Putting The Consumer At The Center Of Healthcare
It was not that long ago when it was heresy to talk about the consumer and healthcare in the same sentence. We, as consumers, did not help the situation. Many of us did not feel we knew that much about healthcare. It was generally something that was ‘done’ to us. As a result, we did not feel we had ‘standing’ or the ‘right’ to talk about it with the professionals to whom we entrusted our well-being. And a lot of the healthcare professionals whose advice we sought did not think we knew that much about it either. Some of them were quite happy keeping it that way. After all, the medical community had the language of science on its side. It was highly technical. It was obscure to most of us… and it was scary. So, many of us learned NOT to ask questions and basically do what we were told by the healthcare professionals we trusted.
Historically, most of us also had no idea what the healthcare services we consumed were costing us — because someone else was paying. Until very recently approximately half of the U.S. population received healthcare insurance through their employers. Most of the rest of us received some sort of government funded insurance which gave us access to healthcare services — either through Medicare, Medicaid, or the Veteran’s Administration. A smaller number were in the individual market, including exchanges put in place through the Affordable Care Act passed in 2010.
The only place where we did understand the cost of the healthcare services we consumed was in the purchase of over the counter medications and in the area of Lasik surgery and cosmetic dermatology. The latter two are interesting because they still need to be delivered by physician specialists and cannot be purchased directly by consumers. What has made Lasik surgery and cosmetic dermatology different is that neither of these procedures has been covered by insurance. Consumers had to pay out of pocket. And here, unlike in other areas of healthcare delivery, they behaved like consumers do in other parts of their lives. They shopped, and they looked for cost and quality evidence about why they should go to one facility/provider over another.
Over the last 30 years, the Centers for Medicare and Medicaid Services (CMS) has tried to bend the proverbial healthcare cost curve — generally unsuccessfully. It is the economic disconnect between the patient/consumer and healthcare systems that has been a big factor in the rise of healthcare costs. But it has not been the focus for most of the intervention coming from CMS.
In the last 10 years with healthcare costs exploding, employers have shifted some of the cost of healthcare onto their employees in the form of high deductible health plans, larger deductibles, and bigger co-pays. All of this was geared to making us better informed and more engaged in asking questions. Why am I getting this test? Where should I get it that’s most convenient/cost effective? And where is the data that tells me who does a better job? The ultimate objective was to ensure we had obvious ‘skin in the game’ and could engage in shopping for non-emergent healthcare services in efforts to drive down cost. In the absence of data to the contrary, the assumption has been that all care/services are created equal (they are NOT), so the only variable might be cost and trade-offs for convenience. It has been the only part of our lives where we do not know the cost until it is too late. All of this is in process of changing. And that is what’s exciting.
There has been a shift in mind-set. Even a year ago studies suggested that most of us (~ 60-70%) preferred receiving healthcare services from their own doctor in the office or in the hospital. It takes time to create new norms, especially those involving a physician or other care provider outside of their usual office settings.
Unless there is a pandemic, that is.
Covid-19 has had an incredible impact on consumers. Consumers’ eyes and minds have been opened. As a result, it is becoming imperative that healthcare executives and the general public let go of the notion that someday soon, all will return to ‘normal’ — even in healthcare. This is not a temporary blip. It is becoming the moment we will all remember as the one that changed American healthcare.
There was a time not that long ago that healthcare executives thought patient/consumers could only evaluate three things about their care: 1) the timeliness of getting seen; 2) how friendly staff were; and 3) the cleanliness of the facility. If the services involved an inpatient stay, a fourth item was added to the list—the quality of the food. All of this has slowly been changing. We are now on the path to being able to get meaningful information about the quality of the actual services we may be interested in buying. Resources like Consumer Reports On Health, Kaiser Health News, AARP, and others provide comparative information and guidance to patient/consumers about the kinds of questions they should be asking.
One of the underlying dynamics is an effort to bring greater accountability and transparency to healthcare — accountability for care delivery across the care continuum as opposed to disjointed episodic encounters and transparency in both cost and quality. If we look at this drive towards greater accountability through the lens of healthcare delivery organizations, there is enormous angst about these shifts accompanied by significant resistance. It is really ironic that many point to the lack of control over consumer/patient behavior as a key obstacle in assuming accountability for outcomes! And, there is truth to this. Our own behavior choices have enormous impact on the outcomes associated with our care.
We are (fortunately) headed towards a market-based model in healthcare — one characterized by greater accountability, payment connected to outcomes that matter, and greater transparency in both cost and quality. It is time for greater partnership across the board. We need better educated healthcare consumers who need to make better choices to impact their own health outcomes. We need to engage differently in partnership with the healthcare professionals we need and should be able to rely on. And we need a financing mechanism that ensures our incentives are all aligned to deliver better health outcomes at lower total cost.