How “Choice” Outsources Work To Customers: The Healthcare Edition

Amazing what happens when reporters–and Sarah Kliff is a good one–actually have to live the stories they cover:

I write a lot about health care for my job here at Vox, and have spent the past seven years covering and explaining the American health care system. But there was something I didn’t understand about American health care until this experience.

Here’s the problem (boldface mine):

It is the considerable burden our fragmented system puts on patients to coordinate their own care.

I’m not talking about the work of managing one’s health, the work that diabetics do to monitor their blood sugar or the healthy eating choices a doctor might recommend for an overweight patient. This can be a significant burden in its own right.

What I didn’t understand was the burden patients face in managing the health care system: a massive web of doctors, insurers, pharmacies, and other siloed actors that seem intent on not talking with one another. That unenviable task gets left to the patient, the secret glue that holds the system together.

For me, this feels like a part-time job where the pay is lousy, the hours inconvenient, and the stakes incredibly high. It’s up to me to ferry medical records between different providers, to track down a pharmacy that can fill my prescription, and to talk to my insurance when a treatment gets denied to find out why…

Every three months, I just know I’m going to lose a few days of my life,” says Aaron Carroll. He’s a pediatrician at Indiana University who directs the medical school’s Center for Health Policy and Professionalism Research, and who also writes about health care at the New York Times’s Upshot…

Carroll has a condition called ulcerative colitis. Every three months, he has to refill his medications — and every time, it requires him to be the middleman between his doctor and his pharmacy….

Carroll told me he almost always runs out of his medication early and ends up rationing pills because something goes wrong — a lab test goes missing, a prescription doesn’t get transferred. And he’s a physician. What about the rest of us?

…But American medicine demands another scarce resource from patients, and that is their time. The time it takes to check in on the status of a prescription, to wait for a doctor, to take time away from work to sit on hold and hope that, at some point, someone will pick up the phone.

There is significant work involved in being a patient,” says Victor Montori, a doctor at the Mayo Clinic whose research focuses on the work health care assigns patients. “But there isn’t any chapter of any textbook, no class in medical school, no theoretical framework we’ve been able to identify that will help nurses and doctors understand this.”

Kliff does some really good reporting, but she misses one thing: the complexity of system is designed to convince people to give up–this is a feature, not a bug. Essentially, this is healthcare rationing, with time as one of the resources used to determine care. Even a low ‘abandonment rate’ (giving up and not seeking care) makes a difference. From a balance sheet perspective, health insurers, like every other kind of insurer, are basically investment funds that also happen to provide insurance–the margins matter. ‘Convincing’ even a small percentage of patients to not seek care–that is, not spend money–is no small matter.

Another thing to note is that this explodes one more reason not to have a national healthcare system, the myth that a national healthcare will be a cold, impersonal system that grinds people down. Why? Because our private system is already a cold, impersonal system that grinds people down. And, in the case of Aaron Carroll, it can harm health (the absurdity of a doctor in a wealthy society having to ration his own medicine really can’t be described with words).

One more thing: while Kliff writes about healthcare, the ‘outsourcing’ of work from the business to the consumer is nothing unique to healthcare. It does improve the business’ bottom line. Sucks for the rest of us, however.

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