The emergence of the new health care consumer. (Part 1: Health Care Futures).

IT USED TO BE THAT IF YOU WERE ON THE RECEIVING end of medicine, you were known as the patient. Today, medicine has metamorphosed into health care, doctors are providers, and patients are routinely being referred to as consumers of health and health care services. In Part 1 of this second annual panel discussion, six experts examine the new health care consumer.

The idea of the consumer, a concept as American as apple pie, still makes people uneasy when it's applied to health care, as you'll discover in the following discussion. Partly, it's because the relationships in the health care sector are nowhere near as transparent as they are in, say, the retail sector. In our health care system, the individual consumer is not necessarily the payer, and choice is often restricted.

An employer funding most, if not all of the employees, health insurance premiums, as well as an increasing menu of preventive care options, may feel entitled to think of the company as a consumer of health care services. Some employers are beginning to look for tangible evidence that their health care expenditures are also good for the bottom line. They want to be able to measure the return on their investment in healthy employees. Two corporate health care directors on the panel talk about this emerging trend and why it may take a while to make the connection between employee health status and productivity.

Whether you prefer consumer, customer, purchaser, end user, ultimate buyer, or beneficiary, one thing's for sure. Many of us are as different from the bygone patient as an HMO is from the general practitioner who came to our house when we had the chicken pox. One of the reasons for many Americans' new interest, knowledge, attitudes, and expectations about health and health care is the Internet, the second topic in this discussion.

The connection between the Internet and the emerging breed of health care consumer may be hard to quantify, but according to this panel, the anecdotal evidence is clear. Unfortunately many physicians aren't ready to use this new tool or to deal with health care consumers who do.

Whether it's meeting the needs of a new generation or exploiting the potential of the Internet for health and health care, the physician executives who will be leading the American health care system have their work cut out for them.

The Physician Executive:

Who is the consumer?

Larkin: I think the consumer is the purchaser of the health benefit, which then makes the payer. which is most often the federal government or the employer, the consumer.

Reinhardt: I've always been uncomfortable with this term. To my mind, consumers are healthy people and patients are sick people, and there's a real difference. If you've got somebody In a coma, it seems a little odd to think of that person as consuming health care, as if that person were a fully informed purchaser of a commodity.

Larkin: Isn't there a spectrum of health services being delivered, because preventive health care is delivered to the otherwise perceived healthy patient?

Reinhardt: Yes, then they are a consumer. Parents who purchase well-baby care or preventive care, or even sort of worried well care. You're a consumer when you have some discretion. But when you're lying there in bed very, very sick, it isn't quite clear where consumerism ends and where you begin to be an infantilized recipient of a service rendered by people to whom you have lost control.

LeTourneau: I'm not really sure that I follow that line of reasoning.

Rippen: Maybe one way to differentiate is that it could be a spectrum. It depends on if you're applying the economic model in the sense of a consumer has choices, whereas if you'll pay anything because it's an emergency and you have to be treated right away, it becomes a different issue.

LeTourneau: But you still make a choice, even if it's an emergency. You choose to be treated or not, you choose which ER you're going to go to, you have some choice as to which physician you see. If you don't like this one you can ask for that one. I mean, you do have choices, even if you decide not to exercise them.

Holt: I think it's important to separate the purchaser, be it the employer or the federal government, from the consumer. I think most of the confusion arises over that distinction. But there's clearly a spectrum of health care consumers, and if someone is admitted to the ER, I don't know that you can call them an active, choice-enabled consumer.

The Physician Executive: If we follow this line of reasoning, then a person's status as a health care consumer decreases as his or her discretion decreases. So if someone is unconscious in a hospital, does that mean he or she is no longer a consumer of health care services?

LeTourneau: That's the thing that I don't get either--the whole concept of choice. I don't know where that ever came from. I've never heard that applied to the consumer. That's like saying that the baby that drinks the formula the mother gives it is not a consumer of the formula. It's hungry and it has no choice but to take what the mother gives it, but it certainly is the consumer of the formula, while the mother is not.

Reinhardt: The switch from patient to consumer in our health policy lexicon was not just an innocent semantic difference. It changed the whole ideology of health care in the sense that it legitimized the market and health rationing by income, all the things that come with the notion of a consumer. On the one hand, you can say that anyone who stuffs something into their mouth is a consumer, but that doesn't bring with it an ideology. In my discipline of economics, it increasingly suggests that consuming health care is just like consuming bread, and that it's perfectly all right to tier the health care experience by income class just as we tier the food experience by income class. I'm not suggesting we shouldn't have that, but you should call things honestly what they are.

LeTourneau: Uwe, I couldn't agree with you more. I think that the use of the term consumer makes a business out of health care, whereas the term patient goes to the heart of medicine, which is that you take care of people. Part of the problem is the divergence between those two aspects of health care, and the terms consumer and customer certainly relate to the business aspect.

Larkin: Changing from patient to consumer also implies somewhat of an Intention to take the individual out of the dependent role of a patient and put them in the more responsible role of consumer.

Reinhardt: That does go with it and may be a positive aspect of it.

Holt: Uwe is quite right in saying that this is extremely tier-based, for example, based on income, especially in the U.S., but also in other countries. If you look at the emergence of what the Institute for the Future calls the new consumer, you're talking about a lot of people, but it's clearly the upper echelon, better educated, more affluent...

Reinhardt: Internet-connected...

Holt: ...Internet-based consumers, who make up about 45 percent of people in the U.S., but it clearly leaves out a lot of people who are still patients.

Weatherup: I think that there are simultaneous roles of both patient and consumer. Unfortunately, there are very few people that actually play the consumer role, which implies some financial responsibility.

Reinhardt: That's true. Recently, I was asked to talk about that, and I gave the talk the title, "Whom Do You Have to Please in Health Care to be a Winner?" That, of course, depends on who you are. If you are a health plan, I identified five markets that you have to please, but the most important one, obviously, is the benefit managers. You've got to please them because if you don't, they might not list you on the menu of plans presented to employees. If you really tick off benefit managers. they might even treat you as business treated the HMOs in Minnesota: They might bypass you completely.

When it comes to the sort of backwater and 18th Century health insurance systems like we have in New York and New Jersey, they don't really give much of a damn about the people who actually buy their product. They deal with the health benefit managers. Half of these plans don't have a Web site that prospective enrollees could surf. If you want to know where a doctor trained, they won't tell you that. These plans have not yet recognized that the ultimate buyers of insurance are people like me and that we are worth worrying about. But I think in the next 10 years they will learn the hard way that they have to be more respectful of consumers, the ultimate purchasers of their insurance products.

Rippen: There's another issue, which is what types of health care people are pursuing. If you look at what people pay out-of-pocket for alternative medicines, there is now increased coverage for that. Utilization rates of non-reimbursable expenditures for seeing a chiropractor, for example, have been really growing a lot because people are not getting what they want from mainstream health care. From that perspective, the idea of the health care consumer is very much market-driven.

The Physician Executive: Greg Larkin and Tom Weatherup, do your employees, who are the ultimate consumers of health care, if I can put it that way, do they have a role to play in this? If you keep getting complaints about a certain health plan, is it not part of your job to look into it and make a change if necessary?

Larkin: Yes, that's absolutely how we operate. We advocate for individuals who have problems with their health care delivery, but we also survey our people rather extensively and publish the results to our entire employee base. At enrollment, they can compare the success of the managed care products, as well as the satisfaction of the indemnity plan. I mean, it's a matter of terms. I'm sure not an economist, but if the marketplace is driven by consumer satisfaction, and I think that is often the case, then the consumer that must be satisfied is the purchaser of the benefits, not simply the user of the benefits.

Rippen: That's true for health plans, but if you're a hospital or a clinic, you're much further removed from the person who's actually buying the health insurance. If you're a hospital or a clinic, your customers are actually patients.

Holt: That may be true for General Motors and other large firms, but I'd argue that, in fact, the majority of Americans who work in small businesses simply have no choice of health plan, and have that decided for them by a benefit manager or the CEO in a small company.

Reinhardt: Actually, half of Americans have a choice of only one plan and another 20 percent a choice of only two.

Holt: Exactly. And furthermore, if you look at the data, of those who change plans, 70 percent do so involuntarily, either because they lost a job, their employer changed it on them, or their spouse's employer changed it. And so what Alain Enthoven at Stanford told us about consumer choice being the future hasn't really come to fruition.

LeTourneau: Well, except that only applies if you're talking about which health plan do they have. There is no health plan that only has one doctor.

Holt: True.

LeTourneau: And for most of them, even if they only have one huge clinic, like the Mayo Clinic or the Cleveland Clinic, there are lots of doctors In that clinic, and not many of them have only one hospital. If you're on the delivery side, you still have to be able to participate in whatever the important plans are in your area, but that doesn't do any good unless you attract patients to you, and in that sense patients become the customers. This is a huge dichotomy within Allina because we have both the delivery side and the finance side, and we think of different people as our customers and as consumers. It's a very big problem.

Rippen: There's a recent survey from William Mercer & Company, I think, about employer concerns in choosing an HMO. The first one was access and coverage and I think the fifth was member satisfaction because obviously cost, quality of care, financial strength, and stability beat out member satisfaction.

Weatherup: I'd just like to respond on behalf of General Motors that there are two reasons why we care a lot about the satisfaction of our employees with their health plan. One is we truly want them to have a good experience and to enjoy their benefit and get what they deserve. The other reason is that our collective bargaining partners in organized labor pay a lot of attention to the satisfaction of their members with their health plans, and when they're unhappy, they point it out to us.

Holt: But even a detailed analysis of the quality of different services being provided by heart surgeons in New York and all types of hospitals in Pennsylvania hasn't changed the referral patterns or network selection that much.

Reinhardt: There's also an article in The New England Journal of Medicine about the Pennsylvania data on the cost and outcome of heart surgery. In Pennsylvania, the cardiologists do not even respond to either cost or quality in recommending surgeons to patients. They used MediQual's Medi-Group software which predicts mortality on the basis of health status of the patient coming into the hospital. So it's about as clean as the software now allows you to make it. And the variation in excess mortality rates and costs across hospitals and surgeons are stunning when you see them plotted. Those hospitals are all over the map. There are a lot of hospitals with high cost and high excess mortality and yet they are chosen.

The Physician Executive: What do you mean by excess mortality?

Reinhardt: Excess mortality here means mortality over and above that predicted on the basis of the patient's age, gender, and health status upon admission to the hospital.

The Physician Executive: Are the concepts of health care consumer and customer in flux these days?

Reinhardt: I would argue yes. I believe the health plans, and to some extent the providers behind the plans, basically have disregarded the role of the patients, who are the ultimate buyers of insurance coverage. That is why patients all over the country are running to the government. That's why you have the Clinton Health Quality Commission and the legislation that will come down the pike. I think that is part of the consumer movement. Oddly, they went to the government, rather than complaining to the health plan to ask, "Why don't you treat us with more respect?" Evidently, the health plans were too arrogant in their dealings with consumers and [the plans] are only now waking up to this failure,

Rippen: Part of it has to do with the idea that "this is all you're going to get." You know, if you have this condition, whether you want to stay longer or not, you have to leave. And the health care provider is saying, "Hey, I can't do anything about it. My hands are tied."

Holt: My colleagues at the Institute [for the Future] play this line. This aggressive group of new consumers, who have been to college or had some college experience, have some familiarity with information technology, and also have incomes above $50,000 in '95 dollars, equates to about 45 percent of Americans. Most of them are in the baby boom generation. They have dramatically changed every industry they've come into: retail, financing, banking, buying autos, all kinds of other industries. And the argument is that they'll do it to health care, too, and that those folks who don't respond to this aggressive consumer are going to suffer very quickly.

My personal argument would be that when these folks get into their high utilization period, when they get to Medicare, when they reach their sixties, they'll have a whirlwind impact on the whole system. But that won't be for another 10 years. But if I were running either a hospital or a health plan, these people are likely to be my best customers, and I would be very, very concerned about what they're thinking right now.

Reinhardt: I don't think I would disagree with you on that. Yesterday I gave a talk to a Blue Cross plan, and I sort of gave them a whole bunch of ideas of how you could develop a friendship with younger people who will be your patients one day. For example, I'm always amazed that my health insurer never surveys me to ask how do I feel about the quality of different hospitals or providers that I have used and that they have paid. They seem not to give a damn. But a smart health plan would do exactly that. I think any insurer that wants to stay in the business should build that bridge to the consumer. My health insurer basically treats me like the IRS does.

LeTourneau: Uwe has a very good point In that when health plans look at quality, they measure It through HEDIS and other ways because that's what the employers want. But what I think they're just starting to learn is that the patients presume that quality is about the same, at least in our market, and what they judge as quality is service and caring and convenience, that I get what I want, when I want it. And that's a very big difference. If they're going to want to appeal to the baby boomers, that's the need they're going to have to fill, not what's the mortality.

Reinhardt: Precisely! The Business Health Care Action Group In Minneapolis, a progressively thinking business coalition, provides employees with precisely the kind of information you enumerate: Patient satisfaction with respect to cleanliness, courtesy during making an appointment, wait for an appointment, wait in the office, a lot of things that are not mortality-related that these baby boomers care about.

LeTourneau: And the delivery side, hospitals and clinics, has measured that for a very long time. The purchasing side, the finance side, is sort of a johnny-come-lately getting in on it.

Larkin: In response to Uwe's comment that managed care seemingly has left out the patient, In fact, when the system is best applied, managed care is the only type of system that really includes the patient in measuring satisfaction. Barbara, you mentioned that it's routine for hospitals to do that, and that may be, but it surely has never been routine for physicians to query their patients about levels of satisfaction. In the managed care environment, that is inherent in their success. Uwe also mentioned earlier about the consumer concept that you're rationing by affordability, but in the managed care environment you're rationing by need.

The Physician Executive: Will employers demand measurable improvements in employee health status from their plans? Is this happening now or do you see it happening in the future?

Larkin: I think that's a very strong evolving trend. Disease management, for example, is conceptually right on target for correlating diagnosis with clinical care and eventual outcome measurements. And you're beginning to start measuring the incidence of mammography in a particular plan, not measuring disease outcome yet, but measuring effective preventive screening services provided. To me, the only reasons employers offer health care are, first, to retain employees because health care benefits are very attractive and highly valued and, secondly, to enhance the productivity of the workforce. And, therefore, you would expect the health delivery system to be best at maintaining health and subsequently enhancing productivity.

The Physician Executive: Do we have any evidence at this point to link improved employee health status with increased productivity?

Rippen: There have actually been several studies, including employer-based health programs, showing that if you target certain types of preventable diseases you can improve absenteeism.

Holt: You can find both instances of that kind of improvement and also of improvement in health status and, therefore, productivity for people in disease management programs. The question really is whether anybody is buying health care on that basis genuinely, outside of a few leading edge, large companies. I doubt it at the moment, which is why I think this move to consumers is going to be a slow one, And the point which, Greg, you didn't mention, is the reason that employers provide health insurance is because of the tax laws, number one. Those other issues are secondary.

Rippen: And also to gain more bargaining leverage to keep employees because they couldn't raise wages.

Larkin: I agree that there are tax and compensation issues around company-sponsored health benefits. But health benefits also have to demonstrate effectiveness and efficiency, just like any other major operational purchases a company makes. If you look at company-provided health benefits just as a tax benefit or an employee retention benefit, you really minimize their role in employee health and company productivity. As a company, we've got to insist on the best quality health care products we can get. There's a real connection between that and ultimate shareholder value.

Holt: But the reason you couldn't hand it over to a consumer, individual-based system right now is because of the tax deductibility of employer-purchased health insurance.

The Physician Executive: Tom, what's your position as a representative of General Motors on improving employee health status to increase productivity?

Weatherup: I agree with Greg. The concept has great appeal, the whole idea of actually having a delivery system that has accountability and responsibility of maintaining and improving the health status of a population of people, and paying for that, as opposed to reactive intervention when things happen and when they happen to show up on your doorstep.

Larkin: But there are a lot of obstacles to getting to that point.

LeTourneau: I would challenge whether you're actually measuring improving employee health status, I think you're looking at a few indirect measures, like the mammography rate which there is some evidence that it might improve employee health status, but to actually measure improvement in employee health status takes years and years. The incentive to health plans is to cut costs in the short-term and not affect employee health status in the long-term because the contracts change and switch on a yearly basis. So it's very uncommon to have five- and 10- year contracts that actually give them the opportunity to improve employee health status.

Weatherup: I don't disagree with you at all. We're nowhere near that point on many different fronts. For one, we can't measure employee health status right now, so to measure improvement in it is a huge obstacle. And as you mentioned, health status is a long-term issue, so a delivery system that had responsibility for the health status of a population would want that to be a long-term, not a short-term, responsibility.

The Physician Executive: So, how realistic is this idea as a future prospect?

Larkin: I think all of us, in order to drive the marketplace to continue to improve the quality of the products, purposely view our current managed care partners as something that may be temporary if they don't meet performance measures. But part of the sophistication we all strive to develop is that even though our association with a particular health plan vendor may be short-lived, we look for the inherent processes that would anticipate long-term benefit to the employee, because we anticipate that employee will be with us longer. To Barb's point, it is true that if you allow those health benefit plans simply to have processes that give them a short-term gain but with no long-term results, part of your demand for performance should be processes, be it disease management or something else, but that inherently will have a long-term benefit with all your future partners.

Rippen: In addition, on the whole issue of employee health status from an employer's point of view, there's a privacy and confidentiality issue as far as whether an employer has the right to know an employee's health status.

Reinhardt: There's even a Nurse Ratchett effect.

Rippen: I can't wait to hear what that is.

Reinhardt: It has to do with the idea of rewarding health plans financially for the health status of their entire population. I'm opposed to that because I think it sort of leads you down the path of a Chinese commune. For one, it leads to discrimination of whom you let in unless the instruments for [risk] adjusting are very good.

For example, if you were to evaluate me by the intellectual accomplishments of my students and peg my salary on that, I would probably start discriminating on whom I would or would not allow to enroll in my classes, And I would have certain prejudices, some of them based scientifically, some just preconceived notions about who will or who will not be a good student and act accordingly. Plus, I might intervene with students. I might see them at a party and say, 'You know, if you go out and party, my rating goes down,' and intervene. That's the Nurse Ratchett effect. You know, if she would see you eating a meringue pie, the first thing you know you get an email from your HMO scolding you. I think that idea is not a good one.

But you can go down the HEDIS [NCQA's Health Plan and Employer Data Information Set] list, which is a process measure, and do certain things that we believe will improve health status. That's easy to do and we can do that now. If you go down the FAcct [Foundation for Accountability] route, they really are trying to do very imaginative things, but that'll take a decade to make major progress. There's no reason not to do that, but you shouldn't oversell it.

The Physician Executive: How will the patient/doctor relationship change in the next five to 10 years?

Rippen: It'll be more of a team approach.

Reinhardt: I was just saying to a student who wants to become a doctor that this is not going to be so easy as it used to be, because these patients will come to you having already read three pieces from The New England Journal of Medicine and you may only have read two.

Rippen: It's already happening.

Reinhardt: They may, in fact, be ahead of you when they come to you. Not everyone, but-who was it, Matthew mentioned 45 percent-there's an awful lot of very savvy, computer-literate people coming down the pike.

The Physician Executive: What do you mean by team approach, Helga?

Rippen: Physicians are going to be serving as the experts in the sense that the patient will come in with background information. Physicians will also have physician assistants and nurse practitioners and the key is really what is the best strategy as a group, as opposed to only the physician saying what course of treatment will occur. The dynamics change a little.

The Physician Executive: This sounds like something Larry Weed has talked about, where the physician becomes more of a coach.

Rippen: Yes.

Holt: I'd say that this is a very difficult period coming up for physicians and it's going to get worse, because although the people that Helga was talking about, people suffering from diseases that impact the younger and more affluent, I'm talking about AIDS, breast cancer, and potentially prostate cancer now, it's probably not yet filtering through to people who make up the majority of interactions with physicians and with the health system, to the elderly, the chronically ill, and those folks who tend to be of lower socioeconomic status. Physicians have to deal with both ends of the spectrum. There's also this funny thing going on in which any consumer, any patient, on the one hand, wants to have complete control of their situation, but on the other hand, really wants someone to explain to them exactly how to do it and what to do and to take care of their every need.

Rippen: Oh, yes.

Holt: And that dichotomy is never going to go away.

Rippen: And, you know, I think I prefer that it doesn't if I'm sick, because that's why I'm paying them and that's why they went to school all those years. I agree, but I think that physicians, I guess I'm an optimist, are going to rebound as far as the physician/patient relationship is concerned. It really depends on the community of physicians and where they want to be in the future.

LeTourneau: What we're seeing in Minnesota is a sort of a grass roots public attempt to get the physicians back to being the patient advocates and I wouldn't be surprised if, over the next five years, we start to see that around the country, because what patients really want is to have a physician that has their interests in mind, not a health plan's interests. There's starting to be a perception, I think, that physicians are being put in a bad position by health plans. I think we're going to start to see a push toward a more traditional patient/physician relationship, with the physician as the patient advocate.

Rippen: I agree.

The Physician Executive: What roles can physician executives play in the evolving patient/doctor relationship and the advent of more aggressive health care consumers?

Holt: I have some very strong views about this. Seventy percent of American physicians are specialists, and they have what I call the Mike Tyson or Latrell Spreewell attitude toward customer service. They believe they're such superstars that they can get away with anything they like, The reason we have people concerned about 40-minute and two-hour waiting times in doctors offices, and generally not being treated as a proper customer, is because of this concept amongst physicians, especially amongst specialists, that they can get away with this behavior because they have the all-powerful knowledge. Changing that culture is the most important thing that physician executives can do. Maybe you disagree with me as to how bad that is, but I feel very strongly that that's the issue that is really going to be important for the next five to 10 years for physician executives.

Rippen: I think the key thing is to focus more on the longer term strategies, like disease prevention and health promotion, especially in a consumeristic model. If you start looking at the top diseases of the baby boom generation in terms of morbidity and mortality, that's going to be the key thing.

The Physician Executive: And what's the role of physician executives in that regard?

Rippen: Making sure that it's a long-term approach. If you're managing health care facilities, you can have a lot of influence over some of the policies.

Usually you have patients for two years at a time in health plans and what goes around comes around. There needs to be some sort of understanding in the field, I think, that if everyone immunizes 85 percent of their population, everyone benefits. It's disease prevention.

Larkin: The physician executive is going to have a crucial role in what's evolving. My experience has been that in many studies, the person who designs a health benefit plan is someone who wears many hats in a small business and they neither have the time or expertise, even though they may have the interest, to separate out different managed care products that are billboard rich and content poor. The physician executive on that side of it can help drill through some of that and better understand health care delivery systems and help identify those benefits.

The physician exec has another responsibility and that is not to allow a lot of inappropriate or poor excuses given by health care delivery systems for treatment failures. If the managed care organization made a lousy decision, it's often presented as if the physician had no other options In advocating for the patient, and that's simply not true. I can't speak for all managed care products, but I haven't seen one yet that tells the physician to give up their license,

Reinhardt: I think a lot of physician groups will probably try to take full risk, as Brown & Toland in San Francisco is already doing, and the real issue for physician executives is going to be to walk this tightrope. On the one hand, taking full risk means you have to manage the risk, but, on the other hand, you should not lose the sense of collegiality, because if this just becomes a structured hierarchy, then there is a great danger that people in the trenches will be disassociated from the generals.

There is also a danger that the customer, that is the patient, will see physician-driven delivery systems as just another form of HMO with the same motives, with the same focus on the bottom line, and that is in some sense worse than having an HMO. You expect insurance people to be commercially-oriented business people, but you don't expect doctors to be that way. You don't ever want to suspect that when you don't get an MRI, that [the cost of that MRI] somehow winds up as some doctor's hubcap on a luxury car. You want to think of the doctor as your friend who is somewhat disinterested in financial matters, as long as they get a half-way reasonable income. Managing organizations that project that image rather than the image of a doctor-driven delivery system which is just another insurance company, that'll be a really tricky job for physician executives. But that is what they'll be called upon to do in this world of provider service networks.

LeTourneau: I agree with you, Uwe. The role of physician executives is to walk that tightrope. Physicians who have provided clinical care and understand how to balance what the purchaser wants with what the patient/member wants are going to play a key role. That role uniquely confronts the physician executive who has knowledge in both areas.

Reinhardt: I always think of a well-run university as a model for doctors. Our executives are almost all former professors or people who still teach some, such as the dean of the faculty and the president of the university. And that really does matter, that they're one of us. Universities are run on a collegial model. We have conflicts of interest, but it works reasonably well. And it's amazing how much respect there is for people in the trenches, like I am, or the dean of the faculty who helps set my salary and so on, because we feel like colleagues when we meet. I don't really think of this guy as some alien creature in wing-tipped boots who is going to sell out Princeton, I think it is so important to create an atmosphere of collegiality that shows respect for that pediatrician who is out there slogging in the trenches.

The Physician Executive: How important is the Internet now in health and health care?

Holt: I've done some research on this and the answer is: Very, very important for a very, very few people. To give you an example, the Community Breast Health Project at Stanford Medical Center is very active on the Internet, tracking down different potential cures for breast cancer, patients and clinicians giving support to each other online in list-servs or in news groups. For some of the patients whom I've interviewed and had in focus groups, this is clearly a big part of their life and the major way they are focusing on their disease. For the rest of us, I don't think it makes that big an impact yet.

Rippen: Actually, it depends on what you mean by impact. If 25 percent of people over 16 are Internet users and if you believe the statistics that 43 percent of Internet users have retrieved medical information within the last year using specific health-type retrievers, and that three and one-half hours a month is the average Internet use but that health users access it every day, I agree that's a relatively small subset. This percentage is actually smaller than the percentage of physicians using the Internet,

With regard to the support function that the Internet plays, it can be extremely important for patients, for example, their chat rooms, especially with the chronic diseases that are difficult to cure, such as cancer. I know that many of you may have looked on the Internet for health information for loved ones that might have had a diagnosis. So I think for getting general information, it's fairly important, but as far as what does that have to do with impact on health, I don't think we have figured that out yet. There are a lot of people using it pretty intensively. The question is, relative to what and what's the impact. I'm not sure.

Weatherup: I think there are a fair number of both employers and health plans that are trying to harness the power of the Internet to replace some of the administrative functions and there's an opportunity for physicians to link into that. We're currently in a pilot right now, putting physician directories on the Internet for about 200 of the health plans that we participate in, The purpose is to help our enrollees identify physicians that participate in plans that we're telling them are good plans that are near them geographically and to provide information on the physicians beyond just what their name is, but also information on where they were trained, are they board certified, what gender, what languages do they speak, what office hours do they have. It's actually a key part of our strategy of helping people identify that managed care will work for them.

The Physician Executive: How is this qualitatively different from the more traditional approach of giving brochures to your employees?

Weatherup: We're attempting to integrate that information along with other consumer information. For instance, on the Web page where they can identify pediatricians in their area, there is also the option of reading an article about how to select a pediatrician. So, there's consumer education information integrated with a physician directory.

Larkin: Another probable evolution of the Internet beyond patients accessing medical or plan information is the increasing speed and availability of transmitting images which also may change the health care delivery system. For example, when a dermatologist in Pennsylvania can look at a presenting rash in Indianapolis almost immediately and consult. These Internet applications may change how health care is actually provided.

Holt: The Internet is a fantastic medium because it allows you to communicate between information systems that don't necessarily talk to each other, the legacy-type systems. All of a sudden you can do things like telemedicine and transfer information in secure ways. The key is we have to learn how to do it in the most effective, efficient way, and then also learn how to use it in all facets of the health care delivery systems.

LeTourneau: One area where the Internet is becoming important, and I'm not a big Internet user, but what I hear from docs is that every day at least one or two patients come in with vast reams of information that they've gotten off the Internet about experimental things and new therapies, expecting the physician to know about them and to advise them. Maybe as many as 25 percent of the people are using the Internet to get health care information and it's just starting.

Holt: Barb, can I give you some data on that? The Institute for the Future surveyed physicians earlier this year and I asked two questions. One, have you recommended to a patient that they go look? In the low 20 percent of physicians, maybe high teens, recommended that their patients go look on the Internet. The second question was how many of you have had patients who've come in with data, and over 70 percent of physicians had patients coming in with information from the Internet. This was back in March of 1997.

LeTourneau: This is getting to be a significant trend because it puts physicians at a disadvantage, especially primary care docs, and it slows them down. They don't get paid for this and it reduces their productivity. I'm not saying it's a bad trend, but I'm starting to see some hostility from physicians that patients come in with all this stuff off the Internet and none of it's pertinent information.

Weatherup: You know, while Internet technology provides this information to the patients, there's also push technology available that would help physicians sort through the mass of medical literature that comes out and actually have the topics they're interested in come straight to their computer so they can really stay on top of their areas.

Reinhardt: Actually, I'm on the board of such a company. They want to put computers in physicians offices, so, in the morning when the doctor comes in, the first thing he or she sees is what the patients are likely to have read in the daily papers today in case they bring it up, and then what should you have read to be ready for them. But I had not thought about Barbara's point that half-baked information really could slow physicians down. That had always been one of my problems with Larry Weed, that, on the one hand, this kind of computer-driven decision making makes a lot of sense, but you could also see it slowing up things where a physician's experience and intuition could just cut through a lot.

Holt: Well, Larry would say that you wouldn't have a physician doing most of it. You'd often have a less qualified person. But I want to add something else, which is that I actually think the most important thing that the Internet does is reduce communication costs and transaction costs. For the next few years, the most important thing that the Internet or other transaction mediums are going to do for physicians is deal with the business and administrative side. You're going to see either the Internet or other networks extending the ability of physicians to file claims, do referrals, do U.R., be on the phone with insurance companies and case managers, and all the rest of that--all the stuff that ruins their life at the moment and which they and their back office have to deal with. All of that will become automated fairly quickly, especially the more administrative tasks. A lot of that is being pushed by standards that were in the Kennedy-Kassebaum legislation and are going to be rolled out over the next year or two. That's not a glamorous area in terms of patient care, but I think that will change physicians' lives a great deal, and it's something that organizations should be right on the cutting edge of.

Rippen: I agree with you, but there's no reason why you can't make an intelligent system that can help do decision support, that can personalize information for health care providers and their patients. The issue Is that you have to understand how to use it.

The Physician Executive: Is there any evidence to show how significant a factor the Internet is in health and health care now?

Rippen: It depends on what you mean. There have been studies to show that Internet technology has improved the relative quality of health for people with chronic diseases because of the support group functionality of It. It's more for the oncology and HIV patients.

Holt: Did you see the story about the patient in China who had a complication and because of access to the Internet, thousands of physicians all over the world worked on the problem and got that information back to the physician in China? I wouldn't downplay the revolutionary impact of the Internet in individual cases.

Rippen: And If you start talking about disease outbreaks, especially when you had the Ebola virus issue, the epidemiological surveillance and the tracking was really done through an email, Internet type of a system. So there's been a beneficial impact on the public health aspects, too.

Larkin: Like many other organizations, we have an Internet site for diabetics and they can surely track a large number of hits and responses coming back to the company, either asking for additional information or expressing gratitude for the depth of knowledge. So on various disease states, the knowledge base is increasing due to the interaction of the Internet, which can be very contemporary with content.

Holt: What's happened so far is scratching the surface of what could be done if you combine two or three pieces. One is the community aspect of those with diseases which is now going on in these telecommunities. We know that people with strong social relationships and all the other things that go with that do better in their health.

We know, too, that the cost of video-conferencing or doing any of these other things used to be so high and the cost of going online is now coming down so fast that over the next five years it'll be almost free, not quite, but close, to put in Internet connections in the home. The devices themselves and the bandwidth will be much, much cheaper, and there's going to be improvement in access to technology from that.

And the third piece which we haven't really touched on yet, but is very, very important, is that for disease management and chronic care management, monitoring patients when they're well is the key to stopping them from getting sick. Greg, your company knows very well that diabetics, if they keep to their regimen and do the things they're supposed to do, stay basically okay. It's the ones who fall off that path who end up in the emergency room.

What the Internet and other communication devices are going to be able to do over the next five to 10 years is be attached to all kinds of sensors which are going to be attached to people. Sensors will be attached to their medicine chests, attached to their insulin to see whether they took it or not, and attached to these people themselves. We'll then really be figuring out what's going on with those individuals when they're at home. There will be an increased amount of tracking of all of that. Communicating via the Internet and other types of media is going to really change the way people think about managing the chronically ill.

Reinhardt: The way we do home care now is actually very primitive. We don't even check who these people are or if they have criminal backgrounds and they're invariably not well trained. When the parents of the fairly well-to-do layer of yuppies, whatever it is, 30, 40 percent of the population, are getting older, they may feel much more comfortable having machinery at home that constantly monitors their parents. I've seen such equipment already that feeds that information via the Net to a clinic or to a hospital and alerts them when intervention is necessary. I agree that home care will be totally changed by the Internet and whoever can grab that business, whether it's hospitals or medical clinics, is going to be well positioned.

The other thing that I always thought the Internet would do is globalize health care. Given that American physicians are ranked second to none, I think the U.S. is very well positioned to give medical advice to a lot of people all over the world, but I'm not enough of an expert to know how you charge for this. How could you make a living of it? American physicians are so damned good and the world needs them and what they know, so how could there be a surplus of them?

Rippen: Actually, they are using them in Saudi Arabia via telecommunications. All good medical centers have certain countries that they link to give them an expert opinion.

Reinhardt: It's already happening?

Rippen: Yes, but for countries that have money.

Reinhardt: I'm not expert enough on the economics of billing for that, but you could imagine a first rate physician who could spend half time attached to a clinic, but the rest of the day actually export health care advice for money all over the world.

The Physician Executive: Kaiser has some initiatives in that regard and the Mayo Clinic as well.

Reinhardt: I know Duke University does.

Rippen: And Hopkins does, too.

LeTourneau: But you know, I'm on the Minnesota Board of Medical Practice and Licensing Board and we are seeing around the country lots and lots of licensing boards concerned about the very thing that Uwe mentioned, not only for telemedicine but also for Internet connections, I mean, it's great If the worlds expert does that, but if one of the charlatans that can't make It in real practice does that, it's a real problem. So this is one of the problems that the Internet is raising, is how do we license people to do that, or should we, or how's that going to work?

Rippen: That addresses the whole issue of quality and how do you know what you're really getting, because anyone could have a Web site and if you're very sophisticated, you could link to a prestigious organization by just adding a few extra digits. I guess that will always be a problem. As far as licensing, there are methodologies that you can use to kind of stamp your page or your browsers, intelligent browsers that could select out certain sites.

But I think one of the other key concerns that you really need to think about too is the appropriate use of the technology and the appropriate gathering of information and what do you do with it. You can monitor patients at home and get their personal profiles when you're doing a health risk assessment, but the question is, who gets that data, and who has access to it, and what is it used for? There's a big responsibility. The government is only addressing specific areas, for example HIPAA [Health Insurance Portability and Accountability Act of 1996] which addresses only some areas of privacy, confidentiality and security. But all of these issues are going to have to be addressed.

Holt: I don't think that the issue of charlatans and confidentiality and all the rest of that is ever going to go away. It's been magnified somewhat by the Internet, but you are already seeing the emergence of self-organizing standards bodies in the financial industry and elsewhere. There's this E-Trust being run by the Electronic Frontier Foundation to try to guarantee that if you give your details over the Internet, your name won't be resold. It's a huge marketplace, but like any other marketplace, all the vendors have is consumer confidence in their product and, therefore, the best people and the best medical organizations and health care and delivery systems will establish these functions and command the same kind of brand confidence they have in real life.

Rippen: You have charlatans now, but they don't have the far-reaching effect where more people can be involved. Now they're in a defined geographic area where they can be held accountable in that area for their actions. whereas if you have a doc from Florida who's giving advice to someone down in Houston and that Florida physician makes a mistake and is not licensed in Houston, then how are you going to hold that doc accountable? That's a problem that you didn't have with the old-style charlatans that just were in one geographic area.

The Physician Executive: What about folks who don't have access to computers or the Internet?

Rippen: I'd say they're the same ones, unfortunately, that don't have access to health care in general.

Holt: This is a real problem now. PC ownership at home provides the best proxy for Internet access and 45 percent of Americans currently have a PC in their household. It's, of course, skewed dramatically. Seventy-five or 80 percent of those who've been to college have them, and probably only 15 to 20 percent of the elderly and those earning less than $15,000 a year.

So it is skewed the way you'd expect it to be skewed. But if you look at how many Americans have Nintendo machines in their household, color TV or telephones, it's basically everybody. Why? Because they're down to the price point where it's become an impulse purchase and anybody can afford it. But cheaper and cheaper computers are being developed, and if you plot out Moore's Law, which says that the price of computing is halved and the capacity doubled every 18 months, by the time you look five to 10 years out, I think this problem will almost be solved, so long as there's a killer entertainment application to run on It. People are not going to put computer equipment in their home for health care, but they will for entertainment.

LeTourneau: I think it's a big mistake to assume that just because people have a computer in their home that they're actually using it for the Internet. I have two computers and I never turn them on. I use one at work for the Internet and our company, but the baby boomers that don't use computers now are probably not likely to be using them to get health care information in the next 10 or 15 years. But I do think you're going to see It Increasing because the 20-somethings as they get older, they're going to use it as their source of information.

Holt: But, Barb, do you watch television?

LeTourneau: Very seldom.

Holt: You're too difficult, but most Americans watch a lot of TV, and some are spending more time on the Internet. And it's easy.

LeTourneau: But it's much easier to watch TV than it is to get on the Internet.

Holt: That's the problem now, but in five years you won't even recognize that problem.

Rippen: Actually, they're saying that the Internet is taking away from TV viewership.

Holt: For the Olympics. because NBC's doing such a lousy job! But go back five years. You had to be a computer scientist to get on the Internet. Now America Online signs up thousands of users a week.

LeTourneau: Now you just have to be 12 years old. If you're 48, it's still impossible.

Rippen: The key really will be what we're doing in the schools and which schools have computers and how people are trained. If you can train all the socioeconomic groups in getting used to using it, I think that would be the best way to overcome that issue.

Larkin: Well, even today's colleges are wiring dorm rooms for direct access.

Rippen: Yes, but that's already a skewed group.

The Physician Executive: What roles can physician executives play as the Internet intersects with health and health care?

Rippen: They need to get online.

Reinhardt: Keep abreast of it.

LeTourneau: Well, I know how to use email. It's as much as I need right now.

The Physician Executive: There seems to be a relatively low percentage of physicians using the Internet and that was reflected in what Matthew said earlier.

Holt: The other number from that report is that about 37 percent of physicians we surveyed said that they had used the Internet or some online service to look for generic clinical information, in other words to do a Medline search, and I think that number will go up.

Rippen: It was about 5 percent five years ago and now it's about 25 to 30 percent, depending on what surveys you want to refer to. The interesting thing, though, is that about 43 percent used the Internet for professional purposes and about 26 percent of them have other people use it on their behalf.

LeTourneau: That's what I was going to ask. How much of it is them personally using it or them asking someone to get the information for them on the Internet?

Rippen: I'd say half. And that's what makes it really interesting.

Larkin: Part of it is also going to be the age of the physician.

Rippen: Definitely.

The Physician Executive: Would that someone else be a nurse practitioner or a physician assistant?

Rippen: Anybody from a nurse ...

LeTourneau: Could be a librarian or a data analyst. There are lots of different people that would do that, I think the other thing you're going to find is big regional differences. In the Midwest or South there may be fewer people using the Internet than there are on the East Coast and the West Coast.

Rippen: The other thing that's interesting is in Medicine on the Net's article on physician trends, 9 percent of physicians have their own Web page and 22 percent of physicians plan to have one in the next 12 months.

Holt: I would think a very important role for physician executives of a medical group is to make sure that the organization is represented on the Web, both for marketing purposes and for ease of customer service. For instance, Kaiser Permanente Northwest Region and also in the Bay Area or Southern California is already starting to allow patients to book their own appointments over the Web. The whole customer service area could change very quickly. This is what has now made Charles Schwab a lot of money, and is going to continue to do so, and has killed full service retail brokerage houses. It's very easy to do.

But the other thing is that you are going to have to continue to educate and work with physicians in the trenches, as Uwe described, because they're going to need to realize that the world is changing around them with the use of the Internet by their patients and by their colleagues.

Reinhardt: But let me ask you, isn't it possible that as a patient, instead of having to call up and there may not be somebody there, I could email a query to a clinic and expect within an hour that some physician might get back to me with an answer? A thing like that could be staffed 24 hours.

Holt: And it will be.

Reinhardt: I remember when our first-born was about 18 months old, he developed an eye infection and when we called at five, the doctor said the office is closed and that was that. There was no advice from all the docs of Boston, And I never forgot that. It seems incredible that we can get any kind of information 24 hours a day, but not medical. If you're sick at eleven, unless it's the emergency room, there's really no way to get any kind of information. I could imagine physician executives having to worry about making medical advice from their institution available to patients 24 hours a day.

Rippen: I was going to say that there usually is someone on call. I hope you changed practices. There are places that are currently providing 24-hour response rates, but it's more ask-an-expert. And there's the issue of what is the practice of medicine. Are you practicing medicine answering a question, and is that really appropriate because do people really provide you with the appropriate information? And what are the liability risks associated with that? So I think it's kind of one of those dangerous lines to cross and it'll be interesting to see how It develops.

Larkin: You can kind of tie this back to the first half of this discussion when we talked about consumers and satisfaction and selecting physicians. The Internet, when appropriately applied, is very strong in communication and education, two areas that I think patients would say often that's what the delivery systems fail to do. When physician executives get their clinic or their organization on a Web site that improves communication and education, and with today's demographics. if the more desirable patients already have access to Internet, well, this Is one way to attract them.

The Physician Executive: Any closing thoughts on health care consumers or the Internet?

Reinhardt: Particularly the Net is somewhat futuristic. I think the issues about the consumers we were talking about are not so speculative...

Holt: I actually would disagree. I would say it's the other way around.

Reinhardt: Really?

Holt: I think that with the pace of technology change, if you go back five years, in early 1993 there was no Mosaic, there was no Netscape...

Rippen: No Java.

Halt: Java wasn't even thought of. I mean, in 1991, I used to read soccer results from England on the early news groups one line at a time. Now I can get all the English newspapers before my friends in London get them. I have them at four in the afternoon California time when they're published on the Net, while my friends are still in bed! If you think of that change and project that out another five, 10 years, things change quite dramatically.

My thought about the consumers is that although I think the new consumer, the younger baby boomer, more affluent consumer will change the whole health care system, they're not going to be really big health care utilizers for another 10 to 15 years, so that's probably a slower change. But my advice to physician executives would be that you've really got to be on top of both of these issues because either one of them, if it happened quicker than either Uwe thinks the Internet will or I think consumers will, either one of them could really change your lives very, very quickly, and not necessarily pleasantly.

Reinhardt: I agree with Matthew. I don't know how many conferences I've gone to that talk about consumer-driven health care, and I always have to laugh because I really think that it isn't really yet driven very much by consumers. The consumer, by and large, has stood by confused, perplexed, stunned by what was happening. I mean, my basic problem at Princeton always is to try to figure out who's insuring me today. There's always a new card. There's a new intermediary. You never really know what health plan you belong to anymore.

The other thing is that we don't really know what this Medicare Choice Plus will do, that was passed as part of the balanced budget act, where the elderly were given a lot more choices. In the past, the elderly, in a way, had free choice of doctors, but now they will really have to become active choosers of health insurance products and a lot of them are not Internet users. Some of them probably will ultimately be more active, but not at the moment. There will be a lot of frustration among the elderly in the next few years.

Rippen: One of the fastest growing segments of Internet users, according to some studies, is the elderly.

Reinhardt: Oh, really?

LeTourneau: At least the ones that can remember their password.

RELATED ARTICLE: HEALTH CARE EXPERTS WHO PARTICIPATED IN THE PANEL DISCUSSION

The following participated in Part 1 of this discussion, conducted on February 19,1998, via telephone conference call:

Matthew Holt is a Director with the Institute for the Future (IFTF). a nonprofit applied research and consulting firm in Menlo Park, California. His work at IFTF covers the finance and pro vision of health care and the applications of information technologies in health care settings.

Gregory N. Larkin, MD, ABFP, is Director of Corporate Health Services for Eli Lilly and Company in Indianapolis, Indiana. He is the Founder and Chairman of the Indiana Large Employers' Round Table Health Benefits group and represents Eli Lilly and Company on the Midwest Business Group on Health and the Washington Business Group on Health.

Barbara LeTourneau, MD, MBA, FACPE, is Vice President, Medical Affairs. North Region, of Allina Health System in Minneapolis, Minnesota, and President of the American College of Physician Executives.

Uwe Reinhardt, PhD, is James Madison Professor of Political Economy and Professor of Economics at Princeton University in Princeton, New Jersey.

Helga E. Rippen, MD, PhD, MPH, is Director and Co-founder of the Health Information Technology Institute in McLean, Virginia. She is currently leading the effort to develop an Internet-based tool to help consumers assess the quality of health information on the Internet.

Thomas G. Weatherup is Director of Health Care Initiatives at General Motors Corporation in Detroit, Michigan. He represents General Motors on the Foundation for Accountability (FAcct), the Midwest Business Group on Health, and the American Medical Association's American Medical Accreditation Program (AMAP).

Robert P. Carlson conceived and moderates these annual panel discussions. His articles appear in health care journals throughout the United States. He also provides marketing communications counsel to physician groups and other health care entities. He lives in Indianapolis and can be reached at 317/769-4609.