Of 266 metro areas studied by the Health Care Cost Institute, using 1.3 billion medical claims, only seven have hospital markets that qualify as genuinely competitive. New York. Los Angeles. Chicago. Riverside. Philadelphia. Miami. Washington, D.C. Everywhere else, patients in most service lines are not shopping. They are arriving. And healthcare built a decade of digital strategy on the premise that they were choosing.

That doesn't mean the premise was entirely wrong, and it doesn't mean the work was wasted. It means the consumerism frame that the industry borrowed from retail was always a partial fit, and the digital investments that had the most impact were often working for reasons the frame didn't quite describe. Insurance constrains patient options before anyone opens a browser. Crisis eliminates preference entirely. Specialist and complex care decisions follow referral patterns, not consumer shopping behavior. The "competitive market" that consumerism theory assumes exists reliably in about seven cities.

The friction-reduction work, though, was real and its effects are measurable. In June 2019, 10% of Americans had ever had a telehealth visit. Today 54% have, and 89% report satisfaction with their most recent virtual care experience. A 2025 access-to-care study found that 23.3% of patients who experienced appointment scheduling friction said it led to worsened health, and more than half switched providers. That work didn't succeed by winning a competitive fight. It succeeded by removing barriers that had always been there.

Chris Boyer and Reed Smith examine what the last decade of digital investment was actually accomplishing, where the consumerism frame helped and where it pointed the work in the wrong direction:

Why healthcare "choice" was always constrained by insurance networks, referral patterns and market structure, before anyone built a digital front door
What the friction-reduction work was actually doing, and why it had value the consumerism frame didn't fully explain
Price transparency as the case study for what happens when the wrong frame drives the deliverable
Why telehealth succeeded by removing access barriers rather than winning a consumer preference battle
What complexity management looks like as a forward frame, and why it applies to patients, staff and referring physicians equally

Price transparency is the sharpest example of the frame producing the wrong result. The CMS Hospital Price Transparency Rule was built on a consumerism premise: give patients price data, they will shop, prices will fall. As of November 2024, only 21% of hospitals were fully compliant with all requirements. The GAO found the published data so difficult to use that most stakeholders relied on third-party vendors just to make it parseable. The rule produced compliance behavior aimed at regulators. It did not produce a consumer tool. The frame predicted the wrong outcome.

If the work was never really about out-competing a rival health system, the question worth asking now is whether the experience built in most markets actually makes the complexity easier for the person who has no choice but to navigate it.

Mentions from the Show:

HCCI Health Cost Landscape, April 2026: https://healthcostinstitute.org/all-hcci-reports/what-is-the-health-cost-landscape/
AJMC / HCCI Healthy Marketplace Index: https://www.ajmc.com/view/nearly-75-of-us-hospital-markets-highly-concentrated-hcci-report-shows
Axios Future of Health Care Newsletter, April 2026: https://www.axios.com/newsletters/axios-future-of-health-care-ee174520-3387-11f1-8096-e7d285bf9bf6.html
Patient Rights Advocate, Seventh Semi-Annual Hospital Price Transparency Report, November 2024: https://www.paubox.com/blog/hospital-price-transparency-requirements-and-compliance-challenges
GAO-25-106995, Health Care Transparency, October 2024: https://www.gao.gov/products/gao-25-106995
Perficient Access to Care Research, 2025: https://blogs.perficient.com/2025/07/09/rethinking-access-to-care-maslow-and-transtheoretical-model-inform-smarter-digital-investments/
hims & hers National Survey / State of Telehealth 2025: https://www.dimins.com/blog/2025/04/03/the-state-of-telehealth-in-2025/
Press Ganey, Evolving Consumer Expectations in Healthcare, 2024: https://www.pressganey.com/hx-insights/the-evolving-expectations-of-todays-healthcare-consumer/
Commonwealth Fund, Consumer Choice in U.S. Health Care, 2021: https://www.commonwealthfund.org/publications/fund-reports/2021/nov/consumer-choice-us-health-care-using-insights-from-past
Reed Smith on LinkedIn: https://www.linkedin.com/in/reedtsmith/
Chris Boyer on LinkedIn: https://www.linkedin.com/in/chrisboyer/
Chris Boyer website: http://www.christopherboyer.com/
Chris Boyer on BlueSky: https://bsky.app/profile/chrisboyer.bsky.social

Reed Smith on BlueSky: https://bsky.app/profile/reedsmith.bsky.social

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TP483: The Market That Competition Forgot