Carolyn McClanahan, Contributor
We all know health care costs are a serious problem and most of us feel powerless to do anything about it. In this country, there is a perception that more health care means better health, and this is simply not the case. A recent article in Health Affairs by Roseanna Sommers, et al., beautifully outlines four challenges of involving patients in health care cost decisions. The study involved questioning twenty-two focus groups, and although the study is not scientific, it is very insightful and disheartening, with a good dose of appropriately optimistic solutions thrown in at the end. In this article, I share the results and of course provide my two-cents.
Challenge #1: Patients want only the best
To patients, health is paramount. This is understandable. When provided with two types of care, and even when told the second-best and cheaper choice was considered “good enough,” patients viewed the more expensive option as better. Many want the “best care” to eliminate all risk of missing something, which those of us in the medical field know is not possible. Of course, it is easy to make this choice if the patient and the family do not have to pay the bill. In the study, one patient stated, “… I wouldn’t care if it cost $10 million, give it here. I ain’t got $10 million, but give it anyway.” My take? On a societal level, we all want to reduce health care costs. On an individual level, too many people are not willing to budge when it comes to their health care choices. Rationing already occurs in our health care system, but maybe we need to take it to a different level. At least with taxpayer dollars, we should set limits on treatment that is appropriate and cost effective.
Challenge #2: Reluctance to make trade-offs between health and money
Patients are not accustomed to thinking about costs when choosing health care. Some felt the more expensive option would be cheaper in the long run. Others stated they bought insurance so they could avoid considering whether medical procedures were worth the money. One component of this challenge I found interesting? Many health experts, and me (not a health “expert” even though I am doctor) – “believe that financial insecurity can have negative consequences for patients’ health and well-being” – participants seemed to see health and finances as completely separate. I have news for you – poor health creates poor finances. I see this all the time. The majority of serious illness is preventable, and it is a shame patients let their health go without planning in advance for the price of poor health. I think people see this and know it happens, but refuse to believe it can happen to them. We could save a lot of money individually and as a country plus have a better life if we focus on wellness and prevention first. By the way, that is an important component of Obamacare.
Challenge #3: Lack of interest in costs borne by others
The participants in the groups felt they had done nothing to cause the problem of unsustainable costs, so why should they help solve it? They also were under the delusion that cost-consciousness was unnecessary to reduce health care spending. Finally, they had negative attitudes against the insurers and the government, and choosing higher cost options was a way to “stick it to the man.” This section truly depressed me and made me sad about my fellow humans. Of course, I am colored by my father’s reaction to his stage four lung cancer diagnosis. He refused treatment for two reasons – it wasn’t going to cure him and most poignantly he stated, “Why should everyone else have to pay for something I brought on myself?” Maybe that attitude got lost with the Greatest Generation.
Challenge #4: Noncooperative Behavior
About one quarter of the patients in the study reflected that it was in everyone’s long term interest to spare private insurers, Medicare, and Medicaid from extra expenses. However, most felt that personal interests trumped communal responsibility. Participants stated they didn’t believe others would cooperate with reducing health care costs, so why should the participant cooperate? Gratefully, these “focus groups” were just that – a bunch of people answering questions in a group, where group mentality can prevail. Attitudes are infectious. I would be curious to see how strong personalities citing responsibility and a concern for others in addition to the individual would change the answers of the group. This brings me to the optimistic part of the article, and regular readers know I like to operate from the optimistic viewpoint – ways to create substantial shifts in public attitude in health care spending. I read with glee the three examples they highlight, as all are great ways to reduce what I consider a significant public health problem – overuse of medicine. The chosen examples:
Solution #1: The palliative care movement
Decades of research have identified strategies to improve end-of-life care. Continued media exposure has significantly improved the conversation about this expected life event. Better end-of-life education and care reduce costs, and there has been a decline in hospital deaths in the elderly and improved use of hospice services. This snowball has been decades in the making, and is approaching avalanche proportions. The Conversation Project and National Health Care Decision Day are programs dedicated to raising awareness and improving communication around the end of life. The Coalition to Transform Advanced Care is working on a curriculum to educate patients about financial issues around the end of life (full disclosure – I am working with them on this project.) Eventually, patients will get the education and care they need at the end of life, instead of the unnecessary and misguided treatments they currently face. This has significant promise in reducing future health care costs.
Solution #2: The “Choosing Wisely” campaign
This effort spearheaded by ABIM Foundation and Consumer Reports aims to educate both physicians and patients about unnecessary tests and treatments. Thirty five specialty societies identified multiple procedures and treatments that are not effective and are basically a waste of money. Educating the public and physicians about these specific regimens will ideally reduce how often people ask for unnecessary care and provide physicians with better educational material in turning down those requests.
Solution #3: The National Institute for Health and Clinical Excellence (NICE)
I need to take the authors of the Health Affairs article out to dinner because their third example is NICE in the United Kingdom. I have been a vocal proponent of a variation of NICE in the United States for some time. England doesn’t have the best health care system, but they have an objective approach to rationing unnecessary health care and this approach is supported by almost the entire country. The program is administered by the National Institute for Health and Clinical Excellence and is a sterling example of how to incorporate costs into coverage decisions. I’ve written about this before, and it would be great if we could have a NICE equivalent to determine the optimal use of taxpayer dollars. If you don’t like the NICE decisions, pay for it out of pocket or purchase individual insurance that will provide the coverage for unnecessary treatment.
So overall, despite the findings of these focus groups, I’m optimistic. Although it will take time and effort, there are solutions. Share this with your friends and see if we can change some attitudes for the better. Questions or comments? Post here, reach me on Twitter @CarolynMcC, or at Carolyn.email@example.com.