Consumer-Directed Care Bets Against Human Nature
MANAGED CARE October 2004. ©MediMedia USA
How many patients have the intelligence and skills to choose on the basis of medical quality?
A mom with four children will tend to treat simple fevers at home for a few days before checking in with a pediatrician's office via phone. Even then, when a nurse says it's up to her whether to take the child in for an appointment, the mother is likely to suggest they wait a little longer. Thing is, she's made the same decision many times before, and — absent any sign of pain in an ear — the fevers have gone away on their own.
Most health care choices, however, are one-time occurrences. And when people are faced with making a decision for the first time, they're not very good at it, says Carl E. Schneider, JD, a professor in the law department at the University of Michigan and the author of The Practice of Autonomy: Patients, Doctors, and Medical Decisions (Oxford University Press, 1998).
Too much information
Many reasons are behind it. To make health care choices takes a good deal of information, for example, but the more information people get, the harder it is for them to assimilate it, Schneider says. Plus, a lot of people aren't very good at processing information about odds and have trouble doing the mathematics that it takes to understand them.
"This is not just something that I am speculating about," says Schneider. "Psychologists love to give people tests like this, and the results are very discouraging."
But what does this body of knowledge mean for the potential success of consumer-directed health plans, which are based on the theory that given more financial responsibility and control, as well as information, consumers will make better, more cost-effective health care decisions?
Some researchers who study consumer and patient behavior admit that everyone is different and that some personality types will appreciate the additional responsibility associated with CDHPs. Others say physicians who are working with patients in such plans can learn a lot from behavioral research, such as how best to deliver the information people need to navigate the plans. But many behaviorists are leery, claiming the tenets of CDHPs don't appear to add up.
"It's wildly optimistic to suggest that people are going to start making such good consumer decisions that you are going to get more rational health behavior," Schneider says.
CDHPs are typically high-deductible PPOs harnessed to health reimbursement accounts that employers fund to help employees pay for the first part of the deductible. They are often supported by online information and health assessment tools as well as disease management programs.
The idea behind CDHPs is that if consumers know that an office visit really costs $70 as opposed to their $10 copayment, or that an MRI is much more expensive than an X-ray — which they will learn when they pay for the service out of their HRA or out of their pocket — they won't go to the doctor unnecessarily and they'll choose the treatment options that offer the best value.
Consumers will ask more questions, seek out more information, look for better quality providers who charge more reasonable fees, and perhaps even live more healthily, proponents assert.
As an economic proposal, the basic premise of CDHPs holds true. It's widely known by actuaries that as copayments and coinsurance rates go up, people use fewer health care services.
In theory, it works
"In the traditional benefits world, we know that we start changing behavior when we change copayments and other financial aspects of the benefit design, and a lot of what is happening in health care consumerism comes under the larger banner of whether we can get people to change their behavior," says Seth Serxner, a senior consultant at Mercer Human Resources Consulting.
Yet CDHPs are asking people to do more than simply use fewer health care services. In theory, the plans make members more accountable for managing their health by using information to make health care decisions, Serxner says. "The theory is that if you are shopping for a digital camera, you spend a lot of time. Well, when you are shopping for a doctor, you need to spend a little more time."
The first behavior change CDHPs require, then, is to get people to use information. Consumers traditionally have not chosen physicians based on cost or quality measures, says Michael Trangle, MD, associate medical director of behavioral health and chief of adult psychiatry at HealthPartners, a health plan in Minnesota. "People generally have chosen physicians by word of mouth and by whether the physician creates an office that feels cozy, warm, and welcoming. Whether the physician is technically good or not has not been front and center in people's consciousness."
While one problem with changing that behavior is the lack of quality and cost information available, a significant behavioral issue is that even when data on hospitals and medical groups have been offered to consumers, they haven't applied it to decision making, Trangle says. "There have been fledgling efforts to pass cost and quality data on to consumers, but they haven't captured people's attention."
That may be because asking someone to shop around for a doctor and for services "puts an unbelievable and unfair burden on the patient," argues Barry Schwartz, a professor of psychology at Swarthmore College and author of The Paradox of Choice: Why More is Less (Ecco, 2004), in which he draws on his own research to show that offering people too many options can create more problems than it solves. And this is aside from the fact that some of the quality data are suspect. An article in the August 18, 2004 JAMA concludes that "Except for CABG surgery, the operations for which surgical mortality has been advocated as a quality indicator are not performed frequently enough to judge hospital quality." Yet people do use these insufficient data to judge hospitals.
"Medical care is not a consumer good," Schwartz says. "Cloaking this in the language of consumer autonomy and consumer choice is a blatant misrepresentation of both its intent and its effect. The only aim of this is to save money. It is not to improve the quality of medical care."
People already regard deciding whether to go to the doctor as a serious matter, he points out. "Because of the bureaucratic and overburdened medical system that we have in this country, I don't think anyone goes to the doctor causally. It's just too inconvenient. So adding the problem of trying to decide whether you can afford to go to the doctor is going to make the burden even greater."
The fact that annual checkups and other preventive services are often covered at 100 percent in CDHPs, without the employee having to pay for them out of his health reimbursement account, is a telling sign that such plans aren't "consumer-driven," he says. "It's completely patronizing to say, 'We don't trust you to make a good decision about getting checkups, so we're going to keep that the way it is currently. But from that point on, we can trust you.'"
A patient is also not in the position to judge, for example, whether he should have an MRI or a less expensive X-ray, Schwartz says. "I'm a very well-educated person, and I wouldn't know how to begin to determine which of those things I should have if I had pain in my stomach. And if I went and looked at Web sites, I wouldn't have any confidence that I was looking at the right Web site or that I was even asking the right questions. Putting the burden of making these decisions on patients is just ludicrous."
Finding out what you need to know to compare services based on cost may be impossible for consumers, says Kevin Peterson, MD, MPH, an assistant professor at the University of Minnesota Medical School. "You can't call a hospital and find out how much it costs to fix a broken arm. It's like asking how much an airplane seat costs. There are 1,000 different prices for 300 different seats. If you break your arm and you call the hospital, it will depend on which doctor you see and what kinds of tests are ordered. I suspect there aren't two broken arms that get charged the same amount of money in any given year. So how would a person obtain that?"
It's also simply not clear that knowing the cost of a health care service would influence a person's decision. In the field of behavioral research in medicine, there's not much information on how money directs behavior, Peterson says.
"Money is often a facilitator and an enabler, not necessarily a motivator for people to change their behavior," says Peterson, who, under a grant from the Robert Wood Johnson Foundation, is studying how primary care physicians and their staffs can get people to change unhealthy behavior.
The reasons behind whether a person is ready to make a lifestyle change such as improving his diet are very complex, Peterson says. "There are specific reasons why people do not change their behaviors, and those reasons are often particular to the individual. There are family and social factors; sometimes the person doesn't control what he eats because someone else in the family makes the food. Other people don't really believe that making a change would be good for them. And others have an emotional resistance: They believe they should eat better, but they have emotional reasons why there's a conflict about it."
Behaviorists talk about decision balances: People make specific decisions based on the way they feel and the way they judge or analyze a situation — they have an intellectual approach and an emotional approach.
"Money would be part of the intellectual debate, but it is certainly not a fundamental driving force, unless that person happens to be particularly focused on money," Peterson says. "But more people are driven by emotions than by money. A person's interaction with his doctor, for example, is likely not driven by money but by his emotions."
Older consumers, in particular, put a greater emphasis on their relationships with physicians, says David Wolfe, an expert on consumer behavior and coauthor of Ageless Marketing: Strategies for Reaching the Hearts and Minds of the New Customer Majority (Dearborn Trade, 2003). "The older mind really works in some respects at a higher and more complex level than the younger mind. As we grow older, we put more value into our experiences with the people we deal with than we do in the product and services we get from them. That's a more complex way of assessing value."
Yet many senior citizens will gladly take on a stronger decision-making role when it comes to health care, Wolfe says. "There's a tendency among older people to become increasingly autonomous. It's a very common behavioral attribute of later life."
When making a decision, older consumers also relate better to stories than to straight facts, Wolfe advises.
"Cognitive processes tend to slow down as we age, so it takes a little more concentration and effort to follow the information when it's delivered in a didactic manner," he says. "But stories are much more effective at arousing emotions. Older people have years of experience with thinking through situations and problems. All it takes in the brain is just a little bit of an emotional trigger, and they've got the whole picture before them. Stories are very good at doing that, at getting across concepts — much better than just a lecture-type delivery of information."
In any age group, there will be personality styles that are a good match with CDHPs and some that aren't, says Trangle of HealthPartners. Some people will want the flexibility to search out specialists for everything, while others will prefer to stick with the advice and care of a primary care physician, he says. And people will want different levels of information.
Trangle says: "Some people come in and they have explored the Internet and they say, 'This is what I've learned.' Other people say, 'I don't want to hear the details or about side effects; just tell me what to do.' Some people get very upset if they feel that a physician is trying to shove all kinds of data down their throats. They don't want to hear it. If you're a physician, you have to be flexible and meet patients where they're at."
Those with chronic illnesses are likely to be in the best position to make sound health care choices, says the University of Michigan's Schneider. "People who are chronically ill, who come in regularly with recurring problems, often get to be pretty good at understanding what is going on in their bodies and having some idea of what sorts of responses make sense to them."
But even health care experts sometime can't make a decision, Schneider says. For example, a national committee that had been set up to write guidelines for testing for prostate cancer couldn't agree on standards, so it said that individual patients and their doctors should decide whether or not to screen the patient.
Schneider and a physician then did a study in which they attempted to give about 40 men enough information to decide whether or not they would like to be screened, taking as much as an hour to explain the facts to the patient.
"Even after spending all of that time — which no doctor is going to devote to a single question — lots of the people we talked with still hadn't understood what we were saying," says Schneider. "They hadn't understood what we were saying partly because people don't approach a question with a blank mind that the educator fills up. They approach the question with a lot of misconceptions about how their bodies work, about how disease works, about how health care works — you name it. So they hear everything through the filter of their misconceptions. And this warps what they hear and how they analyze the problem."
Put another way, says Schneider: "I have been teaching for 25 years. I work really hard to teach. And my students are specially selected for their aptitude in learning the law. But when I read the blue books, I feel very discouraged every semester. Teaching and learning are extremely difficult things for both parties."
So one of the flaws of a system that attempts to give consumers information and asks them to make more financial decisions when it comes to health care is that "we have so much evidence about how hard it is to acquire, assimilate, and use the evidence you get," Schneider says. "It's not because people are stupid or lazy. It's because these things are very difficult. You become expert in a profession by handling problems in it over and over again. And patients don't have that kind of experience."