Maggie Mahar
02/01/2007
To many employers, “consumer-driven health care” sounds like the answer to their health care prayers. Give employees some skin in the game in the form of a high-deductible plan that requires that they pay, say, the first $2,000 of their medical bills, and these employees will be motivated to make sure that they are getting the best value for their dollars—quality care at a reasonable price.
There is just one catch: Patients already have skin in the game—their
own. And if they could, they would dearly love to protect that skin by making
sure they are getting the best possible care. No one wants an unnecessary
angioplasty, a sloppy colonoscopy or daily doses of an expensive drug that has
not been fully tested—no matter who is paying.The problem is this: Patients have no way of accurately determining whether the care they get is quality or not. Consequently, they still make bad medical choices, and employers never realize savings on the benefit plans they manage.
The myth that consumers are in a position to oversee their doctors was dealt a blow by a study of 236 elderly patients in two HMOs that was published in the February 2006 issue of Annals of Internal Medicine. When patients were asked to rate the quality of their care, they gave their caregivers an average score of 8.9 out of 10. That score seems fine, except that when researchers looked at the patients’ records and checked to see whether the HMOs were meeting generally accepted treatment guidelines, they determined that, on average, the score should have been 5.5. Diabetics were not being screened properly; patients diagnosed with acute myocardial infarction had not received aspirin within an hour.
Moreover, the patients receiving the worst care were just as likely to give their provider a 10 as those receiving the best treatment. The patient’s perception of quality tended to depend heavily on the physician’s communications skills. Did he appear to be listening? Did he speak confidently and clearly? These were the qualities that won high grades—even if the doctor was negligent.
Similarly, patients are likely to judge a hospital by its service rather than its science. As one hospital CEO told me: “Patients know if they like the room, the food, the nurse—but they have no way of knowing if they are getting the best care.” Even the most sophisticated patient can never be sure if his condition would have cleared up on its own if he had not had the operation, or if a less expensive treatment would have served just as well.
Medicine Show
Overtreatment drives skyrocketing costs. The consensus among medical researchers monitoring quality is that, today, one out of every three health care dollars is squandered on unnecessary treatments, unproven procedures and new, overpriced drugs and devices that are no better than the ones they have replaced.
In theory,
health care plans with high deductibles inspire consumers to sniff out value and
avoid unnecessary care. But in practice, surveys show that when cost-sharing
increases, patients are just as likely to skimp on necessary treatments as they
are to skip inappropriate care.
One study, published in June 2006 in the New
England Journal of Medicine, compared Medicare patients suffering from chronic
diseases who had pharmacy benefits capped to similar patients with no caps.
Those with limited coverage were less compliant in taking drugs their doctors
prescribed, had poorer control of their disease, and subsequently had higher
bills for both hospital and emergency care than those without caps on their
pharmacy benefits.
In other words, while in the short run these patients
were spending less, over the long run someone would spend more—and that someone
includes their employers and the taxpayers who fund Medicare. When consumers
make the wrong choices, everyone loses.
By trying to shift decision making to
patients, we are ignoring the real cause behind runaway health care costs. It is
not wanton consumption. By and large, health care inflation is a supply-side
problem. Patients buy what suppliers tell them they need.
Meanwhile, in a
profit-driven system, drug manufacturers, device makers and health care
providers are selling—and sometimes they are selling hard. In our zeal to reduce
health care costs, we cannot expect consumers to guess which treatments are
ineffective or needlessly expensive. Medical professionals—with no financial
interest in the outcome—must set standards for what insurance should cover,
based on the best scientific evidence available. This is not a job for the
patient.
Photograph by Matt Mahurin.
 | Maggie Mahar is the author of Bull! A History of the Boom, 1982–1999 and most recently, Money-Driven Medicine: The Real Reason Health Care Costs So Much. |