Patient v Payment Centric Healthcare Delivery

The Health Market Series 

Continuing observations on the nature of the US Healthcare market.

We know that the US health market is different, peculiar by world standards, and incomprehensibly complex. We know that it is difficult to understand as a market because the person receiving the care is not the same person directly paying for care. We have government regulation but the means of delivery are not owned by the government. 

Multi-party structures disrupt normal market information exchange about service definition, cost, and quality. The result is an endless and constantly changing set of definitions, rules and regulations, and third parties defining the experience. 

If healthcare was a sentence, “patient” would be the object and not the subject or the verb. Even if we substitute “person” or “consumer” for the patient, the way healthcare is delivered always makes the person receiving the service the object of action by somebody else. Given the asymmetry of knowledge, experience, and professional control structure, could it ever be otherwise? 

If we add the complexity of payment, we see the “patient-person-consumer” has limitations on what services are available, who delivers them, and under what conditions because what action is done is pre-determined by somebody, not the patient. What’s different is that there are many, many people and not a single source like the government. 

So far, the idea of healthcare as patient-centric seems far-fetched. Aspirational at best. A mere marketing concept. A feel-good-ism. 

A work of great influence on the understanding of health care delivery in our culture is the historical account rendered in The Social Transformation of American Medicine by Paul Starr, 1982. This book details how healthcare evolved in the US up to about 1980. It documents an evolution from profession-centric to institution-centric to corporate-centric, the dawn of the Healthcare Cartel and the medical-industrial complex. 

After 1980, one could add administrative-centric as DRG’s and other government programs began to drive what constitutes payment for defined services. The influence of government along with its corporate-sponsored large health plan distribution system can now be thought of as a payment-centric model of healthcare.

It has been often mused that even if someone had a cure for cancer, it couldn’t be used if it didn’t have a CPT code (government recognized payment code). No care happens without payment assurance. Assurance comes from somebody else and not the person who needs the service. 

Patient-centric, which so far in our history has never existed, is now reduced not to a definition or set of actions or shared authority or agency, but to a series of descriptors. 

In general, the descriptions are a series of attributes that focus on what a patient wants or needs…as interpreted by health professionals and delivered through a payment-centric system. But throw in “holistically” or “individualized” or “shared-decision making “and you get the picture.  

How could there be actual patient-centric healthcare? Through realigning the healthcare market such that the health service and the payment for the service occur between the same two parties. Like other markets. Where choice and accountability are distributed and shared. 

If patients had to pay directly for each service delivered then providers of service would begin to focus on patients in the same way any business focuses on delivering customer service. This is not the same as regulation-free healthcare, but it would cause more focus on patients-persons-consumers. And the power asymmetry between professional control structure and patients would become more equal. 

Changing the payment system for healthcare is not likely to happen in the US. We are talking about altering a $4 Trillion size ox. It is most likely that payment-centric healthcare will always dominate over patient-centric healthcare. 

But who knows? If knowledge is power, perhaps we will eventually see a change through distributed knowledge and greater transparency.

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