of healthcare, given the finite resources available to most people. Hospital committees, insurance boards, government agencies are taking a serious look at how to deliver the optimal care for the money available. Patients are beginning to question the clinical outcomes for their economic contributions. But what happens when a new medicine comes along with amazing cure rates to treat critical and chronic illnesses, but with a price tag approaching $100,000 per course of treatment. Science has progressed enormously to enhance our understanding of genetics and systems biology. New monoclonal antibodies are being introduced to cure hepatitis C for the first time, and that is just the start of these “super-targeted” drugs that pave the way for personalized medicine. But who has $100,000 sitting around in the bank waiting to pay “out-of-pocket” for these new medicines when a committee, board, or agency denies coverage on their drug formulary? And if there are some funds available for a certain number of treatments, who get them and who doesn’t?
So, if I am a person with a rare and debilitating disease that now has a new medicine with a 95+% cure rate and a price tag of $100,000 available to me, and I get denied by my insurance company, what recourse do I have to shout out, “unfair!” Well, in the not too distant past, I could go to my local newspaper and have someone print an article about my hardship and unfair treatment, and maybe if enough sympathetic readers supported my plight and echoed my sentiments, I could get the attention I rightfully deserve. But such isolated attempts to right a perceived wrong had limited reach, and rarely changed policies.
Now we have social media! With a flick of a button I can transmit an injustice to thousands, or hundreds of thousands, of like-minded people who can take up my cause and shout from the tallest roof-tops. A few keystrokes on my smart phone and I have opened up a world of support, literally! Can this new-found digital power change the face of healthcare delivery in America? Insurance companies and hospital committees who have denied patients expensive medical interventions for what may be very legitimate reasons (a balance of cost and clinical outcomes), now come under fire from public scrutiny and yield to the pressure rather than suffer a public relations crisis. But has more money suddenly appeared in the overall healthcare budget? Have all these digital companions reached into their pocket and forwarded money to these “victims?” Have hospital formulary budgets suddenly come up with new sources of funds? Doubtful. In a system of finite resources, it is like squeezing the balloon in one area only to have it pop out in another area. It is a game of trade-offs. If a budget has to suddenly cover the cost of an expensive medical intervention to someone who might have been deemed a less qualified patient, then this digital blitz has only resulted in some other service being cut elsewhere to pay for this unexpected campaign. Healthcare has become a business with limited resources, and the rationalizing of healthcare has become a reality. Personalized medicine will yield greater targeted outcomes, but the price for precision care will be challenging for most people and payers. And while social media can make a tremendous noise to perceived injustices, in the end who really pays for it? We all pay for it in one way or another, through increased premiums, co-pays, and out-of-pocket expenses to reduced services in other areas of healthcare delivery.
Can social media change healthcare delivery? Yes, but is it changing it for the better? Are the unintended consequences of a social media blitz merely to serve those who can make the most noise, while resulting in fewer services to those who suffer in silence? Social media is a powerful tool, and used the right way can make a positive impact on healthcare delivery. But, it must be used wisely and provide social justice to the many and not just the few.