By Sachin H. Jain
Forbes, April 17, 2018
For decades, many have been dreaming of a revolution in healthcare based on the premise that making patients more accountable for healthcare costs—making them “consumers”—will result in higher quality and lower costs. It’s a brilliant vision. And smart people believe it makes sense. Except for one little detail: For many patients, it’s not a dream, it’s a nightmare.
Misplaced Conventional Wisdom
There is a conventional wisdom about patients that is inconsistent with the reality that many patients live. It starts with the premise that patients want to shop for healthcare like they shop for other goods and services. We assume patients want to go on-line and manage their health and make all of their own healthcare decisions. We assume they want to use rating ranking sites to make decisions about where to get their primary care and medicines. We assume they want to shop like it’s Black Friday.
The conventional wisdom continues with assumptions about the literacy, engagement, capability, and wealth. For many healthcare entrepreneurs, the median patient is assumed to be an MBA graduate with significant disposable income. The imagined patient has a “Type A” personality and wants to be obsessively engaged in every aspect of their health or healthcare.
And, on a related note, the conventional wisdom assumes high levels of digital literacy. The average patient has a sophisticated smartphone and multiple paired Bluetooth devices and knows how to use them. And would be able to improve their health if they just had the right tools to do so.
The implementation of this view is the proliferation of point solutions that aim to solve problems that we assume that patients prioritize: transparency of lab data, access to on-line medical records and easy access to appointment scheduling. While these are wonderful convenience features that we should undoubtedly adopt, they do very little to fundamentally change the healthcare cost or quality for consumers.
And they’re oddly implemented as an endless maze of disconnected portals, tools, and apps—few of which speak to each other and few of which delivers anything close to the value that we believe that they will. Either because patients don’t use them as intended, or they fail to capture the complexity of the broader ecosystem in which our patients live.
And there are many companies and startups that excite the people that are built on this vision of consumerism with clever tag lines that mask the incrementalism that underlies them. These are healthcare solutions that are really good for the 80% of patients who account for 20% of our healthcare costs. But the question is whether this perspective on the empowered consumer works for the 20% of patients who account for 80% of the costs.
Because if you are really trying to change the cost or quality equation in healthcare—you need to imagine a different consumer profile. One where the patient doesn’t want to be engaged in the traditional sense of the term—but where everything just works right for the patient. Where needs are anticipated and addressed before the patient or family can articulate them. One where we push beyond the superficial causes for problems—and dig far deeper into their root causes.
A Different View of Consumerism
CareMore, the company I lead, espouses a very different vision of consumerism. By way of introduction CareMore is a $1.4B Medicare and Medicaid delivery system that focuses on the care of more than 150,000 high-cost, high-need and vulnerable patients in 10 states. Our mission is to make health care more accessible, affordable and simple for the patients we are privileged to serve.
CareMore’s view of consumerism is grounded in the following simple ideas: 1) Healthcare should anticipate and deliver on consumers’ needs proactively. 2) Sick people should not have to shop for the care they need. 3) Consumers should not pay out of pocket for the things that they need.
Sick Patients Shouldn’t Have to Shop
Probably most controversial notion is the idea that sick people shouldn’t shop. But think about it. You’ve just been diagnosed with breast cancer. Multiple sclerosis. Diabetes. Do you want to be flipping through directories to find a doctor? Or do you want the appointment to be set up for you urgently with exactly the right specialists for your condition? Do you want the right durable medical equipment needed for your delivery to just show up or do you want to look through a website to pick your equipment? While I recognize there are a number of consumers—who given the opportunity to make these choices, would want to be in the driver seat—I would argue that most would not. They would want, most simply to just be cared for.
There is poverty in thought and intellectual laziness when we simply say consumers want to make these decisions.
By Don McCanne, M.D.
In this article, Sachin Jain presents the fallacy of consumer-directed health care, that somehow the patient has the desire to use their own expertise and control of their own funds to shop for the best care available and in doing so will improve the quality and reduce the costs of health care. Jain explains that, instead, patients do not want to shop for their health care but would prefer that beneficial care be offered proactively without financial barriers that impair access to that care.
In other words, patients want the health care they need when they need it without having to shop in a complex health care environment in which they have little or no expertise. This is an argument for supporting a robust and efficient primary care infrastructure. Such a system should provide easy entry to appropriate technological and specialized services for patients with medical needs, not to mention being a source of preventive services.
It should be noted that the conclusion presented by the author, but not included in the excerpts above, is quite biased. Sachin Jain, MD, MBA is President and CEO of CareMore Health, a subsidiary of Anthem that provides Medicare Advantage and Medicaid managed care plans. Rather than framing the solution as primary care, in the rest of the article he essentially is marketing their private Medicare and Medicaid plans.
Although many of us at PNHP support integrating health care through a primary care infrastructure, we remain opposed to private Medicare Advantage and Medicaid managed care plans, especially those offered through a for-profit Wall Street corporation. The primary care professionals collectively, loosely arranged within a community and interacting with the specialized services and facilities available, or a community health center, or an integrated delivery system such as Kaiser Permanente, would be examples of the type of primary care infrastructure that would serve us well.
This comment clearly is not an endorsement of privatized Medicare or Medicaid, but it is a recognition that an individual representing the medical-industrial complex can still have the wisdom to recognize what a con the consumer-directed movement in health care has been. So we should to listen to everyone but reject the bad while implementing the good.
Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.