By Marc A. Rodwin. Available online from the National Health Law Program website, http://www.healthlaw.org/pubs/2000rodwin.html
Markets don't work if providers are insensitive to consumer demand. The impact is obvious when the lights go out in California, less so when the provider is a health‐care organization. Yet the inability of managed care organizations (MCOs) in the USA to respond to consumer preferences and experience has profound implications for the quality and effectiveness of their services.
Marc Rodwin provides a clear analysis of the failure of MCOs to deliver accountability to individual consumers through the market. MCOs are insurance‐based providers that manage comprehensive packages of health‐care for large numbers of consumers. If individuals choose to transfer to an alternative provider (i.e. to `exit'), this tells their current MCO almost nothing about how they can prevent similar actions in the future.
Rodwin demonstrates that these large corporate providers effectively operate as public institutions. Participation in MCO plans is often not voluntary (as employers make this decision for all their employees); MCOs both ration and redistribute resources among their consumers, and they pursue a public purpose. Yet they remain private organizations with minimal public accountability: consumer `voice' is not formally established within their operation.
The choice between `exit' and `voice' is the starting point for this fascinating exploration of consumer influence on contemporary American health‐care management. `Voice' encompasses all the forms of direct consumer input to health‐care decision‐making, including complaints, protests and formal representation. Rodwin presents MCOs as the product of a complex history in which health‐care policy has veered between commitment to community participation and determined market economics. The result is arguably the worst of both worlds: unaccountable private institutions which fail to respond to consumer demand.
Rodwin argues that this impasse will not be overcome by trying to make the market work better or by legislating for patient rights, although both of these may help. His focus is on the opportunities within MCOs to increase patient voice, principally through formal processes of representation. He claims that if MCOs want to be successful in providing services which are tuned to their consumers' interests, they should involve consumer representatives in all aspects of their decision‐making. He goes on to describe in some detail the possible approaches to consumer representation in the context of American health‐care delivery.
I suspect that most of those who read this report will agree with the author's central assumption, i.e. that patient voice is good for health‐care decision‐making. However, although he makes an articulate case for the benefits to MCOs of listening to consumer views and involving consumers in decision‐making, it is far from watertight. He acknowledges that if consumer voice is to be an engine of change, this requires `shifting some authority from other groups with power', but does not explore how this may affect professional willingness to invest in mechanisms of representation. In practice, it is very hard to make a business case for consumer representation if there is no existing commitment to the principle of consumer involvement within an organization. Any business case must also be explicit about the risks and costs of consumer involvement, which Rodwin keeps to his penultimate page.
The other weakness of the report is its overwhelming focus on representation as the route to enabling consumer voice in MCOs. If an MCO wants to listen to the voices of its consumers in order to provide a more appropriate range of services, it can go about this in many other ways. Although surveys and focus groups are mentioned, these are seen as compromized by the lack of consumer control over their findings. However, there are a myriad of ways in which a health service provider can engage with patients and local communities to find out their interests and develop services in partnership. Representation is always about the consumer engaging on the terms of the provider. There is just as strong a case for the provider going out to the community and engaging with lay people on their own terms. Partnership with consumers and communities encompasses processes both of representation and of outreach.
Although this report is written with a very explicit focus on American health‐care delivery, the issues are likely to be relevant to any health economy where the impact of consumer preferences is at issue. The illustration on the front cover of British pound coins escaping from a pill bottle is not inappropriate: the dimensions of newly formed Primary Care Trusts (PCTs) in England are remarkably similar to those which Rodwin ascribes to MCOs. PCT members have much to learn from the experience of MCOs and will hopefully do so from this grounded and accessible report.