Ethics Toolbox: Blending Ethics and Empowerment with Consumer-Driven Healthcare


May / June 2005

Ethics Toolbox

Blending Ethics and Empowerment with Consumer-Driven Healthcare

For the past three decades, cost containment, control, efficiency, and reduction efforts have remained at the forefront of healthcare policy, overshadowing innovation, quality, and safety concerns. A disparate array of proposed fixes and solutions have been imposed and adopted, offering tourniquets to an ailing system, ranging from the precise, defined, and targeted to the vague and ill-defined. Impacting virtually every sector of the healthcare continuum, these efforts have led sometimes to misguided solutions and fixes and to the creation of health system agencies, QIOs, prospective payment, and managed care. These have lead to capitation, utilization management, withholds, concurrent review, retrospective review, case management, demand management, disease management, second opinions, centers of excellence, pharmacy benefit management, specialty pharmacy management, rare disease management, self-referral constraints, and anti-kickback provisions. Caregivers and facilities have been intensely scrutinized and, at times, become the carnage of these efforts. The aggregate results are consistently lost ground in the raging battle against escalating healthcare costs and several negative sequels. Denial-based mentalities have prevailed in the fabric of decision making, coupled with medical management intermediaries who in a posture of fiscal arrogance have diverted dollars earmarked for purchasing healthcare into their own pockets at the expense of patient care. Rather than managing care, we have done little more than manage limited premiums and shifted costs.

Despite such detours to the dark side, we are beginning to see the light and find the path to “getting it right” after years of false starts. We have learned that we must strive to do the right thing and not only do it well, but to do it better. Part of that realization involves a swift and deft move away from denial-based to consumer-driven healthcare (CDH). We sincerely hope that CDH, when blended with pay-for-performance (P4P) and accompanied by predictive modeling, will provide the antidote we have been seeking. An engaged patient might indeed help save a buck while gaining autonomy and getting healthier in the process. To ensure the success of CDH we must be vigilant to ensure that such laudable efforts do not become reduced to hollow mantras and empty slogans. We must not allow our consumer-related efforts to masquerade as patient friendly without cultivating a clear understanding of the downside. Cleverly disguised efforts to save a buck at any cost do not work!

If we are truly interested in cultivating CDH, we must provide the consumer with the knowledge and ability to make more discriminating choices. We must design CDH as a “win-win,” to make things better for the consumer and control costs in the process. If it’s no more than a smokescreen to cover shifting costs from purchasers to patients, we will have missed a great opportunity.

This opportunity requires our best efforts in addressing challenges, as well as rethinking safeguards and safety nets for those who opt for consumer-driven scenarios. We must guard against people falling through the cracks when their circumstances change and they can no longer afford needed services. We must engineer the system to avail patients of the best we have to offer and help them and the system achieve mutually desired goals of efficiency, quality, and cost control. Effective case management services that have been targeted for the sick or likely-to-be-sick should be expanded to keeping the well well and the healthy healthier. We must engineer the system to mandate that patients use preventive protections such as stop-loss insurance to cover unanticipated expenses if and when they opt for consumer-directed programs. A facile caveat emptor mentality is no longer acceptable.

Further, we must consider the impact such programs have for society, and whether society should inherit the costs of imprudent decisions made by those who were bad predictors of costly events and failed to secure adequate financial protections and safeguards. We need to cultivate partners in the process, not adversaries. Incentives and supports for modifying behavior towards healthier outcomes can truly shape our society into “healthier” outcomes. These are indeed challenges worthy of our attention, energy, and effort.

Education and support must be blended with recognition of what’s plausible. For example, we cannot underestimate the fact that despite this emerging of an era of self-enlightenment, we are encouraging patients to challenge and evaluate the judgment of seasoned healthcare professionals who have over a decade of college, post-graduate education, and training, coupled with years of clinical experience. Merely embracing consumerism will not magically equip patients with medical knowledge they need to make good choices. Trade-offs also complicate the picture. Will patients willingly spend their dollars on medications to treat their symptom-less conditions of diabetes, hypertension, and high cholesterol? Or, if given the chance, will they spend their tax-advantaged funds on Botox and liposuction? As we proceed down the pathway of P4P initiatives, should we take money away from healthcare practitioners for doing a “bad job” if they recommend the “right” medication or behavior, but the patient elects to choose another path? We need to be there to help guide the patient to make educated, informed, and healthy choices.

Positive incentives, better health, education, and support, however, are being stretched by frustrated and over-eager purchasers and employers. Being unhealthy was bad enough, but now the fear of becoming unemployed because of costly and risky health behaviors exacerbates this discussion for some. Smoking and obesity are the first employer-selected targets. What should guide us in traversing and negotiating this new terrain? If improving the nation’s health is our goal, could we envision taxing soft drinks, fast foods, and potato chips in an attempt to make apples and carrots more attractive? Reports have already surfaced about employees who have either been terminated or threatened with termination, in one case in Michigan if they would not stop smoking and in another case at an Atlantic City casino because of increased body fat.

Now that we have moved from admonishing behavior to job loss, the stakes have risen dramatically. If we deny employment to smokers and the obese, what is stopping us from banning the next group that fails to please us? At what point do we begin to sound like modern-day practitioners of eugenics? We must be sure that our efforts are thoughtful rather than thoughtless!

Putting band-aids on a broken system doesn’t do anything to fix the underlying problems. Cost-shifting from employer to patient doesn’t do any good if the patient lacks the tools to analyze their options for care. Posting “list prices” for hospitalizations, pharmaceuticals, and physician services is meaningless if only the uninsured and the uninformed pay retail. Do these programs for consumer involvement offer the value we seek?

These challenges are opportunities for us to make a difference and be part of the solution to nagging healthcare woes. If we are willing to put our energies and monies into the “consumer-driven” movement, then we must also put on our thinking caps to address the challenges with the opportunity. If done right, this effort may indeed be the one that truly works.

Dennis Robbins ( is a healthcare innovator, author, and thought leader. He is president of Integrated Decisions, Ethics, Alternatives, and Solutions (IDEAS) and co-founder of the Policy Group. Robbins has worked extensivelyÝon the interface of ethics with quality, liability, payment systems, health law, and health policy. He has served as an advisor on ethics and related issues for major national organizations, associations, law firms, hospital systems, and government. Robbins holds a PhD in philosophy from Boston College and a postdoctoral master’s degree in public health from Harvard. He is a member of the Editorial Advisory Board for Patient Safety and Quality Healthcare.

Joel V. Brill (, is chief medical officer of Predictive Health, LLC. Brill is nationally recognized for his expertise in coding and reimbursement methodologies coupled with service on national technology assessment and pharmacy and therapeutics committees. He has over a decade of experience in clinical medicine, medical management, predictive modeling, and pay-for-performance systems with employer groups, health plans, and medical groups. He is an advisor to the AGA on reimbursement issues, the American Medical Association (AMA) RBRVS Update Committee (RUC), the CPT Editorial Panel, the Practice Expense Review Committee (PERC), and the AMA Physician Consortium for Performance Improvement.