Transcript What Ails Healthcare--- And What Can Really Heal It?

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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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!!
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There is a major conflict between our concerns
about cost & demands for choice & freedom
People do not want to make trade offs in
healthcare……
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It is viewed as a societal, not a market model
The public doesn’t 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
have—and 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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What can we expect from
consumers?
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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 ,
it’s the doctors that advise and it’s the
systems that reimburse, but it is the
patient that decides!!!
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A tsunami is coming!!!
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We’re getting older
We’re 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?
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We are eating more…no 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 don’t 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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Lifestyle Changes
that Promote Sedentary Behavior
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The “Perfect Storm” for
Obesity
Policy
Environment
Built
Environment
Commercial
Environment
Human
Biology
Social/Cultural
Environment
Obesity
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Stages of change
Source: Prochaska & DiClemente
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How do consumers view their role?
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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 don’t adhere very well ….
there are other barriers……….
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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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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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Do people want to be involved?
The data is conflicting
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>60% 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 hadn’t 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?
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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 physician’s 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 information…AND
consumers are a bit schizophrenic about it
too!
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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 doctor’s advice even if it conflicted with reliable
information from another knowledgeable source!!
HarrisInteractive, 12/04
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How do physicians
[‘AMERICAN IDOLS’]
need to change?
It’s really simple!!! (Ha!)
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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
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Patients won’t 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?
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Science: What works best given
what we know today
Clinician training & experience
Patient preferences,
understanding and values
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This isn’t 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!
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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?
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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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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!!
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Latest trend to make docs behave!
>100 P4P P’s & P’s 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….
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Withhold/bonus opportunity needs to represents
>10% 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!
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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 patient’s
understanding was the least frequently noted, at
2% (probably the most important to the doctorpatient relationship and to patient compliance)
(study of >3000 medical decisions involved in 1,000 visits; looked at 6 key
elements of informed consent or shared decision-making)
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What’s Needed &
What’s Missing?
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Trust (hard without a real long-term doctor-
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Good communications skills (physicians aren’t
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patient relationship)
really taught to communicate)
Adequate time (tough with a 5’48” office visit)
Incentives (docs aren’t 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 don’t think it
will make a difference in
the patient’s behavior!!
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What should employers/plans
do?
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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:
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Rewarding more efficient and high quality
care
Improving DM services for patients with highcost 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
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‘RED PILL/BLUE PILL’
(the Matrix Redux….)
Paternalism & Control
“I’m too busy to worry about fixing
the healthcare system”
Cost
“It’s an exit strategy”
“ I can predict my costs, as I shift
more to employees”
Quality
“It’s a plan issue”
“Why can’t physicians get their act
together”
“I need to focus on cost
management”
Empowerment & Support
“I can be an agent for community
collaboration”
Cost
“I’ll reward efficiency: P4P”
“I’ll 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
IT
“I make widgets!”
“I spend enough on healthcare
as it is!”
“I need to help my employees with
information”
“Good decisions will help productivity”
Benefit design
Benefit design
“My plan is the expert”
“One size fits all is fine”
“I don’t want to have to worry
about adverse selection”
“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 Healthcare—
a political consensus point?
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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’
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Collectively funds ~60% of
healthcare….perhaps its greatest leverage
point!
Other tools……
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Administrative law
Regulation
Executive orders
Legislation
The ‘bully pulpit’
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How Can Gov-Mint Be
Useful??
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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 industries—
a model??
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1st generation: personalized service
house calls, pharmacy delivery of meds, the milk man, full
service gas station, dry cleaning delivery
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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
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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 industries—
a model??
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4th generation: hybrid-customer
convenience + operational efficiency
on-line checking; catalogue ordering; Ebay
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Today’s 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???
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