Posted 1/22/12 on Forbes
OK, maybe I misread the cover of the dog-eared copy of Glamour perched in a magazine rack at the gym. Perhaps I was confused by the multi-colored headlines promising an improved physical appearance (“101 One Minute Makeover Tricks”), a more organized daily routine (“12 Ways to Get Your Sh*T Together”) and, of course, better sex (“Guys Talk Sex! The 16 Things Almost EveryMan is Attracted To”).
(Note to other males: No, I couldn’t get up to sixteen, either.)
But as a health care wonk, what really caught my eye was this: “6 Health Problems You Can Fix Yourself. Save Your Co-Pay!”
Yes, a “how-to” about high-deductible health plans had made its way to the pages of Glamour.
It’s always interesting to watch health reform concepts move from policy shops and peer-reviewed papers into the mainstream. Provider report cards have surfaced in venues as diverse as Martha Stewart Living and The Examiner, a supermarket tabloid that promised to reveal “America’s 50 Best Hospitals.” (To be fair, that was under a much larger headline proclaiming: “Found! JFK Jr.’s Secret Diary.”
Even more telling is when health system failures spark sardonic commentary. The comic strip Dilbert dinged doctor handwriting (A physician dismisses the danger of unreadable prescriptions by noting, “That’s a little thing I call marketing”), while another comic, Sylvia, had its heroine wistfully wishing she could go from hospital to hospital warning patients about medication errors. Years ago, Doonesbury took aim at the hazards of low-volume hospitals in a strip where a surgeon confided he kept his skills sharp by practicing brain surgery on large melons.
One of my favorites in this category was a brief item in The Onion reporting that what an Iraqi hospital wanted most was bilingual “Employees must wash hands” signs. The hospital director is quoted as saying, “The importance of hand-washing could not, unlike doctors and nurses, be overstressed.”
Various types of high-deductible health plans have been around for about a decade, gradually working their way up to covering some 21 million people, or about 12 percent of the privately insured market, in 2011, according to the non-partisan Employee Benefit Research Institute (EBRI). They have been embraced by employers trying to limit their responsibility for rising health care costs by passing on more of the risk to workers, but employees themselves have been less enthusiastic. Euphemisms such as “consumer-driven health care” and acronyms such as HSAs (health savings accounts) and HRAs (the even-vaguer health reimbursement arrangements) haven’t cleared up the cloud of suspicion.
Physicians and hospitals have also been wary, both because of concerns that patients will economize on needed care for financial reasons and because high deductibles have been linked to bad debt problems during a period of economic instability.
There are also fears about an encroachment of commercialism. A cartoon in the Jan. 23, 2012 issue of The New Yorker shows a young boy telling his mother about his career dreams: “When I grow up, I want to go into medicine and help people who can pay out of pocket.”
The core concept underlying these various health accounts is the belief that marketplace incentives will lead workers to healthier behaviors and more cost-conscious use of medical services. So, for example, the Glamour article lays out “6 Health Problems You Can Fix Yourself (And 6 You Can’t).” The former range from the obvious (pressure and a Band-Aid for a minor cut) to a couple I’m guessing they don’t talk about in Girl Scouts (bad PMS; home pregnancy testing). The latter category includes ongoing depression and various types of pain and infections, including possible STDs.
The problem is that the expected economic impact of these plans, touted loudly by conservative economists and politicians, does not take into account that buying health care services is very different than, say, shopping for a car. That’s both because of the stakes involved (dead consumers don’t get a chance to make a better purchase next time) and the complexity for the average person of judging what services are needed and when they are needed.
Unfortunately, contrary to what the Glamour article seems to suggest, healthy behavior does not necessarily mean spending less money out of your health savings account. (Although, of course,not going to the doctor will save your copayment). An EBRI survey released in mid-January 2012 found “very little difference in account balances by level of exercise.” As for being a better “shopper” for health care services, “next to no relationship was found between either account balance or rollover amounts and various cost-conscious behaviors.” Worse, when a difference was found, those exhibiting cost-conscious behaviors were actually “found to have lower [medical savings] account balances and rollover amounts.” Using cost or quality information wasn’t much help, either.
The academic literature tells much the same tale. A paper published last year in Health Economics used three different methodologies to examine what happened when a traditional health plan was fully replaced by a high-deductible health plan (HDHP). Their conclusion: “Overall, introduction of HDHP had no impact on health-care costs, positive impact on the number of outpatient visits and mixed impacts on the impatient and emergency room visits.” The latter, of course, are far more expensive than the former.
Separately, a study in Health Services Research found even more unsettling results. “HDHP enrollment was associated with reduced emergency room uses, increases in prescription medication uses and no change in overall outpatient expenditures,” the researchers concluded. However, “chronically ill enrollees and those who clearly had a choice of plans were more likely to increase utilization in specific categories after switching to an HDHP plan.”
The Medicare changes proposed by Rep. Paul Ryan (R-WI) as a quasi-official Republican blueprint for health reform include moving Medicare towards the high-deductible health plan model. This type of plan is also part of the mix among the various health reform proposals of all GOP presidential candidates. That signals a lot higher profile controversy.
Look for the debate over high-deductible plans to move from The New Yorker cartoon page to the cover of The New York Times Magazine and from Glamour to the slightly less glamorous millions who each month read a much different publication: AARP: The Magazine.