Sick care versus health care

90202 ALL ALL ALL ALL Blog 11 Sick care vs health care 1140x720

We've all seen headlines about how the American health care system is the world's most expensive, and yet our health outcomes are no better—and in many areas much worse—than those in other developed countries. With costs steadily rising and the treatment of chronic conditions consuming a disproportionate share of our health care resources, trends are not moving in the right direction.

The basic problem is that we have a sick care system designed to maximize outcomes for individual patients, rather than a health care system invested in the wellbeing of all consumers. If you have good health insurance, there is no better place to be a really sick person than in America. But even with good health insurance, it's costly.

While U.S. health care is effective in the most complicated care situations, a 2012 article in the New England Journal of Medicine offered a harsh assessment of the system as a whole:

A key feature of U.S. health care is its use of a piecemeal, task-based system that reimburses for "sick visits" aimed at addressing acute conditions or acute exacerbations of chronic conditions. Economic incentives encourage overuse of services by favoring procedural over cognitive tasks (e.g., surgery vs. behavior-change counseling) and specialty over primary care. These mismatched economic incentives effectively preclude successful prevention through health maintenance. (Marvasti and Stafford)

There hasn't been enough change since 2012. The practice of health care is still driven by a bias toward clinical action. As consumers, we want medical care that offers quick relief. Physicians and other highly trained providers want to use the latest techniques and medicines.

In a technologically advanced country like the U.S., with access to cutting edge research and the resources to develop increasingly sophisticated medical interventions, this leads to a tendency to use the most expensive care first, even when as good or better clinical outcomes can be achieved through other treatment paths. We "medicalize" issues that could be addressed in earlier, less invasive, or less costly ways that can reduce or even relieve more complicated health issues later.

Invest in more health to reduce sickness

One prominent feature of consumer-driven health care is the idea that it will enable us to be more actively engaged in decisions about how to improve our health—to become informed consumers focused on prevention and health, rather than passive patients reacting to illness. Changing this dynamic requires new forms of health insurance that will fire up the engine of consumerism. When we behave as consumers, we are highly skilled shoppers, if we have the right information. In the current health care system, we are most often treated as patients, and are generally not offered many options. Even asking for a second opinion can be awkward! We are rarely given the price transparency or cost information we need to make informed care decisions.

The Affordable Care Act provided a start down the path of encouraging a more comprehensive health care experience. Under the ACA, nearly all health insurance policies must cover certain types of routine and preventative care. This is a good foundation, especially for healthy consumers. But beyond those basic features, there is no requirement that a plan provides information about alternative, clinically proven treatment paths, nor about the costs associated with a chosen treatment for someone experiencing sickness. Recent legislation requiring providers to show their "chargemaster" prices is more like seeing a Manufacturer’s Suggested Retail Price, not the discounted prices actually paid by insurers or even by consumers who shop around.

Even with purely elective procedures, it can be very challenging for us to get the information we need to make good decisions about our care. The result is process in which care often escalates quickly to the most complex and most costly procedures.

With ongoing chronic conditions—which the CDC estimates to account for 75% of total health care expenditures—the amount spent on preventive measures is relatively small, but can have a huge impact. For example, a number of studies have shown that zero-dollar copays for drugs used to treat chronic conditions leads to better adherence and improved health outcomes, plus lower long-term costs.

Different ways of thinking about health

It is useful to focus on the different questions consumers and providers bring to the table.

Consumers ask questions like:

Providers, on the other hand, ask a different set of questions:

These different questions can lead to very different ideas about how to address the condition.

In addition to how we ask our medical questions, we are also put in the difficult position of having to make financial choices based on very little information. We may know the terms of our health insurance coverage—copays, deductibles, coinsurance, and annual out-of-pocket (OOP) maximum—but we usually don't know the costs of any proposed treatment.

Even if we elect treatment that involves an in-network hospital stay, will we run the risk of surprise billing for out-of-network care? Under these circumstances, it can feel like health care is being done to us, rather than a process in which we have equal standing.

To further complicate this problem, the chronic conditions that drive 75% of our health care spending don't reset during annual enrollment, even if our insurance system covers them this way. So, if we have faithfully followed a treatment plan, have taken our medication according to the prescription guidelines, and have met the annual OOP maximum by December 31st, the entire cost structure resets on January 1. Same disease, same treatment, same patient, but all new deductibles and annual OOP maximums.

No wonder people report avoiding care or under-utilizing their medications. And no wonder chronic conditions remain such a challenging problem to solve.

Eliminate deductibles, provide transparent pricing, and encourage people to use the care they need

Using the insights of big data, it is possible to design quality improvements and innovation into a plan design that offers a very different future—and a much better consumer experience.

First, focus on conditions as regular consumers understand them. Rather than using physicians as the only gatekeepers, allow us to search for care for the problems or conditions as we understand and experience them.

For example, we should be able to first explore a variety of ways to treat "knee pain," find a list of providers, and be able to choose our initial point of contact without a required visit to a physician just to get a referral to another doctor.

Second, show a range of treatments, with clear information about the clinical outcomes associated with each treatment path, and the quality outcomes achieved by the providers.

For "knee pain," we should see all options from chiropractors and physical therapists, all the way through orthopedic surgeons. If we start with low-cost physical therapy and learn we have a torn meniscus that needs surgical repair, we can always be referred for more complicated care. If we start with a surgeon, it is rare to be referred to a less involved form of care.

Third, lower the financial barriers to seeking care. By seeing clear, upfront prices in advance, we can know costs before choosing a procedure, test, or treatment. When we know what we're buying, we're more likely to make informed health care decisions.

The healthcare industry does not have a very good track record of transparency. That has to change. It is clear that eliminating unnecessary complexity across the system is better for the healthcare consumer—physically, emotionally, and financially.

A health plan that offers consumers the tools and information we need to choose better health is a radical departure from a health system that is currently designed to respond best to sickness.

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