"Promoting Accountable
Managed Health Care:
The Potential Role for Consumer Voice"

Preface:
The Concept of Consumer Exit, Voice, and Representation

Market proponents believe that the best way to control health care spending and increase the availability and quality of services is to give consumers a choice among competing managed care organizations. For them, the engines driving change are financial incentives for individuals to shop for the health plan which offers the best value. If the performance of an organization declines, its customers or members will become dissatisfied, and their defections will signal the firm to clean up its act. In short consumers can express their dissatisfaction by exiting, purchasing their services elsewhere.

For Albert Hirschman, author of the classic, Exit, Voice, and Loyalty: Responses to Decline in Firms, Organizations and States, there are two choices: not just exit but voiceÑcomplaints, grievance, protests, and political pressures.1 Consumers may express their voice horizontally, among themselves and potential consumers, or vertically to authorities. They may express themselves individually or collectively. Voice takes many forms. Individuals can state their views when asked, complain, file grievances, protest, bargain collectively, participate in organizational governance, appeal to higher authority, or become active in politics. They may express their concerns to physicians, managers, policymakers or influential outsidersÑsuch as the press or activists-who may take up their cause. Voice can be exercised episodically as special circumstances arise, or continuously through established consultative mechanisms. Sometimes exit and voice reinforce each other, while at other times they may be at cross-purposes. Each has strengths and limitations. Exit, for example, sends a powerful signal that something is wrong, but reveals little or none of the information that voice can provide about the problem or possible remedies.2

Individuals can express their voice by participating in decision-making. At its fullest, participation can mean consumer or citizen control.3 It may also be something less, such as delegated power in a specified area or a partnership between producers and consumers. Participation can also be merely a device for informing those who make decisions, a form of consultation. Organizations can also use token participation as a means of co-optation or manipulation.

Most individuals don't have the time to participate in decision-making or to express their voice on every issue that arises. However, their views or interests can be represented by an intermediary that speaks or acts for the groups they represent.4 How the views of the consuming public are best represented is a major challenge in making voice effective.

One can distinguish three different kinds of representation: (1) Formal Representation, the institutional mechanisms by which representatives are selected and controlled5; (2) Substantive Representation, the process of acting in the interests of constituencies; and (3) Descriptive Representation, choosing representatives to mirror the represented group's ethnic or social makeup or other characteristics.

Consumer representatives can play various roles. These range from directing or controlling policy, exercising delegated power for defined tasks, being a partner with producers, providing advice, or participating without power as a token or symbolic gesture.6 | next | notes |

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