Payor, Provider, Patient: Healthcare by Consensus
Proceedings of the 12th Annual Symposium for Managed Care Professionals
From left: Charles Inlander, Myrl Weinberg, Donald Balfour, M.D., Connie Pastore, and James N. Astuto discuss the influence patients can have on the system.
GENE BEED, M.D.: We're all consumers of health care, but these folks are up here because they also have some additional or different perspective on what the consumer role in health care is. Jim, let's start with you.
JAMES ASTUTO: I handle employee-health purchasing for the Eastern U.S. We spend $600 million a year on health care, and when [our merger with Bell Atlantic] comes together, I think it will be close to about $2 billion a year.
LORRAINE PASTORE: I'm managing director for an advertising agency in New York that specializes in direct-to-consumer advertising. We were the agency that was responsible, along with our client, for changing the FDA's ad guidelines in 1997.
DONALD BALFOUR, M.D.: I represent a multispecialty group in San Diego. We have been [judged as having] the highest quality standards by health plans in California. We were the number one group, out of 143, in California for Blue Cross, and we are, at the same time, the number one group in PacifiCare, out of 187 groups.
MYRL WEINBERG: We are a not-for-profit group of 115 national health-related organizations. We work on three things: To improve quality of health care, to promote the importance of medical research, and to improve awareness of our organizations. We conduct a lot of research related to patients, primarily people with chronic disease and disabilities. We will not use words like "rights" and "responsibilities" outside the legislatures or D.C. We will not talk about being an "equal partner" with your doctor. The theme is, "It's your health. You call the shots."
BEED: Very good. And comrade Inlander?
CHARLES INLANDER: Yes, I'm comrade Inlander. The People's Medical Society is the largest not-for-profit consumer health advocacy group in the United States. We have two goals. The first is to get information to the public about health care and diseases. The second is to reform the system to be more responsive to consumers. Our thrust is to empower consumers when they interact with providers. When they interact with doctors and hospitals, they will change the system far more effectively with the information they have than all the legislation to promote change. We're also one of the largest publishers of consumer health information. We've published over 115 consumer health books, such as Take This Book to the Hospital With You and four of the Dummies books about health and first aid.
BEED: And if you never read any of Charlie's organization's books, Take This Book to the Hospital With You recommends that if you're having surgery on a knee, take a permanent indelible marker and before you go to the hospital write "Left knee, this is the one. Right knee, do not touch." Great practical things! Well, about how we buy health care: What if, when we buy an automobile, we pay a $5 copayment for the car, and we can only go to "B" dealerships that our employer selects for us, and the salesperson determines the proper car for us to drive? If that makes no sense, why does our health care system do that?
INLANDER: We do buy cars that way, for the most part. Most of us don't pay out of pocket we get a loan. The salesman talks up a price, and gets us a bigger car that we probably can't afford with more gadgets than we actually need. But you can look at Consumer Reports to see how they rate the car. You can check with the National Transportation Safety Board to find out if the air bags work, if it had recalls, if it blows up when it gets hit. You can see mandatory disclosures. But when you go to the hospital, you get zilch. You don't know what the infection rate is. You don't know the names of the doctors who had privileges suspended. You don't know the drug-error rate. You know nothing about your doctors when you go to their offices, except a few of things that are put on the wall. You don't know anything about their outcome rates or about their competence.
BEED: Jim, do GTE employees want you picking their insurance? Does it help them, or would they be better off making their own choices?
ASTUTO: They make their own choices, because we give them a lot of them. We have at least three indemnity programs to pick from, plus the quality HMOs. But I want to go back to the first question about paying for it, and then about choice. This morning, I went down to the AstraZeneca breakfast, which was free. I didn't complain about the menu. If I didn't like it, I could have hustled over to one of the other cafeterias and ate on my ticket. So our opinion is, when we're paying, I think we have a right to make the menu. If you don't like it, dig into your pocket and buy something else.
WEINBERG: We have found that often, the changes in health plans offered to employees are made solely on the basis of not quality, but employee complaints. That speaks to the power that the patient can have, and that's one thing we're working to help them understand.
BEED: Don, how does this affect the way care is practiced at Sharp Rees-Stealy?
BALFOUR: Well, right now in Southern California, health care is what I call a wholesale business. Employers pay for health care, and employees sometimes have only one option. Sea World, in San Diego, decided this year it would offer only Kaiser. That's what I call wholesale. What we're talking about, really, is going to the retail side giving patients a voucher, allowing them to choose where they want to receive care.
BEED: How do we empower those consumers, Lorraine is it through television, so we can see that if we take a pill, we can climb the mountain?
Patore: If the managed care organizations are concerned about what DTC advertising is doing to health care consumption, then they have the solution in the palm of their hands. They can be communications companies, too, and improve their image the very same morning.
PASTORE: Make fun of it, Gene, but the fact is that consumers are learning from DTC advertising and are participating more in their own care. Charles made the point that people don't know about their doctors and hospitals. But they know about their drugs. It has helped in other ways, too: It has helped about a third of patients be more compliant about their medications. It has helped another third remember to get refills.
BEED: [Takes a question from an HMO medical director in the audience.]
QUESTION: Patients are being informed now on the Internet. My physicians say patients come to them with information that they don't even have yet. And they don't know what to do with it.
INLANDER: Consumers are desperate for information, and the system has never been one to disclose it. The system has been set up to intimidate. I lectured at Yale School of Medicine. I walked in, and these second- and third-year medical students were sitting in white coats. Now, what's going to spill on them while I'm talking to them?
BEED: Maybe some gourmet coffee.
INLANDER: I thought, "This is absolutely absurd." And so, the system that is set up is: I walk in, you call me Charlie. I call you doctor. It should be the other way around. It's a service. Consumers and the system have never been able to communicate.
BEED: Don, Charlie brings up a good issue: Doctors aren't trained to talk. It would be nice if docs would take time to explain. But if they do this, what are they not going to do? What are we doing now that technology can help us do more efficiently?
BALFOUR: The electronic medical record will allow physicians to spend more time with the patient, and less time in nonpatient contact. And that's been proven at the Mayo Clinic in Jacksonville. They have EMR now it's paperless. And that has shortened the nonphysician contact time that every interaction with a patient [generates]. If a patient calls for a prescription refill or for test results, instead of calling back in an hour or the next day when you pull the medical record, you can bring it up on a screen and do it right then. It takes 20 seconds.
BEED: [Takes another question.]
QUESTION: Jim, within your benefits managers group, have you thought about giving employees incentives, say, for good health patterns? Say, for example, $250 extra for those whose weight is within particular parameters, and another $250 for blood pressure that is in good shape? It seems that employees that take good health to heart subsidize those that don't. Is there a way to reward the educated consumer that tries to stay healthy?
BEED: Yes, Jim, what about a "fat tax"?
ASTUTO: We've been discussing it, I think, for four years. We call it the health plan for the healthy. So, you're diagnosed with diabetes? If you are willing to come into disease management not that you have to get the disease totally under control, but you agree to participate you're going to watch your weight, you're going to take your insulin, you're going to exercise, and we'll reimburse you 100 percent of your health care costs. If you're really not interested, if you just want to show up as a train wreck and be fixed, we'll say, "That's OK, too. But now it's going to be 80 percent." I've never heard a health man come in and want to do that.
INLANDER: Jim Fixx was the leader of the whole jogging thing. He dropped dead jogging down the street. Do you have to get a refund from his family because he was doing the right thing but he died anyhow? You can't pin it on whether someone is in a range. Pin it on whether someone's in a program, and not necessarily on results, because results can be all over the place. It could be because the doctor is using the wrong medication. It could be because a patient can't afford certain things. An even more powerful thing an employer can do and most still don't do this is [demand that health plans use] better providers. You're not hiring better providers now; you're hiring everybody who will take your deal.
BEED: But Charlie, doesn't that run counter to consumers? Didn't health plans expand provider networks because consumers said they wanted every provider?
INLANDER: Right. And I don't think that's good.
BEED: But that's what consumers say they want.
Inlander: Most knowledgeable consumers support the concept of managing care. The problem is that we don't have very many managed care companies managing care.
INLANDER: Consumers say they want it, because no one demonstrated that they were managing any care. Most knowledgeable consumers support the concept of managing care. The problem is that managed care companies manage money. Therefore, they took in everybody because consumers said, "Look, you're not doing anything." So they hire anybody to get an employer to sign up."
BEED: Jim, how come you guys are doing it?
ASTUTO: There's no differentiation in medicine. A doctor is a doctor, they're all "good" and that's the problem. Consumers say, "You can't tell me this doc is better than that doc, so bring my doc in." And the employer says to the managed care plan, "If you want us, 55 percent of my employees go to these three groups. Bring them in, because you're not showing me anybody is any better."
BEED: Are you saying that if a health plan came to you and said, "Our network is smaller than the other networks, but let us tell you what our criteria are and why it's smaller," that would sell you guys?
ASTUTO: Kaiser is just that. We have huge enrollments in Kaiser, and we try to steer our people towards those models. We think we can show that the group model is a far superior model for providing quality care.
BEED: We're going to let folks contemplate on that one.
INLANDER: We need a user-friendly system. There are plenty of ways to simplify the health system down to what consumers need to know. I'm a not a physician, but I read more medical journals than most physicians. I read PDR. But you don't hear me talking that language. You don't hear me talking about contraindications and myocardial infarctions. I say heart attack. And that's what you need to do to focus on the people who are going to receive care. Then they will be able to use the system and have more respect for you and the information they get from you when making decisions.
PASTORE: I think that's a great point. When we call disease management programs "disease management," you're not going to get people to raise their hands and say, "Yes, that's me, I have a disease." They want to say, "I'm helping myself. I am improving my health. I'm not labeled as having a disease," and I think that's an important thing.
WEINBERG: There are persons who may be very well educated but hail from some other culture, speak some other language, use words in a different way. If we do not find a way to have real communication with that person, we're never going to solve this. We have to have multiple strategies for communication. If we're going to use the Internet and give people data that is as specific as we need to know how our doctor is doing, then we need common data elements and a common language.
BEED: [Takes a question from the audience.]
QUESTION: Let's talk about the Patients Bill of Rights. I see what is really a "provider bill of rights." It's really about letting doctors go back to doing what they do. I'm a physician. Docs have formed an alliance with the consumer. They say, "We're in this together, and the bad guys are the HMOs." Yet I hear you saying very different things. And I wonder, with all the [bad press] about managed care, if there aren't a lot of intelligent consumers saying, "Yes, we've got problems. But you know, this is a system that can drive all of this stuff you folks have been saying, and we need that. So we can't have legislation that's going to ruin the system."
INLANDER: You are absolutely right about the Patients Bill of Rights. Never was a patients' bill there was only one quasi-consumer advocate on the group that came up with it. It's a political thing. Washington can run back to constituents and say, "I introduced a bill." There are thousands of bills about health care that are grandiose and nothing ever comes of them, but a representative can say, "Look what I'm doing for you." And the public doesn't know there's never going to be a vote or that it's never coming out of committee.
BEED: So Charlie, is there a role for consumer organizations like yours to counterbalance that?
INLANDER: We try to ignore most of that stuff. What we're trying to do is change the customer. You don't see Congress giving incentives to employers to create better disease management, because health care is not regulated at the federal level it's regulated by states. And at the state level, it's almost impossible for a consumer advocate to go state by state to fight everything that comes along. The AMA is powerfully organized at those levels. So you have to do this through the media. You have to yell and scream, and hopefully build a consensus. I wish that providers like you, who obviously agree with these issues, would speak out publicly, and not just let one trade association of health plans speak for everybody, when they don't speak for everybody.
WEINBERG: Yeah, but patients have nowhere else [to turn]. They're frustrated that they can't find a way to draw attention. So it would be totally inappropriate for them to oppose something like [the Patients Bill of Rights]. If they had their preference, they would go some other way. But if you can't get it done some other way, then the only way to get attention is to take it to the legislature.
INLANDER: And what the legislatures say to you is, "Next time, we'll fix it." When they [established] the Data Bank, Ron Wyden had to keep it from public view to satisfy the AMA and a few other groups. He said to us then, "Look, I know you're opposed to this, but in a year or two, I'll fix it." Well, here it is, 14 years later and we have been back to him and others umpteen times. Never once has there been a piece of legislation to open the Data Bank publicly. This is how we and most consumer groups are treated. So we try to get people to change their own behavior, and that seems to drive the system more effectively.
ASTUTO: We have this mandatory two-day hospital stay for a newborn. Has anybody ever looked at that? Hundreds of millions of dollars, and I bet we got this much [Astuto makes a "zero" with his thumb and forefinger] clinical improvement.
BALFOUR: Physicians have a real concern about legislation by body part. It's very difficult to turn down mandates if you're looking at them one at a time. Who would ever turn down cancer screenings? But no one is looking at the whole picture. In California, the governor just signed 21 new bills with six new mandates. And those mandates are going to cost $2.50 per member per month for every Californian with health insurance. Health care is going to become more and more expensive, and our uninsured rate now 22 percent in California is going to go to 30, 35 percent, and then the whole system will fall.
BEED: We have one or two minutes left to summarize this session. Jim, what should the employer do to move things forward for the consumer?
ASTUTO: The employer is still pretty apathetic. We need to get back into the game. The chairman of Kaiser, David Warren, said to me the other day, "You guys have never demanded quality." I said, "Oh, yes, we've always bought quality. We've just never been able to show that you delivered it."
WEINBERG: The Robert Wood Johnson Foundation looked to the future of health care. The only factor they could identify that could significantly change the whole system was consumer action. And so what we should do is find ways to provide consumers with the information they need to be assertive patients in an appropriate manner.
INLANDER: My only comment is that when you're dealing with your clients and each other, remember: The bottom line is, "How are we getting health care to consumers?" Are they being informed? Always put yourself in those shoes. Could you make this decision with the amount of information you have? If you do that, you are going to start thinking the way you want people to think about you.
BEED: I think that's the golden rule: Do unto others as you would have them do unto you. I can think of no better way to conclude.
Payor, Provider, Patient: Healthcare by Consensus
Old Saying Appropriate For Current Environment
David Brennan, Senior Vice President, Commercialization and Portfolio Management, AstraZeneca Pharmaceuticals
Health Status, Health Maintenance, and Health Care in the 21st Century
Louis Sullivan, M.D. , President, Morehouse School of Medicine;
Secretary, U.S. Department of Health and Human Services, 1989–1993
Health Care Reform: Payor, Provider, Patient
Health Care Reform: The Consumer's Viewpoint
Changing the Public's Image of Managed Care
Nancy Wilson Dickey, M.D. , Immediate Past President and member, executive committee, AMA
Treating Diseases and Managing Cost
The Power of Perspective
John Cassis, President, the Cassis Group
The 12th Annual Symposium for Managed Care Professionals was held November 11–13, 1999 in Scottsdale, Arizona, and was sponsored by AstraZeneca.
The opinions expressed in this special supplement are those of the symposium participants, and do not necessarily reflect the views of the sponsor or the publisher, editor, or editorial board of Managed Care.
PHOTOGRAPHS BY DENNY COLLINS