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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. To Recap…….

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consumerism in healthcare who needs to change and how do we make it happen

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

to recap
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!

but there are some disconnects that must be addressed
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 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
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!
the next big question

If this is to be the ‘Brave New World’ of healthcare, how do we ensure it is operationalized appropriately???



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..….

what can we expect from consumers
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’)

1 st personal responsibility a prime tenet of cdhc
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!!!

a tsunami is coming
A tsunami is coming!!!
  • 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
why are we getting fatter
Why are we getting fatter?
  • 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”!!!)


Super-size Everything

National Geographic August 2004

the perfect storm for obesity
The “Perfect Storm” for Obesity













Stages of change

Source: Prochaska & DiClemente

how do consumers view their role
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

2nd be compliant with therapy
2nd Be Compliant with Therapy

Without really good behavioral health communication programs patients really don’t 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
3rd shop for the best care
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

do people want to be involved the data is conflicting
Do people want to be involved? The data is conflicting
  • >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

what about the use of cost and quality information
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 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?
STILL, folks argue about whether consumers are capable of using information…AND 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 doctor’s advice even if it conflicted with reliable information from another knowledgeable source!!

HarrisInteractive, 12/04

how do physicians american idols need to change
How do physicians [‘AMERICAN IDOLS’]need to change?

It’s really simple!!! (Ha!)

  • Design their practices to be customer focused
  • Practice evidence-based medicine (EBM)
  • Engage in shared decision-making
1st customer focused practice
1st Customer-Focused Practice
  • 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!
2 nd ebm
2nd EBM

What is it?

  • Science: What works best given what we know today
  • Clinician training & experience
  • Patient preferences, understanding and values
this isn t happening
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

more evidence
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

one might conclude
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


When the rules of clinical practice are not clear, variation results from subjective opinion, practice preferences, and hospital capacity.

why is there all this variation
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…

IF there is evidence you are not a consistently good cook,


what do we do we p4p
What do we do? We P4P!!
  • 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

and once again consumers side with their docs
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??)

lack of enthusiasm aside will it be effective
Lack of enthusiasm aside….Will it be effective??

That depends….

  • 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
3 shared decision making
3. Shared Decision-Making

“Extreme Makeover “


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.

the evidence
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 patient’s understanding was the least frequently noted, at 2% (probably the most important to the doctor-patient 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)

what s needed what s missing
What’s Needed & What’s Missing?
  • Trust (hard without a real long-term doctor-patient relationship)
  • Good communications skills (physicians aren’t 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”……)

but the real barrier is
But the real barrier is….

Physicians don’t think it will make a difference in the patient’s behavior!!

what should employers plans do
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
how can employers really control costs
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)

red pill blue pill the matrix redux
Paternalism & Control

“I’m too busy to worry about fixing the healthcare system”


“It’s an exit strategy”

“ I can predict my costs, as I shift more to employees”


“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”


“I’ll reward efficiency: P4P”

“I’ll focus on care management”


“I recognize the need for total system redesign”

“I need to focus on integrated care & outcomes”

‘RED PILL/BLUE PILL’(the Matrix Redux….)
red pill blue pill

“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 don’t want to have to worry

about adverse selection”


“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”

the politics of healthcare
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 !!
consumerism in healthcare a political consensus point
Consumerism in Healthcare—a 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.
the power of guv mint
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’
how can gov mint be useful
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
consumerism in other industries a model
Consumerism in other industries—a 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

consumerism in other industries a model47
Consumerism in other industries—a model??
  • 4th generation: hybrid-customer convenience + operational efficiency

on-line checking; catalogue ordering; Ebay

  • 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