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You Can't Always Get What You Want

There's a refrain from a classic Rolling Stones song in the early 70s that says, "You can't always get what you want, but if you try sometime...you get what you need."

A nice thought, but is it true for the fractured world of modern American health care? "Consumer-driven care" is almost a mantra among the health futurists, who predict a coming age when health care expenditures are over 20 percent of the national gross domestic product, and people are able to customize a personal health care plan from a dazzling display of technologies, just-in-time services, and helpful e-health information at their fingertips.

Obviously these are consumers with money. Health futurists seldom talk about people without money. Economically speaking, they don't exist and are easy to ignore.

That pesky little problem aside, what do consumers want, and what do they really need?

• Over 75 percent of people want to see the doctor on the day they call. Many of them don't need to see a doctor at all.
  
  
• Americans want unlimited health care services, and they are used to having someone else pay for it. They need to pay for more of it themselves if market forces are ever to work.
  
  
• People want the latest and greatest drugs to improve their health. They need to change unhealthy habits and lifestyles that necessitate use of the drugs in the first place.
  
  
• People want immediate treatment for acute episodes. They need an integrated program of chronic disease management to reduce the level of acute episodes.

Not all wants and needs are out of whack. Seniors want to have care in their own homes, and they need it to avoid expensive inpatient services. Persons with serious mental illnesses don't want to be hospitalized, and with adequate community health resources, many of them wouldn't need to be. People want one-stop health care in an integrated setting instead of having to navigate a confusing array of specialty silos, and that's just what they need. If we're ever to have an effective and efficient health care system.

The problem here is confusing wants with needs. First dollar coverage and exotic care are like a drug: They're easy to take, addictive, and lead to an ever spiraling cycle of dependency. If the money for the fix ever runs out, millions will experience serious withdrawal symptoms.

But how do we break the bad habit of immediate gratification in an acute and episodic care world and get people to accept a better future payoff through more self care, preventive health and integrated disease management? It won't happen overnight, but here are a few ideas:

• Use consumer incentives. Take a chapter from the business world and "bribe" consumers with things like airline miles and calling cards to fill out health surveys, track their blood pressure, and so on. It's tacky, but it works.
  
  
• Involve businesses. Employers need to move from a model of health care as a cost to employee health as an asset. Health plans and providers need to provide more preventive and integrated care products to employers that they can push with their employees.
  
  
• Change the training model. The medical model is morphing into a service and management model. People coming out of medical, nursing, med tech and related training programs need to learn how to understand and influence human behavior in addition to being technically competent.
  
  
• Change the definitions and language. What we name something drives how we deal with it. "Units of care" does not begin to describe how both consumers and providers experience the "system," and is surely antithetical to a proper understanding of it.

Even with these and other efforts in play, there will still be those who get neither what they want nor what they need when it comes to basic health care. Another early Rolling Stones hit from the sixties has the right message when it comes to our responsibility to help those who truly need it: "Not Fade Away."