Fractured user experience fuels consumerism criticism

The consumer movement in healthcare is largely failing, which has fueled a debate over whether it’s worth saving.

People wait months for appointments. Quality data is scarce and obscure. Hospital discharge packets are several inches thick. Confusing charges fill surprise bills. Providers sue patients.

Healthcare executives are trying to change that. They are rolling out online portals, remote monitoring devices, virtual consultations, and scheduling and billing tools to try to get individuals more involved in their health.

While they argue this is an essential pursuit in search of healthcare’s “value-based” mantra, skeptics contend that consumers don’t have the information to best steer their care, so ultimately putting the onus on patients may do more harm than good.

“There is a fatal flaw with a lot of consumerist thought,” said Andrew Ryan, professor of health management and policy at the University of Michigan. “Patients are not doctors.”

That has contributed to the current conflicting dynamic. Patients may come to the doctor with research and suggestions, but they’re often dismissed, given their lack of expertise.

Now industry experts are claiming a more cohesive partnership is the best way forward. But to get there, they must overcome years of mistrust and doubt. “This is a big ship to turn,” said Joe Fifer, CEO of the Healthcare Financial Management Association.

In theory, a consumer-focused healthcare system will naturally weed out waste as consumers gravitate toward high-quality, low-cost providers that serve them best. Individuals get treatment quicker and are ultimately healthier, saving everyone time and money.

Much of this hinges on accurate data. Up to this point, the work putting data and decisionmaking in consumers’ hands has not produced a healthy partnership with clinicians, said Anna Sinaiko, assistant professor of health economics and policy at the Harvard School of Public Health.

“Efforts to report on quality and price haven’t been able to overcome the central challenge, which is patients knowing what they need for care,” Sinaiko said. Even if they do, clinicians typically weren’t trained in having conversations about costs, she added.

The customer knows best—except in healthcare. That has been somewhat by design as cost and quality data are hard to find, inaccurate or nonexistent, and the medical system’s general approach is to keep patients on a need-to-know basis.

Stakeholders still have incentives to dig in to protect their turf. At the same time, not all individuals want to control their care path.

That isn’t the case in most consumer scenarios. Whether people are shopping for a car, finding transportation or booking a hotel, they can easily compare prices and quality, quickly navigate websites or apps, and troubleshoot with minimal effort. But healthcare, in all its complexity, is different.

Catching up: Borrowing the best from those who are further along

Source: Modern Healthcare reporting

The consumer experience has largely been an afterthought. Typically for healthcare organizations, growing in size and shrinking costs by “beating up” competitors comes first, said Dr. Sachin Jain, CEO of CareMore Health System.

Most healthcare spending is directed toward the sickest individuals, who often aren’t equipped to articulate their needs or shop around for care. Expecting the most vulnerable, complex patients to navigate the system isn’t pragmatic or realistic, Jain said.

Some experts worry that consumerism will continue to marginalize certain populations. Individuals with an annual household income of $75,000 or more were more likely to be offered access to their medical information, data from the Office of the National Coordinator for Health Information Technology show. Healthcare data was offered more often to those with college degrees, according to the ONC.

This leaves certain populations without critical information to make informed decisions, perpetuating the current fragmented system. 

But some believe it’s too early to reach any conclusions that consumerism is a bust. “This is where I disagree. I think consumerism will decrease the gap of inequity,” said Dr. Stephen Klasko, CEO of Philadelphia-based Jefferson Health, arguing that technology and a new philosophy can help fill food deserts, gaps in care and aid the most vulnerable. “It just depends on how you look at things.”

High-deductible health plans were intended to drive patients toward lower-cost, higher-quality providers since they’d have more skin in the game.

Behavior changed, but not in a desired way, Harvard’s Sinaiko said, noting that patients pulled back on both appropriate and inappropriate care. There is no evidence of patients shopping for more affordable elective care, she said.

Consumers aren’t typically shopping for care, even as the number of price estimators has grown. Healthcare emergencies limit their use and consumers typically pay more attention to location, quality and reputation, studies show.

A new report from the Massachusetts attorney general’s office found that price-comparison tools are used by only a small fraction of residents, and are not influencing consumer decisionmaking or healthcare spending in a meaningful way. The number of searches per 100 health plan members ranged from 2 to 6.6 in 2017 and 2018, according to the analysis. Moreover, few consumers hold their payers to the cost estimates.

There are several impediments, University of Michigan’s Ryan said. The price varies depending on the insurer, and out-of-pocket costs fluctuate based on the deductible. The price for an X-ray may be straightforward, but costs change with physician fees or follow-up care, he said. Ryan described it as a moral obligation for health plans to help consumers understand the price they will pay when they have more financial exposure.

When it comes to quality reporting for the patient, efforts began without a clear understanding of how they comprehend and process it, he said. “Dumping an array of quality metrics is basically useless,” Ryan said, adding that hospital star ratings are often flawed.

It’s hard for patients to anticipate the care they need and shop accordingly. It’s easier to get care within the system they have already chosen rather than try to switch systems and hope the proper data follows. Providers also have incentives to keep patients within their system, even if that is not the most affordable and effective option.

“What we are missing is the connective tissue about the patient’s specific needs versus the right next action,” said Ben Albert, CEO of Upfront Healthcare Services, a digital patient navigation startup. “Without (that), patients are going to fall back on what they know—going to the ED or waiting for a doctor’s appointment.”

Just because some strategies have failed, that doesn’t mean cost and quality transparency efforts aren’t worth pursuing, most experts emphasized.

The approach can be as simple as asking a question: “Can you afford this?” according to the HFMA’s Fifer. Although some physicians are afraid to ask this question given the complexity of the economics and benefit plans, the query can kick-start a productive patient-physician relationship, he said. “This doesn’t take fancy tools and technology,” Fifer said.

Many are turning to telemedicine to facilitate a two-way conversation or setting up shop at shopping malls to offer more convenient access points. If consumers have to come to an office, many providers are partnering with ride-hailing companies to fill transportation gaps. Some employers are selecting centers of excellence, providing incentives to travel to lower-cost, higher-quality providers.

Simplicity is key, Sinaiko said, and cost estimates are inherently complex. Reference-based pricing—in which payers say they will pay for a baseline amount and any extra expense will come from patients’ pockets—has worked, she said. So have narrow or tiered networks, Sinaiko said.

Part of the systemic problem is also how doctors are trained, Klasko said.

“Doctors are selected based on their organic chemistry tests, and we are amazed that they are not more empathetic and creative,” he said, citing Thomas Jefferson University’s Sidney Kimmel Medical College’s Jefferson Scale of Empathy, which measures emotional intelligence in the context of educating health professionals.

Jefferson is training students to text frequent emergency department users with simple tips and tools. That has cut costs per patient by about a third as well as lowered ED admission rates and lengths of stay, Klasko said.

The academic health system offers nutrition counseling via telehealth and has leveraged its 24/7 telehealth service to redirect ED-bound patients. It has turned dilapidated lots in Philadelphia’s food deserts into green spaces and invested in an ambulance service that estimates out-of-pocket cost and pick up/drop-off times.

“Most healthcare providers need a strategically aligned payer—none of that makes sense if the only revenue is coming to the hospital,” Klasko said.

Altamonte Springs, Fla.-based AdventHealth assigns care navigators to the most acute patients to help figure out insurance coverage, transportation, nutrition plans, even how to combat loneliness. Like many systems, AdventHealth has an app that allows patients to quickly pull up lab results and other medical data as well as schedule appointments.

“We have created an environment where consumers have been trained to sit back and disengage because healthcare is so hard to understand,” said Daryl Tol, CEO of AdventHealth’s central Florida region. “Our view is consumers want it to be easier and our responsibility is to make it accessible, if they want it.”

Renton, Wash.-based Providence has an Express Care same-day care service at retail clinics and through its telehealth platform. It uses a chatbot to answer questions, direct care and coordinate online scheduling.

“We try to take very big complicated problems and break them down into smaller digestible problems,” said Aaron Martin, chief digital officer at Providence.

Each patient is different. Access to food, care, transportation and education all vary, along with interest. Some people want all their medical information at their fingertips, others would rather leave it up to their doctors.

“That is what is hard about care being patient-centered—patients are very different,” Sinaiko said. “That takes more effort, understanding and connection with different groups. Often the data is what’s missing—it’s hard to address the solution when you don’t know the barrier.”

“There are too many standard templated pathways in medicine today,” Upfront’s Albert said.

Treatment needs to be tailored to a person’s needs, Martin said. Rather than segmenting patients around socioeconomic groups, they need to be categorized by access to family caregivers, what economic support they have and if they need more help navigating the healthcare system, he added.

“Technology allows you to personalize the experience,” Martin said.

The arrogance needs to be removed from the patient-provider relationship, Tol said. “There is no value that comes from the egotistical position that we are in a parental role and the consumer should just shut up and do what they are told,” he said. “The best outcomes will always come from the well-trained clinicians paired with the informed consumer.”

But a cultural shift will need to happen to facilitate that dynamic, experts said. 

“There is zero question in my mind that we will have a consumer revolution,” Klasko said. “The only question is whether those of us that are involved are the dinosaurs.”