Consumer Power Will Put HMOs, Physicians on Spot


Peter Lee, J.D.

Better-informed patients need not be a bane to other players in the health care industry. Interaction doesn’t have to be adversarial and should include the historical “have-nots.”

Four themes will continue to grow in importance as the shift to consumer and patient empowerment continues into the 21st century. Consumers will want more and better information so they can participate in decisions about their health care. Consumers need to be more directly engaged in the challenge of keeping medical costs in check. The calls for accountability will extend beyond health plans to individual doctors. And, there will be increased recognition of the necessity of addressing both the needs of the health consumer “haves” and the health consumer “have-nots.”

Informed consumers

Patients are walking into doctors’ offices with material from the Internet — this trend will grow in the years to come. Too often doctors roll their eyes when this happens and think, “Here we go again.” Other doctors say, “Great! Let’s see what you’ve got there and let’s talk about it.”

These situations should be seen as incredibly important opportunities for doctor-patient dialogue. Consumers will be more and more attentive to those they can trust.

Accountability issues

The push for accountability will go beyond the current array of legislative initiatives and consumers will increasingly ask whether they are getting quality health care. Patients will ask tough questions about the quality of their provider — not just of their health plans (they’re already moving beyond that) — but also of their individual doctors and the particular care being recommended. They will ask: “Is this the right care for me and is a person with the right qualifications recommending it?” That’s going to be an increasing source of friction.

Who pays?

Consumers are becoming more sophisticated, looking at when they pay as opposed to when their insurer pays, what’s out-of-pocket, what’s not out-of-pocket. But beyond understanding payment terms, consumers need to be better engaged in the coverage choices that may limit benefits.

Much of consumer concern about managed care has focused on the questions, “Who’s denying what, and what’s the basis of that denial?” They have wondered if a qualified physician is denying care because it truly isn’t medically necessary or an accountant is denying care as part of a health plan’s cost-cutting measure.


In the past five years, the so-called consumer-protection debate has included virtually no discussion of the issues of the health care have-nots — those who are uninsured, are underinsured, or have limited ability to understand the growing array of report cards (in the rare case where these individuals have a choice to make). The high rate of those without health insurance is a national embarrassment and represents thousands upon thousands of individual tragedies.

Hopefully we will get to some form of universal coverage through a variety of means. Beyond expanding coverage, a major challenge is how to respond, on the one hand, to the educated drivers of the health care system while not leaving behind patients who are less educated and assertive.

Peter Lee, J.D., is the executive director of the Center for Health Care Rights in Los Angeles.

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