|
Co-Sponsored
by The Robert Wood Johnson Foundation's Changes in Health Care Financing
and Organization (HCFO) initiative and The Commonwealth Fund. Conducted
by AcademyHealth.
September 15, 2003 - Wyndham City Center, Washington, D.C.
Meeting
Summary
“Consumer-Driven
Health Care: Evidence from the Field,” explored early study
findings and offered a useful forecast on the future of consumer-driven
health care. The take-home message seemed to be that the jury is
still out on the effects of consumer-driven health plans, but this
phenomenon bears careful watching. While efforts to advance this
type of insurance product continue, the health services research
community should continue its efforts to evaluate the product’s
pros and cons. Whether these plans thrive or go the way of managed
care is yet to be determined.
Employers’ Adoption of Consumer-Driven Health Plans
Jon
Gabel (HRET), Meredith Rosenthal (Harvard University), Roger Chizek
(Medtronic Inc.), and Peter Hayes (Hannaford Brothers Company) presented
research findings outlining a landscape of consumer-driven health
plans today. In a session moderated by Jennifer Edwards (The Commonwealth
Fund), they provided evidence on perceptions of and openness to
consumer-driven health plans, both through research findings and
real world experiences.
The
sentiment by many who participated in the conference was probably
best summed up by Gabel, who said, “I believe there [will
be] an irreversible trend towards consumer-driven health care in
the next few years, but that, too, can change.” In his analysis
of various sizes of employers, Gabel noted that while employers
are fairly familiar with consumer-driven plans, they do not appear
to be wholeheartedly embracing them; they question whether improved
quality of care and cost control will truly be the hallmark of these
plans. According to Rosenthal, early projections from a survey of
health plans suggest increasing enrollment in consumer-driven plans
over the next year. She added, however, that there is not a clear
indication that consumer-driven health plans will spur value driven
competition in the health care market.
Offering
an employer’s perspective, Chizek touted consumer-driven health
care as a product that made sense for Medtronic. Chizek pointed
out that their goal in offering a consumer-driven plan was not to
reduce the company’s health care costs, but rather to offer
an alternative product designed to inform consumers, create awareness,
change behavior, and increase access. Hayes expressed a similar
sentiment, noting that at Hannaford Brothers Company, consumer-driven
health care is viewed as “partnership-fostering”—
a partnership among physicians, hospitals, and employees. The challenge,
said Hayes, has been to get employees interested in gathering information
to make the right health care decisions and get the right care.
Risk Selection: Who Chooses Consumer-Directed Health Care?
Roger
Feldman (University of Minnesota), Laura Tollen (Kaiser Permanente),
Stephen Bandeian (MAMSI), and Terry Jayne (Group Health Cooperative),
moderated by Anne Gauthier (AcademyHealth), explored the potential
for favorable and adverse selection into consumer-driven plans,
as compared with other offerings to the same employee population.
Results here were mixed. Feldman’s early findings suggest
that consumer-driven plans may not lead to the undesirable consequence
of segmenting the risk pool into healthier and less healthy groups,
at least among the University of Minnesota employees. In Tollen’s
examination of Humana’s consumer-driven plan, she noted that
preliminary results suggest possible risk segmentation. She emphasized
that a number of unanswered questions remain relative to the consequences
of such segmentation, and that an important factor is how employee
choices are designed.
Bandeian
pointed out that the occurrence of risk selection is highly situational
and suggested that more research is needed to truly understand the
how, when, and why surrounding this issue. He further noted that
while adverse selection is extremely hard to detect in practice,
the failure to detect and monitor such a trend, whether in a consumer-driven
plan or traditional plan, could lead to unfortunate consequences.
Jayne
highlighted the issue of consumer takeup and noted that while consumer-driven
plans may be the “new kid on the block,” there are many
consumers who are not interested in something “new.”
They would rather have something “familiar.” Out-of-pocket
costs, plan complexity, network restrictions, and deductible size
are just some of the factors that employees consider when evaluating
a consumer-driven plan.
Consumers’
Experience
Jon
Christianson (University of Minnesota), Jinnet Fowles (Park Nicollet
Institute), Judy Hibbard (University of Oregon), and David Lansky
(FACCT), with moderator Katie Martin (AcademyHealth), highlighted
employees’ experience with consumer-driven products, including
the rationale for their choice, their satisfaction with the choice,
and how well they were able to navigate plans. Christianson described
the actions of the hypothetical “savvy consumer” versus
the “naïve consumer”— the two extremes of
individuals who make relative choices in consumer-driven plans.
In Christianson’s study of individuals enrolled in Definity
Health, a consumer-driven plan, and other health plans, early findings
suggest that Definity enrollees were neither savvy nor naïve.
There did not appear to be deliberate differentiation among plans.
Rather, choices were made simply on the availability of options
that work best for the consumer.
Fowles
observed some potentially troubling trends in her analysis of Humana
employees enrolled in a consumer-driven plan, such as the potential
for increased costs, increased confusion, and increased risk segmentation.
The success of a consumer-driven approach, according to Hibbard,
rests on the assumption that if consumers are given financial incentives
and cost and quality information, they will make cost-effective
choices. She noted that there are challenges in making such choices,
including a steep learning curve for consumers as they sort through
the many new features of consumer-driven plans. Early choices and
behaviors may change over time. Accordingly, said Hibbard, a longer
window of opportunity to observe consumer experience with these
plans will provide a richer understanding of how the plans are fairing.
For consumers to realize the many potential advantages of these
plans, appropriate educational and informational support is required.
In
focusing on what it is that consumers really want, Lansky remarked
that consumers make health care decisions based on relationships.
Consumers will pay more and make choices based on their ability
to interact with a provider, rather than on objective information
about providers’ qualifications and experience. Given this
fact, the information on which those decisions are made is inadequate,
whether the information is coming from consumer-driven plans or
other plans. Lansky noted that his research shows that health care
consumers want four things: (1) help choosing treatments and providers;
(2) good communication with providers; (3) information about which
of the “best practices” apply to them; and (4) their
providers’ economic incentives. Consumer-driven plans may
not yet be giving consumers the tools to get this information.
Evidence about Utilization, Spending, and Cost
Steve Parente (University of Minnesota), Tomas Valdivia (Definity
Health), and John Bertko (Humana Inc.) highlighted the experience
of employers and employees with respect to utilization patterns,
spending, and costs associated with consumer-driven plans, as compared
with more traditional plans. Thomas Rice (UCLA), who moderated the
panel, noted that it is critically important to determine through
research whether consumer-driven care leads to more or less squandered
resources. Parente cautioned that his research involving employers
who offer Definity Health is at its early stages, and while evidence
on costs and utilization was mixed, more work will be needed to
verify and fully understand his results.
Valdivia
noted that currently, Definity Health’s membership total is
greater than all other consumer-driven plans across the country
(more than 75 employers offer Definity Health). He suggested that
increasingly, consumers are driving provider behavior and influencing
outcomes measures. This, he believes, will ultimately lead to improved
care, lower costs, and greater satisfaction.
Bertko
discussed some of the experiences of Humana employees who selected
a consumer-driven plan. He noted that employers who offer consumer-driven
plans are most interested in what it will cost them, and how much
of the cost savings should be shared with employees.
Implications: Good News? Bad News?
In
the final panel discussion, Karen Davis (The Commonwealth Fund),
Paul Ginsburg (Center for Studying Health System Change), Mark Pauly
(University of Pennsylvania), Gerald Shea (AFL-CIO), and Robert
Stevens (Ridgeview Medical Center) discussed the strengths and weaknesses
of consumer-driven health plans in light of the research findings
described earlier in the day. The panel was moderated by Susan Dentzer
(News Hour with Jim Lehrer).
Davis
noted that it is really too early in the life of consumer-driven
plans to know whether they will serve as a major strategy for reforming
the U.S. health care system. While there is modest interest in the
plans right now, there is also serious concern about the potential
for risk segmentation and heavy financial burdens for low-wage workers.
Davis noted that more systematic data collection on costs and quality
is needed at the individual and provider level.
Ginsburg
pointed out that the core of the consumer-driven plan is the health
reimbursement account (HRA) — an account from which consumers
draw to make health care purchases. He questioned whether an HRA
is an efficient way of providing health benefits, noting that in
the process, employer dollars are given to healthy employees who
would not otherwise have those dollars. Ginsburg suggested that
the role for government in these plans could be to gather and supply
quality information about providers.
Pauly
concluded that sorting through consumer-driven plans ought to be
left to the market, not federal policymakers. Pauly also noted that
consumer-driven plans were not likely to control health care costs
and improve quality—that there is no way “to have more
for less.”
Shea
noted that the jury is still out on consumer-driven plans and it
is clear that the system will not work for everyone. He pointed
out that the current health care system would benefit from standard
performance measures, a more efficient way of gathering performance
information, an alignment of payment with quality care physicians,
wide public reporting, and a different approach to educating physicians
on how best to partner with consumers.
Stevens
echoed Shea’s sentiment and noted that the government should
take a more direct role in the distribution of quality information
about hospitals and physicians. Stevens, who works as a physician
in a physician/hospital organization that offers its employees a
consumer-driven plan, further noted that much more needs to be invested
in the development of the electronic medical record and other information
systems that can provide real time information to employees.
|
