Wednesday, October 22, 2008

Of Motorcycle Laws and Consumer Directed Health Plans

The Disease Management Care Blog spent the last few days in sunny Texas, where motorcycle drivers seem to have a remarkable affinity for offering themselves up as potential organ donors by forgoing protective headgear. This display of two-wheeled freedom during the car ride to DFW reminded the DMCB of consumer directed health plans.

How so you ask?

When patients have to choose between using their own money for medical care versus not spending it and forgoing potentially important care, is this exercise in choice-making awful? According to the Blue Cross Blue Shield Association, the answer is 'not necessarily.' This press release states consumers enrolled in consumer directed health plans (CDHPs) are ‘more likely to be cost conscious and shop around.’ CDHPs have a lower monthly premium, which makes them a policy option in the search for stemming healthcare cost inflation.

As an aside, the DMCB hasn’t seen the BCBS data, but it wonders if this may be a classic example of ‘self selection bias.’ While the non-critical reader would be tempted to go along with the notion that CDHPs cause healthcare frugality, it’s just as possible that the opposite is going on. Persons inclined to cost consciousness may choose (i.e., ‘cause’) CDHPs. But that’s not the point.

If one accepts the notion that CDHPs put 'skin in the game,' the larger question is whether persons enrolled in CDHPs who actively minimize their out of pocket medical expenses are a) knowingly or unknowingly being b) thrifty or cheated over a c) responsibility or a right to d) commoditized health services or necessarily illness treatment for e) preference sensitive or preference insensitive care? Back in the days of DMCB’s clinical practice, it wasn’t unusual for its patients to decline to follow its recommendations for a variety of reasons including inconvenience, lack of time, fear of side effects, independent judgment of the potential benefit (especially among healthcare workers) and the out of pocket cost. The DMCB didn’t sweat it just so long as its patients were making a truly informed choice. Just like the Lone Star State’s attitude about its bareheaded iron-horse cowboys, the DMCB figured that persons had a right to choose to be unwise. If motorcyclists are being allowed the risk of having Mr. Brain get up close and personal with Mr. Concrete, maybe society should be willing to accommodate the exercise of cost-based patient autonomy.

Has the DMCB been seduced by the Wild West? While it did admire them cowboy hats, it would like to point out that there is a considerable body of data that suggests much of health care recommended by doctors is a) fraudulent or b) unsupported by any credible evidence or c) of only marginal benefit and high cost. Contrast that truism with the results from this article in Health Affairs that determined that persons enrolled in high out-of-pocket cost CDHPs experienced an absolute increase of about only 2-4% of going without ‘recommended care.’ While that percent probably included care that was not fraudulent, was evidence-based and was high value, the DMCB asks this: if patients use economics to make informed choices about paying for health care services, is that small increase bad judgment or bad policy? Can it be improved upon to be one of many approaches to controlling healthcare costs among the insured? Or is it the medical equivalent of a silly helmet-optional law that deserves to be repealed?

Last but not least, if we are going to rely on some version of CDHPs as an approach to tackling rising healthcare costs, the DMCB believes disease management (DM) has a proven track record in helping patients participate in wise decision-making and that it can be deployed here. Incorporating economic considerations in its patient coaching strategies is well within the industry's expertise.

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