You don’t need to use a silver bullet. But if you forge one, you don’t need to depend on the kindness of monsters. – Lex Luthor, Batman vs Superman: Dawn of Justice
Over the last couple of years, the growth of insurance coverage (Thanks, Obama), higher deductibles, price transparency, patient data access, retail care facilities, digital health tools, and more have begun contributing to the development of a more person-centric, modern, conveniently accessible health care system. In a word, consumerism. As the story goes, this movement will dovetail with the shift towards value-based payment and result in delivery system transformation. And, as always, what’s hyped and hoped differs from what happens.
We know that the demand side of the seesaw is filling up, particularly with employer-covered shoppers. Price transparency startup Healthsparq offered a look at over a quarter million employees’ searches in a recent data visualization revealing a swath of mostly young, mostly female demographic that’s interested in a few key areas: expensive procedures, family planning, and day-to-day care (e.g. allergies, physical therapy.)
This is a great signal – but there’s much more to consumerism. For one, transparency tools have their limits. Secondly, not all Americans enjoy access to the tools yet – this was nicely highlighted in a recent patient focus group by the New York Academy of Medicine. But more broadly, for the seesaw of consumerism to move, the healthcare system will need to get on board the other side in a balanced fashion. And it’s becoming evident that there’s no app for that.
Cost and complexity challenges
You may have seen the new data that U.S. healthcare costs will exceed $10,000 per person on average. This is in part because “many Americans are gaining access to health coverage for the first time, aging into Medicare, or finding that a greater share of their health expenses needs to be paid out of pocket.” And, despite increased volume that’s tied to shifts in demographics, disease burden, and new enrollees, there’s evidence that much of the costs are driven by prices that are simply too high. In California, considered one of the nation’s more successful implementations of the Affordable Care Act, insurers are looking to hike up 2017 rates by over 13 percent, the first double-digit rate increase in the last three years.
With rising prices and higher deductibles, some people are putting off needed care due to concerns over costs. Data are showing that people tend to put off needed care (prescription drugs, follow-up appointments, preventative screenings) due to cost concerns. Another emerging issue is that as health benefits have gotten more complex, people have trouble understanding them and shopping effectively. A problematic example is that some people with high deductible plans tend to forgo free or low-cost preventative visits and screenings because they didn’t know or understand how their benefit worked. This is the opposite of what we want – it’s antithetical to the empowered consumer narrative.
Again – while there are some opportunities for employers to educate their members, many people, particularly those entering the system for the first time on the wings of the ACA, face a barrier of complexity and a lack of customer service. For folks getting coverage through the exchanges, health plans still rely almost exclusively on telephone lines and dense PDF files when it comes to support and explanation of benefits (EOB). Navigator programs have had mixed results, and continue to be dependent on grants and public funds.
For those of us who own a smartphone, it shouldn’t be too hard to imagine a digital navigator that replaces your insurance card, keeps track of your particular plan, and encourages appropriate care based on a patient’s benefit design and claims history (e.g., follow-up, prescription refill). If Dunkin Donuts can do it, insurers have no excuse. But until health insurers swallow the costs of delivering this to all members (not just their employee populations), we remain far away from an equitable consumer marketplace.It shouldn’t be hard to imagine a digital navigator that replaces your insurance card... Click To Tweet
Getting the horse to drink
As the saying goes, you can lead a horse to water, but you cannot make it drink.
Costs aside, perhaps the biggest kryptonite to consumerism in health care is timely access to care when it’s wanted and/or needed. A recent study looked at how easily secret shoppers were able to secure a new primary care appointment in California. Calls were split evenly between those that sought a routine physical and those that sought an urgent care appointment. The outcomes were nothing short of abysmal (note – these results have been summarized and rounded):
- In 10 percent of the calls, the providers listed in the directory were either no longer with the group listed, or had never been with the group at all
- In 30 percent of the calls, the specialty listed in the provider directory did not match the one stated by the receptionist on the call
- In 20 percent the cases, callers were unable to get through due to disconnected lines, unreturned messages, or busy signals
- In 10 percent of the cases, providers did not accept any new patients
- Overall, in over 70 percent of calls, callers were unable to set up appointments with the providers they were trying to reach.
- In about 30 percent of the cases, callers were able to set up appointments, though some of these were not with the doctor selected from the directory.
The kicker: In the small chance a caller with urgent needs was able to get through to booking an appointment, the average wait time ranged from 8 to 12 days. Can you imagine if only 30 percent of your Uber bookings came through, and they made you wait eight times longer than normal? No wonder retail care and telemedicine are eating primary care’s lunch. While those alternate venues of care are okay for some circumstances, they pose a conundrum for health systems that are responsible for the care and outcomes (and costs) of populations. Put simply, health systems face a challenging set of roadblocks on the road to becoming consumer friendly.No wonder retail care and telemedicine are eating primary care’s lunch Click To Tweet
Breaking down the wall
Some of these issues fall onto the shoulders of health insurers – such as making sure everyone who signs up for health insurance understands their plan and is able to access a doctor from a directory. Others will require healthcare providers to step up to the plate: appointment scheduling, ensuring access to someone on the care team who can answer financial or practical questions about the care plan. Today, neither side is where they need to be; these sides are playing hot potato with each other instead of getting on the seesaw.
Games aside, consumerism is ultimately about crafting a seamless experience that is easy to use and responsive when problems arise. In healthcare, the fragmentation of “who pays who how much for what” makes this approach a lot tougher than it ought to be. The tightly defined boundaries of employer-sponsored healthcare (payer-employer-network) show that progress is possible. Beyond those boundaries, the dysfunction and fragmentation of our system are begging for entrepreneurs and tech startups to enter the fray with new ideas (we’ll take a look at some of those opportunities in an upcoming post).
Until that happens, to paraphrase The Donald, we’ve built a wall to keep consumers out…and made them pay for it....we’ve built a wall to keep consumers out...and made them pay for it. Click To Tweet
Latest posts by Naveen Rao (see all)
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