Welcome to part three of the Chasing the Essence of Healthcare series. Having discussed the two facts at the foundation of healthcare, it is now time to look at healthcare from the eyes of the patient. In the following essay, I will explain the particularities of the patient’s needs and how healthcare systems try to come to grips with those needs.
Healthcare is about discomfort
Let’s start by acknowledging that people don’t generally wake up and think to themselves, Oh, I miss visiting my doctor, I should go there soon, and nor would they say, It’s been awhile since I have been to the hospital, I should add that to my bucket list for this year. We look forward to visiting family and friends, going shopping, watching a movie, and we dream about houses, cars, wedding parties, and trips, but healthcare is not something we long for.
As a general rule, feeling of discomfort must exist in order for a patient to visit or communicate with a healthcare institution. Discomfort, being a trigger for the patient to have contact with healthcare can be seen in two ways: the patient either experiences a tangible discomfort (like pain, disability, or mental health issuesI consider to be tangible the psychological discomfort that may come from a hard life episode (e.g. war, abusive relationship, etc). Despite our poor understanding of the brain, it seems pretty clear that our mind and body are one.
) or fears discomfort in the future (the chance of having pain).
Therefore, healthcare seems to exist to alleviate the patient’s discomfort. As a direct consequence, the reasons a patient buys healthcare are to restore the well-functioning of mind and body or to get peace of mind that one is protected against negative events that could happen down the roadFor example, scheduling preventative visits can be seen as a deliberate action to avoid discomfort, and thus peace of mind.
The patient is helpless and uncertain
In part two of this series, we discussed the two main facts at the foundation of healthcare: (1) the enormous value attributed to human life and (2) many diseases are still unsolved problems. What happens when these two facts meet with the patient’s discomfort that we have just discussed?
Remember the big pile of tangled wires and the goal of untangling them all? We have already separated two wires, the foundational facts, and now we have separated another, the patient’s discomfort. Throughout this series, we will continue to identify more wires and make their connections clearer.
I believe that there are four elements, all stemming from the two fundamental facts and the patient’s discomfort, that define the patient’s needs. As a consequence, it is these four elements that shape any healthcare system too. But before diving into the healthcare system, let’s first understand the elements I put forward.
For convenience, I will refer to them going forward as the four elements shaping the patient’s needs, and I have highlighted them in bold in the figure below:
When looking at four elements in the diagram, what grabs your attention? The patient’s needs are shaped by helplessness and various kinds of uncertainties.
Let’s address them one by one:
Uncertainty as to when – the moment in time in which the patient may need healthcare is largely unpredictableScheduled preventive visits do remove some element of the unpredictability, but not completely. There is no way to know if something will be detected in an exam with a doctor.
Chance of relevant losses – by definition, if the patient is in need of healthcare, his or her “ability of functioning well” (or living at all) is under assault and can be lost. Since life is considered highly valuable, there are chances of relevant losses for patients themselves and also for their loved ones.
Helplessness without others – patients are unable to solve most of their healthcare needs by themselves. Even if they are technically competent (say, they are doctors themselves), they often are hindered by a physical and or psychological condition (remember: discomfort). They may also depend on specific equipment only available at certain locations (e.g. sterilized material found in hospitals).
Uncertainty about success – it is clear that many diseases have no reliable cure. Even in the case that the perfect intervention is well known for the patient, there is always a chance that something could go wrong (e.g. acting too late, human misjudgments, etc).
Having understood how the patient’s needs are shaped by these four elements, let’s move in to the healthcare system itself now.
The dependable expert and the risk bearer enter the scene
Healthcare materializes itself through physicians, hospitals, health insurers, pharmaceutical companies, etc. If the patient is the ultimate beneficiary of healthcare, then it should follow that the healthcare system exists in its current form as a way to “address” the patient needs.
But how does one go from the patient’s needs to these healthcare institutions?
I believe the four elements shaping the patient’s needs help take us there:
Dependable expert? Risk bearer? These names may sound a bit odd at first, but, trust me, they actually are quite descriptive titles for the two most fundamental healthcare institutions (can you guess who they are?). I coined these names on purpose because, as you will see, they will help uncover what exactly makes the two institutions special.
The dependable expert helps the patient overcome the discomfort and reduce the chances of future discomfort. It’s a role played, of course, by physicians and related professions. The dependable expert is obviously deeply connected to the patient’s helplessness without others. In fact, most of the time it is the “others” that come to help.
A risk bearer is someone who takes on risk from somebody else. In the context of healthcare this means someone who helps the patient cope with the chance of relevant losses and the uncertainty as to when the losses could happen. In practice, the risk bearer is either a private health insurance company (for most Americans and many Brazilians) or the government itself (as usual in many countries with universal public care). The risk bearer is, in other words, the institution that plays the role of an insurer in any given healthcare system.
This thing called insurance consists in two parties (the insurer and the insured) making a seemingly magical exchange: the insured trade the chance of a large financial loss to the certainty of making a more affordable payment to the insurer. The risk bearer therefore helps to make the financial sideNote that I am explicitly using the term financial side of risk. There are other sides to any healthcare-related loss, especially emotional ones that are not insurable. What is insured in healthcare are the financial costs of treating a disease.
of the patient’s risk more manageable via insurance.
In many ways, health insurance lightens the burden of uncertainty of the patient by making the healthcare risk more affordable and predictable. But because there is no free lunch, such arrangement does not come without its own trade-offs and dilemmas, which we will explore in an upcoming essay.
Where are we going from here?
Needs that are triggered by discomfort, needs that make the patient helpless without others, and needs that are surrounded by pervasive uncertainties. From anywhere you look at it, healthcare does stand out.
I have just started revealing the nature of the system that exists to help the patient with his or her healthcare needs. If we are to really comprehend the essence of healthcare, there are more wires to untangle.
In the next two essays, I will examine the mechanics of:
- the rather unique patient-physician relationship
- the dilemmas and asymmetries of health insurance
Talk to you soon!
- Why bother?
- Precious creatures, unsolved problems, and morality
- What does the patient need? (you are here!)
- … (soon)
Chasing the Essence of Healthcare is a series of essays where I try to deconstruct the complexity of healthcare systems into a few distilled fundamentals.
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