A paradigm shift: from doctor–patient to payer–patient relationship

INTRODUCTION

Before the Second World War most individuals had a physician who was responsible for their health from cradle to grave. I don’t want to idealise that situation but there is no doubt that the relationship was a private interaction based on trust. In the past, the payer used to be the patient and the relationship was clear; now we pay indirectly. The payer may be the government through a mixture of taxes, employer contributions, and national insurance, or they may be an insurance company or a health maintenance organisation.

In the brave new world after the Second World War many countries developed models of universal health coverage. The benefits of universal health coverage for the citizens were explicit and defined in the Bismarck model;¹ they were vague and implicit in the Beveridge model.² However, this did not much matter because modern medicine was in its infancy, the populations were younger, and medical technologies relatively cheap. There was no mention or thought given to quality of care provided, the assumption being that the physicians would do their best. In most people’s minds health was simply the absence of illness.

The increasing costs of new technologies³ and the ageing population have made the promises of full universal health care very challenging as the payers collect data in their effort …