Consumer-Directed Health Care
http://www.100md.com
《新英格兰医药杂志》
For the past century, a premise of health policy has been that patients are ill equipped to judge the merits of tests, treatments, and providers. Conventional wisdom says that physicians should fill this gap by acting as patients' agents, telling them about the risks and benefits of clinical alternatives and ignoring costs when assessing these alternatives.
But a diverse group of business leaders and public officials intends to overturn this wisdom and radically transform the physician's role. To motivate patients to take charge of their own care, they're aiming for a wholesale shift of medical costs to consumers. To empower patients to take charge, they're developing sophisticated ways to spread information about treatment efficacy, provider quality, and price.
This past August, President George W. Bush ordered Medicare and other federal health programs to report publicly on the prices and the quality of care provided by doctors and hospitals. Within a few days, Aetna announced that it would post on its Web site quality ratings of specialists, along with the prices it has negotiated with doctors. Later this year, Revolution Health, a firm created by America Online cofounder Steve Case, former Secretary of State Colin Powell, and others, is expected to launch a Web-based venture offering information about costs, quality, and efficacy — to "put patients in control of their health care decisions." These steps are a shock to an industry that treats prices as competitive secrets and is, at best, ambivalent about measuring and comparing quality.
Entrepreneurs focused on clinical transparency are counting on a large shift of costs to consumers, a shift that appears to be underway. Deductibles and copayments are rising faster than inflation, and insurers are aggressively promoting "consumer-driven health care," which combines high-deductible coverage with tax-advantaged medical spending accounts. Consumers and employers save on premiums, but out-of-pocket costs can exceed $10,000 per year for families. Critics warn that such plans will leave many people less healthy and at risk for financial catastrophe. But proponents promise that the plans will transform patients into value-conscious purchasers.1
For market-oriented health care reformers, this shift represents an extraordinary turnabout. For a generation, they wagered on managed care and on the premise that competition among health plans would hold down costs. In the mid-1990s, medical spending temporarily stabilized. But consumers rebelled against managed care's constraints, health plans backed off, and spending again soared. Americans seemed willing to pay for clinical freedom. Some observers concluded that consumers wouldn't accept overt cost–benefit trade-offs in health care. Others argued that competition had merely been misdirected — that consumers should manage their own care and would do so if they had "skin in the game."
In the late 1990s, a few small insurers tried this approach, by linking high-deductible coverage to health care reimbursement accounts, to which subscribers (or their employers) could contribute annually. Reported success in trimming spending attracted interest among benefits consultants and libertarian conservatives. An alliance coalesced among conservative activists, insurers, and financial institutions that saw potential revenues in medical savings plans. They lobbied Congress for tax changes to encourage consumers' interest in savings vehicles for out-of-pocket health care spending.
They also persuaded the Bush administration to include the "consumer-directed" paradigm in its "ownership society" agenda. Political success followed. The 2003 Medicare prescription-drug law permits insurers and employers to offer health savings accounts (HSAs) to purchasers of high-deductible coverage. HSA holders and their employers can contribute amounts up to their deductibles (subject to caps) to these tax-free accounts and spend the funds on health-related services without restraint by utilization reviewers. Advocates argue that the accounts' tax-free status offsets employees' ability to pay for health insurance with pretax dollars and that consumers are empowered by having control of their own resources.1
So far, benefits consultants and health plans have had limited success in selling HSA–high-deductible plans: only 20% of American workers were offered such plans in 2006, and only 4% chose them (see bar graph).2 Many employers remain skeptical about claimed cost savings and wary of workers' reactions. But no other approach on the political horizon promises relief from massive cost increases.
Health Plan Enrollment According to Type of Plan.
Data are from Claxton et al.2 Information was not obtained for point-of-service plans in 1988; 2006 is the first year for which data were collected on high-deductible health plans with savings options as a distinct type of plan.
Critics press several objections. Some dismiss proponents' talk of "consumer direction" as thin cover for shifting costs from firms to their workers as employers try to limit labor costs. Patients' cost sharing has increased since the 1990s, as have employees' shares of insurance premiums. Indeed, a comparison of HSA–high-deductible plans and conventional coverage showed similar levels of cost sharing.3 But greater cost sharing is inevitable, in the absence of employees' willingness to accept lower wages to maintain current coverage levels. So long as medical spending rises faster than overall compensation (salaries plus fringe benefits), it will impose a growing burden on workers and their families. Better information about prices and quality can help them to manage this burden.
Whether the HSA–high-deductible model can achieve meaningful cost control is unclear. Skeptics note that most medical spending occurs on an urgent basis, in the hospital, after patients have reached their out-of-pocket maximums. Copayments and deductibles have minimal influence on spending in these circumstances.4 But outpatient tests and doctors' visits — the kind of care discouraged by copayments and deductibles4 — often trigger cascades of clinical intervention that result in costly hospitalization, covered by insurance. High out-of-pocket requirements thus restrain hospital spending indirectly, by discouraging consumers from seeking care initially. The extent of the ensuing savings is unknown, as are the health risks of failure to diagnose and treat illnesses at an earlier stage.
Indeed, critics warn that self-paying patients will skimp on high-benefit, low-cost preventive services. But high-deductible plans can cover preventive care fully, without copayments or deductibles. So far, most plans have done so, but such coverage should be a legal requirement. Market forces won't guarantee it, since workers change jobs (and health plans) too quickly for employers and plans to capture the financial benefits of prevention.
Skeptics also point to the inadequacy of the price information available to consumers willing and able to shop for savings and value. Providers and health plans typically treat negotiated prices as competitive secrets, and patients often discover what they owe only when they are billed. Katherine Baicker, a member of the Council of Economic Advisors and a White House point person on health policy issues, asserts that migration of patients into high-deductible health plans will compel providers to post prices. Aetna's move toward price transparency is promising, as is the appearance of Web portals like that planned by Revolution Health. But neither providers that discount strategically to maximize revenue nor health plans that want to prevent competitors from beating their negotiated discounts have much incentive to publicize prices.
Lack of information about providers' quality and the efficacy of tests and treatments is an even larger problem. Research on efficacy has been limited by the resistance of drug and device makers and medical specialty societies, which fear that such information might reduce demand for their products and services. Health plans have the clinical data to conduct more of this research but lack incentives to support it at the needed levels, since the benefits accrue to all, not just to those who pay for it.
Despite some progress toward empirically valid measures of quality, such data have not been collected comprehensively and made accessible to patients at the moment of decision.5 Firms like Revolution Health could become pioneers in this arena if they can build sustainable business models, perhaps by selling data to employers and health plans. Regulation, along with pay-for-performance schemes, may be necessary to win widespread provider cooperation with performance measurement.
Critics also warn that insurance risk pools will unravel if healthy people opt for high-deductible plans, leaving the sick with much higher premiums for traditional coverage. If such self-selection occurs within an employer's covered population, cross-subsidies from healthier to sicker subpopulations could compensate for risk variation, or the employer could hedge differences in risk by engaging a single health plan to offer multiple coverage alternatives. But these solutions offer little help to patients with serious, chronic, or recurring illness who find themselves in HSA-based plans. Not only will they quickly deplete their HSAs, they will also have to pay out-of-pocket maximums that greatly exceed most HSAs — for many, a formula for financial ruin. Potential solutions — lower out-of-pocket maximums and higher employer contributions to HSAs for the chronically ill (however they are defined) — would be expensive, undermining the appeal of HSAs as a cost-control strategy.
Fixes of this sort can at best soften the impact of medicine's movement toward multiple levels of care, meant to accommodate patients' individual "menu" selections, based on ability to pay. Socioeconomic disparities in care are becoming more deeply embedded in national policy, and racial disparities are liable to widen. Comprehensive, workplace-based coverage rendered employment more relevant than wealth in determining access to care. High cost sharing, by contrast, magnifies the importance of family resources. Large gaps in wealth between blacks and whites, and thus differences in purchasing power, persist across all income brackets (see line graph), a legacy of past inequity and present disparities in inheritance.
Median Net Worth According to Race and Income.
Among Americans with an annual income of more than $119,999, the median net worth of non-Hispanic whites is $5,778,250; and of blacks, $657,900. Data are from the Federal Reserve Board's 2001 Survey of Consumer Finances; analysis by Seth Stephens-Davidowitz of the Brookings Institution.
For physicians, the shifting of costs to patients poses profound ethical challenges. Should they offer multiple levels of care — indeed, does Hippocratic fidelity to patients' needs (including their financial constraints) require them to do so? Or should doctors resist, perhaps by adopting sliding-fee scales and pressing hospitals to do the same?
Moreover, how should medical malpractice law, which defers to standards set by physicians, treat these differing levels of care? Should licensing and accrediting boards accept them? Should medical educators teach trainees to provide them?
Whether patients will tolerate an overt clinical class system is uncertain. Americans have become accustomed to multiple tiers of comfort and convenience in myriad spheres of life. But they may rebel against an open link between wealth and life-preserving effort, forcing health care payers to find alternative ways to set limits.
Source Information
Dr. Bloche is a professor of law at Georgetown University and a nonresident senior fellow at the Brookings Institution, both in Washington, DC, and an adjunct professor at Bloomberg School of Public Health, Johns Hopkins University, Baltimore.
References
Scandlen G. Consumer-driven health care: just a tweak or a revolution? Health Aff (Millwood) 2005;24:1554-1558.
Claxton G, Gabel J, Gil I, et al. Health benefits in 2006: premium increases moderate, enrollment in consumer-directed health plans remains modest. Baltimore: Health Affairs, September 26, 2006 (Web Exclusive).
Remler DK, Glied SA. How much more cost sharing will health savings accounts bring? Health Aff (Millwood) 2006;25:1070-1078.
Newhouse JP. Consumer-directed health plans and the RAND Health Insurance Experiment. Health Aff (Millwood) 2004;23:107-113.
Statement of Paul B. Ginsburg, President, Center for Studying Health System Change, before the Congress of the United States, Joint Economic Committee, hearing on the next generation of health information tools for consumers. May 10, 2006. (Accessed October 5, 2006, at http://www.hschange.com/CONTENT/845/.)(M. Gregg Bloche, M.D., J.)
But a diverse group of business leaders and public officials intends to overturn this wisdom and radically transform the physician's role. To motivate patients to take charge of their own care, they're aiming for a wholesale shift of medical costs to consumers. To empower patients to take charge, they're developing sophisticated ways to spread information about treatment efficacy, provider quality, and price.
This past August, President George W. Bush ordered Medicare and other federal health programs to report publicly on the prices and the quality of care provided by doctors and hospitals. Within a few days, Aetna announced that it would post on its Web site quality ratings of specialists, along with the prices it has negotiated with doctors. Later this year, Revolution Health, a firm created by America Online cofounder Steve Case, former Secretary of State Colin Powell, and others, is expected to launch a Web-based venture offering information about costs, quality, and efficacy — to "put patients in control of their health care decisions." These steps are a shock to an industry that treats prices as competitive secrets and is, at best, ambivalent about measuring and comparing quality.
Entrepreneurs focused on clinical transparency are counting on a large shift of costs to consumers, a shift that appears to be underway. Deductibles and copayments are rising faster than inflation, and insurers are aggressively promoting "consumer-driven health care," which combines high-deductible coverage with tax-advantaged medical spending accounts. Consumers and employers save on premiums, but out-of-pocket costs can exceed $10,000 per year for families. Critics warn that such plans will leave many people less healthy and at risk for financial catastrophe. But proponents promise that the plans will transform patients into value-conscious purchasers.1
For market-oriented health care reformers, this shift represents an extraordinary turnabout. For a generation, they wagered on managed care and on the premise that competition among health plans would hold down costs. In the mid-1990s, medical spending temporarily stabilized. But consumers rebelled against managed care's constraints, health plans backed off, and spending again soared. Americans seemed willing to pay for clinical freedom. Some observers concluded that consumers wouldn't accept overt cost–benefit trade-offs in health care. Others argued that competition had merely been misdirected — that consumers should manage their own care and would do so if they had "skin in the game."
In the late 1990s, a few small insurers tried this approach, by linking high-deductible coverage to health care reimbursement accounts, to which subscribers (or their employers) could contribute annually. Reported success in trimming spending attracted interest among benefits consultants and libertarian conservatives. An alliance coalesced among conservative activists, insurers, and financial institutions that saw potential revenues in medical savings plans. They lobbied Congress for tax changes to encourage consumers' interest in savings vehicles for out-of-pocket health care spending.
They also persuaded the Bush administration to include the "consumer-directed" paradigm in its "ownership society" agenda. Political success followed. The 2003 Medicare prescription-drug law permits insurers and employers to offer health savings accounts (HSAs) to purchasers of high-deductible coverage. HSA holders and their employers can contribute amounts up to their deductibles (subject to caps) to these tax-free accounts and spend the funds on health-related services without restraint by utilization reviewers. Advocates argue that the accounts' tax-free status offsets employees' ability to pay for health insurance with pretax dollars and that consumers are empowered by having control of their own resources.1
So far, benefits consultants and health plans have had limited success in selling HSA–high-deductible plans: only 20% of American workers were offered such plans in 2006, and only 4% chose them (see bar graph).2 Many employers remain skeptical about claimed cost savings and wary of workers' reactions. But no other approach on the political horizon promises relief from massive cost increases.
Health Plan Enrollment According to Type of Plan.
Data are from Claxton et al.2 Information was not obtained for point-of-service plans in 1988; 2006 is the first year for which data were collected on high-deductible health plans with savings options as a distinct type of plan.
Critics press several objections. Some dismiss proponents' talk of "consumer direction" as thin cover for shifting costs from firms to their workers as employers try to limit labor costs. Patients' cost sharing has increased since the 1990s, as have employees' shares of insurance premiums. Indeed, a comparison of HSA–high-deductible plans and conventional coverage showed similar levels of cost sharing.3 But greater cost sharing is inevitable, in the absence of employees' willingness to accept lower wages to maintain current coverage levels. So long as medical spending rises faster than overall compensation (salaries plus fringe benefits), it will impose a growing burden on workers and their families. Better information about prices and quality can help them to manage this burden.
Whether the HSA–high-deductible model can achieve meaningful cost control is unclear. Skeptics note that most medical spending occurs on an urgent basis, in the hospital, after patients have reached their out-of-pocket maximums. Copayments and deductibles have minimal influence on spending in these circumstances.4 But outpatient tests and doctors' visits — the kind of care discouraged by copayments and deductibles4 — often trigger cascades of clinical intervention that result in costly hospitalization, covered by insurance. High out-of-pocket requirements thus restrain hospital spending indirectly, by discouraging consumers from seeking care initially. The extent of the ensuing savings is unknown, as are the health risks of failure to diagnose and treat illnesses at an earlier stage.
Indeed, critics warn that self-paying patients will skimp on high-benefit, low-cost preventive services. But high-deductible plans can cover preventive care fully, without copayments or deductibles. So far, most plans have done so, but such coverage should be a legal requirement. Market forces won't guarantee it, since workers change jobs (and health plans) too quickly for employers and plans to capture the financial benefits of prevention.
Skeptics also point to the inadequacy of the price information available to consumers willing and able to shop for savings and value. Providers and health plans typically treat negotiated prices as competitive secrets, and patients often discover what they owe only when they are billed. Katherine Baicker, a member of the Council of Economic Advisors and a White House point person on health policy issues, asserts that migration of patients into high-deductible health plans will compel providers to post prices. Aetna's move toward price transparency is promising, as is the appearance of Web portals like that planned by Revolution Health. But neither providers that discount strategically to maximize revenue nor health plans that want to prevent competitors from beating their negotiated discounts have much incentive to publicize prices.
Lack of information about providers' quality and the efficacy of tests and treatments is an even larger problem. Research on efficacy has been limited by the resistance of drug and device makers and medical specialty societies, which fear that such information might reduce demand for their products and services. Health plans have the clinical data to conduct more of this research but lack incentives to support it at the needed levels, since the benefits accrue to all, not just to those who pay for it.
Despite some progress toward empirically valid measures of quality, such data have not been collected comprehensively and made accessible to patients at the moment of decision.5 Firms like Revolution Health could become pioneers in this arena if they can build sustainable business models, perhaps by selling data to employers and health plans. Regulation, along with pay-for-performance schemes, may be necessary to win widespread provider cooperation with performance measurement.
Critics also warn that insurance risk pools will unravel if healthy people opt for high-deductible plans, leaving the sick with much higher premiums for traditional coverage. If such self-selection occurs within an employer's covered population, cross-subsidies from healthier to sicker subpopulations could compensate for risk variation, or the employer could hedge differences in risk by engaging a single health plan to offer multiple coverage alternatives. But these solutions offer little help to patients with serious, chronic, or recurring illness who find themselves in HSA-based plans. Not only will they quickly deplete their HSAs, they will also have to pay out-of-pocket maximums that greatly exceed most HSAs — for many, a formula for financial ruin. Potential solutions — lower out-of-pocket maximums and higher employer contributions to HSAs for the chronically ill (however they are defined) — would be expensive, undermining the appeal of HSAs as a cost-control strategy.
Fixes of this sort can at best soften the impact of medicine's movement toward multiple levels of care, meant to accommodate patients' individual "menu" selections, based on ability to pay. Socioeconomic disparities in care are becoming more deeply embedded in national policy, and racial disparities are liable to widen. Comprehensive, workplace-based coverage rendered employment more relevant than wealth in determining access to care. High cost sharing, by contrast, magnifies the importance of family resources. Large gaps in wealth between blacks and whites, and thus differences in purchasing power, persist across all income brackets (see line graph), a legacy of past inequity and present disparities in inheritance.
Median Net Worth According to Race and Income.
Among Americans with an annual income of more than $119,999, the median net worth of non-Hispanic whites is $5,778,250; and of blacks, $657,900. Data are from the Federal Reserve Board's 2001 Survey of Consumer Finances; analysis by Seth Stephens-Davidowitz of the Brookings Institution.
For physicians, the shifting of costs to patients poses profound ethical challenges. Should they offer multiple levels of care — indeed, does Hippocratic fidelity to patients' needs (including their financial constraints) require them to do so? Or should doctors resist, perhaps by adopting sliding-fee scales and pressing hospitals to do the same?
Moreover, how should medical malpractice law, which defers to standards set by physicians, treat these differing levels of care? Should licensing and accrediting boards accept them? Should medical educators teach trainees to provide them?
Whether patients will tolerate an overt clinical class system is uncertain. Americans have become accustomed to multiple tiers of comfort and convenience in myriad spheres of life. But they may rebel against an open link between wealth and life-preserving effort, forcing health care payers to find alternative ways to set limits.
Source Information
Dr. Bloche is a professor of law at Georgetown University and a nonresident senior fellow at the Brookings Institution, both in Washington, DC, and an adjunct professor at Bloomberg School of Public Health, Johns Hopkins University, Baltimore.
References
Scandlen G. Consumer-driven health care: just a tweak or a revolution? Health Aff (Millwood) 2005;24:1554-1558.
Claxton G, Gabel J, Gil I, et al. Health benefits in 2006: premium increases moderate, enrollment in consumer-directed health plans remains modest. Baltimore: Health Affairs, September 26, 2006 (Web Exclusive).
Remler DK, Glied SA. How much more cost sharing will health savings accounts bring? Health Aff (Millwood) 2006;25:1070-1078.
Newhouse JP. Consumer-directed health plans and the RAND Health Insurance Experiment. Health Aff (Millwood) 2004;23:107-113.
Statement of Paul B. Ginsburg, President, Center for Studying Health System Change, before the Congress of the United States, Joint Economic Committee, hearing on the next generation of health information tools for consumers. May 10, 2006. (Accessed October 5, 2006, at http://www.hschange.com/CONTENT/845/.)(M. Gregg Bloche, M.D., J.)