I read a lot of articles about consumerism and how employees need to be better consumers. And as one who implements technology I am very familiar with most of the decision support tools in the market and all the online symptom checkers. So let me make a bold statement. It is all garbage. I have always thought that individuals will never have enough knowledge to make educated health care decisions. Health care is too complex and always changing so how am I ever going to have the time to keep my knowledge current. I don’t want to, trust me. And the last time I needed health care I was driving very quickly to the emergency room. Not a lot of time the think there.
I recently listened to a presentation that Aetna CEO Mark Bertolini gave a few years ago at Stanford. (you can see it here) The final question asked of him was as follows: “How do you create a more educated consumer in a marketplace where they are being directing their own health care decisions?” What surprised me was his answer.
“Trying to educate to everybody on how the health care system works and the level of detail isn’t going to work. Sorry to say. And the reason is that unless the amount of information I can gather is immediately available and that when I act on it has an immediate response I am not going to pay attention to it.”
With all the articles out there about consumerism and directing one’s own health care I thought I was the only one that had such view.
Every time I have my car fixed I am wondering whether I am getting ripped off. I don’t know enough about cars to “shop the market” for service. I remember watching 60 minutes or one of those shows where they show auto mechanics taking advantage of everyday consumers by doing things people didn’t need. That’s me. I wish I had a trusted auto consultant who would tell me whether I really need the services some mechanic is saying I need. You get my point. If I don’t know whether my car is getting the proper treatment how the heck am I expected to figure out whether my doctor is doing the right thing.
Just last night my wife and I had a debate about the value of multivitamins and we couldn’t even agree on whether they worked or were a waste of money. So I Googled the topic, read a bunch of articles, and still don’t know whether multivitamins work.
Let’s not confuse choosing health care versus choosing health insurance. When choosing health insurance is one supposed to be predicting what their needs are going to be in the next 12 months to essentially “game the deductible”? Insurance is supposed to protect one from an unanticipated event that may cause financial duress if one were not insured. Anything that doesn’t fit into this category is simply a reimbursement plan. Dental insurance is almost not insurance. It is a prepaid reimbursement plan for most. There should be two types of insurance plans. One that runs like dental and is simply discounted reimbursements, and another that is real insurance. It is for this reason health savings accounts should rule the day.
So what is the solution? I don’t like when people run around talking about the problems without giving viable solutions so I won’t do that myself. I always say that stating the problem is easy, it is the solutions that are tough. Let me start with what I would want as a consumer. I would want someone who would give me sound advice as to what is proper treatment. I want someone who has an incentive to do the right thing for me. I want someone who would spend my money as if it were their own.
I think the solution requires properly placing incentives. I want to live a healthy, happy, long, and financially viable life. I want someone advising me who understands my goals which I will safely say that these goals are more than likely shared by many. I am all about incentives. It is funny how when you have the right incentives you get better outcomes. That requires having someone who wants me to be healthy and not just fix me when I am broke. This sounds like the things I would want from my car consultant who would advise me on how to take care of my car. I want my car to last long, be healthy, and financially viable. I am not sure what a happy car would look like.
There are emerging models out there that will provide this type of service. And making consumer based decisions around the small stuff may become common. But as a means of controlling healthcare costs, no way. We all know that the majority of health care costs come from few people with chronic conditions. If I need to have my oil changed maybe I can shop the market. But if I need a new engine I would hope to have a very educated mechanic at my side to help me make the best decisions.
I could not agree more. In the words of Sir William Osler, “A physician who treats himself has a fool for a patient.” A non-physician is at even more of a disadvantage in making medical decisions.
What will work is to put the knowledge and the incentives together. For example, in the case of investments, advisors commonly get paid as a percentage of assets. I think that is sensible- what is good for the investor is good for the advisor. Similarly, with health care, someone needs to be rewarded for keeping the patient healthy and controlling costs. I believe that the arrangement best designed to meet these goals is the accountable care organization, where a group of health care providers is rewarded for doing exactly that. (I think that physician-owned ACO’s are a more practical design than hospital-controlled ACO’s, but that is another discussion- also, I think that there is a case to be made for fully integrated delivery systems like Kaiser Permanente.)
In the past, the ACO arrangement and other alternatives to fee-for-service might not have worked due to misaligned financial incentives and the absence of reliable data about quality of care. However, as electronic health records, and programs to analyze the data they contain, have developed, I think that we have created the possibility for real accountability for accomplishing Berwick’s triple aim.
Santiago – I have written an article on exactly what you mentioned in your comments. Check out my article about “The Coming End to the Health Insurance Business as We Know It – And What Brokers Can Do About It”
100% agree. It is why I hate the proponents of the HSA/High Deductible plan. They say consumerism will bring prices down. I say, in actual practice, it’s serves as a retirement medical IRA for those with most means to pay for their health care out-of-pocket. Another tax-deferral scheme for those with the means.
Slightly different take. Using your car analogy, most people don’t have car insurance that funds oil changes or engine replacements. But, even if you did have insurance for engine replacements, would you go without oil changes until the engine seized?
I agree with you that health care consumerism is ineffective once you are the patient, and/or once someone else is responsible for payment.
So, the focus of health care consumerism should be at least three fold:
(1) Individuals do need to be financially responsible for medical expenses that are budgetable and affordable – preventive stuff and expenses up to the deductible/out of pocket expenses,
(2) A person’s focus should not be on next year’s anticipated medical expenses, but on maintaining or improving health so as to avoid medical expenses (or at least deferring expenses until a future year), and
(3) Individuals should accumulate monies/assets in anticipation that someday, they will have to meet those out of pocket expenses.
The data clearly confirm that, when spending their own money, individuals will tend to moderate their use of medical services – and manage the cost of services/Rx. Higher point of purchase cost sharing has been shown to reduce Rx expenses through the use of mail order for maintenance Rx and substitution of generic for brand name Rx – without negatively impacting patient outcomes. Long ago Rand studies, and more recent studies show that individuals refrain from using medical services, both needed services and unnecessary services, when there is sizeable point of purchase cost sharing.
In terms of concierge services, in the selection of and utilization of medical services, I couldn’t agree with you more – just like when I need legal representation or a car repair – in terms of gaining expert insight first.
But, when you are on your way to the ER, it is too late to be thinking about consumerism – hopefully, in the years leading up to your trip to the ER, you gave is considerable thought!
I agree with all your points. Consumerism should be in low cost items that actually should not even come under an insurance contract. Insurance should not cover oil changes. And the consumer can shop for the oil changes. The collective costs of the small ticket items do not bend the cost curve.