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Healthcare: Need for Transparency

Health literacy and effective decision support tools are the “soft underbelly” of Healthcare Consumerism (HC). Creating smart patients lags behind the other building blocks of HC. If this area of current weakness is not resolved properly and/or if plan sponsors do not emphasize and support health literacy in materials and actions, HC may fail.

To be successful, HC should have extensive educational, informational and decision-supporting tools. The plan member needs help with product selections, and patients need support with clinical options, cost concerns and lifestyle decisions. These tools serve as the foundation for encouraging behavioral changes by helping individuals make informed health care and medical treatment decisions. Information is intended to supplement the patient/physician relationship and provide a level of understanding about a potential or proposed course of treatment.

Decision aids help shape consumers’ knowledge of the benefits and patients’ understanding of the risks of each treatment option. With improved knowledge of expected outcomes, consumers using decision guides have been more involved and effective in making decisions as partners with their doctors.

Five compelling points underline why consumer decision guides are an integral part of the HC process.

  1. Patients as consumers want information — and control. They want to pick their health plans, doctors and treatments; they want information, options and involvement.
  2. Patients as consumers use — and like — decision aids. When offered and effectively communicated, people use them and find them helpful.
  3. Decision aids change minds. When personal choice plays a critical role or patients are undecided about their options, decision aids are particularly useful.
  4. Decision aids improve the quality of care and lower costs. Informed medical decisions can reduce unnecessary visits and services, increase use of highly effective services and ultimately lower costs.
  5. Decision aids are getting smarter. Use of prescribed decision aids have become increasingly effective as health plans use predictive modeling to identify specific opportunities to support smart decision making.


Health Literacy by Generation

First Generation Decision Support

First generation decision support services focus on providing members information on discretionary expenses such as, prescription drugs costs, relative office visits costs, plan comparison cost calculators and basic clinical library information.

See also: Insurtechs Are Pushing for Transparency  

Consumer information tools help individuals assess the relative value of purchases, whether paid for personally or covered by their medical plan. Such tools may help individuals:

  • Compare benefit plans;
  • Evaluate wellness, wellbeing and preventive care lifestyle changes;
  • Locate in-network providers;
  • Select alternative prescription drugs based on cost and efficacy;
  • Evaluate the risks and benefits of expensive procedures or tests;
  • Compare providers based on quality indicators; and
  • Understand acute and chronic conditions and how best to manage them.

Second Generation Decision Support

Appropriate content, form of messages and good programs and tools are necessary but not sufficient to change consumer and health behaviors. Second generation decision support tools that focus on changing health and consumer behaviors require active patient involvement with learning, practice, reinforcement and rewards. Although measurement of the value of behavioral changes can be challenging, collection and evaluation of program metrics are essential.

The road to providing education and support tools is neither an easy nor a short path. A Kaiser Foundation study of how consumers compare the quality of health care among different providers showed they would first seek a friend or family member, followed by a health care professional. At the bottom of the list fell published materials and a toll-free number. More recently, health consumers have shown a strong interest in web tools. Smart phone technology and readily available phone apps are easy and convenient sources of medical information. Be sure that plan members are provided the right tools that are consistent with the plan design and coverages.

Without question, HC requires significant effort and responsibility from individuals. They must make decisions about how they want to spend their healthcare dollars, which providers to see and what services are necessary. Both proponents and critics agree that success depends on members making good health and healthcare decisions based on medical evidence, personal preferences and overall value. For HC to ultimately succeed within an organization, it must put interactive action-based health decision tools into the hands of its members.

Below is a listing of typical decision support tools.

Basic Design Information:
—HRA fund accounting
—Underlying PPO plan design
—Disease and/or medical management
—HSA fund accounting
—Debit/credit card

Personal Benefit Support:
—Plan comparison cost estimator
—Account balance
—On-line claim inquiry
—Summary plan description

Personal Health Management:
—Health risk appraisal
—Health & wellness information
—Targeted health content
—Medical record, history
—Health coach

Provider Selection Support:
—Physician quality comparison
—Physician cost comparison
—Hospital quality comparison
—Hospital cost comparison

Care Support:
—On-line provider directory
—Provider scheduling
—On-line Rx comparisons
—On-line patient decision support
—24/7 nurse line

Third Generation Decision Support Tools

Third generation tools extend the impact of decision support tools to other health, safety and performance metrics of an organization. Aggregated claim and risk assessment data can serve as the foundation to help identify opportunities for ongoing improvement in the health needs of the employed population. Targeted information, assessment, self-help and interventions in areas such as stress relief though lifestyle change and work process changes can have a dramatic impact on health and performance. In addition, organizational resources (other compensation, safety and recognition programs) may be better leveraged to optimally engage and support the employee’s health, well-being and productivity.

For example, there can be an integration of and hot links to HR programs of financial management, leadership training, family support programs and other corporate self-help and training.

Fourth Generation Decision Support Tools

Fourth generation decision support tools will focus on the individual needs of each member. As fourth generation concepts develop, vendors can provide “arrive in time” information and services at critical moments for care. “Information therapy,” as promoted by Healthwise, suggests the active use of patient oriented information with clinical evidence based medicine. Information needs to be embedded into the process of care — as information therapy.

See also: Is Transparency the Answer in Healthcare?  

“Information therapy” is the prescription of specific, evidence-based medical information to a patient, caregiver or consumer at just the right time to help that person make a specific health decision or behavior change. It is the ultimate consumer decision support aid.

For example, Healthwise identifies potential of “prescribing decision support” aids for each of the following tests and treatments:

  1. Prostate surgery
  2. Back surgery
  3. ACL surgery
  4. Coronary artery bypass surgery
  5. Medication for depression
  6. End-of-life care
  7. Prescription of beta-blockers following heart attacks
  8. Early-stage breast cancer testing
  9. Colon cancer screenings
  10. Immunizations and eye test reminders for diabetics

Information is powerful if used as an important part of medical care and if supported with incentives and part of a value chain for treatment. If properly integrated into care, it can be as important to health and healthcare as a medical test, medication or treatment. With good information, people can achieve better health outcomes at lower costs. With good information, consumers will be better equipped to fully accept their role in the new world of HC.

The information presented and contained within this article was submitted by Ronald E. Bachman, President & CEO of Healthcare Visions. He is the author of a book entitled “Understanding Healthcare Consumerism.” You can find more information and free videos regarding Health Literacy and Healthcare Consumerism at www.ihcuniversity.com.

Private Exchanges May Be the Free Market Solution to Cost Control and Healthcare Consumerism

While the Patient Protection and Affordable Care Act (PPACA) is sometimes shortened to the “Affordable Care Act” or ACA, the act has few features that will make insurance more affordable.  Government studies and industry experts have indicated that strict coverage mandates, limited premium classifications, community rating, added benefits, single risk pools, and price compression will raise premiums more rapidly than if the ACA had never been passed.

The development of exchanges, both government and private exchanges, are part of an evolution that will change the way insurance is sold and bought.  It is a new way of connecting products with customers.   Government exchanges are likely to be used mainly by those qualifying for a federal subsidy.  The standards and restrictions on government exchanges are likely to attract poor risks and high cost claimants.  The government exchanges will use government paid “navigators” rather than independent licensed agents.  The government exchanges and navigators are not expected to offer supplemental products, life insurance or other products and services.

Private exchanges may be the free market solution to real cost control and lowering the number of uninsureds.  With 40-50 million uninsureds, the traditional agent distribution system for insurance is not working.   About 60% of the uninsured are under age 35.  Studies conducted in Georgia by the Center for Health Transformation Uninsured Working Group showed that 35% of the uninsured could afford insurance but did not know it.  Another 40% needed lower cost options that were not available to them either because insurers emphasized high premium products, or because existing state laws or legislative mandates increased premiums and favored insurers over consumers.

Many uninsureds work for a small businesses that do not offer insurance. They may be self-employed, part-time, or doing contract work.  In most cases, the need is for individual insurance, not group plans.  Selling single policies can be time consuming with little financial rewards for an agent.  Many potential individual sales are halted at the kitchen table when in the process of completing an application issues arise that could cause a declination.   Information derived by an insurer during the underwriting process is typically fed into an industry association called the Medical Information Bureau.  That information is shared across companies and a declined health application could have ramifications for future applications of life insurance, disability coverage and other forms of insurance. 

Private exchanges are developing that will offer individual and group products that emphasize wellness and treatment compliance for those under medical care.  PPACA requires insurers to “community rate” their products.  That is, individuals or small groups will not get direct credit for healthy activities.  New entities are forming that will likely attract healthy individuals and the less healthy members interested in getting better.  Developing private health cooperatives, captive mutual companies, and new insurers may be unencumbered by an existing unhealthy membership or a current business model that limits attracting customers willing to be engaged in healthy behaviors. 

Healthcare consumerism is more likely to emerge through private exchanges than government exchanges.  Private exchanges will provide a transition from employer-based insurance to individual-centered or consumer-centered insurance.  In theory, both large and small employers will be able to purchase health insurance through the private exchanges, and their employees can choose an individual health plan from those offered by participating insurers.

Time will tell.  We are in the beginning stages of a major market revolution.  We already know that government exchanges as originally promised for small groups have been delayed one year until 2015.  As private exchanges come on line, I believe each will be a little different and offer varying levels of products and services.  For awhile it will be a “wild west” show.  Ultimately, the success and failure of each exchange’s product and distribution model will lead to consolidation and better products, services, convenience, help, and information for the consumer.  In the end, more product competition and price transparency will lead to more citizens being insured and lower insurance costs will prevail.  This is the way free markets create successful products and services that consumers want to buy.