JAMA Commentary on Consumer Driven Health Care: It's Time to Give Healthcare Consumers a Chance

In the latest (January 21 and not on line yet) issue of JAMA, physicians Robert Berensen (of the Urban Institute) and Christine Cassel (of the American Board of Internal Medicine) argue that consumer driven health care may not be what patients need. Briefly, they argue that this kind of approach – in which consumers have full access to information on price, quality and services and get to choose accordingly – places patients at a huge disadvantage. It also discounts the proven and long standing value of physician professionalism. According to Drs. Berensen and Cassel, the knowledge needed by the consumer is too complicated, the relationship with the health care system too asymmetric and patients are too vulnerable to making bad choices. Compared to your physician healthcare system tour-guide where your doctor can act as an advisor, fiduciary and advocate, the medical marketplace is a lousy option.

The Disease Management Care Blog doesn’t entirely buy this at several levels.

While physician professionalism is an ideal, physicians are also:

Humans who carry their own bias and agenda into their patient encounters.

Vulnerable to economic factors when framing patient options.

Even when salaried and even when in premier academic settings, may belong in organizations that are monopolistic, predatory and not acting in their patients’ interests.

Drs. Berensen and Cassel also fail to distinguish between preference sensitive and insensitive care. The former involves healthcare services that are subject to patient choice (for example, a total knee replacement for progressive osteoarthritis), while the latter involves services are not readily optional (for example, a total hip replacement following a fracture). The DMCB accepts the notion that women in labor, men with heart attacks and grandmothers with hip fractures generally cannot exercise the usual laws of economics in a medical marketplace.

However, persons with chronic illness – such as osteoarthritis, prostatism, diabetes, high blood pressure and coronary artery disease – generally do have the ability and the time to get involved in determining much of the content of their care. This includes the outcomes they want from treatment and the amount of money and effort they are willing to expend to get there. There is plenty of great commentary and reviews that show that consumerism is an untapped force in healthcare.

The DMCB has lived through decades of physician professionalism and isn’t all that impressed. While it’s a great notion, relying on its routine applicability to day-to-day medical practice, while attractive, is at best naïve and at worst the last refuge of the status quo. It's what the doctor ordered, not what patients need.

We can work on expanding and improving the profesionalism but it’s time to give the consumers a chance when it comes to health care choices for chronic illness.

Of Motorcycle Laws and Consumer Directed Health Plans

The Disease Management Care Blog spent the last few days in sunny Texas, where motorcycle drivers seem to have a remarkable affinity for offering themselves up as potential organ donors by forgoing protective headgear. This display of two-wheeled freedom during the car ride to DFW reminded the DMCB of consumer directed health plans.

How so you ask?

When patients have to choose between using their own money for medical care versus not spending it and forgoing potentially important care, is this exercise in choice-making awful? According to the Blue Cross Blue Shield Association, the answer is 'not necessarily.' This press release states consumers enrolled in consumer directed health plans (CDHPs) are ‘more likely to be cost conscious and shop around.’ CDHPs have a lower monthly premium, which makes them a policy option in the search for stemming healthcare cost inflation.

As an aside, the DMCB hasn’t seen the BCBS data, but it wonders if this may be a classic example of ‘self selection bias.’ While the non-critical reader would be tempted to go along with the notion that CDHPs cause healthcare frugality, it’s just as possible that the opposite is going on. Persons inclined to cost consciousness may choose (i.e., ‘cause’) CDHPs. But that’s not the point.

If one accepts the notion that CDHPs put 'skin in the game,' the larger question is whether persons enrolled in CDHPs who actively minimize their out of pocket medical expenses are a) knowingly or unknowingly being b) thrifty or cheated over a c) responsibility or a right to d) commoditized health services or necessarily illness treatment for e) preference sensitive or preference insensitive care? Back in the days of DMCB’s clinical practice, it wasn’t unusual for its patients to decline to follow its recommendations for a variety of reasons including inconvenience, lack of time, fear of side effects, independent judgment of the potential benefit (especially among healthcare workers) and the out of pocket cost. The DMCB didn’t sweat it just so long as its patients were making a truly informed choice. Just like the Lone Star State’s attitude about its bareheaded iron-horse cowboys, the DMCB figured that persons had a right to choose to be unwise. If motorcyclists are being allowed the risk of having Mr. Brain get up close and personal with Mr. Concrete, maybe society should be willing to accommodate the exercise of cost-based patient autonomy.

Has the DMCB been seduced by the Wild West? While it did admire them cowboy hats, it would like to point out that there is a considerable body of data that suggests much of health care recommended by doctors is a) fraudulent or b) unsupported by any credible evidence or c) of only marginal benefit and high cost. Contrast that truism with the results from this article in Health Affairs that determined that persons enrolled in high out-of-pocket cost CDHPs experienced an absolute increase of about only 2-4% of going without ‘recommended care.’ While that percent probably included care that was not fraudulent, was evidence-based and was high value, the DMCB asks this: if patients use economics to make informed choices about paying for health care services, is that small increase bad judgment or bad policy? Can it be improved upon to be one of many approaches to controlling healthcare costs among the insured? Or is it the medical equivalent of a silly helmet-optional law that deserves to be repealed?

Last but not least, if we are going to rely on some version of CDHPs as an approach to tackling rising healthcare costs, the DMCB believes disease management (DM) has a proven track record in helping patients participate in wise decision-making and that it can be deployed here. Incorporating economic considerations in its patient coaching strategies is well within the industry's expertise.

A Type 1 Diabetic's Insights About Insurance, Quality and Cost (& an erratum re Lifemasters)

While DiabetesMine is a famous must-read blog for all things diabetic, the Disease Management Care Blog discovered this morsel at Finding Our Way. Ms. Erika also has type 1 diabetes and her latest blog is a telling essay that gives the patient's points of view on all these high falutin concepts about insurance, quality and cost. When I read this, I thought about:

Risk vs. retail: Can we be confident that the Material Girl's efforts are reasonably destined to save her and her insurance company money in excess of the $14,000 per year? Suppose a cheaper pump were used and testing was limited to 4 times a day? Cost would go down and the risk of increased claims expense might go up, but by not as much. Maybe the retail dimensions are more important: her insurer can use its purchasing power to gain discounts on the cost of supplies and share the expense outside notions of insurance risk. Reconciling both functions is difficult but it's the right thing to do.

Benefit design and silos: it's not clear if the yearly cap of $3500 applies to all costs or some; it's possible that "durable medical equipment" like pumps have a different cap. The point is that from the patients' point of view, it doesn't really make that big a difference. Money is money. Health is health. Maybe there is a role for 1st dollar coverage of 'no-brainer' health care like pumps.

Consumer Directed Health Plans or variants thereof: it's pretty obvious that Running Mama is going to blow right through her out of pocket cap in just a few months. If interpreted correctly, this new insurance could possibly represent a simple cost transfer from the insurer to the enrollee. On the other hand, it's clear the 'consumer' is now carefully weighing the pros and cons of high frequency testing and making rational economic decisions based on her values and life style.

The Doctors: Think docs cost a lot of money? Think again. Depressing isn't it? Of the 14 grand, her physician occupies only $500. Yet, that doc presides over a whopping amount of money. It seems to the DMCB that the doc deserves better compensation in general and should also be rewarded for making sure the $14,000 is spent in the best interest of the patient with dimensions that include quality and value.

Disease management: This patient is obviously doing such a good job with DM, if I were a vendor, I'd stay away and move onto the next patient. However, perhaps there is a future role for DM companies is to help persons navigate the insurance benefit design. This will be examined in a future post.

Thanks Erika, for sharing.

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Postscript: the DMCB has issued its first ever erratum (and hopefully last) on a prior post, mistaking Lifemasters for Healthways. The DMCB has made the necessary corrections & regrets the error.

Consumer Directed Health Plans, Cancer Screening, Colonoscopies and Disease Management

In the latest Annals of Internal Medicine is a noteworthy report on the impact of the adoption of a Consumer Directed Health Plan (CDHP) on cancer screening. Many readers may recall that CDHPs are both admired and reviled for helping consumers put "skin in the game."

Performed at the award winning Harvard Pilgrim Health Care, the study examined HEDIS rates for mammograms, paps and colon cancer screening over the year before and the year after for just over 3100 persons who were switched into a CDHP. The rates were compared to persons who remained in a standard HMO. The CDHP had first dollar coverage for mammograms, paps and fecal occult blood testing but not colonoscopy, flexible sigmoidoscopy or double contrast barium enema. To the authors’ credit a sensitivity analysis restricted the sample to members who were less likely to have had a previous colorectal cancer screening.

Mammogram and pap smear rates were no different in the two groups. In the control group, the colonoscopy rate went up, while in the CDHP, it dropped. In the meantime, the covered fecal occult blood test went up, giving the authors the reasonable impression that the enrollees in the CDHP “switched” from the expensive colonoscopy to the less expensive (and covered) occult blood test. The degree of change in screening rates in absolute terms was no more than three percentage points.

So, are Consumer Directed Health Plans bad for colon cancer screening? The Disease Management Care Blog doesn’t necessarily so:

• What’s wrong with health care consumers making an informed decision to switch from gold plated screening to just OK screening? Lines have to be drawn somewhere.
  

• 7.1% of the CDHP patients apparently agreed that colonoscopy screening was necessary and took advantage of it, versus 9.6% of the persons with first dollar coverage. It’s not like colonoscopy rates caved in.
  

• The CDHP went to the Harvard Pilgrim Health Care HarvardPilgrim.org web site and looked for the information that helps consumers decide where the best colonoscopies were (defined as having a low complication rate, performed by expert providers with emergency back-up) at the best price. It can’t find it. This is Boston and New England after all, and the DMCB doubts there are any colonoscopy centers that are willing to post quality measures or pricing. Lacking a transparent market that helps consumers decide if they are getting value for the money, should the study findings be all that surprising?
  

• Maybe persons who are actually paying for the test were more willing to ask about the trade-offs in complication rates vs. the benefit.
  

• This study was performed in an integrated delivery system, which may not make it generalizable to much of the real world. For example, the Disease Management Care Blog doubts very much that Harvard Pilgrim was willing to use its purchasing clout to steer patients to colonoscopy providers offering the best quality at the lowest price. A free standing insurer and/or an employer-based plan may not hesitate to do that. If a transparently and competitively priced colonoscopy option was in network, the impact of high out of pocket expense could be lessened. Insurance underwriters recognize the level of risk from preventable colon cancer, but another role of large purchasers of medical services should be to find the best retail price for their enrollees. See the prior post on risk vs. retail.
  

• If the price of colonoscopy is what is getting in the way of higher cancer screening rates, perhaps the answer is not adjusting the benefit package of a CDHP. Rather, the answer may include finding a way to lower the price of a colonoscopy. In addition to jawboning the providers for better contracting terms, the Disease Management Care Blog found this other way to offer the service at a lower price.

• Finally, other patient support interventions such as this and this may help overcome patient reluctance to undergo screening. Note both fit nicely with the type of interventions already available in population-based wellness, health promotion and disease management programs. In fact, many disease management vendors are already out there promoting cancer screening under a variety of insurance benefit designs. They are probably doing a very good job at it too. Does anyone have any data to share?

By the way, kudos to Harvard Pilgrim for conducting the study. We need more real world research like this to inform public policy.