Attempts to control healthcare costs, to link cost to value, and to expand access to insurance have all led to important changes for patients engaged in the healthcare marketplace. Those changes, which encourage patients to be “consumers” as they navigate options for care, support the impression that patients are engaged and empowered to make their own decisions. Although the patient engagement movement had made steady progress, patients still rarely have access to all the information they need to make fully informed, rational medical decisions.
Price and quality are the factors most of us consider when making purchasing decisions, but that information is not available to inform healthcare decisions. Even if it were, patients wouldn’t always have enough medical knowledge to make optimal choices on their own. Ideally, patients would be fully informed and work together with their clinicians to make the best decisions. However, the financial pressure of having “skin in the game” – a vestige of consumerism – may override other considerations. Knowing that a $2000 deductible stands between you and the care you need may be enough disincentive to cause avoidance or delay.
These and other issues related to consumerism in healthcare receive good coverage in various outlets, including the March 2019 “Patients as Consumers” issue of Health Affairs, an earlier post on this blog, and an editorial for STAT by Engaging Patientscontributor Michael Millenson), among many others.
Health plan design influences decision-making
The design of health insurance plans – the details of coverage and expenses that patients must pay out-of-pocket – also affects patients’ decision-making and has received less attention. I hadn’t thought about health plans in the context of patient engagement, nor patient safety, until I read “Vulnerable and Less Vulnerable Women in High-Deductible Health Plans Experienced Delayed Breast Cancer Care” (in that same issue of Health Affairs)and had the opportunity to talk with Frank Wharam, M.D., the lead author.
Wharam is director of the Division of Health Policy and Insurance Research in the Department of Population Medicine at Harvard Medical School. Using a vast repository of insurance claims data, Wharam studies the effects of high-deductible health plans on patients in defined populations. In addition to results of the breast cancer study, his research group has recently published studies that examine the effect of high-deductible plans on patients with type 2 diabetes.* He is also a practicing general internist in the Atrius health system in Boston. [Full disclosure – I interviewed Wharam while developing an article for Patient Safety Beat, newsletter of the Betsy Lehman Center for Patient Safety.]
Health plans are important drivers of behavior, but the results of that influence are not well understood. Wharam’s research is a beginning, and some of the early results demonstrate that the effects are complex. In the Patient Safety Beat interview, he comments, “High-deductible plans have grown steadily for more than a decade. You’d hope that by now we’d have good data about the health effects, but we don’t.” He also points out, “Studies in health insurance claims data need to be carefully constructed to deliver meaningful results.”
Wharam’s studies may begin to inform choices that companies, organizations and individuals make regarding health insurance, but the results are difficult to generalize. Evaluating the effect of large-scale policy changes across populations amounts to learning from a “natural experiment” unfolding in real time – in contrast to analyzing the effects of targeted treatments in randomized, controlled trails.
It’s sobering to realize that consequential shifts in health coverage and access to care are based largely on intuitive, common sense beliefs, which may or may not be accurate. As the research being done by Wharam and other researchers continues, patients, advocates, clinicians and others interested in supporting patient engagement should consider the effect of health plans, especially those that shift cost onto the consumer. Meaningful participation in health decisions begins with awareness, followed by information and consultation. What kind of health insurance coverage patients have may impact decision-making and health outcomes, as well as their finances.