Achieving the Promise of Consumer Empowerment in Health Care

This is the last issue of the journal's 40th year. In the past year, we've focused on what are, for me, many of the major issues confronting the health care system: the slow but steady movement to paying for better outcomes (volume 39; number 2); the evolving role of electronic medical records in our health system (volume 40; number 1); the needed shifts in the patient-centered medical home (volume 40; number 2); the dramatic changes in the health professions in the lifetime of the journal (volume 40; number 3). The last issue in this 40th year culminates in what is for me the most important issue-the role of consumers. It is a challenge that the entire American population is confronting at this time.

I am lucky to wear several hats. In addition to editorial responsibilities at the Journal of Ambulatory Care Management, I am lucky to have worked in a very modest way on health care policy legislation/rule-making, am a health services researcher, and am a practicing physician-and I still don't get it. In fact, there is a lot that I don't get about our health care system.

I came to understand a long time ago that a substantial (not a majority, mind you) of Americans do not believe that all American citizens should have access to a basic set of health services. To convince the vast majority of Americans to accept this proposition of access to basic health care, political leadership still has not been able to successfully articulate the case in a clear and effective manner. Why not? I just don't get it.

In addition, despite the evidence going back decades to the contrary, some political leaders are fixated on high-deductible health plans that do not discriminate between services that are shown to be of value. Why can't we somehow come to an agreement-across the political divides-to make sure that diabetic patients who are taking insulin and have health insurance get their insulin for free? Why can't we come to an understanding that the politicians in this country do not countenance, as people like Senator Cruz are currently doing, the selling of health insurance plan that pays up to a small amount a day for hospitalizations and/or expensive medication. I still don't get it.

I've worked for 3M Corporation for almost 30 years. I appreciated David Lansky's historical articulation of the move toward consumer-directed health plans and the role of employers in this important shift. I agree with David's comment that consumers need to look at the financial and clinical sides of patient engagement. However, in general, I've never seen employer's being fundamentally interested in anything but the financial side of consumer engagement-for a very simple reason. As the head of benefits for a major airline told me years ago, we are in the airline business not the health care business. Why aren't employers more involved? I just don't get it.

I've been a practicing physician for more than 40 years. All my patients have my cell phone number ... and some still go to the emergency department for what I consider to be minor problems. Yet, I am a passionate believer in the measurement of consumer activation/empowerment. We know that empowered consumers have better clinical outcomes and cost less. But yet Medicare, Medicaid, and private health insurance plans do not incentize medical practices and health systems to improve consumer empowerment. I still don't get it.

I've been a health services researcher for 40 years. I believe that we in the health services research community have done consumer movement a fundamental disservice in our work for national accreditation organizations such as the National Quality Forum (NQF) and many others. The NQF endorses and other organizations require hundreds and hundreds of measures-instead of insisting that organizations need only a small number of outcomes measures. Such a movement toward a focus on fewer than 10 outcomes measures would make it immeasurably easier for consumers to be engaged with both the clinical and financial sides of engagement. I still don't get it.

That said, I am the eternal optimist. I never give up; I have no choice. This issue of the journal culminates our 40th anniversary year. The focus of this issue on the many differing possible visions for consumer engagement, activation, or empowerment highlights what I believe is our only hope. We need a relentless focus on improving consumer engagement-both for the individual's own health and, just as importantly, for the joint effort by consumers to eliminate waste and improve outcomes. Hopefully, the consumer empowerment movement will look back to this issue of the journal as a helpful contribution to the dream of consumer empowerment in health care-both on the individual and political ends-which has only just begun to achieve its promise.

The remainder of this issue of the journal highlights equally important topics including both community health centers and the dramatic efforts to reform our health care system in Oregon (Kautz et al); the evolving roles of community health workers (Reinschmidt); electronic medical records (Morgan); cost accounting for the patient-centered medical home (Lieberthal); and measurement issues in ambulatory care (Morgan).

-Norbert I. Goldfield, MD

Editor