It is unclear if, left to their own devices, the providers who run health systems would aim to promote or restrict patient empowerment. While all health-care systems strive for the good of their constituents, it has been recognized that paternalism has dominated the practice of medicine (i.e., physicians ‘care for’ patients rather than provide clients a service). While a number of health systems have attempted to promote consumer rights and patient-centered medicine, these are potentially a reaction to external pressures from patient groups calling for patients’ rights, as well as financial pressures from increased health-care consumerism, health tourism, and competition between providers. Again antecedents and barriers that support/limit the health-care system’s role in patient empowerment have been identified in the literature, as well as potential outcomes of patient empowerment on the health-care system.
Health System Antecedents
Regardless of how paternalistic or patient-centered health-care systems may set out to be, there are a number of antecedents that promote an atmosphere of patient empowerment within the health-care system: technology and innovation, competition, and clinician initiative and leadership. Arguably, technological change has done more to empower patients in the past 30 years than any other factor. Not only do we have new treatments, and even cures, for many diseases, but through innovation patients now need to spend less time in the hospital, have better access to information (especially through the Internet), and play an increased role in their own care. Competition drives innovation, whether it is promoted by way of professional, academic, or financial motives. By attempting to reach a larger customer base, physicians, hospitals, insurers, and industry have to provide products and services that patients deem beneficial. Finally, through the leadership of clinicians (especially nurses, social workers, and a limited number of physicians), health-care systems are changing to become more patient friendly. For example, the Institute of Medicine has been a major promoter of patient-centered care in the United States, and, at the micro and mesolevels, physicians, nurses, and other health-care professionals have, and will continue to play, an important role in the empowerment of patients. While patient-centered care is not new, some of the interest in patient-centered care, especially in the United States, can be seen as a backlash to the ‘financial-centered care’ approaches of managed care or reaction against health-care rationing in countries with national health systems with finite resources.
Health System Barriers
From a social justice perspective, health care is widely considered as a special good. Health care is also a complex good in that there is a great deal of uncertainty surrounding it. Limited resources for health care and substantial variations in care quality have led to government involvement in the financing and delivery of health care to ration and redistribute health care equitably. Rationing is often based on egalitarian principles, so that most people can afford health care as a means to function in society, or as a right. However, this perspective is often manifested as a form of paternalism instead of a respect for individual patient values and preferences. The historical development behind public provision, regulation, and financing of health care has often resulted in systems that impose barriers for patient empowerment in the health-care system such as inertia in work practices (especially in government bureaucracy), legal constraints, and financing by third-party payers.
Health care in any country is delivered (and in certain cases, financed) by a nexus of autonomous and semiautonomous agencies, spanning a range a professional and even cultural barriers, and thus pervaded by inertia. This is complicated by the traditional approach to medicine predominantly based on expert opinion and clinical judgment; thus care practices established over time have strongly influenced regulations, the role of professional societies, and governing agencies. Such an entrenchment of institutions/work practices – understood here as the customary ways, working rules, and legal regulations that shape and pattern behavior – in turn provides a context that explains the political and legal constraints to empowerment. For example, health reforms in many countries have encountered resistance to changes in medicine – a type of stickiness or path dependence – resulting in incremental reforms dominating the landscape of health policy making. Reliance on third-party payers or insurers can similarly inhibit empowerment as manifested by the development and spread of managed care financing approaches that insulate patients from decisions about health-care purchases. These three types of barriers may impede patient empowerment and perpetuate the current paternalist culture in medicine.
In the name of cost efficiency, choices are made on behalf of the patient. Choices available to the patient are purposely restricted both in terms of the range of providers available and the level of health care that can be consumed. The development of health technology assessment agencies aimed at promoting cost effectiveness, efficiency, and value of health care similarly have the potential to perpetuate medical paternalism and ignore the values of the patient through technically oriented evaluations and assessments, especially if they are restricted to the financial need of payers. In recognition, there is currently a movement to make these systems of evaluation more patient-centered, by explicitly assessing patient satisfaction with care and patients’ involvement in care, eliciting patient preferences about care and desired health outcomes to support shared and informed decision making, so that a dialogue is opened up between the health-care system and patients, expanding patient choice and patient involvement.
Health System Outcomes
The benefits of patient empowerment are not limited to the patient, but can affect health-care providers and the health-care system in positive ways, especially through increased respect for patients, increased adherence, and cost savings. As mentioned earlier, the active involvement of the patient has important consequences not just at the micro level (the patient’s own health) but at the macro level as well in terms of successful public health efforts to improve health and achieve cost savings from effective programs. A major outcome of patient empowerment in the health system will relate to how patients are viewed. If patients are perceived as co-equals with health-care providers, then they will be treated in a manner that respects their unique needs, individual priorities, and personal well-being. Recognizing the individuality of every patient may lead to greater support from patients in their treatment plan – a mutually agreed to regimen. This may represent an ideal model of care given the high prevalence of poor treatment adherence, limiting ability to achieve therapeutic goals as well as the efficient use of resources. Cost savings can be generated from a decrease in the duplication and misuse of services, a reduction in hospitalization rates in favor of outpatient services, and an increase in the use of efficacious and acceptable medical regimens.
Conclusions
While many of the processes supporting patient empowerment have been occurring through patient advocacy, facilitated though professional encouragement by some key clinicians, the path to widespread patient empowerment will require significant health system reforms. These system reforms need to institutionalize empowerment concepts, approaches, and processes, as well as to correct power imbalances in the system. Such reforms will need to challenge existing power structures, especially the dominance of the physician. Further, such reforms will challenge existing systems of health-care financing, particularly the paternalistic national, social solidarity systems that emerged over the twentieth century. Healthcare reforms will also be needed to transfer a greater degree of control to patients over their own health care. These include giving insured individuals greater choice in selecting treatments, level of premium payments, and user-fees. An example worth noting in this regard is Switzerland, which is regarded as a model of consumer-driven health care (CDHC). Switzerland reformed what was essentially a mosaic of 26 unique health-care systems into one healthcare system through the Health Insurance Law, which took effect in 1996. From voluntary coverage, the reform made compulsory the purchase of health insurance coverage by households and redefined solidarity in the context of calculated premiums and premium subsidies. From risk related premiums prior to 1996, premiums are community rated while subsidies of health insurance premiums are means-tested.
Another example can be found in the Netherlands, which replaced its system of compulsory health funds and private health-care insurance with a single statutory regime anchored in individual choice and responsibility beginning in 2006. Under the new system, every resident has the choice of insurer and policy, including a replacement scheme in the form of a health savings account for conscientious objectors (i.e., people who are opposed to insurance in principle). Like Switzerland, individuals in the Netherlands are free to choose the level of out-of-pocket costs that they are willing and/or able to bear.