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If Only Obamacare Empowered Patients

What If Obamacare Really Did Something About 
Patient Education & Empowerment?

The patient-oriented elements of Obamacare have largely to do with free screenings that are often double-edged swords – likely to promote as much unnecessary treatment as true life-saving interventions.

What Obamacare doesn’t sufficiently address – and what true healthcare reform requires – is the need for better patient education so patients can make these determinations themselves. One of the core sources of our medical dysfunction is the knowledge and power imbalance between doctors and patients – a lack of medical literacy by medical consumers.

This gap can never be fully closed, of course, but better informed patients are more likely to make better quality, less fear-driven decisions about their medical treatments (see “America’s Health Scare System“).

In terms of chronic diseases that account for 75% of our healthcare spending, patient involvement in their treatment and lifestyle choices is even more important. Those with chronic diseases are at higher than average risk for both dangerous medical interventions and for the added expense of chronic disease care over a lifetime.

Empowered Patients Could Save
Our Broken Healthcare System

Here are a few measures missing from Obamacare that could transform patients’ roles in their medical care to full partners in their medical decision-making:

  1. Reform Informed Consent – Medical malpractice reform would afford an opportunity to reform the “Informed Consent” process to be more a patient education platform and less a legalistic defense mechanism for doctors and hospitals (see Our Healthcare Sucks for examples of how this process is abused today). Reduced malpractice exposure would permit this transformation to occur.

Doing so meaningfully would mean removing this from the hospital admission process. Assigning trained patient educators could elevate this to what it should be – a solemn duty to assure patients know not just what are the risks of what may be done to them, but the risks and benefits of the alternatives to what’s being done to them.

This is best done before hospital admission, not at the last minute when patients are likely to “go with the flow” because they’re already committed to one course of action. By doing so and fully exploring patients’ treatment alternatives – rather than the one that will make their treating physician the most money – informed consent could be converted to what some patient advocates have called “informed choice”.

In this day of internet access and online tools (see my last post – “A New Year’s Resolution For Smart Patients” – for a few examples), this is something that needs to be brought into the 21st century for maximum patient benefit and risk reduction. Unfortunately, Obamacare essentially side-steps malpractice reform – one of its more glaring omissions (see “Medical Malpractice – What Obamacare Misses“).

2. Beef-Up Public Health Efforts – Beefing up our chronically underfunded public health system would also be a mark of true health reform – at least reform that purports to put health back into the disease-treatment paradigm of American medicine.

The pharmaceutical industry has co-opted legitimate public health efforts by intruding into disease “prevention” to expand its markets to even healthy patients. The bottom line, however, is that we could truly prevent many diseases with better-funded public health initiatives.

The reduction in smoking in America – the only lifestyle behavior where Americans actually do better than our European and Asian counterparts – is owed largely to public health efforts to educate the public about the dangers of smoking (along with aggressive taxation of cigarettes, of course).

While American medicine claims credit for improved rates of cardiovascular disease, the credit belongs as much to these unheralded public health and tax policy campaigns as to high-tech cardiology.

Instead, however, public health is slated to be level-funded under Obamacare, meaning it declines as a percentage of federal government health spending from 40¢ per $100 spent on healthcare to 30¢ per $100 spent on healthcare by 2015.[1]

This is a big mistake given the central role of lifestyle-related diseases in our medical spending.

As much as physicians need to be more proactive in counseling patients about their need for lifestyle changes to complement their medication treatment regimens, the reality is this is unlikely to occur – especially with 30+ million more Americans in the healthcare system under Obamacare and few additional doctors to treat them.

An intelligent and enlightened health reform program would recognize this obvious disconnect and increase public health funding to help shift some of this patient education burden from doctors – already ineffective at it – to the public health system, which at least has this as a core part of its mission. 

This could also be a way to counter the effects of direct-to-consumer drug advertising with Public Service Announcements and other direct-to-consumer information that isn’t driven by corporate profits. Of course, if Obamacare were true health reform, it would have eliminated direct-to-consumer advertising by pharmaceutical companies – something only the U.S. and New Zealand currently permit.

There was some additional Obamacare funding in the Health & Human Services budget for select public health initiatives, but their priorities are questionable. There was $1.4 billion, for example, to help prevent smoking by teens, $450 million of which comes from user fees from tobacco companies.

The remaining $950 million, however, represents an extremely long-term investment, since the biggest payback of avoiding smoking among teenagers won’t be realized for 40 or 50 years.

By contrast, a token $20 million was included in Obamacare for chronic disease prevention to spread among 10 of our largest cities.

Chronic disease prevention offers a much faster return on investment since chronic disease care accounts for 75% of our medical spending – or over $2 trillion annually – and pre-disease interventions have a near-term benefit in avoided medical care. $20 million is pocket change in proportion to the magnitude of chronic disease effects on our medical spending. This should have been a prime target under Obamacare for reallocating federal spending to more practical and financially-rewarding activities.

3. End-of-Life Counseling – Despite the “death panel” distortions of Obamacare opponents, this is a much-needed benefit – that isn’t enhanced by Obamacare – that would help patients and families confronting difficult end-of-life choices to make better-informed decisions instead of going with the default of profit-driven medical practices.

A study discussed in another post of patients facing end-of-life choices found that the vast majority of patients shown videos of what end-of-life ICU care entails switched from heroic and other death-prolonging measures to unanimously rejecting these in favor of comfort-based hospice care (see “End-of-Life Care in America: Death-By-ICU” for more on this).

This is a classic example of how better informed patients can have a meaningful impact in reducing futile end-of-life care that fattens medical coffers and in producing an improved experience for the affected patients and their families. 

Reducing Our Dependence

The above wish list would go a long way to reducing our current dependence on high-risk invasive medicine and its associated expense.

Our healthcare would still be far from perfect. Perfect isn’t a realistic goal. But cutting current excesses by half, over time, is reasonable and achievable – though not without taking on the vested interests that dictate health policy in America.

Doing so will require a full-bore effort at disrupting current medical practices for safer, more efficient, better quality, and more affordable healthcare – something for which neither political party has the stomach.

I’ll explore what form some of these measures might take – and how they’d help us gain control of our medical spending – in Part 2 of this post.

[1] National Health Expenditure Projections 2008-2018.

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