Consumerism in Healthcare-- Who Needs to Change and How Do We Make it Happen?

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Consumerism in Healthcare--Who Needs to Change
and How Do We Make it Happen?

• Jon R. Comola
• Marcia L. Comstock, MD MPH
• Wye River Group on Healthcare
• June 7, 2005

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• The challenge
• How do physicians need to change?
• How do consumers need to change?
• How can employers/plans support the change?
• And what about governments role?

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To Recap.

• Experience would strongly suggest that having
  either public sector (i.e., govt) or private
  sector (employers/health plans) arbitrate the
  tension between limited resources unlimited
  expectations is incompatible with American
  culture.
• SO., whether you believe putting patients in
  control of these decisions is the right thing to
  do or not, there are no other viable choices!

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But there are some disconnects that must be
addressed!!

• There is a major conflict between our concerns
  about cost demands for choice freedom
• People do not want to make trade offs in
  healthcare
• It is viewed as a societal, not a market model
• The public doesnt believe trade-offs are
  necessary
• The public believes that corporate greed and
  waste in the system are responsible for rising
  costs
• With scientific advances, the struggle will be to
  define what treatments are covered by insurance
  what are lifestyle enhancements that will have to
  be paid out of pocket

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• In a consumer driven health care system, we
  will each get to choose what we want to haveand
  what we are willing to pay!

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THE NEXT BIG QUESTION

• If this is to be the Brave New World of
  healthcare, how do we ensure it is
  operationalized appropriately???
• CHANGE IS HARD!!!

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REMEMBER!!

• Medical care revolves around the
  doctor-patient relationship ultimately that
  relationship determines the cost and quality of
  care! The role of all other parties is to
  support that relationship...

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THE CONSUMER

• The natural role for the consumer in a market
  economy is to make informed, price-sensitive
  choices based on personal preferences and subject
  to individual budgetary constraints.
• This paradigm is poorly matched to the special
  features of health care. . A purely
  consumer-driven health care system would be
  grossly inefficient as well as grotesquely
  inequitable.
• Jamie Robinson

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What can we expect from consumers?

• Take responsibility for practicing healthy
  lifestyles
• Be compliant with therapy
• Shop' for the best care
• OK, is this realistic today???
• (sort of Trading Spaces)

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1st Personal responsibility..a prime tenet of
CDHC

• When it comes to the day to day on-going
  decisions about exercise, diet, smoking
  cessation, and other health behaviors , its the
  doctors that advise and its the systems that
  reimburse, but it is the patient that decides!!!

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A tsunami is coming!!!

• Were getting older
• Were getting fatter (many of us!)
• The resulting chronic care needs will be REALLY
  expensive!!
• Obesity, as a key underpinning factor (no joke!)
  of chronic disease alone explains almost as much
  of the healthcare cost increases as tobacco

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Why are we getting fatter?

• We are eating moreno kidding!!!
• We are eating out more (In 1970 34 of the food
  budget was consumed outside the home in late
  1990s it was 47)
• Everything is super-sized at home and at
  McDonalds
• We dont exercise
• 35 of the population is obese or severely obese
  (almost doubled in 25 years!)
• (We need The Biggest Loser!!!)

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Super-size Everything
National Geographic August 2004
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New Monster Thickburger On Sale
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(No Transcript)
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Lifestyle Changes that Promote Sedentary Behavior
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The Sedgewaylets remove the last bit of
physical activity from our lives!
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The Perfect Storm for Obesity
Commercial Environment
Policy Environment
Human Biology
Obesity
Built Environment
Social/Cultural Environment
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Stages of change
Source Prochaska DiClemente
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How do consumers view their role?

• Aware that a healthy lifestyle can improve and/or
  prevent many medical problems
• But generally unwilling to require people who are
  overweight or who do not exercise regularly to
  pay more for their coverage and care
• Appreciate great differences between quality of
  care provided by different hospitals and
  physicians for serious medical problems
• But not willing to pay more for access to
  better-quality hospitals or physicians
• A large majority say they would be willing to
  work an extra 2-3 years to ensure they have
  enough money to pay for their health care in
  retirement
• HarrisInteractive, 12/04

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2nd Be Compliant with Therapy

• Without really good behavioral health
  communication programs patients really dont
  adhere very well .
• there are other barriers.
• Patients fail to comply due to language barriers,
  cognitive impairment, lack of knowledge
• Low health literacy affects 40 M Americans
• Therapy because it is difficult, complicated, or
  lifestyle disruptions interfere with regimen
• Patients make clear decisions to alter or stop
  treatment

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People dont adhere

• 30 to 40 of all patients fail to follow
  preventive regimens
• 20 to 30 of all patients fail to follow curative
  medication regimens
• 50 of all patients on long term regimens fail to
  adhere
• 50 of all patients requiring life style changes
  fail to adhere
• Bayer Institute for Healthcare Communication

(Hayes et al, 1979 DiMatteo et al, 1994 Clark
Becker, 1998)
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3rd Shop for the best care

• Effective healthcare is all about decisions
• Decisions about healthy or unhealthy behavior
• Decisions on whether and when and where to seek
  care
• Decisions about drugs, tests, surgeries
• To make good decisions, consumers must have
  access to personalized care management tools or
  decision-aides for guided self-care management

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What are decision-aides?

• Self-administered information tools that prepare
  patients for making informed decisions
• Help patients gain a better understanding of
  options, risks and treatment alternatives and
  provide patients with a higher level of awareness
  about expected medical outcomes
• Designed to work within the framework of a
  clinician-patient relationship
• Videos and DVDs, Internet-based guides, on-line
  interactive tools, decision-boards, books, and
  CD/ROMs
• Information has to be easily available, clearly
  presented, relevant and timely-- pushed to the
  patient at the time of need

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Do people want to be involved? The data is
conflicting

• gt60 of Americans searched for information to
  help them make treatment decisions in the last 12
  months 1/3 said info found affected their
  treatment choice or choice of healthcare facility
• 94 of those who hadnt said they would if they
  or a family member needed medical care
• 52 said they wanted to make the final decisions
• 38 wanted to make it with their physicians
• Patients using aides are more likely to make more
  conservative choices
• BUT despite their interest in being involved,
  most do not think they are in a position to
  affect the cost or quality of the care they
  receive!!
• RAND Survey 3/05

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What about the use of cost and quality
information?

• Access to cost estimates for drugs, tests, and
  surgical procedures is increasingly a reality
• Cost transparency for hospital comparisons is
  rapidly improving
• Transparency for most physicians rates is still
  some years away
• Transparency of quality information is on a
  similar trajectory
• April 1, 2005 CMS posted quality performance data
  for "nearly all" the nation's hospitals on its
  new "Hospital Compare" Web site
• Cooperation among representatives from different
  sectors important one model might be the
  Consumer-Purchaser Disclosure Project
• BUT is the information spurring people to alter
  their use of health care?

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• STILL, folks argue about whether consumers are
  capable of using informationAND consumers are a
  bit schizophrenic about it too!
• Nearly two in three Americans feel that they
  would become more involved in decision-making if
  the health care system were easier to navigate
• BUT, over a third of consumers say they would
  still follow their doctors advice even if it
  conflicted with reliable information from another
  knowledgeable source!!
• HarrisInteractive, 12/04

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How do physicians AMERICAN IDOLSneed to
change?

• Its really simple!!! (Ha!)
• Design their practices to be customer focused
• Practice evidence-based medicine (EBM)
• Engage in shared decision-making

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1st Customer-Focused Practice

• Patients wont wait an average of 38 minutes for
  an appointment!
• Patients will demand convenience, continuity of
  care, comprehensiveness collaboration
• Consumers will drive the provider community to
  respond.and some are understandably anxious
  about this!

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2nd EBM

• What is it?
• Science What works best given what we know today
  
• Clinician training experience
• Patient preferences, understanding and values

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This isnt happening!!

• We see unwarranted variation related to
• Under use of effective care--services shown to
  work and that patients want
• Misuse of preference-sensitive care-- where
  more than one approach is reasonable and patient
  values should be considered
• Overuse of supply sensitive care--services driven
  by providers
• Dartmouth Atlas of Healthcare

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More Evidence..

• The practice of medicine is anything but pure
  science today!
• 29 of US adults reported that they or a family
  member received a second medical opinion from a
  doctor in the past 5 years
• In 46 of cases the diagnosis was different from
  the original
• In 2/3 of these cases treatment was different as
  a result!
• Harris Interactive, 3/05

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One might conclude

• there is sufficient evidence to suggest that
  most clinicians practices do not reflect the
  principles of evidence-based medicine but rather
  are based upon tradition, their most recent
  experience, what they learned years ago in
  medical school, or what they have heard from
  their friends.. John Eisenberg, AHRQ
• SO
• When the rules of clinical practice are not
  clear, variation results from subjective opinion,
  practice preferences, and hospital capacity.

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WHY is there all this variation?

• Physicians can't keep up with current science
• Most don't see health plans paying for
  evidence-based care
• Plans may not be in agreement with best practices
• EBM challenges physicians professional turf and
  they chafe about cookbook medicine
• AND most consumers side with their physician in
  preferring eminence-based medicine over
  evidence-based medicine

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One consumer organizations perspective

• How Technocrats are Taking Over the Practice of
  Medicine
• Rigid standards of care imposed on patients
• Restriction on professional freedom and judgment
• Rationing of health care services
• Politicization of medicine
• Citizens Council on Health Care, 1/05

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BUT

• IF there is evidence you are not a consistently
  good cook,
• WHAT IS WRONG WITH A COOKBOOK??

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What do we do? We P4P!!

• Latest trend to make docs behave!
• gt100 P4P Ps Ps by P P entities.
• Denounced as a scam designed by multimillionaire
  CEOs of health insurance companies to cut
  reimbursement by taking advantage of gullible
  physicians
• Wm Plested, MD, AMA Board Chair, 2004

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and once again, consumers side with their docs

• The US public is only moderately supportive of
  having health plans pay more to doctors for
  higher quality 38 yes, 17 no, 32 indifferent
  UNLESS it lowers their health insurance costs
  67 yes.
• HarrisInteractive 5/2005
• (perhaps this is more driven by self-interest??)

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Lack of enthusiasm aside.Will it be effective??

• That depends.
• Withhold/bonus opportunity needs to represents
  gt10 of average physician revenue
• Payers need to agree on a measurement set
• CMS leadership is central to furthering the goal
• Percentage of public/private payers/purchasers
  sponsoring these programs projected to increase
  from 40 in 2003 to 80 in 2006

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3. Shared Decision-Making

• Extreme Makeover
• (needed!!!)
• The news is similarly grim when it comes to
  research on just how frequently and just how
  deeply the average physician gets into shared
  decision making with the average patient.

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The Evidence!

• 9 of all the decisions reflected even a limited
  degree of shared decision-making
• Not one in 3,000 included all 6 elements
• A discussion and an exploration of the patients
  understanding was the least frequently noted, at
  2 (probably the most important to the
  doctor-patient relationship and to patient
  compliance)
• (study of gt3000 medical decisions involved in
  1,000 visits looked at 6 key elements of
  informed consent or shared decision-making)

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Whats Needed Whats Missing?

• Trust (hard without a real long-term
  doctor-patient relationship)
• Good communications skills (physicians arent
  really taught to communicate)
• Adequate time (tough with a 548 office visit)
• Incentives (docs arent paid to communicate)
• Commitment and conviction as to the value (you
  need to experience it to appreciate it!)
• (but the real Weakest Link)

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But the real barrier is.

• Physicians dont think it will make a difference
  in the patients behavior!!

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What should employers/plans do?

• Communicate the need for and advantages of the
  new model and serve as information brokers
• Design comprehensive programs in prevention and
  disease management based on behavioral change
  model
• Change reimbursement mechanisms to reward quality

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How Can Employers Really Control Costs?

• 3 strategies rated as the most effective
• Rewarding more efficient and high quality care
• Improving DM services for patients with high-cost
  conditions enhancing primary case management
  applying evidence-based guidelines to determining
  when a test or procedure should be done
• Increasing collaboration among private insurers,
  Medicare, and Medicaid to adopt common payment
  methods and rates and streamline administrative
  costs
• Commonwealth Fund Health Care Opinion Leaders
  Survey
• (academia/research business, insurance, health
  care industry, labor/consumer advocacy orgs,
  govt)

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RED PILL/BLUE PILL(the Matrix Redux.)

• Paternalism Control
• Im too busy to worry about fixing the
  healthcare system
• Cost
• Its an exit strategy
• I can predict my costs, as I shift more to
  employees
• Quality
• Its a plan issue
• Why cant physicians get their act together
• I need to focus on cost management

• Empowerment Support
• I can be an agent for community collaboration
• Cost
• Ill reward efficiency P4P
• Ill focus on care management
• Quality
• I recognize the need for total system redesign
• I need to focus on integrated care outcomes

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RED PILL/BLUE PILL

• IT
• I make widgets!
• I spend enough on healthcare
• as it is!
• Benefit design
• My plan is the expert
• One size fits all is fine
• I dont want to have to worry
• about adverse selection

• IT
• I need to help my employees with information
• Good decisions will help productivity
• Benefit design
• I need to pay attention to details!
• People need to be able to shape benefits to meet
  their needs
• I need to ensure incentives for wellness
  prevention

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The Politics of Healthcare

• The last big opportunity for broad scale social
  programs
• A potentially politically polarizing vision
• An unfriendly environment for system wide change
  !!

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Consumerism in Healthcarea political consensus
point?

• Political pollsters repeatedly confirm the gap
  between what people say they want and what
  elected officials act on
• BUT...In healthcare consumerism there is
  potential alignment of political interests
• The basic model of robust information plus
  incentives has been articulated by political
  polar opposites Ralph Nader and Newt Gingrich.

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The Power of Guv-mint

• Collectively funds 60 of healthcare.perhaps
  its greatest leverage point!
• Other tools
• Administrative law
• Regulation
• Executive orders
• Legislation
• The bully pulpit

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How Can Gov-Mint Be Useful??

• Develop reimbursement mechanisms that reward
  providers who practice EBM
• Better technology assessment.get real innovation
  into practice sooner
• Support medical effectiveness (clinical outcomes)
  research
• Support development of standards for information
  on quality measurement
• Support CDHC in public programs
• Support integrated chronic care management
• Make savings accounts more flexible

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Consumerism in other industriesa model??

• 1st generation personalized service
• house calls, pharmacy delivery of meds, the
  milk man, full service gas station, dry cleaning
  delivery
• 2nd generation customer convenience
• stores staying open after 5 and on Sunday the
  telephone company accepting payments through the
  grocery store, multiple locations for paying
  bills or customer service booths, travel agents
  who negotiate for you
• 3rd generation information access technology
• credit card over the telephone, 24 hour access
  to account information over the telephone, then
  fax and eventually internet

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Consumerism in other industriesa model??

• 4th generation hybrid-customer convenience
  operational efficiency
• on-line checking catalogue ordering Ebay
• Todays consumerism
• Has redefined expectations and created demand
  for things that look and feel more like self
  service-- you pump your own gas, you book your
  travel on-line you print your own airline
  tickets and check your bags at the kiosk you
  scan your own grocery purchases
• WHAT WILL THIS LOOK LIKE IN HEALTHARE???