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Consumerism in Consumerism in Healthcare--Healthcare--

Who Needs to Change and How Who Needs to Change and How Do We Make it HappenDo We Make it Happen??

Jon R. ComolaJon R. Comola

Marcia L. Comstock, MD MPHMarcia L. Comstock, MD MPH

Wye River Group on HealthcareWye River Group on Healthcare

June 7, 2005June 7, 2005

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To Recap…….To Recap…….Experience would strongly suggest that Experience would strongly suggest that

having either public sector (i.e., govt) or having either public sector (i.e., govt) or private sector (employers/health plans) private sector (employers/health plans) arbitrate the tension between limited arbitrate the tension between limited resources & unlimited expectations is resources & unlimited expectations is incompatible with American culture.incompatible with American culture.

SO…., whether you believe putting patients in SO…., whether you believe putting patients in control of these decisions is the right thing control of these decisions is the right thing to do or not, there are no other viable to do or not, there are no other viable choices!choices!

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But there are some But there are some ‘disconnects’ ‘disconnects’

that must be addressed!!that must be addressed!! There is a major conflict between our concerns There is a major conflict between our concerns

about cost & demands for choice & freedom about cost & demands for choice & freedom People do not want to make trade offs in People do not want to make trade offs in

healthcare……healthcare…… It is viewed as a societal, not a market modelIt is viewed as a societal, not a market model The public doesn’t believe trade-offs are necessaryThe public doesn’t believe trade-offs are necessary The public believes that corporate greed and waste The public believes that corporate greed and waste

in the system are responsible for rising costsin the system are responsible for rising costs With scientific advances, the struggle will be to With scientific advances, the struggle will be to

define what treatments are covered by define what treatments are covered by insurance & what are lifestyle enhancements insurance & what are lifestyle enhancements that will have to be paid out of pocketthat will have to be paid out of pocket

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In a consumer driven health In a consumer driven health care system, we will each get to care system, we will each get to choose what we want to have—choose what we want to have—and what we are willing to pay!and what we are willing to pay!

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THE NEXT BIG QUESTIONTHE NEXT BIG QUESTION

If this is to be the ‘Brave If this is to be the ‘Brave New World’ of healthcare, New World’ of healthcare, how do we ensure it is how do we ensure it is operationalized operationalized appropriately???appropriately???

CHANGE IS HARD!!!CHANGE IS HARD!!!

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REMEMBER!!REMEMBER!!

Medical care revolves Medical care revolves around the doctor-patient around the doctor-patient relationship & ultimately relationship & ultimately that relationship determines that relationship determines the cost and quality of care! the cost and quality of care! The role of all other parties is The role of all other parties is to support that relationship..to support that relationship..….….

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What can we expect from What can we expect from consumers?consumers?

Take responsibility for Take responsibility for practicing healthy lifestyles practicing healthy lifestyles

Be compliant with therapyBe compliant with therapy ‘‘Shop' for the best careShop' for the best care

OK, is this realistic today???OK, is this realistic today???(sort of ‘Trading Spaces’)(sort of ‘Trading Spaces’)

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11stst Personal Personal responsibility…..responsibility…..

a prime tenet of CDHCa prime tenet of CDHCWhen it comes to the day to day on-When it comes to the day to day on-

going decisions about exercise, going decisions about exercise, diet, smoking cessation, and other diet, smoking cessation, and other health behaviors , it’s the doctors health behaviors , it’s the doctors that advise and it’s the systems that advise and it’s the systems that reimburse, but it is the patient that reimburse, but it is the patient that decides!!!that decides!!!

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A tsunami is coming!!!A tsunami is coming!!!

We’re getting olderWe’re getting older We’re getting fatter (many of us!)We’re getting fatter (many of us!) The resulting chronic care needs will The resulting chronic care needs will

be REALLY expensive!!be REALLY expensive!! Obesity, as a key underpinning factor Obesity, as a key underpinning factor

(no joke!) of chronic disease alone (no joke!) of chronic disease alone explains almost as much of the explains almost as much of the healthcare cost increases as tobacco healthcare cost increases as tobacco

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Why are we getting Why are we getting fatter?fatter?

We are eating more…no kidding!!! We are eating more…no kidding!!! We are eating out more (In 1970 34% of the food We are eating out more (In 1970 34% of the food

budget was consumed outside the home in late budget was consumed outside the home in late 1990s it was 47%)1990s it was 47%)

Everything is super-sized at home and at Everything is super-sized at home and at McDonaldsMcDonalds

We don’t exerciseWe don’t exercise ~35% of the population is obese or severely ~35% of the population is obese or severely

obese (almost doubled in 25 years!)obese (almost doubled in 25 years!)

(We need “The Biggest Loser”!!!)(We need “The Biggest Loser”!!!)

1313National Geographic August 2004National Geographic August 2004

Super-size Everything

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New Monster Thickburger: New Monster Thickburger: On Sale On Sale

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Lifestyle Changes Lifestyle Changes that Promote Sedentary Behaviorthat Promote Sedentary Behavior

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The “Perfect Storm” for The “Perfect Storm” for ObesityObesity

BuiltEnvironment

Commercial Environment

Policy Environment

Social/Cultural Environment

ObesityHumanBiology

1919Source: Prochaska & DiClementeSource: Prochaska & DiClementeSource: Prochaska & DiClementeSource: Prochaska & DiClemente

Stages of changeStages of changeStages of changeStages of change

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How do consumers view their How do consumers view their role?role?

Aware that a healthy lifestyle can improve and/or Aware that a healthy lifestyle can improve and/or prevent many medical problemsprevent many medical problems

ButBut generally unwilling to require people who are generally unwilling to require people who are overweight or who do not exercise regularly to overweight or who do not exercise regularly to pay more for their coverage and carepay more for their coverage and care

Appreciate great differences between quality of Appreciate great differences between quality of care provided by different hospitals and care provided by different hospitals and physicians for serious medical problemsphysicians for serious medical problems

ButBut not willing to pay more for access to better- not willing to pay more for access to better-quality hospitals or physiciansquality hospitals or physicians

A large majority say they would be willing to work A large majority say they would be willing to work an extra 2-3 years to ensure they have enough an extra 2-3 years to ensure they have enough money to pay for their health care in retirement money to pay for their health care in retirement

HarrisInteractive, 12/04HarrisInteractive, 12/04

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2nd Be Compliant with 2nd Be Compliant with TherapyTherapy

Without really good behavioral health Without really good behavioral health communication programs patients really don’t communication programs patients really don’t adhere very well ….adhere very well ….there are other barriers……….there are other barriers……….

Patients fail to comply due to language barriers, Patients fail to comply due to language barriers, cognitive impairment, lack of knowledge cognitive impairment, lack of knowledge

Low health literacy affects 40 M AmericansLow health literacy affects 40 M Americans Therapy because it is difficult, complicated, or Therapy because it is difficult, complicated, or

lifestyle disruptions interfere with regimen lifestyle disruptions interfere with regimen Patients make clear decisions to alter or stop Patients make clear decisions to alter or stop

treatment treatment

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3rd Shop for the ‘best’ 3rd Shop for the ‘best’ carecare

Effective healthcare is all about decisions:Effective healthcare is all about decisions: Decisions about healthy or unhealthy Decisions about healthy or unhealthy

behaviorbehavior Decisions on whether and when and where Decisions on whether and when and where

to seek careto seek care Decisions about drugs, tests, surgeriesDecisions about drugs, tests, surgeriesTo make good decisions, consumers must To make good decisions, consumers must

have access to personalized care have access to personalized care management tools or decision-aides for management tools or decision-aides for guided self-care managementguided self-care management

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Do people want to be Do people want to be involved? involved? The data is The data is

conflictingconflicting >60% of Americans searched for information to >60% of Americans searched for information to

help them make treatment decisions in the last help them make treatment decisions in the last 12 months; 1/3 said info found affected their 12 months; 1/3 said info found affected their treatment choice or choice of healthcare facilitytreatment choice or choice of healthcare facility

94% of those who hadn’t said they would if they 94% of those who hadn’t said they would if they or a family member needed medical careor a family member needed medical care

52% said they wanted to make the final decisions52% said they wanted to make the final decisions 38% wanted to make it with their physicians38% wanted to make it with their physicians Patients using aides are more likely to make more Patients using aides are more likely to make more

conservative choices conservative choices BUT despite their interest in being involved, most BUT despite their interest in being involved, most

do not think they are in a position to affect the do not think they are in a position to affect the cost or quality of the care they receive!!cost or quality of the care they receive!!

RAND Survey 3/05RAND Survey 3/05

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What about the use of cost What about the use of cost and quality information?and quality information?

Access to cost estimates for drugs, tests, and surgical Access to cost estimates for drugs, tests, and surgical procedures is increasingly a realityprocedures is increasingly a reality

Cost transparency for hospital comparisons is rapidly Cost transparency for hospital comparisons is rapidly improvingimproving

Transparency for most physician’s rates is still some Transparency for most physician’s rates is still some years awayyears away

Transparency of quality information is on a similar Transparency of quality information is on a similar trajectorytrajectory

April 1, 2005 CMS posted quality performance data for April 1, 2005 CMS posted quality performance data for "nearly all" the nation's hospitals on its new "Hospital "nearly all" the nation's hospitals on its new "Hospital Compare" Web site Compare" Web site

Cooperation among representatives from different Cooperation among representatives from different sectors important; one model might be the Consumer-sectors important; one model might be the Consumer-Purchaser Disclosure ProjectPurchaser Disclosure Project

BUT is the information spurring people to alter their BUT is the information spurring people to alter their use of health care?use of health care?

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STILL, folks argue about whether STILL, folks argue about whether consumers are capable of using consumers are capable of using information…AND consumers are a bit information…AND consumers are a bit schizophrenic about it too!schizophrenic about it too!

Nearly two in three Americans feel that they would Nearly two in three Americans feel that they would become more involved in decision-making if the become more involved in decision-making if the health care system were easier to navigatehealth care system were easier to navigate

BUT, over a third of consumers say they would still BUT, over a third of consumers say they would still follow their doctor’s advice even if it conflicted with follow their doctor’s advice even if it conflicted with reliable information from another knowledgeable reliable information from another knowledgeable source!!source!!

HarrisInteractive, 12/04HarrisInteractive, 12/04

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How do physicians How do physicians [‘AMERICAN IDOLS’][‘AMERICAN IDOLS’]

need to change?need to change?

It’s really simple!!! (Ha!)It’s really simple!!! (Ha!) Design their practices to be Design their practices to be

customer focusedcustomer focused Practice evidence-based medicine Practice evidence-based medicine

(EBM)(EBM) Engage in shared decision-makingEngage in shared decision-making

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1st Customer-Focused 1st Customer-Focused PracticePractice

Patients won’t wait an average of 38 Patients won’t wait an average of 38 minutes for an appointment!minutes for an appointment!

Patients will demand convenience, Patients will demand convenience, continuity of care, continuity of care, comprehensiveness & collaborationcomprehensiveness & collaboration

Consumers will drive the provider Consumers will drive the provider community to respond….and some community to respond….and some are understandably anxious about are understandably anxious about this! this!

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22ndnd EBM EBM

What is it?What is it? Science: What works best Science: What works best

given what we know today given what we know today Clinician training & experience Clinician training & experience Patient preferences, Patient preferences,

understanding and values understanding and values

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This isn’t happening!!This isn’t happening!!

We see unwarranted variation related to:We see unwarranted variation related to: Under use of effective care--services Under use of effective care--services

shown to work and that patients want shown to work and that patients want Misuse of ‘preference-sensitive’ care-- Misuse of ‘preference-sensitive’ care--

where more than one approach is where more than one approach is reasonable and patient values should reasonable and patient values should be considered be considered

Overuse of supply sensitive care--Overuse of supply sensitive care--services driven by providers services driven by providers

Dartmouth Dartmouth Atlas of HealthcareAtlas of Healthcare

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More Evidence…..More Evidence…..

The practice of medicine is anything The practice of medicine is anything but pure science today!but pure science today!

29% of US adults reported that they or a 29% of US adults reported that they or a family member received a second medical family member received a second medical opinion from a doctor in the past 5 yearsopinion from a doctor in the past 5 years

In 46% of cases the diagnosis was In 46% of cases the diagnosis was different from the originaldifferent from the original

In 2/3 of these cases treatment was In 2/3 of these cases treatment was different as a result!different as a result!

Harris Interactive, 3/05Harris Interactive, 3/05

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One might conclude…One might conclude…“…“…there is sufficient evidence to suggest that most there is sufficient evidence to suggest that most

clinicians’ practices do not reflect the principles clinicians’ practices do not reflect the principles of evidence-based medicine but rather are based of evidence-based medicine but rather are based upon tradition, their most recent experience, upon tradition, their most recent experience, what they learned years ago in medical school, or what they learned years ago in medical school, or what they have heard from their friends….”. what they have heard from their friends….”.

John Eisenberg, AHRQJohn Eisenberg, AHRQSO………SO………

When the rules of clinical practice are not When the rules of clinical practice are not clear, variation results from subjective clear, variation results from subjective opinion, practice preferences, and hospital opinion, practice preferences, and hospital capacity.capacity.

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WHY is there all this WHY is there all this variation?variation?

Physicians can't keep up with current science Physicians can't keep up with current science Most don't see health plans paying for Most don't see health plans paying for

evidence-based careevidence-based care Plans may not be in agreement with best Plans may not be in agreement with best

practicespractices EBM challenges physicians’ professional turf EBM challenges physicians’ professional turf

and they chafe about ‘cookbook medicine’and they chafe about ‘cookbook medicine’ AND most consumers side with their AND most consumers side with their

physician in preferring “eminence-based” physician in preferring “eminence-based” medicine over evidence-based medicine…medicine over evidence-based medicine…

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BUTBUT…………

IF there is evidence you IF there is evidence you are not a consistently are not a consistently good cook,good cook,

WHAT IS WRONG WITH A WHAT IS WRONG WITH A COOKBOOK??COOKBOOK??

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What do we do? We What do we do? We P4P!P4P!!!

Latest trend to make docs behave!Latest trend to make docs behave! >100 P4P P’s & P’s by P & P entities….>100 P4P P’s & P’s by P & P entities….

Denounced as a scam designed by Denounced as a scam designed by multimillionaire CEOs of health multimillionaire CEOs of health insurance companies to cut insurance companies to cut reimbursement by taking advantage of reimbursement by taking advantage of gullible physiciansgullible physicians

Wm Plested, MD, AMA Board Chair, 2004Wm Plested, MD, AMA Board Chair, 2004

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and once again, and once again, consumers side with their consumers side with their

docsdocs

The US public is only moderately The US public is only moderately supportive of having health plans pay supportive of having health plans pay more to doctors for higher quality [38% more to doctors for higher quality [38% yes, 17% no, 32% indifferent] UNLESS yes, 17% no, 32% indifferent] UNLESS it lowers their health insurance costs it lowers their health insurance costs [67% yes]. [67% yes].

HarrisInteractive 5/2005HarrisInteractive 5/2005

(perhaps this is more driven by self-interest??)(perhaps this is more driven by self-interest??)

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Lack of enthusiasm aside….Lack of enthusiasm aside….Will it be effective??Will it be effective??

That depends….That depends…. Withhold/bonus opportunity needs to represents Withhold/bonus opportunity needs to represents

>10% of average physician revenue>10% of average physician revenue Payers need to agree on a measurement setPayers need to agree on a measurement set CMS leadership is central to furthering the goalCMS leadership is central to furthering the goal Percentage of public/private payers/purchasers Percentage of public/private payers/purchasers

sponsoring these programs projected to increase sponsoring these programs projected to increase from 40% in 2003 to ~80% in 2006 from 40% in 2003 to ~80% in 2006

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3. Shared Decision-3. Shared Decision-MakingMaking

““Extreme Makeover “Extreme Makeover “

(needed!!!)(needed!!!)

The news is similarly grim when it The news is similarly grim when it comes to research on just how comes to research on just how frequently and just how deeply the frequently and just how deeply the average physician gets into shared average physician gets into shared decision making with the average decision making with the average patient.patient.

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The Evidence!The Evidence!

9% of all the decisions reflected even a 9% of all the decisions reflected even a limited degree of shared decision-makinglimited degree of shared decision-making

Not one in 3,000 included all 6 elementsNot one in 3,000 included all 6 elements A discussion and an exploration of the A discussion and an exploration of the

patient’s understanding was the least patient’s understanding was the least frequently noted, at 2% (probably the most frequently noted, at 2% (probably the most important to the doctor-patient relationship important to the doctor-patient relationship and to patient compliance) and to patient compliance)

(study of >3000 medical decisions involved in 1,000 visits; looked at 6 (study of >3000 medical decisions involved in 1,000 visits; looked at 6 key elements of informed consent or shared decision-making)key elements of informed consent or shared decision-making)

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What’s Needed & What’s Needed & What’s Missing?What’s Missing?

Trust Trust (hard without a real long-term doctor-(hard without a real long-term doctor-patient relationship)patient relationship)

Good communications skills Good communications skills (physicians (physicians aren’t really taught to communicate)aren’t really taught to communicate)

Adequate time Adequate time (tough with a 5’48” office (tough with a 5’48” office visit)visit)

Incentives Incentives (docs aren’t paid to communicate)(docs aren’t paid to communicate) Commitment and conviction as to the value Commitment and conviction as to the value

(you need to experience it to appreciate it!)(you need to experience it to appreciate it!)

(but the real “Weakest Link”……)(but the real “Weakest Link”……)

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But the real barrier is….But the real barrier is….

Physicians don’t think it will Physicians don’t think it will make a difference in the make a difference in the patient’s behavior!! patient’s behavior!!

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What should employers/plans What should employers/plans do?do?

Communicate the need for and Communicate the need for and advantages of the ‘new model’ advantages of the ‘new model’ and serve as ‘information brokers’ and serve as ‘information brokers’

Design comprehensive programs Design comprehensive programs in prevention and disease in prevention and disease management based on behavioral management based on behavioral change modelchange model

Change reimbursement Change reimbursement mechanisms to reward qualitymechanisms to reward quality

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How Can Employers How Can Employers Really Control Costs?Really Control Costs?

3 strategies rated as the most effective:3 strategies rated as the most effective: Rewarding more efficient and high quality Rewarding more efficient and high quality

carecare Improving DM services for patients with high-Improving DM services for patients with high-

cost conditions; enhancing primary case cost conditions; enhancing primary case management ; applying evidence-based management ; applying evidence-based guidelines to determining when a test or guidelines to determining when a test or procedure should be doneprocedure should be done

Increasing collaboration among private Increasing collaboration among private insurers, Medicare, and Medicaid to adopt insurers, Medicare, and Medicaid to adopt common payment methods and rates and common payment methods and rates and streamline administrative costsstreamline administrative costs

Commonwealth Fund Health Care Opinion Leaders SurveyCommonwealth Fund Health Care Opinion Leaders Survey

(academia/research; business, insurance, health care (academia/research; business, insurance, health care industry, labor/consumer advocacy orgs, govt)industry, labor/consumer advocacy orgs, govt)

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‘‘RED PILL/BLUE PILL’RED PILL/BLUE PILL’(the Matrix Redux….)(the Matrix Redux….)

Paternalism & ControlPaternalism & Control““I’m too busy to worry about I’m too busy to worry about

fixing the healthcare system”fixing the healthcare system”

CostCost““It’s an exit strategy”It’s an exit strategy”

“ “ I can predict my costs, as I shift I can predict my costs, as I shift more to employees”more to employees”

QualityQuality““It’s a plan issue”It’s a plan issue”

““Why can’t physicians get their Why can’t physicians get their act together”act together”

““I need to focus on cost I need to focus on cost management”management”

Empowerment & Empowerment & SupportSupport

““I can be an agent for community I can be an agent for community collaboration”collaboration”

CostCost““I’ll reward efficiency: P4P”I’ll reward efficiency: P4P”

““I’ll focus on care management”I’ll focus on care management”

QualityQuality““I recognize the need for total I recognize the need for total

system redesign”system redesign”

““I need to focus on integrated care I need to focus on integrated care & outcomes” & outcomes”

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‘‘RED PILL/BLUE PILL’RED PILL/BLUE PILL’

ITIT““I make widgets!”I make widgets!”

““I spend enough on healthcare I spend enough on healthcare

as it is!”as it is!”

Benefit designBenefit design““My plan is the expert”My plan is the expert”

““One size fits all is fine”One size fits all is fine”

““I don’t want to have to worry I don’t want to have to worry

about adverse selection”about adverse selection”

ITIT““I need to help my employees I need to help my employees

with information”with information”

““Good decisions will help Good decisions will help productivity”productivity”

Benefit designBenefit design““I need to pay attention to I need to pay attention to

details!”details!”

““People need to be able to shape People need to be able to shape benefits to meet their needs”benefits to meet their needs”

““I need to ensure incentives for I need to ensure incentives for wellness & prevention”wellness & prevention”

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The Politics of The Politics of HealthcareHealthcare

The last big opportunity The last big opportunity for broad scale social for broad scale social programsprograms

A potentially politically A potentially politically polarizing visionpolarizing vision

An unfriendly environment An unfriendly environment for system wide change !!for system wide change !!

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Consumerism in HealthcareConsumerism in Healthcare——

a political consensus point?a political consensus point? Political pollsters repeatedly confirm the Political pollsters repeatedly confirm the

gap between what people say they want gap between what people say they want and what elected officials act onand what elected officials act on

BUT...In healthcare consumerism there is BUT...In healthcare consumerism there is potential alignment of political interestspotential alignment of political interests

The basic model of robust information plus The basic model of robust information plus incentives has been articulated by political incentives has been articulated by political polar opposites: Ralph Nader and Newt polar opposites: Ralph Nader and Newt Gingrich. Gingrich.

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The Power of ‘Guv-mint’The Power of ‘Guv-mint’

Collectively funds ~60% of Collectively funds ~60% of healthcare….perhaps its greatest healthcare….perhaps its greatest leverage point!leverage point!

Other tools……Other tools…… Administrative lawAdministrative law RegulationRegulation Executive ordersExecutive orders LegislationLegislation The ‘bully pulpit’ The ‘bully pulpit’

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How Can Gov-Mint Be How Can Gov-Mint Be Useful??Useful??

Develop reimbursement mechanisms that reward Develop reimbursement mechanisms that reward providers who practice EBMproviders who practice EBM

Better technology assessment….get real Better technology assessment….get real innovation into practice soonerinnovation into practice sooner

Support medical effectiveness (clinical outcomes) Support medical effectiveness (clinical outcomes) researchresearch

Support development of standards for information Support development of standards for information on quality measurement on quality measurement

Support CDHC in public programsSupport CDHC in public programs Support integrated chronic care managementSupport integrated chronic care management Make savings accounts more flexible Make savings accounts more flexible

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Consumerism in other industriesConsumerism in other industries——

a model??a model?? 11stst generation: personalized service generation: personalized service

house calls, pharmacy delivery of meds, the milk man, house calls, pharmacy delivery of meds, the milk man, full service gas station, dry cleaning deliveryfull service gas station, dry cleaning delivery

22ndnd generation: customer generation: customer convenienceconveniencestores staying open after 5 and on Sunday; the telephone stores staying open after 5 and on Sunday; the telephone company accepting payments through the grocery store, company accepting payments through the grocery store, multiple locations for paying bills or customer service multiple locations for paying bills or customer service booths, travel agents who negotiate for youbooths, travel agents who negotiate for you

33rdrd generation: information access & generation: information access & technologytechnologycredit card over the telephone, 24 hour access to account credit card over the telephone, 24 hour access to account information over the telephone, then fax and eventually information over the telephone, then fax and eventually internetinternet

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Consumerism in other Consumerism in other industries—industries—a model??a model??

44thth generation: hybrid-customer generation: hybrid-customer convenience + operational efficiencyconvenience + operational efficiencyon-line checking; catalogue ordering; Ebayon-line checking; catalogue ordering; Ebay

Today’s consumerism:Today’s consumerism: Has redefined expectations and created demand for Has redefined expectations and created demand for

things that look and feel more like self service-- you things that look and feel more like self service-- you pump your own gas, you book your travel on-line; you pump your own gas, you book your travel on-line; you print your own airline tickets and check your bags at print your own airline tickets and check your bags at the kiosk; you scan your own grocery purchasesthe kiosk; you scan your own grocery purchases

WHAT WILL THIS LOOK LIKE IN WHAT WILL THIS LOOK LIKE IN HEALTHARE???HEALTHARE???