Patient and Power no longer an oxymoron. Just follow the money.

For as long as I've been involved the healthcare industry, both as a physician and healthcare executive, I've always viewed the patient as the most disenfranchised, powerless cog in the wheel. This didn't come from any sort of disdain for patients. In fact, every time I or a family member had to engage with the healthcare "system" I too felt powerless. If I had any power at all it came only from my insider's knowledge of medicine, my better understanding of how system works and perhaps my ability to access my professional colleagues for information or a favor.

Why have patients been at the bottom of the totem pole in healthcare? Two reasons come to mind. One is their general lack of engagement. I've shared my views about this in a prior post (see The Fallacy of Patient Engagement). People don't really want to be "engaged" with their doctors or the healthcare system when they are healthy. And when they sick, they absolutely don't want to be engaged any longer than it takes them to get healthy again. Even over the course of that time their engagement may be lacking. However, to understand the real reason why patients have had so little power in healthcare all you need to do is follow the money.

Up until a few years ago, most large employers offered fairly comprehensive health insurance coverage. Although that coverage in many cases wasn't "free" to employees who often paid for a portion of it through payroll deduction, it was still a pretty good deal. It insulated employees from big healthcare expenditures. If your doctor ordered a CT scan or MRI or prescribed an expensive drug, you didn't much care because your health insurance usually paid for most of it. Not so anymore. Today, many of those same companies have shifted to high deductible insurance plans attached to health savings accounts. Employees may be subject each year to the first $3000 to $10,000 of many healthcare costs until their family deductible is met. That means starting each January, the employee is going to feel the full cost of that expensive test or drug the doctor orders.The only relief comes after the patient blows through his or her yearly deductible. Let me tell you, this is having a profound effect on doctors and hospitals. Not only are patients challenging the recommendations of their doctors, physicians and hospitals are having to deal with collecting a lot more money directly from the patient. While patients may not yet be equal partners with the insurance industry, they now have a lot more skin in the game making them not only more engaged in their healthcare, but demanding as well.

Adding to the fire, many new payment scenarios require healthcare organizations to move from volume based, fee-for-service care to value based care. Besides payments being linked to quality and outcomes, this also requires healthcare organizations to take on risk. Quality and risk have components of patient satisfaction built in.This means if the patient is dissatisfied and drops out of the healthcare organization's risk pool, payments and profits are on the line. This is yet another force giving patients more power and influence in the healthcare they receive.   

Changing dynamics are fostering all kinds of opportunities for new technologies and businesses hoping to disrupt the healthcare system as it exists today. Entrepreneurs talk about the "uberization" of healthcare as if they can quickly disrupt the system much as Uber is disrupting the taxi industry. Here I would add a cautionary note. While there is a lot that can and should be disrupted in healthcare, there are some areas where the disruptors are likely to hit a wall. Keep in mind that healthcare is a highly regulated industry and healthcare services are tightly controlled by the "power of the license". In other words, when you need a medication that is sold only by prescription, or you need a procedure or operation that can only be performed by a licensed professional, how do you disrupt? Making an end run on a taxi service is one thing. Finding an easy substitute for highly educated, licensed healthcare professionals is a bit more daunting.

So yes, patients today have more power and more choice. That power, being increasingly felt by the healthcare industry, is disrupting the status quo. It also serves as a spark that is igniting lots of venture capital investment in businesses and technologies that will change up the playing field. How fast and how far remains to be seen. For patients the upside will hopefully be more choice, greater influence, and lower costs.

Bill Crounse, MD Senior Director, Worldwide Health Microsoft