In recent years, one of the prevailing schools of thought in health-care reform has been to put consumers more in charge of their health care.

This "consumer driven" approach has slowly crept into Medicare under the guise of Medicare Advantage Plans (the managed care option, known as Part C) and the Medicare Prescription Drug Plans (Part D) that give beneficiaries a choice of discount drug providers.

The basic philosophy behind this would-be enlightened consumer empowerment is that each person, not the government, is better able to make decisions on the quantity and quality of health care received. In the aggregate, the reasoning goes, millions so empowered will choose less expensive goods and services, thus lowering the overall costs of care. While that sounds like a salient political slogan, in reality it's troubling.

Such was the thinking behind high-deductible medical plans that were paired with tax-sheltered health savings accounts (HSAs), which were introduced more than a decade ago. Economists at the time believed that by giving consumers the ability to fund their own HSAs, and receive a tax break for doing so, they would spend wisely and not overuse health services.

While it's not known if HSAs produced significant savings overall, the philosophy lives in the form of self-directed Medicare reform approaches. Instead of the fee-for-service model, the self-directed model would give beneficiaries a lump sum or voucher to buy their own health insurance. Would it save the government and beneficiaries money? That is currently an unknown. It was such a charged issue during the presidential politics in the last-election cycle that it hasn't been discussed much lately, although count on it to resurface.

David Rothman, Ph.D., a professor who teaches social medicine and the history of medicine at the Mailman School of Public Health at Columbia University, convened focus groups last year that asked some basic questions about American attitudes toward various health care reforms, and the answers may have telling implications for Medicare.

In a Feb. 5 blog post for Health Affairs, Rothman details some of the conflicts between consumer perceptions and reality. Based on focus group evaluations in Chicago, New York and Atlanta, here are some of the key findings:

• People want to take more responsibility for their care. "Although participants generally trusted their doctors, they recognized that physicians were often under time constraints and might well have financial ties with drug and device companies. Participants did not want to directly challenge medical authority but felt obliged to verify for themselves the wisdom of proposed tests, drugs, and treatments."
• Internet research for better-informed health care decisions may not be the best route. They consulted websites as "WebMD, the Mayo Clinic, and Consumer Reports. They knew very little about the sponsors of these sites; for example, they were unaware that WebMD was a for-profit company that received substantial revenue from the drug and device industry."
• They were generally in favor of more testing as opposed to less. "Whether the procedure involved standard blood tests, EKGs, mammograms or PSA screening, it was always preferable to be tested. When we presented them with counter-arguments— including a high rate of false positives and unnecessary biopsies and anxiety— they were unimpressed.  From their perspective, getting a false positive result was a matter of getting good news the second time round."
• Direct-to-consumer drug advertising made them suspicious. "They distrusted pharmaceutical companies, speculating that their doctors had been induced to prescribe more drugs, or were receiving kickbacks. Surprisingly, Direct-to-Consumer advertising reinforced their negative attitudes: the long list of possible side effects in newspaper and television advertising overwhelmed the promises of benefits."

Rothman concludes, "(W)e need to explore the types of public messages likely to prove effective and the optimal methods for delivering them. The medium matters. It may be better to give consumers the opportunity to delve into the data themselves rather than rely solely on press stories."

Rothman's study is not a rigorous survey of attitudes—focus groups often simply reinforce what researchers already know—and it avoided asking some of the most pressing ethical questions when examining the consumer-driven model.

Some of these include: How is it possible for consumers to even evaluate a plethora of studies on a given drug or procedure? Is more information necessarily better? Even if someone has vetted the leading chemotherapies, for example, how do they know how they’ll react to the side effects? As someone who personally has known more than a half-dozen people with cancer, that's not a question anyone will ever be able to answer.

All too often, as the consumer-driven argument advances, the idea of a greater volume of consumer information is conflated with better decision-making or lowered costs.

While anyone can look up anything concerning medical treatments or drugs online, the sheer complexity of the information is daunting. Do most people know the difference between "controlled" and "double-blind" studies? Are they in a position to evaluate some of the (now-disclosed) conflicts between researchers and the corporations funding them? What's a good way of verifying whether someone is getting the best possible treatment at the lowest cost?

It may very well be that the consumer-driven model will be inadequate when it comes to informing future beneficiaries of every aspect of treatment. It's too much to ask of average health care consumers to understand scientific method, the limits of medical science and the tremendous economic pressures behind certain drugs and treatments. 

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