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Healthcare Consumers: Problem or Solution?

by Scott MacStravic

There seems to be a serious disconnect in how healthcare provider organizations, commercial and government insurance, employers, and healthcare reformers think about and deal with “consumers” as they seek to achieve their separate and often conflicting goals. On the one hand, consumers are often seen as “the enemy”, the reasons for the severe and worsening problems that the healthcare system faces. On the other, they are seen as essential partners in solving those problems. This connect varies across the stakeholder categories, and even across different problems and issues to be resolved.

Increasingly, as we find the genetic differences that make it essential to “personalize” the treatment of consumer health problems, we recognize how many such problems are bred into consumers, with genetic predispositions to gain weight, become addicted to a variety of behaviors, etc. This tends to “absolve” consumers of responsibility for their health problems, and increasingly call for medical and pharmaceutical “solutions”, such as nicotine replacement therapy for smoking, bariatric surgery or drugs for weight loss, etc.

On the other hand, we also seek to make consumers more responsible, accountable, and motivated to alter their health behaviors in order to reduce the incidence and prevalence of expensive illness and injury. We differ as to whether a “carrot” or “stick” approach will work best, often trying one first, then seeing if the other will work, or even combining them by punishing them for “bad” health behaviors, while rewarding them if they change them.

This is accompanied by conflicting notions as to what healthcare providers can be held accountable for. If consumers are responsible for how they behave — whether they comply with prescribed medications, adhere to recommended or agreed-upon lifestyle changes, participate in proactive health management (PHM) initiatives, or not – we are treating them as people with free will. If they are, then how can we hold providers of sickness care or health management services accountable for what their patients do?

At the same time, we are talking about “medical homes” in which primary physicians, nurses, pharmacists, and other clinicians, even non-clinician “coaches”, perhaps supported by hospitals or payors, take responsibility and are paid for managing their patients’ health, risks, and diseases. This indicates we think that consumers can be controlled by such providers, who get pay-for-performance (P4P) bonuses, “gainsharing” based on money saved, or continuous “retainers” to keep patients well.

The conflicts and disconnects regarding how we “partner” with consumers in sickness treatment or health management is sure to complicate both, as well as confuse consumers. Moreover, one way or another, it will inevitably add to the costs of care, by either making medical solutions more expensive (e.g. bariatric surgery or lifetime drug “dependence”), or adding incentive costs to consumer-focused efforts to effect behavior and lifestyle changes needed to make sickness or health solutions work.

For example, the recent report of the potential for reducing the incidence and prevalence of just seven chronic condition categories (cancers, heart disease, hypertension, mental disorders, diabetes, pulmonary conditions, and stroke) foresees a total of $8.5 trillion being saved between now and 2023. These savings are split roughly 80/20 between workforce productivity and sickness care cost savings, and details on how they are to be achieved are not included.

Moreover, the report does not include even a discussion of whether the “solutions” required rely on payer, provider, or consumer “reforms”, or any mix of the three, to bring about such dramatic savings, nor how much they will cost. The estimated savings are not net of the expenditures needed to achieve them, nor are the ROI ratios or amounts expected included. [R. DeVol & A. Bedroussian” An Unhealthy America Santa Monica, CA; The Milken Institute Oct 2007 (www.milkeninstitute.org)]

Until we clarify the consumer roles in achieving the outcomes described in this report, along with those of payors and providers, its vision of the future is likely to be a beautiful dream, rather than becoming a much-desired reality. It may well be that the consumer role will vary by the particular challenge to be addressed, and change with the particular approach being used to address each. But since the costs of solutions will vary enormously, depending on which roles providers and consumers assume, and how they can be persuaded to assume them, until these “devilish details” are worked out, this potential will remain a dream.

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