Envisioning 2.0

I enjoy reading Dr. Benjamin Brewer’s regular column in the Wall Street Journal. He has a great way of highlighting issues while providing a valuable reality check. In the latest installment of “The Doctor’s Office” Brewer talks about why he is shutting down efforts to communicate with his patients electronically. He lists many reasons why he decided to take this action, but two stuck out for me.

o Patient apathy: Over time, Brewer realized that many patients still preferred to contact him via telephone when they had a problem or needed a consultation.

o Inconvenience: Worried about patient privacy laws Brewer installed an expensive system that would have required patients to memorize a new password and jump through a few hoops to contact him. This proved to be a non-starter with patients who preferred to be contacted via plan-vanilla e-mail – despite the fact that it is less secure.

In the end, Brewer might have benefited from some basic research. Brewer admitted that he never surveyed his patients to find out if they wanted to communicate with him via e-mail. This was a bad idea.

Communications might have been another problem. Did Brewer communicate aggressively about the new service (and its benefits) with his patients? His column indicates that he may not have. Like many others, he thought that if he built it, they would come. Unfortunately, things don’t work that way.

Overall, this is an interesting column that sheds light on some of the barriers faced by physicians in smaller practices seeking to use innovative technology.

See what readers think of this column by viewing the Wall Street Journal’s online forum.

Note:  I was inspired to write this post because of an article I read in the current round of the Health Wonk Review.  Check out the latest excellent edition here.

A couple of weeks ago, Jane Sarasohn-Kahn published a great analysis of some of the latest data from EBRI and the Commonwealth Fund focusing on the state of consumer-driven health plans (CDHPs).  In sum, the data’s not good.

Before I get into a discussion of Sarasohn-Kahn’s analysis, it’s best to talk briefly about the war of words currently swirling around CDHPs. Last year, , Gred Scandlen published a report, “CDHPs – ‘Working As Intended,’” where he noted that many studies are flawed and obscure the true benefits of CDHPs.  He argues that:

-    Recent surveys find CDHPs have continued to grow rapidly
-    High-deductible plans encourage people to take their care seriously, e.g., they are much more likely to go to their doctors to manage chronic conditions
-   “CDHP members are [not] likely to forego care due to cost”

Now, with that in mind, let’s look at what EBRI and the Commonwealth Fund found.  Most importantly, their study indicates that the healthy and wealthy are most likely to use CDHPs. Sarasohn-Kahn notes that this is not what CDHPs were designed to do. In fact, they have been touted as a means of getting more people into insurance plans.  In addition, although more affluent individuals are using these plans, Sarasohn-Kahn notes that “members of CDHPs and HDHPs are more likely to delay going to a doctor, visit a specialist, or undergo medical tests than members of comprehensive plans.”

I’m not going to take a position on whether CDHPs are successful just yet.  However, juxtaposing Scandlen’s analysis with EBRI’s research raises some interesting questions.  Most importantly, which numbers are we to believe?  Unfortuantely, there’s no good answer for this question.

Yesterday, the New York Times published a story focusing on how the British National Health Service (NHS) quietly has evolved into a two-tier system.  That is, all patients receive free care, but must endure long waiting times and sometimes do not have access to the latest treatments.  Frustrated, some are bypassing the system and paying for parts of their care themselves.  However, the NHS is not allowing this practice to spread unfettered.  According to the Times: “Officials said that allowing [people] to pay for extra drugs to supplement government care would violate the philosophy of the health service by giving richer patients an unfair advantage over poorer ones.”

But, that’s happening already. The Times reports that “patients, doctors and officials across the health care system widely acknowledge that patients suffering from every imaginable complaint regularly pay for some parts of their treatment while receiving the rest free.”

The United Kingdom’s hidden two-tier system was thrust into the spotlight when a female cancer patient, Debbie Hirst went to the press because officials would not allow her to pay for an expensive cancer treatment herself.

To me this story illustrates several points that are sometimes overlooked by some participants in the health reform debate:

1.    Countries that offer universal health care do a lot of rationing.  While it takes all comers, people often have to wait months or years for certain treatments.  Expensive medications are sometimes provided past the point where they may be effective.  (This happened in Hirst’s case.)

2.    The well-off will find ways to get better care.  Either they supplement their public insurance with private plans that offer additional services or they “go outside the system” to access treatments.

This is not to say that making access universal is not an admirable and necessary goal.  However, even in the most ideal situations, patients will practice consumerism and demand – and access – care that is not available to all.

Currently, Americans collectively owe hospitals $40 billion in unpaid bills.  This, combined with the fact that 47 million Americans are uninsured, is making hospitals worry about the consequences of mounting debt on their bottom lines.

Now, hospitals are looking for ways to identify which patients will be more likely to be unable to pay their medical bills.  Fair Issac Corp, which developed the FICO credit score, is investing in a company Health Analytics, which (according to news reports) is developing a scoring system that will help hospitals and providers identify financially risky patients.

MSNBC contacted Healthcare Analytics recently and the company denies it is developing a MedFICO product.  According to spokesperson Tom Hurley the tool “will be used after patients receive care and after a bill is generated to help hospitals make better financial planning decisions.”  No one will be denied care because of a low score, he says.

Consumers are not buying it.  After the story appeared on MSNBC’s Website thousands of people have weighed in to blast MedFICO as ill-advised and unethical.   I see this as another consequence of the consumerism trend.  As organizations realize that consumers will be asked to assume responsibility for their care, it is only natural that some will begin to examine patients’ ability to pay.

My major concern is that a MedFICO will lead to severe (and improper) rationing of care – i.e., turning patients away if they look like financial risks.  I’ll be interested to see whether the folks developing this product will be able to successfully manage the legal and regulatory issues associated with it.

John Bell, who writes the blog Digital Influence Mapping Project, has an interesting post about a subject near and dear to my heart: health literacy.  He outlined an idea  for helping consumers understand health information better.  I’ve reproduced some of the points he made in his post below:

“There is a terrific opportunity to provide health literacy programs to help all consumers get smarter about the healthcare options available to them. . . .

This new health literacy program is the perfect initiative for a brand-conscious, consumer-committed pharmaceutical company. Each of the pharmas struggle between ambitions to make their corporate brand meaningful to consumers and their need to build product brands and sales. . . .

The U.S. Government has an initiative afoot under HHS’s Health Resources and Services Administration. They will have an event at the end of October which is apprently Health Literacy Month. NIH has it’s own effort, as well. We should not leave this up to the government. A smart pharma could make this their signature CSR (corporate social responsibility) effort.”

For more about his idea, please click here.

 

Yesterday, the Wall Street Journal Health Blog cited a “closely watched” survey focusing on the predictable annual rise in health insurance premiums.  Digging past the headlines, Jacob Goldstein noted that “high deductible [health] insurance plans tied to special savings accounts continue to lag behind expectations, despite being praised high and low as a tool to slow the rise in . . . costs.”

You can learn a lot about why a product or service is not gaining ground by reading comments left on blogs, online bulletin boards and other sources.  Many of those commenting on the Health Blog’s story cited poor administration and mass confusion as reasons high-deductible plans have not taken off.  Some relevant comments are below.

Without Information I Can’t Make Good Decisions

“I have tried the consumer approach to health insurance. It is very difficult to obtain pricing or exact information from insurance companies or providers. How can you be an active shopper of health care if your ill and no one will provide the information to create an informed decision? You will not be having success connecting the consumer or provider until one can truly negotiate and understand the pricing.”
-Paul Brunner

Incompetence Ruined My Experience 

“My last job was with a Fortune 100 company. Their HSA administrator was completely incompetent. I had claims denied several times that clearly fell within the guidelines (contacts and eye exam, for example) while they were giving me excuses as to why they didn’t. Reimbursement checks were “lost in the mail”. In the end, it just seemed like a scam to take my money and my time. I did lodge a formal complaint with our HR department who told they had similar complaints and not many people sign up for a second year.”
-AMC in Florida

High Deductibles, Poor Service Keep People From Coming Back

“If someone actually needs the funds for health care, they offer few advantages except for a lower premium cost because the coverage starts after a high deductible. Duh. For a medical practice as a business, they are nightmares. Patients usually do not know how much is in their accounts and how providers are paid. We rarely have a clue as to how much we will be paid and how much the patient will owe. We need to bill the third party, wait until they adjudicate the claim and then try to collect from (often disappointed) patients.”
-Eric Einstein

Yesterday, the Wall Street Journal published an article highlighting an issue many of us in the health policy sphere have known for a long time: consumers are not embracing health savings accounts.  Why?  Well, according to the Journal:

- Most employers are not investing the resources – in coverage or education – needed to jumpstart enrollment in the plans

- Many consumers are confused and dissatisfied with the plans.  In fact, those seeking information on the cost and quality of medical services are often frustrated and ill-informed.

The litany of consumer complaints about health savings plans goes on.  In fact, perceptions were so negative that one expert said the data indicates that consumer-driven plans should be significantly retooled.

Clearly, the solution is better education and communication with employees.  But, with few companies having the time and resources to invest in these tools, the future of consumer-driven health plans looks very grim.

An article published in the Memphis Business Journal recently highlights the tough road ahead for those seeking to get more people enrolled in consumer driven health plans (CDHP). Younger, healthier and wealthier people have signed up for Health Savings Accounts (HSAs) but the majority of the insured are loath to try them out. Michael Dreve of UCL Financial Group explains why most of the low hanging fruit has already been plucked:

“When someone is told that under an HSA their doctor’s visit will cost them $180 for primary care and $230 for a specialist, they’ll typically retreat for the PPO and the $20 co-pay. What they don’t see, Dreve says, is the $1,300 the employer is paying each month. Brokers call it the ‘hidden paycheck.’”

Experts say that the key to winning over skeptical employees to HSAs and other forms of CDHP is education and flexibility. Specifically:

-Plant the seeds early with middle managers and explain the benefits and drawbacks of CDHPs

-Explain the positive financial implications of HSAs

-Where possible, have employers match employee funds placed into HSAs to increase acceptance

-Don’t force people into an HSA; show them the benefits of switching from a traditional managed care plan and let them decide what they want to do

An interesting article published in today’s New York Times reveals the perils of the individual insurance market – especially for people with pre-existing conditions. The Times focuses on the plight of the uninsured middle class, including freelancers and independent contractors. According to the article, realtor Vicki Readling:

“[D]oes not receive health benefits from an employer. She tried to buy a policy in the individual insurance market, but — having had cancer — could not obtain coverage, except at a price exceeding $27,000 a year, which was more than she could pay.”

Yes, many uninsured are not poor, unemployed or illegal immigrants. Instead, one-third have incomes of more than $40,000 a year.

For consumer-driven healthcare boosters, this group represents an ideal market, but many high deductible plans are too expensive for them to purchase. Can sites insurance shopping services like the one being planned by Revolution Health help?

Only time will tell.