Consumers-Directed Policies - The Healthcare Imperative - NCBI Bookshelf
consumer perceptions drive market realities in healthcare. WHITE PAPER unlikely band of change agents, consumers are taking a stand and hoping to stakeholder. .. RELATIONSHIP WITH CONSUMERS WILL REQUIRE MUCH MORE. Healthcare consumers are the key stakeholders in patient-centered and patient- driven as a powerful tool to accelerate changes in the delivery of care (Binder, ). about healthcare provider quality will shift consumer decisions and drive the . Larger incentives, such as a 20 percent coinsurance difference between. stakeholder and consumer organizations, providers and advocates, and stakeholders working together to address the major challenges of today's Governors Association address the urgent need to drive fundamental change in the.
Market exchanges for health insurance let people choose from a large variety of insurance coverage plans and options. A movement toward personalized health treatment is also developing through the advancement of genetic, behavioral, and digital tools that are designed to monitor and manage personal health. Health insurance products and benefit structures that increase consumerism are helping to manage benefit costs. With the increased financial responsibility, consumers are reevaluating how and when to spend on healthcare services.
Specifically, CDHP members were more likely to say that they had checked whether the plan would cover care, had asked for a generic drug instead of a brand-name drug, had talked to their doctors about prescription options and costs, had checked the price of a service before getting care, had asked a doctor to recommend less costly prescriptions, had talked to their doctors about other treatment options and costs, had developed a budget to manage healthcare expenses, and had used an online cost-tracking tool provided by the health plan.
Changes in the healthcare marketplace going forward are requiring patients to spend more of their own money on their medications.
How health-reform stakeholders will be affected by recent changes
They are no longer uninvolved players in the selection of treatment and the use of drugs or health services. The pharmaceutical industry is discovering that it is important to understand the behavior of its consumers if it wants to meet sales expectations.
Drug manufacturers can no longer expect to have commercial success by simply proving that their drugs meet the established measures of safety and efficacy with traditional clinical customers ie, providers.
Manufacturers must now understand consumer behaviors if they want to meet the increasing demands of patient expectations.
One area in particular that already has become more expensive for consumers is specialty medications, which treat complex conditions.
It is anticipated that prescription abandonment rates will continue to rise throughalong with the growth of middle-class wage earners who are facing high-deductible plans. Growth of Quality Measures Increases, Becoming More Structured Reported by many sources sincethe United States spends more on healthcare than any other industrialized country; however, the US healthcare system is not better, and its quality is inconsistent. One reason for this is that the healthcare system is primarily fee for service FFSin which providers receive payment for each service rendered, leading to incentives to provide more, not better, services.
The federal government implemented the National Quality Strategy in March to increase the quality of healthcare and to decrease its cost. Quality measures are increasingly being used to determine how much providers will be paid. Mounting evidence shows that leadership engagement positively impacts healthcare quality. Several organizations develop and evaluate quality measures, and an even larger number of public- and private-sector organizations use different measures for evaluating and reporting on the performance of providers.
These organizations use a transparent approach to give the public an opportunity to review and comment on their draft measures, to refuse to use proprietary measures, and to make their measure-scoring mechanisms transparent. Private sector—focused organizations, such as the Leapfrog Group and the National Business Coalition on Health, focus on commercial plan sponsor needs to measure successful plan performance, including quality.
Like their public-sector colleagues, these groups operate transparently at the local, regional, and national levels to give real-world data on provider or health plan performance to sponsors and members. These efforts are gaining momentum going intoand have had successes in the market to drive change without publicizing or publishing like public sector agencies. Although there have been successes, failures and lack of significant change have remained issues going back to the use of several preventive measures eg, the flu vaccine, aspirin, and cardioprotective agentseven in the hospital setting.
It is more likely that with shared savings and ACOs in the marketplace, more attention will be placed on compliance with proved clinical solutions or treatment guidelines because of the negative economic implications of not following guidelines. Overall, there is an increasing focus on single measures that are useful across care settings and are more aligned with the entire patient course of disease.
Simplifying the large number of similar but different quality measures to more successfully implement change for better clinical and economic outcomes has become a focus going into The use of quality measures is expanding and increasing the demand for new, innovative care-delivery measures that can deliver desired plan performance by plan sponsors and by patients. Revenue Pressure Driving Healthcare Stakeholder Consolidation A fundamental shift in healthcare economic risk is taking place, driven by an aging population and the increasing incidence of behaviorally induced chronic conditions.
Overlapping with these views, representatives from the employer sector asserted that they value not only maintaining healthy and productive workers and families at the lowest cost possible, but also focusing on enhancing community health.
Meanwhile, providers on the panel desired evidence-based, effective diagnostic interventions and treatments that are delivered efficiently. They also considered value in terms of focusing principally on appropriateness of care discussions that fully engage providers and consumers together, rather than conversations about controlling costs. Participating payer representatives emphasized a value orientation around evidence-based medical interventions that are highly effective and around structuring incentives to encourage the use of these interventions.
Despite these differences in perspectives, many stakeholders indicated areas of commonality, suggesting that beneficial social outcomes, such as improved school performance and productivity, may be hard to monetize yet could be considered in assessments of value in health care. Importantly, several presenters also separately identified problems with the current delivery system, indicating a misalignment of payment incentives with the goals of value.
Mark Fendrick suggested that while healthcare reform discussions focus predominantly on controlling costs, it is the concept of health that should be uppermost. Despite the relative lack of attention to the value proposition, Paul B. Ginsburg stated that rigorous methodologies to measure health outcomes per level of expenditure are available, transparent, and well accepted. Both discussants underscored the misalignment between the current health delivery and financing system and the achievement of value.
Fendrick asserted that we instead have two streams of concern—quality improvement and cost containment—that create conflicting incentives for patients and clinicians. Some quality improvement initiatives are designed to improve patient self-management by increasing participation in specific high-value interventions that are becoming costlier to patients.
Yet rising out-of-pocket costs discourage the use of recommended services and the overuse of interventions of questionable benefit. He commented that studies demonstrate that when patients are required to pay more for their health care, they buy less of both essential and excessive therapies alike Newhouse, Meanwhile, current clinician reimbursement systems create additional financial barriers to providing adequate primary care and follow-up services.
Fendrick stated that consumers require education about the value of the services they are consuming and payers can assist by providing financial incentives to encourage the use of high-value services. Using this approach, the promotion of services and interventions with high benefit-to-cost ratios will produce greater value—defined as health per dollar spent—at any level of aggregate health expenditure.
Value-based insurance design offers a potential incremental solution to enhance efficiency in healthcare spending, suggested Fendrick. The more beneficial a therapy is likely to be, the lower is the cost share.Changing the way insurance works: Vitality globally
By aligning financial incentives in this way, high-value care is encouraged, while low-value or unproven services are discouraged. Ultimately, Fendrick asserted that such a strategy would produce more benefits at any level of expenditure.
Ginsburg asserted that pursuing a value-based strategy that discourages low-value interventions will be much less successful. He specified that to implement these strategies successfully, consumers, providers, payers, and researchers must be involved.
Expanding on this idea, he said that since value determination will require extensive knowledge of the outcomes and costs of the services being evaluated, it will necessitate enhancing the commitment to effectiveness research.
Ginsburg also cautioned that while it is conceptually appealing to consider a medical intervention as either valuable or not, value is a continuous outcome, not a binary one. Medical services span a continuous scale, ranging from those with positive benefits to those without benefit and even to those that cause harm.
Ginsburg said that although some may argue that enough evidence exists to enable distinguishing useless and harmful interventions from those that could provide utility, recent history has demonstrated our inability to determine the harms of many medical products prior to their widespread use in clinical practice.
Beyond identifying a need to form consensus about the best methods of measuring and utilizing value assessments, a common theme discussed by both discussants was the critical need to reform the healthcare provider payment system to reward outcomes over volume.
Without this, they suggested, we will continue to struggle against powerful incentives that work counter to the achievement of better value. Perspectives from Patients Sabrina Corlette stated that the patient community is not monolithic and there is a wide range of consumer and patient perceptions of value.
Engaging consumers to manage health care demand
Corlette expanded on this idea, saying that people generally do not question the quality of care they receive, even if their attention is called to the epidemic of medical errors and the huge geographic variations in quality in the United States.
She stated that there is an unwillingness to accept the idea that the doctor they see and personally chose is not a high-quality doctor. She cited a recent poll by the National Business Group on Health that found that 72 percent of the employees surveyed thought their doctors were very or completely trustworthy sources of health information compared to 66 percent for nurses, 43 percent for health plans, and only 22 percent for employers National Business Group on Health, Given the emergence of health information technology HITGriffith stated that patients have legitimate concerns about the privacy and security of their health information and the use of this information in ways that they do not understand and have not authorized.
However, the general public will be willing to accept some privacy risks because it recognizes the benefits of interoperable health records, she continued. With new leadership for the nation, she believes there is hope that the focus on HIT will bring a concurrent focus on the protection and privacy of medical records.
Engaging consumers to manage health care demand | McKinsey
Yet as consumers face escalating cost exposure and bear more out-of-pocket costs, there is both an increasing recognition that costs are rising at too high a rate and, over time, an increasing acceptance of some elements of the value agenda. Yet health care is different from other industries, Corlette maintained. She continued that proponents of value need to focus on quality and access and that any cost savings should just be an ancillary benefit of improved quality.
He explained that unrelenting market competition and the imperative of competitive labor costs have driven employers to unprecedented levels of engagement in healthcare transformation and cost control. The discussants agreed that evidence generation is foundational to value acquisition in health care. These factors, he said, have been demonstrated to deliver better performance at work, reduced absenteeism, and increased workplace productivity. Darling concluded that employers and other stakeholders must be bold in their efforts to increase the value obtained from health care in this country.
In the milieu of a sagging economy and rising unemployment, she articulated that the nation can address the deficiencies of the system and drive higher achievements in value only by shifting its focus from providing more care to a goal of delivering higher-quality, more effective, and more efficient care that can not only decrease the growth of healthcare spending but actually reduce it.
Perspectives from Providers Physicians view value in a different dimension than other stakeholders, noted Howard Beckman.
Stakeholder Perspectives on Value - Value in Health Care - NCBI Bookshelf
He added that when cost is presented as distinct from an assessment of quality, physicians view those who promote cost reduction as largely motivated by dollar savings that do not accrue to either providers or patients. The result is the perception that these cost-saving programs are untrustworthy. The discussants agreed that professionalism demands considering the needs of patients first. Confronted with talk of cost reductions, Beckman asserted that physicians hear two important messages: