The "information rx"

In October 2007, Zagat Survey LLC, the company long known for its popular restaurant and hotel guides, announced a new venture: a Zagat's guide to doctors. In collaboration with WellPoint Inc., the nation's largest health insurance company, Zagat began in January 2008 to do online surveys with select patients. Following the same format developed for its other guides, Zagat's collected information about patients' satisfaction with their physicians on four criteria- trust, communication, availability, and office environment-and used them to rank doctors on a thirty-point scale. As Nina Zagat, the company's co-founder, explained, "With this tool, WellPoint is helping to give consumers the power to make smart decisions about selecting doctors based on other people's experiences." Eric Fennel, WellPoint's vice president of consumer innovation, echoed her enthusiasm, saying that such "peer-to-peer information" constituted "the missing piece of information needed to engage consumers" and provided a much needed adjunct to the "clinical and cost information" that the company already provided its enrollees. ₁ Zagat's entry into the doctor rating field prompted a range of responses from the amused to the skeptical. "Would you like dessert with your diagnosis?" one headline read, while another announced "the time is coming when you can pick up the 'burgundy bible' to find the best restaurant in town, and then search a similar guide to find a gastroenterologist to treat the possible stomach ache afterwards." Not surprisingly, physician reaction to rankings based on patient satisfaction was at best lukewarm. The response from James King, the president of the American Academy of Family Physicians, was typical: He warned that "choosing a physician only according to consumer ratings can deprive patients of high quality medical care, particularly if those ratings are based on unrecognized and unvoiced anger or unjustified allegiance."₂ But in spite of such warnings, the enthusiasm for consumer-oriented rankings, report cards, and other information tools reflected in the Zagat's guide seems here to stay in the United States. Besides the Zagat/WellPoint survey, patients can now go online to sites such as Rate MD.com, Vitals.com, and DrScore.com to share their opinions about specific doctors. These so called peer-to-peer evaluations join a field already crowded by other types of information sources intended to help patients make better choices. Some focus on therapeutic issues (is this the best treatment or hospital for me?); others concentrate on cost effectiveness (is this the most economical use of my health care dollar?) While measuring very different phenomena-subjective measures of trust as well as seemingly more objective measures of therapeutic success or fiscal prudence-these consumer information sources all purport to be a more neutral, reliable sort of information than the paltry sources available to patients in the past. In tandem with similar efforts aimed at better assessing physician performance through supposedly objective measures of quality and cost effectiveness, better forms of information technology are frequently hailed as a promising new direction in health care reform. As USA Today observed in a 2008 article on the Zagat/Wellpoint venture, "medicine is just the latest profession to feel the Internet's power to gather information and disseminate it to consumers hungry for the best service or value, and it's going to have to adapt as the others did."₃ Underlying faith in this "information Rx"-that is, the belief that providing more and better information to individual consumers can reform the American health care system-is the related assumption that the health care market needs to become more like other aspects of the American economy. If only consumers had access to the same quantity and quality of information available for goods such as appliances or automobiles, so the argument goes, they could be a powerful force for improvement in health care. As one commentator put it, "if Zagat's can rate Chinese restaurants and Greek tavernas, and Consumer Reports can rate skateboards and digital cameras, why can't we rate doctors?" With better information about physicians, hospitals, and insurance plans, Regina Herzlinger, Michael L. Millenson, and others have argued, consumers will reward the good and avoid the bad, thereby turning the power of individual choice into a powerful tool of change.₄ This conception of an information-driven consumer health "revolution" exemplifies two important trends of the last forty years: the reliance on market forces to reform an ailing health care system and the enthusiasm for computerassisted information technologies, including but by no means limited to the Internet. The proliferation of decision making tools nowadays offered the affluent American patient/consumer illustrates the strong faith in what art historian Theodore Roszak has referred to as the "godword" of information, a once "nondescript word rarely used for anything more exalted than requesting a telephone number ('Information, please')" that in his words now enjoys "the mystique once reserved for Reason, Faith, [and] Grace."₅ The information Rx, as well as the larger field of quality assessment upon which it rests, has gained this exalted status for many reasons. The idea of the informed patient/consumer reflects a venerable American tradition of relying on individual education as a tool of personal and collective change. Informed patient choice seemingly applies to medicine the same processes that have worked to improve other sectors of the American economy over the last century. The emphasis on individual preference is particularly well suited to the decentralized, "marketized" health care system that has evolved in the United States since the 1970s. Last, but not least, more and better consumer information is one of the few policy goals on which liberals and conservatives have consistently been able to agree since the 1970s.₆ The political appeal and ideological expediency of the information Rx makes it all the more difficult to question its value. Yet question it we must, for informed policy discussion requires taking a long hard look at its utility. Other chapters in this volume ask hard questions about the implications of new information technologies for physicians and other health care decision makers. This chapter focuses on the perceived link between consumer empowerment and information access. My intention here is not to discredit the idea that consumers deserve good information, a principle that it is hard to dispute, but rather to raise more basic questions about what constitutes "good" information, in the hope of encouraging a more realistic appreciation of what the consumer information Rx can-and cannot-accomplish. My argument here employs what, at first glance, may seem like an irrelevant or inappropriate methodology, namely historical analysis. One of the most common assumptions about the modern information revolution is that it is without historical precedent. The Zagat's guide, and all it represents (e.g., patients using the Internet, consumers "driving" the health care market) are invariably presented as the innovation without precedent, the "something new under the sun," that has no history. To the historian (or at least this historian) that kind of claim is like catnip to a cat, or red meat to a dog: it is an assertion that begs for contradiction. Hence the purpose of this chapter is to sketch the history of buying guides, report cards, and other rating devices aimed at patient/consumers. It attempts to put the brave new world of the modern health consumer exemplified by the Zagat's guide, and its many competitors and imitators, into long range historical perspective. By tracing the evolution of arguments linking consumer empowerment with new information technology, I hope to accomplish three goals: first, to counter simplistic historical narratives that overemphasize the role of the Internet as the starting point of such developments; second, to complicate the meaning of "consumer information" as a keyword frequently invoked in health policy debates; and third, to highlight the changing, often contradictory meanings of expertise and the question of who "owns" it, as they have evolved over the last half century. As we shall see, the "information Rx" has been not unlike the modern prescription drug: highly effective in correcting an underlying pathology, but accompanied by unexpected side effects. A better understanding of its benefits and risks may help to improve the next generation of remedies.