One of the most common justifications for consumer-driven medicine is reduced health care costs. The reasoning here is two-fold:
- Since they’re high-deductible and low premium, consumer-driven health plans require more out-of-pocket spending. Consumers are more cost-conscious when they have to actively shell out for purchases. As a result, they will user fewer health care services—and thus overall health care costs will fall.
- If consumers are in the driver’s seat, competition in an open market will drive prices down. For-profit providers will want to offer the best deal to get the most business. Consumers will also have better information thanks to the commoditization of medicine, which will translate medical jargon into universally comprehensible knowledge. Smarter consumers translate into less over-payment for services.
This is standard-issue free market orthodoxy at its finest. Unfortunately, this isn’t the whole story. In fact, there’s an even stronger argument to be made that consumer-driven health plans could lead to higher health care costs.
The Wrong Patients Forgo the Wrong Care
Research by the RAND Corporation’s health insurance experiment shows that when you shift costs to the consumer, patients forego both wasteful and effective care. And this is particularly true of the patients who cost us most in the long run—those suffering from chronic diseases.
A 2007 paper from the National Bureau of Economic Research looked at retired California public employees on Medicare, and its findings contradict some of the basic assumption of the consumerist movement.
The study’s authors–from Harvard, MIT, and the University of Oregon– found that chronically patients who are asked to shoulder more of their health care costs deferred, neglected, or opted-out of doctor’s visits and drugs when the price got too high. This short-term cost reduction led to long-term catastrophe, as their hospitalization rates were significantly higher than other patients suffering from chronic diseases. Immediate savings ultimately led to a greater—and otherwise preventable—use of more expensive care. Oops.
This makes a certain amount of sense. Chronic diseases are not always in-your-face. They often simply simmer. But if the disease isn’t managed, ultimately it explodes. Until that happens, it’s easy to ignore the problem, especially in a context of consumerism that places an emphasis on convenience above all else.
Meanwhile, chronic disease is the big ticket item in our health care system. You might think it would be
cancer. But most people with cancer either die or survive-they don’t
linger on, in need of continuous care, for twenty years. Ten percent of
the nation’s sickest patients run up 70 percent of our health care
bill, and most of them suffer from one of five chronic diseases
(diabetes, congestive heart failure, coronary artery disease, asthma
and depression). You can’t manage costs unless the system is built to
manage chronic diseases. Period.
Here consumerists would point out that more transparent information
would help consumers make better choices. But the reality is that no
one looks at health care costs in a vacuum—it’s one of many
expenditures that individuals and families have to juggle. Even if a
chronically ill patient knows exactly what to do, he or she might be
unlikely to do it when given the option to pay for treatment or
something else. That might be the “consumer’s right,” but it means
higher long-term costs for everyone.
Consumer-Driven Medicine Turns Healthcare into a Commodity
In a market-driven health care system, businesses try to maximize
revenue and minimize cost. The quickest way to do that is to market
what’s already out there, rather than waste time on true innovation.
Retail health clinics, for example, want to “cross-sell” by encouraging
patients to pick up other products that the store sells on their way in
or out of the clinic. Why? Because it’s a low-cost way to increase
profits: shuttle patients from the clinic to the prescription counter,
no muss no fuss.
A similar reasoning prevails in the prescription drug industry. A January study
from York University found that the U.S. pharmaceutical industry spends
almost twice as much on promotion as it does on research and
development. Again, it’s easier to troll for new customers than to
build a better product. Every enterprise wants to leverage existing
assets for as much profit as possible rather than incur the cost of
something new and risky. Volume becomes more important than quality.
Even when something new does come along, the emphasis is still on
volume of consumption rather than actual effectiveness. Recall a recent post of mine
on numbers needed to treat. Even though this stat is the final word on
drug effectiveness, it gets no airtime in drug marketing. Lipitor, the
world’s number one cholesterol-lowering drug, only helps one percent of
the people who use it. But this number is nowhere to be found in the
drug’s advertising, and despite its relative ineffectiveness it still
makes up a full one-quarter of Pfizer’s profit and has been prescribed
to over 26 million Americans.
Admittedly, Lipitor’s sales have been tanking recently, thanks to the
roll out of generic alternatives. But this small victory for market
logic doesn’t change the fact that millions of people are taking a drug
that does nothing for them. For consumers, this is not
cost-effective–—but for those selling the product, it is smart
business.
A more commoditized health care system will only exacerbate this
pattern. Yes, early research shows that patients cut down on health
care consumption when they foot more of the bill. But do we know that
what’s left—what they do actually consume—is in fact effective? If I
use less total health care, but what I do use is junk, than the
consumer movement isn’t an improvement.
In a consumer-driven system, where marketing becomes the central
principle behind our health care discourse (even more so than today),
it’s far from a sure bet that reduced consumption means smarter
consumption.
More Inequality
Markets are not about creating equality. This may not seem problematic
in most sectors, but in health care, I think, reinforcing existing
disparities is a dangerous strategy.
Consider health savings accounts, which favor high-income earners
because they are tax-free (richer people save more by not paying
taxes). More money in the savings account means more purchasing power.
More purchasing power means more health care options—not to mention
more providers falling at your feet to get your dollars.
But here’s the rub: such inequality is acceptable only insofar as a
rising tide lifts all boats. In other words, it’s okay if the rich get
relatively better health care so long as the health care of the poor
improves commensurately.
This seems unlikely in a consumer-driven health care system. More
out-of-pocket costs means less affordable care for the poor. Even if
health savings accounts do give some consumers a little health care
nest egg, the amount saved will likely follow income. If you look at
stock ownership in the U.S., for example—another investment that is
consistently promised as a great equalizer—the value of holdings is perfectly contoured to income.
In a market-driven system, health care prospects improve as you move up
the income ladder. But if those at the bottom don’t see a real boost,
we have a problem—socioeconomic status is a major predictor of health.
Ultimately it’s the poor who need access to health care that lies
beyond their means.
Here is the important point: because social environment and daily
living are major influences on health, the disadvantaged suffer more
when they consume less care than do the affluent. And when patients
have asked to have “more skin in the game,” it is the poor who are most
likely to forgo needed care. In 2003, the Center for Budget and Policy
Priorities cited research
from the RAND corporation that found “low-income adults and children
reduced their use of effective medical care services by as much as 44
percent when they were forced to make co-payments, a much deeper
reduction than occurred among those with higher incomes.”
The RAND study also found that “cost-sharing led to poorer health among
low-income adults — including worse blood pressure and vision — than
those who were not subject to co-payments.” Similarly, low-income
children in families with cost- sharing obligations were more likely to
be anemic and to have more untreated dental problems than children who
received free care.
By contrast, when the looked at higher-income people they find no
difference in health status between those who had had higher
cost-sharing obligations and those who did not.” Translation: the poor
have much farther to fall if they miss out on care.
Whether we are talking about people suffering from chronic diseases or
the poor, it turns out that consumer-driven care which shifts costs to
the patient leads certain vulnerable populations to disproportionately
negative long-term health outcomes.
And here, information is no panacea. Even when markets do their thing
and diffuse knowledge, it’s the “haves” who benefit most. A few years
ago two Columbia University professors charted the trajectory
of public health risks over the past thirty years to show that, even
when information did circulate and spur awareness, it was the upper
crust that benefited. Many years ago, smoking, HIV/AIDS, and coronary
artery disease affected everyone equally. But as time wore on, the
affluent became more aware of the risks and dangers. As a result, these
health problems settled in at the bottom of the socioeconomic ladder.
In a market-driven system which thinks of patients as “consumers”, this
disparity will also get worse: information will also be commoditized,
which means that the rich will be able to buy better, more current
information (just as they can now for stocks, investments, or market
projections).
Currently, the price tag of health care for the uninsured is over $40
billion. A system that perpetuates poor access to care for the
have-nots will only drive that bill higher.
Excellent piece!!! I wrote on the subject a while ago and took a slightly different twist to it:
Price competition in health care is a pipe dream —
There is no such thing as price competition in the health care industry, at least not the way we might perceive it. And should we ever get to that point, few patients who are really sick will seek out the lowest bidder for themselves or their kids. It isn’t going to happen.
Just the opposite is likely to occur. In the medical world, high price too often assumes high quality even when the opposite is true, and low price likely points to physicians unable to attract patients, or hospitals unwilling to spend money on proper technology or cleanliness. So the more expensive providers will have the advantage, and prices will increase rather than decrease.
For true competition to exist there must be the free flow of medical data and highly educated patients, both of which is more than we can expect in our society.
See the complete article at
http://moneyedpoliticians.wordpress.com/2007/10/06/price-competition-in-health-care-is-a-pipe-dream/
No healthcare system will save money until that other elephant in the room – medmal- is addressed.
Art, actual Medmal outlays are less than 1/2 of 1% of total healthcare costs, but resulting defensive medicine raises the costs to about 5%. We clearly need to switch to a three-judge medical court, and away from the 12-man jury. And we need a 3-strikes law for attorneys, where after the third frivilous case they have to start paying legal costs for both sides when they lose. But the biggest waste is the 31% consumed by the insurance bureaucracy, and a single-payer system will fix that.
Art, actual Medmal outlays are less than 1/2 of 1% of total healthcare costs, but resulting defensive medicine raises the costs to about 5%. We clearly need to switch to a three-judge medical court, and away from the 12-man jury. And we need a 3-strikes law for attorneys, where after the third frivilous case they have to start paying legal costs for both sides when they lose. But the biggest waste is the 31% consumed by the insurance bureaucracy, and a single-payer system will fix that.
There are two defects with the present system (and the proposals to shift more costs to individuals).
The first is that putting more of the cost on individuals is exactly the wrong thing to do. Catastrophic costs can never be covered by an individual (millionaires, perhaps exempted). That’s why we have an insurance pool. Those who want a free ride oppose having to pay into the pool. For some reason they mostly seem to be younger and healthier. Perhaps their views change when their risk profile increases.
Spreading the costs of risk over the entire population is the basis of a modern society. I’ve yet to hit a highway guardrail, but I’ve paid my portion for the thousands of miles of them that have been installed. I’ll be grateful for their presence if I ever do veer off the pavement. Why are people willing to share this risk, but object to health care?
The second defect is the huge increase in the role of monopoly power in the health sector. Patented drugs are priced at extortionate rates and there is nothing a consumer can do about it. Asking a person to make an “informed” choice when a standard course of chemotherapy costs $100K is implausible. Pay or die is not a good basis for decision making.
There is no rational public policy argument for the rise of monopoly medicine. It’s strictly based upon greed and done with the acquiescence of those in congress who are beholding to drug interests for campaign contributions.
The fact that other countries don’t permit such monopoly control shows that this is a self-inflicted wound on the US health system.
Both problems are political in nature and have political solutions. This is not like solving global warming which is dependent upon technological progress as well.
Get the money out of the electoral process and politicians will listen to their constituents instead of those who are funding their campaigns and you will see progress on health cost controls. Everything is connected.
Consumer driven medicine makes as much sense as consumer driven police or fire!!
“hello, yes my house is on fire, what do you charge for standard extinquishing?”
“what type of house?”
“well, it has two floors, about 1800 sq feet….oh, nevermind I think i have to solicit prices for clean up and construction”
As this once professional service – medicine – keeps churning into a business, private insurers will keep placating physicians because they fit into their overall plan. This has happened in the tort-deform arena and in the medical vendor arena. But businesses will no longer stand still for the exorbitant health care costs, and the consortiums will start creating their own health care systems and mitigate expensive and profitable services. Doctors will ultimately have to become employed by the corporations, because they control employee health care contracts. There is one thing that can be said about free-market executives: they believe in profit as long as it is they who are making it and no one else is. That’s the way business works.
We can choose to have a universal health care system, with proper funding and fair reimbursements, or continue having an HMO-for-all system run by the corporate consortiums whose main goal is cutting costs (services) and increasing profits for itself and/or shareholders, rather than providing high-quality health care. A universal health care system is not socialized medicine because doctors and hospitals remain as independent contractors. Under the present HMO-for-all type systems, doctors are becoming employees of the hospitals instead of remaining as independent contractors.
A universal health care system will not harm health care competitiveness because competitiveness does not exist in present market-driven medicine. Our market-based health care system is driving manufacturers and jobs out of the country. The big-three auto manufacturers make more automobiles outside the United States than inside because their per-employee costs are drastically lower on the outside than on the inside. This happens to many other industries as well.
Profit-seeking executives should not get rich on the backs of the public and our nation. A very good “second opinion” on the failure of our market-based health care was just published in the February 7, 2009 issue of the New England Journal of Medicine.
http://content.nejm.org/cgi/content/full/358/6/549
That is so interesting! I am a big believer in the “free maket” in general, but can really see after reading this where such forces may not apply in the instance of long term health vis-a-vis chronic illness.
Excellent Post, Greg. If you follow the dominoes, the end result MUST BE corporations providing direct care. I understand that Motorola is already doing that.
Here is something I wrote re: HSAs.
First, they are being pushed by an insurance industry trying to stay in the healthcare profit loop, and they are willing to share those profits with the politicians that make it all happen. (Can anybody spell “political corruption”?)
In the process they seek to siphon off the young and invincible and dangle the so-called “savings” to suck them in. Unfortunately some will buy the argument without looking at the risks.
1) People say” “After the deductible, the insurance kicks in, and we’re covered.”
Don’t count on it. You assume that it is catastrophic coverage and the company is not going to bail out (read that; cancel your contract) when you get really sick and you need it. They are already doing that today (ask Blue Cross for details). They all have a legal “out,” and when they need it they look at pre-existing diseases not disclosed (did you think they forgot that?). You assume that when you exceed the personal deductible that they are not going to have gatekeepers and deny care and interfere with the doctor’s decisions like they do today. Don’t count on it. When your money runs out and *they* have to start paying, you are in trouble.
2) Their job is to siphon off the well and leave the sick to fend for themselves. Not only will this drive up the costs of all other insurance policies, it removes the “well patient” from any pool that will make health care affordable for all.
3) Yes, those in the HSA will now start looking at costs and avoid doctors whenever possible. They’ll avoid both wasteful AND needed care, the latter of which will delay care until it is more costly to treat or becomes untreatable. That may help us, incidentally, because those who die prematurely no longer expend costs.
4) Delaying care will be costly, both to you and your employer. Indeed they will end up with a sicker workforce, that’s the only direction it can go. And the current benefits to employers will depart as they start losing workers to better benefits down the street.
Are HSAs a good idea? One way to test this is to mandate them for the politicians. See if they’ll pass that! Another is to eliminate the cash that flows between the insurance industry and the politicians and see if it still passes. Not just delay the money, eliminate it also in years to come.
The answer is, without both of those plumbs, they will continue to push the industry’s agenda. And those who don’t understand the issue will continue to believe the industry’s hogwash.
Jack Lohman
http://moneyedpoliticians.wordpress.com/2008/01/07/ten-needed-fixes-for-the-health-care-system/
When I intubate a critically ill child in respiratory failure I don’t then turn to the parents and ask: “So, do you want the fancy ventilator with all the graphics and special tricks or do you want this plain-Jane one that works pretty well, most of the time at least?” Choosing medical care is not like other consumer choices; the model is fundamentally flawed.
I asked in another comment thread how your proposed system would be different from those in Canada and the UK. The response was that Canada’s is just fine, thanks. We can argue that later, but I’ll ask you this: How is your proposed plan different from that recently started up in MA?
http://online.wsj.com/article/SB120286237129063819.html?mod=todays_us_page_one
No matter how wonderful it would be to provide perfect health care to everyone, you’re going to have to pay for it one way or another.
THe singular of data, of course, is not anecdote. Nevertheless, I had an experience last week that did not speak well to consumer-based medicine, although, when I escalated the matter, it seems to have been taken very seriously by the senior staff at the group.
Last week, I saw a specialist for a consultation. When I left her consulting room, I was trembling with rage, and didn’t get around to revoking records release and permission-to-treat until the next day. Somewhat cynically, I wonder if some of the serious response was due to the front office knowing the formalism of what was not yet the substantive complaint, but the withdrawal of consent and citation of the HIPAA Privacy Rule.
It wasn’t that this was a physician set in her ways for many years; she was younger than I am. We began with the usual “what brings you here”, and I started to review the reason for the visit, essentially specialist consultation on some drug interactions. The earlier discussion with my primary care physician did go to the level of molecular pharmacology, and I thought I’d carry on the specific concerns in the consult.
No such luck. She appeared absolutely unwilling to discuss specific points in a specific manner. In a condescending manner, she seemed to insist that any point I brought up was wrong. Unfortunately, I didn’t bring my copy of Goodman & Gilman’s The Pharmacological Basis of Therapeutics along, which may have been just as well–I might have considered using it as a blunt instrument rather than a reference book.
Serious question: was this a physician that might have been fine in a consumer-oriented environment, as long as her authority was not questioned? Alternatively, was this behavior indicative that she had a need to control every interaction?
It’s a good question if she might have felt more secure with a patient that exclusively used lay terms. Nevertheless, I not only used correct terminology, but expressed them in the same way I produce consultant reports from expert systems.
I suppose there was competition in that I fired her from my case, went to the group medical director, and asked for an alternate clinician.
Even if CDM did cut costs it is likely to do so in a way that’s detrimental to health, so what are the specific policy change/reform objectives? For years there’s been a mantra among nurse health reform activists, as well as others, that reform efforts (political and grassroots), policies, and plans must simultaneously tackle Cost, Access, and Quality because they are so interdependent.
Since the HSA model draws largely on the RAND data, the link below is to an old blog post by J Gruber on Boston’s NPR affiliate, wbur, health reform blog from a year ago fits into this discussion – and even more useful are the many excellent comments/criticisms.
btw it’s going from bad to worse here in Massachusetts; this link http://blog.hcfama.org/?p=1442#comments takes you to tables that outline the myriad proposed – to be voted on tomorrow by state-appointed volunteer bureaucrats – health insurance cost shifts to low income state residents who, under the MA Plan, now have subsidized private HMO coverage. The law was bad on paper before Romney signed it and many of us were doing our best to stop it but we couldn’t. What a disgrace on our state.
http://www.wbur.org/weblogs/commonhealth/?p=23#comments
What is Insurance? by Jonathan Gruber
While consumer directed plans are standard fare for free market conservatives, the fact is there are a series of economic paradoxes working in direct contradiction to conventional market behaviors that undermine cost containment strategies:
· The price inelasticity paradox: People don’t choose to be sick like they choose to buy a car or a pair of shoes. Demand for health care is relatively price-inelastic, meaning a high price won’t necessarily keep them from seeking care, though they may delay care until they can’t wait any longer, triggering greater cost for more expensive care. When you’re sick, you’ll hock the family farm to get care. That’s partially why medical debt is the leading cause of personal bankruptcies.
· The inverse supply paradox: Because demand is price inelastic, when supply is expanded, through additional health care providers, diagnostics or therapies, demand expands with supply. Patients will want all there is, they won’t settle for a mere X-ray if they can get an MRI, or better yet a CT scan if it is available. Medical services are cost-push inflationary – meaning most of the spike in health care expenditures comes from increased utilization of services, not price. In fact, physician fees have been relatively flat or declining for years, yet costs still escalate – a consequence of rising demand and increased utilization.
· The price transparency paradox: Although patients can now access an ever-growing amount of health care pricing and scientific information, the bulk of it is useless for most consumers. As Princeton’s Uwe Reinhardt famously warns, you can’t rely on caveat emptor to police the market, because the emptor doesn’t know how to caveat. Patients lack the sophistication necessary to know what health care they should or should not purchase. Cheap isn’t always best. And imposing evidence-based standards, however clinically sound, may well increase costs. According to a Rand Corporation study last year, patient and payer expenditures are effective only about half the time. One could also observe the considerable sums wasted on quack and self-cures, despite an abundance of evidence against those choices.
· The efficiency paradox: This is what economists call Baumol’s law, for the economist who codified the phenomenon. Simply stated, you can’t impose efficiencies on medical productivity in order to save money, because of the personal, handicraft nature of professional services. No matter the technological advances in medicine, it still must be applied by hand, one patient at a time. Medical productivity has an organic resistance to scalability and its related efficiencies.
· The power curve paradox: This paradox occurs when most of the resources are consumed by a small portion of the grid. There isn’t a health care analyst on the planet who can’t cite the statistics. Twenty percent of the patients account for 80 percent of the health care expenditures. These are your trauma victims and your infirm, disabled, chronic, palliative and end-of-life patients.
What our health care system needs is more transparency. If there is ever to be a link between price and the “value” of health care services, all the players will have to show their cards. Structural and economic impediments notwithstanding, no market – especially in health care systems – can function with incomplete information.
As the market continues to transition away from employer sponsored to consumer directed, if this model is to succeed (which is highly questionable) individuals must have access real-time information on benefits, coverage and costs.
All,
Thanks for your insightful comments. This has been such an interesting discussion that I’m going to post early next week again on this topic, and will rely heavily on the points you’ve made to take the discussion to the next level (each commenter will be credited, of course). I look forward to any additional comments between now and then.
As corporate healthcare benefits have continued to soar, IndUShealth has created a global healthcare solution that can generate immediate hard-dollar savings, and is also easy to implement. Because the first question is typically, “how much can I save?” IndUShealth has created a Global Healthcare Option Calculator that allows corporate benefit managers to obtain estimates of potential savings. See http://www.indushealth.com/corpsavcalc.htm
Offering a Global Healthcare Option to subscribers has also been demonstrated to lower the annual cost increases faced by employers located in certain communities, especially those with fewer competitive local offerings. IndUShealth programs have also begun to result in a reduction in stop-loss insurance claims, thereby reducing premium increases associated with their annual policy renewal. It is estimated that within two to three years of launching their IndUShealth Global Healthcare Option programs, these two forms of additional savings related to access to care in their local communities rival in magnitude to the hard-dollar savings achieved by those plan participants who elect to travel overseas for care.
As corporate healthcare benefits have continued to soar, IndUShealth has created a global healthcare solution that can generate immediate hard-dollar savings, and is also easy to implement. Because the first question is typically, “how much can I save?” IndUShealth has created a Global Healthcare Option Calculator that allows corporate benefit managers to obtain estimates of potential savings. See http://www.indushealth.com/corpsavcalc.htm
Offering a Global Healthcare Option to subscribers has also been demonstrated to lower the annual cost increases faced by employers located in certain communities, especially those with fewer competitive local offerings. IndUShealth programs have also begun to result in a reduction in stop-loss insurance claims, thereby reducing premium increases associated with their annual policy renewal. It is estimated that within two to three years of launching their IndUShealth Global Healthcare Option programs, these two forms of additional savings related to access to care in their local communities rival in magnitude to the hard-dollar savings achieved by those plan participants who elect to travel overseas for care.
To have a good idea of the cost comparison, one can visit http://www.valuemedicare.com/costcomparison.html
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I found a great prescription discount card at http://www.rxdrugcard.com. Let me give you an example of the savings. I’ve seen ads on TV for Caduet. It has two ingredients. One is Amlodipine and the other is Atorvastatin. With my RxDrugCard I can get 30 tablets of Amlodipine for $9 and 30 tablets of Simvastatin for $9. I’ll bet they are charging more than $18 for this new drug! I think that RxDrugCard.com is the best drug card available for prescription discounts. The monthly family membership fee is only $4.95! You can’t beat that!
Whenever there is talk about consumer driven health, some commentators argue against the consumer driven healthcare, based on the assumption that people do not want to take responsibility to educate themselves sufficiently to be able to make their own health decisions. This clearly is a huge assumption, based on little data. Fact is, we, (US or the world) never had consumer or market driven healthcare. Never. If you want to call high-deductible insurance plans combined with an HSA market driven health care, or some feeble attempts at market driven dentistry like http://localdentist4less.com you ain’t seen nothing yet. So basically, we never had consumer really make decisions so far. So there is no data. Get seriously started with it, collect your data, and then create opinions. Otherwise its all hot air and keyboard clicking. Also, keep in mind, in a true market driven health care, an average Joe does not need to take care of the health system, just of his own health, and his own choices for healthcare.
I’ve seen ads on TV for Caduet. It has two ingredients. One is Amlodipine and the other is Atorvastatin. With my RxDrugCard I can get 30 tablets of Amlodipine for $9 and 30 tablets of Simvastatin for $9. I’ll bet they are charging more than $18 for this new drug! Don’t pressure your doctor into giving you something just because it’s new. Do your homework. Find a drug card like I did at http://www.rxdrugcard.com. I think that RxDrugCard.com is the best drug card available for prescription discounts.
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Hey just a thought, you would probably get more readers if you interviewed controversial people for your blog.
For true competition to exist there must be the free flow of medical data and highly educated patients, both of which is more than we can expect in our society.