Three ways payers can help consumers make wise healthcare decisions

The healthcare cost “blame game” villainizes either providers for excessive services or patients for demanding too much.  Right now the blame game has pivoted toward the consumer, leveraging higher cost sharing to constrain their overspending and poor choices. That consumer focus has been at the center of employer benefit plans with higher costs for consumers as well as proposals for Affordable Care Act repeal.

That’s the question health plans, employers and providers should ask if they want to effectively help consumers change their spending.

There is a growing movement of consumers who are demanding better information and data to make better healthcare decisions. But the truth is that consumers don’t have enough information or knowledge to support them. The lack of information starts with essential clinical data about their own health status and extends to knowledge about cost of services pricing and access to information on treatment options.

1. Start by making full clinical information available to patients.

At best, patients get the abridged version of their healthcare record. In part, this is due to where the information lies-either in paper records or in providers’ Electronic Health Records (EHR) systems.

Even if the provider has an EHR, patients don’t always have access to their full data.  At best, they may be able to see or download test results, but will not see physician notes, diagnoses, visit data or synopses of treatments prescribed.  That means that patients are universally required to remember exactly what was said during a visit, including medical terminology used and treatment explanations. Health care is always provided in an “immediate” timeframe, which can stymie patients' efforts to deepen their understanding.

Additionally, patients have no access to data that the physician used to make determinations-which could include unmentioned physical exam details as well as actual images. Because of this, consumers universally have no recourse later to investigate on their own or with other clinicians.

Providers have made huge investments in digital health, but the data has been retained for their purposes in decision-making and analysis. More needs to be done to get this same information to their patients, and this is where health plans and other payers can help. As part of their Value-Based Health Care products and negotiations with providers, payers can create benefits or incentives for provider groups that are sharing data and supporting shared decision-making or goal setting with patients.

• Provide Consumers With Projected Cost Information

Consumers can’t make good decisions without knowing the cost and their share.  But while the lack of price transparency has been a much talked-about concern, little has been done to fix it.  Providers have little incentive to turn patients away from services because their revenues are at stake. 

Payers have ready access to cost information that can be available to consumers for major procedures, annual costs by condition, and even the relative cost of their own providers’ diagnostics, treatments, and facility costs. 

The challenge for payers is how to best channel information to consumers as they need it during the decision-making process. Whether online or by phone, however, health plans and employers can fill the gap that providers have been unable to accomplish in making decisions and communicating with providers: what the recommendations of the provider will cost.

2. Facilitate discussion to treatment alternatives and lifestyle changes

When consumers go searching for information about the benefits and harms of various alternatives, they often can’t find it.  Why? Because access to medical studies is not always accessible without professional credentials and subscription fees.  

Although all National Institutes of Health (NIH) funded research is available to consumers, others can only be obtained through publishing journals. And finding the full article on the published journals, along with relevant data, is prohibitively expensive. The process, even for the most determined consumer, is daunting and likely impossible for patients trying to access multiple articles.

Realistically, researching alternatives involves an understanding of physiological functions and clinical information that many consumers don’t have or is beyond normal expectations. So how can health plans help? They can create a foundation for consumers to have discussions with their physicians.

For example, health plans can provide a list of conditions and procedures where alternative therapies are in use, or effectiveness is under question. This would help consumers raise questions about alternatives with their physicians. Health plans could also educate consumers on questions they should ask about benefits, potential harms, and evidence. Physicians can and should be the curators of medical information for their patients. However, it will take a push from their patients to make that happen.

Patients must gain the confidence to understand the basic concepts of health care. Contrary to accepted belief, medical science is a discovery process and new knowledge is constantly emerging. Therefore, it is essential for consumers to be able to question whether prior assumptions are still correct. Asking simple questions will lead to knowledge of benefit vs. harm-or to the alternative of recognizing that not enough is known.

Payers can also facilitate action on the part of physicians to appreciate the growing awareness and financial responsibility of their patients and to better use a shared decision-making approach.

Once patients ask their physicians to provide literature for major diagnostic and therapeutic interventions, their physicians will be cued to their patients’ concerns and desire for further information. Provider groups should be encouraged through financial incentives and programs to facilitate the shared decision-making approach.  For example, Medicare has recently expanded its coverage of physician care management in ways that will provide incentives for shared goal-setting and discussions of long term treatment options.

Next: Patient engagement vs. patient compliance

Patient Engagement is Not the Same as Patient Compliance

The financial incentives in the healthcare system generally work to provide more services. But with patients paying a larger share of the costs, all stakeholders must be involved in realistic solutions to avoid disease, concentrate on the most effective treatments, and perhaps use more conservative approaches to interventions.

Patients were “dinged” in the past for not blindly following their physicians’ orders.  But we must acknowledge that consumers have financial pressures, don’t always understand the reasons for treatments and have unexpected side effects or harms. Establishing ways for them to participate fully in the discussion of their health status and outcomes is an essential component of getting to lower costs and better outcomes. 

Theresa Hush is the CEO and c0-founder of Roji Health Intelligence. As an expert at creating consensus for desired change through education and collaboration, Hush helps organizations take actions that will direct their future through meaningful technology and programs.