The fact that employers are looking for new ways to contain health care costs is nothing new. What is new are some of the options that are emerging that aim to increase consumer financial responsibility and involvement in their health care choices. This new generation of health care benefits, or consumer-directed health care (CDHC) plans, are typically high deductible plans combined with a tax advantaged health savings account designed to offer the consumer much greater flexibility and discretionary choice in terms of managing their health care options.
The extent to which consumers favor CDHC plans over HMOs and PPOs is still somewhat unsettled. According to a study released last year by the Center for Studying Health System Change (CSHSC), US workers prefer to enroll in PPO or HMO insurance plans rather than consumer-directed health plans. The study, using data from a previous survey of 2,122 randomly chosen private and nonfederal companies, found that 39% of the 2.7 million US residents enrolled in employer-sponsored consumer-directed health plans were not offered other health insurance options. Among workers offered a selection of health insurance plans, including consumer-directed plans and other options such as PPOs or HMOs, 19% chose the consumer-directed plan. Comparable selection rates for PPO and HMO plans when employees were given the option of choosing from a variety of plan types were 55% and 40%, respectively.
One reason for the preference is that although consumer-driven plans have lower premiums, employees might favor PPOs or HMOs because they have significantly lower deductibles. According to the study, a single employee’s monthly premium for a PPO was $61, not statistically different from the $56 contribution for the consumer-driven plan, while consumer-directed plans had an average deductible of $1,459, compared with a $261 deductible for PPOs. Another explanation is that consumers might not choose consumer-driven plans because they are wary of being financially accountable for their health care choices. The study also quotes data from a Kaiser Family Foundation study that indicates that of the approximately 70 million American workers who obtain health benefits from their employer, about 2.7 million, or 4%, were enrolled in a high-deductible health plan with a savings account in 2006, statistically unchanged from 2.4 million in 2005.
Nonetheless, there is reason to believe that the rate of growth in CDHC plans may continue to increase. According to a 2005 survey by Mercer Human Resources Consulting, New York, nearly half (49%) of US companies with more than 500 employees say they are promoting consumerism as part of their health care strategy. And in a 2007 survey, Mercer claims that conditions have never been more favorable for a consumer-directed approach to health care. This is attributed to rising costs, dissatisfaction with traditional managed care plans, and a slow economy—all of which have employers looking for new methods to manage health care quality and costs. Following the pattern of increasing consumer stewardship in retirement benefits, the survey claims, health care has become the latest arena in which consumer involvement is expanding.
Assuming at least some continued growth in CDHC plans, one critical issue becomes the ability of consumers to make informed and appropriate choices when using that option, which begs the real question: Who should be in charge of making sure consumers have significant and substantial information in order to act as their own advocate? Clearly, the consumer and the health care provider bear the primary responsibility, but to what extent is the radiologist responsible for guidance when their economic interests may appear to be at odds with the patients’ economic interests?
The conundrum is complicated by the patient’s readiness to do the background research necessary to educate themselves. Jon Gabel, lead author of the CSHSC study, said, “Not every patient is health literate, and 50% of Americans don’t function above a sixth grade level of reading and math.”
For additional perspective on consumer-driven models, he refers to the Health Insurance Experiment (HIE), a 1982 RAND Study on cost sharing, which he describes as the “gold standard” of social science research on the topic. The HIE remains the only long-term, experimental study of cost sharing and its related effect on service use, quality of care, and health. Among the study’s key findings were that participants who paid for a share of their health care used fewer services than a comparison group given free care; cost sharing reduced the use of both highly effective and less effective services, but did not significantly affect the quality of care received by participants. In general, cost sharing had no adverse effects on participants’ health, but there were exceptions: free care led to improvements in hypertension, dental health, vision, and selected serious symptoms among the sickest and poorest patients. “For people with needs, cost sharing is a blunt instrument that cuts the good with the bad,” said Gabel.
The HIE was conducted over two decades ago when universal health care was the most commonly discussed option. The discussion today has become more centered on market solutions, placing health concerns and needs more squarely in a business environment. “These are ethical issues,” said Leonard Berlin, MD, former chair of the Ethics Committee of the American College of Radiology and currently chair of the Department of Radiology at Rush North Shore Medical Center in Skokie, Ill. Berlin points out that, traditionally, radiological exams used to be requested by the referring physician, but that’s changing. “In recent years, radiologists have been much more aggressive in advertising directly to the public,” Berlin said, “and there’s much more competition. In some cases radiologists have tried to have patients come directly to them.”
Berlin acknowledges that these radiologists’ efforts to attract patients/consumers for prophylactic body scans never really took off. But it is symbolic of the kinds of ethical questions radiologists face in an increasingly business-driven patient care environment. So with private radiologists and freestanding imaging centers all looking for business, with more and more direct advertising to the public, and with an increasing percent of the public taking control of their own medical expenses, how do radiologists and/or stand-alone imaging centers reconcile pursuing their own business interests while at the same time safeguarding the now joined health and economic interests of their patients?
“There is a potential conflict of interest,” said Arl Van Moore, Jr, MD, chair of the American College of Radiology’s Board of Chancellors, adding, “Most of us feel we want to do what’s best for the patients.” Moore agrees that it will be difficult for patients to discern whether a physician is recommending an exam based on their financial interests versus the patient’s health interests. “I don’t know how the patient knows if he needs the study or not,” said Moore. “It takes a pretty sophisticated patient.” Moore emphasizes that, if nothing else, a patient needs to know whether the radiologist and the facility are accredited. Again market forces may be the primary factor affecting the disconnect between the patient’s health interests and the radiologist’s economic interests.
“There are many marginal centers with old antiquated equipment,” said Moore. “They’re trying to stay alive, but they’re also trying to keep prices low.” Since their equipment is already paid for, they decide not to invest in new equipment, thus potentially compromising patient care. In line with the market-driven nature of the emerging scenario, Moore suggests that pricing may be one clue to a patient’s interests. “Price is not the best indication of quality, but if the price is too low, the quality of the radiological services may not be good.” Moore emphasizes, however, that there is no easy answer to the question.
Tracy Weise, vice president of marketing and product management at the Center for Diagnostic Imaging (CDI), Minneapolis, said that while health care plans have provided subscribers with good comparison tools, the burden of providing patient information is also squarely on the shoulders of the service providers. “From our perspective, the patients are going to the providers, and that’s where the conversation is happening,” said Weise. Like Moore, she emphasized that it is the patient’s responsibility to find out if they are going to an accredited radiologist and/or facility. And the patient should realize there are lots of questions that they can ask any provider. However, most people will be frightened and adhere to their radiologist’s recommendation. And lower income people, in particular, may be less likely to access consumer information on their own, and may be intimidated by a radiologist and unable to ask basic, necessary questions.
Recognizing this dilemma, CDI has developed a highly proactive program of consumer education. However, Weise said that the consumer/patient’s first step, and best source of information, is always their health plan. “There are quality differences among providers, and that’s something they need to understand,” Weise said. “The best source of information for cost is the health plan. It can help patients with price and quality comparisons so they’re comparing apples to apples.” CDI has engaged in a program of educating the consumer about what radiology is exactly as well as supporting the consumer’s ability to access information through their employer or their health care provider. Weise added that flow of information has worked in both directions. “Sometimes employers have approached CDI and given us information on the radiologist’s role and how the consumer can compare providers’ services. They’re giving us comparative information to provide to their employees in order to help them make a better choice.”
As part of its overall customer education program, CDI also has instituted a patient’s scorecard. The S.C.O.R.E. refers to information patients need to know about: Staff, Cost-effectiveness of the facility, the Overall service, the facility’s Reputation, and its Equipment. The proactive environment also includes a series of educational leaflets titled “Smart Health Care Choices.” As an example, volume 1 of the series focuses on “The basics of medical imaging,” whereas volume 2 is titled “What’s a radiologist? And why does it matter that I know?”
In addition to the basic platform of information to help with informed choices, the program is also geared to increasing customer satisfaction, a metric Weise ranks as having the same importance as an accredited facility and board-certified technicians. She acknowledged that many health care providers conduct patient-satisfaction surveys, but questions whether they are using them to their fullest potential. From the CDI perspective, surveys should serve multiple purposes—to help identify service issues, communicate satisfaction data to payors and referrers, and help develop (and celebrate) continuous improvements in patient service. Weise added that surveys also should be used to understand how patients came to the facility, what they wish they knew, if and why they would recommend the facility to others, and how they feel about the facility’s staff and radiologists.
The proactive approach taken by CDI may be a model for other facilities, but so far there is no organized effort to standardize or even promote any of these practices. “The issue hasn’t come on the radar screen in an organized way,” said Berlin, “but if the mission and the goal is to educate the public, then it’s worth looking into.” He admits that the lay public and even the nonradiological medical community would benefit from more education. But without an organized effort, he said the only way to gain access to this kind of information is through the media. But, he cautions, that may not always work either. Berlin recalls an effort to promote CT screening for lung cancer among asymptomatic people with a history of smoking. “We took the bull by the horns,” said Berlin, “with well-worded advertising advocating preventive screening. But the ads didn’t bring in very much.” He points out, however, that physicians advertising to promote their own services may have played a role in keeping people away. He notes that the University of Chicago has a different story to tell. “They spend millions on ads and it pays off. Maybe a university health clinic has a better platform for reaching out to the public.”
From Weise’s perspective, the bottom line is that as consumers continue to be more active in—and more responsible for—how their health care dollars are spent, they will be more inclined to search for data that helps them choose a provider. Certainly, service and cost will be factors, but quality metrics will also be critical. Practices that communicate effectively to consumers why they are the best choice may very well capture market share. But all of this will require that radiologists be front and center.
Nikos Valance is a contributing writer for  Axis Imaging News. For more information, contact .