"Managed consumerism"
Consumer-Driven Health Care: Promise And Performance
by James C. Robinson and Paul B. Ginsburg
Health Affairs
January 27, 2009
This paper analyzes the evolution of consumer-driven health care in terms of its original vision, its subsequent implementation, and the transformations it has endured as it moves into its second decade. The market is generating product designs that combine elements of consumerism with elements of managed care, but the trend is always toward a stronger role for consumer choice and a weaker role for management of those choices by physicians, insurers, employers, and regulators.
Impact of the PPO
The insurance market has merged the ideas of consumer-driven health care with those of managed care instead of replacing the latter by the former. The dominant form of health insurance today, by far, is the PPO. It combines network principles from managed care with some of the cost-sharing principles from consumer-driven health care; in 2008, PPOs accounted for 58 percent of enrollment in employment-based coverage. The PPO began to displace the HMO in the late 1990s as HMOs’ gatekeeping and utilization review created too much consumer and provider animosity.
Despite the verbiage and vitriol on both sides, it appears that consumer-driven health care and managed care are complements more than they are substitutes for one another. The mainstream health insurance industry is reorienting itself to replace administrative controls with incentives and information but in a manner in which the health plan functions as an important intermediary for structuring choices and informing enrollees about provider price and quality.
A dilution of principles
The heart of the consumer-driven health plan is the philosophical belief that each individual should make his or her own health care decisions. Health care decisions should not be “managed” by third parties, and especially not by physicians and nurses employed by insurance companies. The consumer-driven health care movement has been obliged to dilute its principles in light of the overuse of inappropriate services and underuse of appropriate services in the real world. HDHPs now incorporate elements of disease management for enrollees with chronic conditions; case management for enrollees with complex or comorbid conditions; and utilization management for patients using particularly costly drugs, devices, or procedures. Most of these medical management programs are obtained from the same diversified insurers that offer HMO and PPO products.
Conclusions
As it moves further along the consumer pathway, health insurance is likely to strengthen rather than weaken some vestiges of its managed care heritage, especially the development of programs seeking to improve the care of enrollees along the spectrum from full health to dire illness. These include preventive and wellness programs for healthy enrollees, service coordination for patients needing acute care, disease management for enrollees with chronic conditions, and intensive case management for enrollees with severe conditions. These likely will be presented as options rather than mandates, consistent with the consumer-driven ethos, although perhaps with higher cost sharing for those who are eligible but choose not to participate. What is unclear, over the long term, is the extent to which more choice for consumers will prevent health insurers from being able to continue to offer the steep discounts they currently wrest from their provider networks.
The market continues to pioneer hybrid forms that incorporate elements of both managed care and of health care consumerism. We can name the emerging system “managed consumerism” or “facilitated consumerism,” or we can find some more felicitous phrase. The important point is that for choice to be meaningful, it has to be choice among meaningful options, and meaningful options need to be designed, built, and managed.
http://content.healthaffairs.org/cgi/content/abstract/hlthaff.28.2.w272v1
Comment:
By Don McCanne, MD
Managed care, consumer-driven health care, managed consumerism - these are just labels for a private insurance industry that has evolved from a role of indemnifying individuals and families against loss in the face of medical need, to an industry that has introduced innovative plan designs to enhance the success of its own business model.
Managed care was not designed to benefit patients. Its primary function was to enhance the business success of the insurers through provider contracting, limiting access and choice for the patients.
Consumer-driven health care was not designed to benefit patients. Its primary function was to enhance the business success of the insurers through the erection of financial barriers to health care, primarily through the use of high-deductible health plans.
The hybrid, “managed consumerism,” is not designed to benefit patients. Its primary function will be to continue to limit access and choice through provider contracting, and to continue to reduce access through the use of financial barriers to care.
These measures are designed to reduce spending by the insurers in order to keep their premiums affordable in a competitive market. For the insurers, the importance of consumers is simply that someone with enough money has to be there to purchase their products. Insurance products that take away choice and expose the ill to excessive costs are not the products that people want, but PPO/HDHPs are the predominant product that insurers offer.
Imagine if we had a single payer national health program - an improved Medicare for all. Would “managed care” even be a topic? Not when managed care has come to mean that individuals lose their choice by segregation of physicians and hospitals into plans to create an artificial market. Would “consumer-directed” health care be a topic? Not when consumer-directed care has come to mean that choosing to have the care that you need will cost you money out of your pocket that you may not have.
Tossing around labels and pretending that they represent solutions to our health care problems has got to go. No more con jobs with “managed consumerism.” It’s time to enact our own public system that simply pays our bills when we need health care - health care of our own choosing.