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PERSPECTIVERearranging The Deck Chairs
In their efforts to make insurance premiums more affordable, employers and health plans are promoting consumer-directed health care as a consumer-friendly alternative that will cut costs and improve quality. In my view, consumer-directed care reflects health care providers’ failure to deliver value and unrealistically assumes that consumers can make sound, cost-effective medical decisions. It also evades the fundamental question of how society defines the limits and obligations of health insurance, and it could stall meaningful action to hold all stakeholders accountable for an equitable, high-quality, and affordable system.
THE MYRIAD PROBLEMS facing the U.S. health care system should be a stimulus for new approaches to addressing the triple problem of cost, quality, and access. At a minimum, new approaches should do more good than harm to the people they affect and to a society eager for affordable, effective, and fair coverage strategies. As the new darling of the insurance world, consumer-directed health care (CDHC) is being lauded as a likely solution for the problems of cost and quality. Before one embraces CDHC, however, it might be useful to consider its genesis and its shortfalls.
The premise of CDHC is that costs will go down and quality will improve "by giving consumers incentives to be prudent managers of their own health and health care."1 These are diplomatic words for mitigating patient demand for expensive, often unnecessary care. Identified some years ago by policy pundits, this problem led to the idea that if patients’ own resources were at stake ("skin in the game"), excessive demand would be curtailed. The problem is not so much the overuse of services that are within the control of consumers (for example, going to an emergency department rather than an urgent care center) but, rather, the overuse of services that require physician authorization, such as getting a magnetic resonance imaging (MRI) scan or being admitted to the hospital. The physician as the traditional medical gatekeeper fulfills several vital functions: to ascertain the most beneficial medical care based on each patient’s circumstances; to ensure that patients are not harmed by self-prescribing; and to provide the basis for insurance coverage only for what is medically necessary. Although patients’ preferences should always be part of the equation, such preferences cannot be a substitute for clinical indications and professional judgment. Using a high deductible to control wanton consumption bespeaks a recognition that physicians have failed as gatekeepers. Some physicians give in, all too early, to what the patient demands, regardless of medical need. Others have their own financial motives for agreeing to or pushing the medical maximum. Some do not keep up with evidence-based guidelines, and practice patterns change slowly. Many do not feel that it is their role to husband society’s resources; instead, their job is to maximize the benefit to the patient, regardless of how speculative that benefit might be. Since CDHC means, in essence, passing the responsibility to consumers to be their own gatekeepers, patients logically will seek advice from their doctors on the cost/value of medical interventions. Can physicians do a better job as advisers than as gatekeepers? There is little reason to assume so. A recent review of the use of standards set by the U.S. Preventive Services Task Force found that many physicians disregard even the most common evidence-based guidelines, resulting in millions of dollars of unnecessary spending.2 The Dartmouth Atlas of Medical Care has long reported the vagaries of physician treatment patterns in different parts of the country, with high costs and high usage showing little relationship to medical need or positive outcomes.
CDHC’s optimistic view of consumers’ ability to make sound treatment decisions has not been confirmed in Sacramento Healthcare Decisions’ (SHD’s) community discussion groups.3 When given the task of developing a basic health plan, participants insisted that if required to pay directly, individuals will ignore needed medical care unless they are practically at death’s door. For example, they argued that vision care should be a component of a basic health plan because people will not spend money out of pocket to get their or their children’s eyes checked. They knew this because many participants were speaking from their own childhood experience. The tendency for consumers to skimp on needed care was illustrated in a recently published study.4 Among Medicare patients with chronic disease, medication usage was compared between those with capped pharmacy benefits and those with unlimited benefits. Those with limited coverage were far less compliant with medications, had poorer control of their disease, and subsequently had higher costs of hospital and emergency care than those without pharmacy limits. It appears that CDHC success will require patient access to reliable, unbiased information; sufficient time, energy, and wherewithal for patients to do the research; and a high degree of patient motivation, risk-aversion, and attention to secondary prevention. Since most providers (from hospitals to device companies) are in business to encourage patient use, consumers will also need to be discriminating judges of all forms of direct-to-consumer advertising. With these challenges, it is doubtful that this new "opportunity" to control their own health care destinies will, in fact, have any positive impact on cost or quality.
Although physicians might be inattentive as gatekeepers, and consumers ill-equipped to take on this role, neither are responsible for the fact that gatekeeping has become so complicated. Advances in medical technology, the expanding definition of medically necessary care, and the pressure to keep patients satisfied have made it harder to discern where coverage lines should be drawn. In an SHD discussion group, an energetic debate arose about covering life-sustaining treatment for terminally ill patients. One participant observed that in the role of citizen making policy decisions about coverage (the purpose of the session), she needed to take into account three competing values: compassion (that is, respecting what is important to the patient regardless of clinical indications), science (that is, adhering to what is supported by medical evidence), and economics (that is, keeping health care affordable). She believed that the role of this citizens group was to consider all three values and find the fairest compromises.5 Summarizing this issue in terms of compassion, science, and economics might seem simplistic; however, they represent major tensions in health insurance because they all have unlimited potential for growth. There are no natural limits to what individuals perceive as important; no limits to discoveries in medical science; and no limits to what we could spend in health care (or in the number of entrepreneurs wanting to sell). Finding the right balance between them is a difficult task and one that must include all the stakeholders. As part of SHD’s project on basic coverage, participants were asked to choose three ways from among seven options to help reduce the cost of health care. Listed here, from most to least chosen, the options were (1) restrict coverage of treatment that does not meet national standards of being effective (61 percent); (2) restrict coverage of treatment that is not critical for patients’ basic functioning and long life (57 percent); (3) limit the use of expensive treatments that provide only a small benefit (50 percent); (4) require patients to pay higher rates if they do not follow medical advice that will keep them healthier (41 percent); (5) limit the choice of doctors and hospitals that patients use (36 percent); (6) except for emergencies, have longer waiting times for services (35 percent; and (7) have patients pay a larger portion of the cost of health care (10 percent). It is particularly noteworthy that the top three vote-getters were about tightening the standards of what is covered, rather than putting more responsibility on consumers. This suggests that there may well be other insurance models that have greater appeal than CDHC.
It is too early to know whether CDHC will deliver as promised or delay serious attempts at health care reform. But in the end, the big-picture questions about health care coverage will have to be asked and answered by many voices, not addressed through an individual’s personal treatment decisions. Regardless of a patient’s willingness to pay a high deductible, should health insurance cover a promising cancer drug costing $100,000 a year? Should insurance pay $1,500 for a scan to diagnose Alzheimer’s disease when no cure is available, or pay for extensive annual medical work-ups for adults without risk factors or symptoms? It is not likely that CDHC will add to the serious debate that Americans must have to reach a just, efficient, and effective health care system. Instead, it may lull policy leaders into thinking that there are simple answers to large and complex problems. The patient is not the only one who must ask herself, "Am I getting my money’s worth?"
Marjorie Ginsburg (ginsburg{at}sacdecisions.org) is executive director of Sacramento Healthcare Decisions in Rancho Cordova, California, a nonprofit, nonpartisan organization that seeks the public’s view on complex health policy issues. The project referenced in this paper was funded by the California HealthCare Foundation. The perspective here is that of the author and does not necessarily reflect the views of the foundation.
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