By DAVIS LIU, MD
The creation of consumer-driven health plans (CDHPs), health insurance policies with high deductibles linked to a savings option and with more financial responsibility shouldered by patients and employees and less by employers, was completely inevitable. The American public likes to have everything, whether consumer electronics or other services, as cheap as possible. With escalating health care expenses rising far more rapidly than wages or inflation, it’s not surprising employers needed a way to manage this increasingly costly business expense.
In the past, companies faced a similar dilemma. It wasn’t about medical costs, but managing increasingly expensive retirement and pension plan obligations. Years ago, companies moved from these defined benefit plans to defined contribution plans like 401(k)s. After all, much like health care, the reasoning by many was that employees were best able to manage retirement planning because they would have far more financial incentive, responsibility, and self-motivation to make the right choices to ensure a successful outcome.
How did that assumption turn out anyway?
Disastrous according to a recent Wall Street Journal article titled Retiring Boomers Find 401(k) Plans Fall Short.
The median household headed by a person aged 60 to 62 with a 401(k) account has less than one-quarter of what is needed in that account to maintain its standard of living in retirement, according to data compiled by the Federal Reserve and analyzed by the Center for Retirement Research at Boston College for The Wall Street Journal. Even counting Social Security and any pensions or other savings, most 401(k) participants appear to have insufficient savings. Data from other sources also show big gaps between savings and what people need, and the financial crisis has made things worse.
In others words a lot of people don’t have enough money to retire. The options they have are simply “postponing retirement, moving to cheaper housing, buying less-expensive food, cutting back on travel, taking bigger risks with their investments and making other sacrifices they never imagined….In general, people facing problems today got too little advice, or bad advice.”
Though employers were able to manage retirement expenses, employees paid a significant price. This wasn’t intuitively obvious in the 1980’s when these plans became more commonplace. Over the past decade, the less than rational behavior by employees hasn’t gone unnoticed by those who study behavioral economics or those in the government. As a result, more organizations and companies are nudging employees into the right behaviors with auto-enrollment into 401(k) plans and auto-allocation of these funds with protection from any future liability as noted in the Pension Protection Act of 2006.
The analogies to health care and specifically consumer-driven health plans should be clear. Workers don’t save adequately for retirement even when in their best interest. It’s very likely that workers won’t save money adequately to fund future health expenses. After all, if people can’t fund retirement, something we undoubtedly all look forward to, which one of us is willing to saving for chemotherapy or open heart surgery, which no one wants? According to the annual Kaiser Family Foundation Employer Benefits Survey, the average annual deductible for single coverage and family coverage is nearly $2000 and $4000 respectively for health insurance plans that are health savings accounts (HSA) eligible. The deductibles are slightly lower in health insurance policies that are linked to health reimbursement arrangement (HRA). About 13 percent of employees are covered under either plan.
Unlike those in retirement planning who can work longer, even if not desirable, employees who are ill may not have an option to work to pay for their medical expenses. There continues to be evidence that people are curbing their health care due to the ability to pay.
Though experts debate on whether this is a good thing (patients are avoiding unnecessary and expensive therapies and opting for less pricey but equally as effective options) or a bad thing (patients are avoiding the preventive screening tests or therapies that overall can decrease future costs), the opportunities to ensure patients make the right choices should be clear from workers’ less than optimal experience with 401(k)s.
If employers wish to help curb medical costs, then they will need to engage workers with programs like employee wellness, assisted decision making (either as second opinions or patient-friendly informed consent), and access to medical experts, equivalent to personal financial advisors, who may be able to help workers make the right choices for their health. Within the business community, there is some acknowledgment that access to these tools will be necessary to not only manage costs but keep employees healthy and productive.
Done correctly, consumer-driven health care can be what everyone hoped they would be, nudging healthy behaviors and slowing health care costs with workers selecting only cost-effective therapies. If implemented poorly and organizations simply shift health care costs and financial responsibilities to workers like retirement planning decades ago, the nation will need to accept more than ever that increasingly more people get the medical care based simply on their ability to pay and not on medical necessity.
As a practicing primary care doctor, I hope that day never comes.
Davis Liu, MD, is a practicing board-certified family physician and author of the book, “Stay Healthy, Live Longer, Spend Wisely – Making Intelligent Choices in America’s Healthcare System.” Follow him at his blog, Saving Money and Surviving the Healthcare Crisis or on Twitter, davisliumd.
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Nobody dies because he can’t afford a Ferrari. People across this country suffer and die unnecessarily every day because they can not afford necessary healthcare. Some of these people still have no access to health insurance at all (thanks to the failure to expand Medicaid in many states) and some of them have only access to the fraud known as “consumer driven” health insurance which allows the insurance company to collect a monthly premium for a policy engineered to not pay for their medical expenses. People do not “prefer” comprehensive health insurance – they need genuine access to proper healthcare. What we do not need is a profiteering insurance industry between ourselves and our doctors, however it may be rearranged. We need a comprehensive, national public healthcare system like every other advanced nation has already had for years.
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Policy Language
the UK’s Funding for Lending Scheme in the first quarter of
Spiller rush to the right for 3 yards to the Buf15. Mar 23vs 5:00 Mon, Nov 21vs FinalCHI 87,2:172nd and 9 @ Den38DENPeyton Manning pass to the left to Eric Decker for 5 yards to the Den43. Tackled by Prince Amukamara. Jan 16vs 8:30 Sat, “There is something so deeply human about that connection, The gulf between popular support and doctors reminds some of how the abortion debate has played out in some regions where the procedure is legal but inaccessible.for the giant $35 billion Origin Energy/ConocoPhillips project in Queensland,In many cases.
I thought the article by Dr Liu was insightful, especially and the analogy to
the promise of 401Ks in the 1980s.
My family has had a high deductible HSA eligible plan since I retired (after navigating the hazardous complexities of the 401K world) and it is a completely different experience than the managed care plan we were comfortable with, requiring decision making about doctor visits, tests, prescriptions, etc. Beyond that, additional book keeping for HSA accounts and tax filing was required.
Based on my experience, I think the expectation that the average family can manage their own HSA high deductible plan is a fantasy. Heck, doctors can’t even tell you how much anything costs!
I think managed care is a good model for health care. Every person for themselves (HSA) is a terrible model for health care and ensures we will have people lined up a emergency rooms for free care.
Having access to information and being able to ask questions of providers is key to this discussion. It’s a two-way street with responsibilities on both sides. Here’s a video that gives some great suggestions: http://whatstherealcost.org/video.php?post=five-questions
http://www.nytimes.com/2011/04/15/opinion/15fri3.html
Representative Paul Ryan and the House Republicans are portraying their budget proposal for the next fiscal year as a courageous effort to finally bring federal spending on Medicare under control. An analysis issued last week by the nonpartisan Congressional Budget Office finds that the Ryan proposal would sharply reduce federal spending — but at the price of shifting more of Medicare’s costs onto beneficiaries and their families.
How much more? Calculations derived from the C.B.O. analysis show that in 2022, when the Ryan plan would kick in, the typical 65-year-old would pay $6,400 to $7,000 more per year than would be paid for comparable coverage under traditional Medicare.
Mr. Ryan’s proposal would change Medicare from an entitlement program in which the government pays for a defined set of medical services into a “premium support” program in which the government would give beneficiaries money to help them buy private insurance. He contends that competition among health care plans and more judicious use of health care services by beneficiaries can help bring down the cost of health care and reduce the federal government’s burden.
But the C.B.O. says a private plan offering comparable benefits would be a lot more expensive than traditional Medicare because the private insurer would have higher administrative costs, would need to make a profit and, in an extrapolation of current trends, would pay hospitals, doctors and other providers substantially more than Medicare does. Beneficiaries would have to pay higher out-of-pocket costs or buy skimpier policies.
The Ryan plan has no chance of becoming law while the Democrats still control the Senate and the White House. But if health care becomes a defining issue in the 2012 elections — as it should — everyone under the age of 55 is on notice that Mr. Ryan’s plan would impose heavy costs on them when they reach age 65.
End snip.
Funny how some non-partisan folk seem to think that costs are going to go up instead of go down or remain the same, despite any efficiencies that are supposed to happen.
That is the market place at work. These absentee payor systems encourage high cost solutions and unproven solutions drive cost up an over time crash the system. Our humanity, the march of technology and are aging population create a marriage! Create a true consumer based system and prices and services level. Look at almost any non covered medical expense over the last twenty years and you will see little or no fee increases and in many situations decreases. My company WellCard Health is working a health product that uses this market based approach. We expect to have over 2 million users by the end of the year. Let’s move risk dollars to more catastrophic and chronic areas of health care.
“Being an A** is not an effective way to generate a discussion or get your point across.”
Is there a study or any polls at least to back this up? I thought I read someplace that the points of an A** are actually very well know so it actually is a great way to get your point across, might not endear you to many people but effective non the less.
Great insight piece….unfortunatly this discussion is disappointing. Being an A** is not an effective way to generate a discussion or get your point across.
I love reading THCB, particularly consumer engagement section – but HATE when people are arrogent in their responses, don’t provide support/reserach/articles for their statements and insult those who disagree with them.
If making attacking statements/insults, at least provide your credentials so we can judge if you are even worth listening to. I don’t care if someone agrees or disagrees – unless they provide support and/or their credentials to make this statement. Research? Literature? Publication?.
Ug…and as a consumer driven health care advocate in mental health, i am excited to see where this movement goes in physical health, and hopefully take lessons learned.
“Most people in our culture just want a clear price for a service and clear knowledge about what they are getting for their money.”
I wouls disagree and argue most people want someone else to pay the bill so they don’t have to worry about price at all. There is even less transparency in traditional plans and I don’t see anyone complaining there.
Could some of the dissatisfaction with HSA’s be due to a lack of clear prices for healthcare services? Most of the patients I see are not dissatisfied to know that a medication they need is $3.50 with free shipping or that a needed imaging study is $400 and not thousands of dollars. What patients hate is making a call to a healthcare facility and not getting a straight answer on the price of a service. Or worse yet, getting wrong information and then getting a much higher bill than anticipated in the future. Most people in our culture just want a clear price for a service and clear knowledge about what they are getting for their money.
All American healthcare is the Ferrari where we pay for only Ferrari mechanics, but the only way you get to drive one is removing essential items. Can’t afford a Ferrari, ok, we’ll remove the engine, or the wheels, or the seats, now go drive your Ferrari.
I want a ferrari more then a pontiac that doesn’t take research to prove. Of course people prefer comprehensive plans that cover everything. That doesn’t matter though becuase people can’t afford such plans just like most people can’t afford ferraris.
Research consistently shows patients are less satisifed with HSAs than traditional comprehensive health insurance. The popularity may not reflect that consumers really want it more than they don’t have a choice. Small employer groups are choosing HSAs because of affordability. Consumers are choosing some coverage rather than none.
Consumers don’t think CDHC will fail, assets in HSAs reached $10 billion!
http://www.businesswire.com/news/home/20110224006591/en/Health-Savings-Accounts-Surpass-10-Billion-Total
“the difference between a government panel saying you’re not allowed to have something and not being able to afford something so I won’t even try.”
So rich people should live (and consume health care resources) and poor people should die? How bout your Granny Nat, will she live or die?
“How do you tax a habit Peter?”
How do you enforce diabetic compliance – jail? You tax bad habits like you tax alcohol and cigarettes. Tax calories, sugar, fat – all usually in fast/processed food, and dedicate those taxes to paying for non-compliant diabetics, as well as heart disease and hip replacements from obesity. You’re a pay-as-you-go guy aren’t you Nate?
Well, Nate, if you’re going to combine insult (“Have you not read the bill Joe”…”buzz words”…”throwing some big words on paper”) with not reading what I have actually written (“You haven’t made one substantive comment yet.”), then I am not having a discussion with you. I certainly don’t have the time to once again lay out everything that I am talking about for someone who clearly did not read them in the first place, either in this discussion or elsewhere in The Health Care Blog.
“I see. you believe that the healthcare reform act removed almost all personal responsibility and told people that they are legally allowed to spend as much as they want.”
Does it require insurance to cover an untold number of preventive benefits at 100%? Common sense these expenses are not insurable risk. Have doctors purposefully misclassified procedures as preventive for years to get them paid at 100% when they really were not? We have doctors call every week asking how to bill something so it will be paid under the preventive benefit.
Does it impose a low out of pocket max annually? Once someone hits that cap what controls are there on their spending?
Have you not read the bill Joe or do you somehow believe these are not real world problems that already happen and are being exasperated? You want to keep throwing buzz words out there but that’s all you seem to have. How does feedback loops on price prevent doctors from billing office visits as preventive when they are really treating a cold? What price controlling regulation is going to reign in hospital charges? Do you have anything besides faddy words to explain how any of this helps control cost? What does measurement do to control poor personal health decisions besides telling us people are making poor personal health decisions?
You haven’t made one substantive comment yet. Your argument seems to be by throwing some big words on paper we will solve the cost problem, ignore the actual real world measureable increases these words are going to do it all.
Peter you don’t have the intelligence to grasp the difference between a government panel saying you’re not allowed to have something and not being able to afford something so I won’t even try.
How much should we tax diabetic producing habits?
How do you tax a habit Peter? Do you want to nationalize your mommy’s swear jar? There is no such thing as a diabetic producing product so sales tax doesn’t work. Maybe we should hire one person to follow around every other person and keep a log of their taxable behavior?
“Is 3 months of extra life worth $20,000 a month in Rx plus additional medical cost?”
Aren’t you an anti “death-panel” guy Nate?
“How much should we spend on non compliant diabetics?”
How much should we tax diabetic producing habits?
I see. you believe that the healthcare reform act removed almost all personal responsibility and told people that they are legally allowed to spend as much as they want. And that it removed all price-controlling regulation, with no caps, no measurement, no feedback loops on price, no price transparency, nothing.
Okay.
“The answer to our overspending is not simply leaving people to die in the street, it is re-designing the healthcare economy so that it is better able to drive toward real value: the best outcome for the lowest cost.”
Do you think the way to accomplish this is to start by removing almost all personal responsibility and telling people they are legally allowed to spend as much as they want?
The problem we have with the past 46 years of Healthcare reform is we are feed statements like yours but the laws passed do the exact opposite. Starting with Medicare the laws have never matched the rhetoric.
the hundreds of thousands of lives we have insured and billions in claims we have paid would disagree with you.
20% of a population will usually account for 80% of the cost. If 30 or 50% of all care is wasteful it obviously is concentrated in the 80% of high dollar care.
How much should we spend on non compliant diabetics?
Should the pool as a whole pay millions of dollars so someone that is unable to have a baby can have 6 eggs implanted and unfortunetly carry all to premature birth?
Is 3 months of extra life worth $20,000 a month in Rx plus additional medical cost?
Those are all cases impacted by lifetime and annual limits.
“Thank you for making the absurd outcome so clear. Of course, no one is proposing such a system.”
Its not proposed its already in place. The proposal was 2 years ago, now that we see whats in it we have law.
That’s quite a picture you’ve got going there, Nate. And that is exactly what would happen if we built a system as stupidly as possible, if we said, for instance, “Government is bad, regulation is bad, so we won’t have any regulation at all, no caps, no measurement, no feedback loops on price, no price transparency, nothing. Oh, but we’ll have one regulation: The government — or somebody — has to pay every last dime demanded by any provider for anything.”
Thank you for making the absurd outcome so clear. Of course, no one is proposing such a system. And fortunately, we do not face a choice between such an absurd outcome and simply letting people suffer and die when they have used too many health services because they have MS or are battling cancer or need dialysis. Such extreme cases are not, in any case, the reason why healthcare costs so much in this country. Healthcare waste is driven rather by the waste in routine cases, by unnecessary and unhelpful but common procedures, by neglecting chronic disease until it needs acute attention. The answer to our overspending is not simply leaving people to die in the street, it is re-designing the healthcare economy so that it is better able to drive toward real value: the best outcome for the lowest cost.
The problem we had been discussing is vastly smaller: Without a lifetime cap on claims, how do you protect a small self-funded group from the rare extremely large claim? I don’t have the answer in my hip pocket, and it may well be that the trend, as you pointed out, is not toward providing an answer but toward simply eliminating small self-funded groups. But it is a problem that could be solved.
“It was written by people with no concept of insurance.”
“$1,000,000 claims were never seen, until carriers raised their lifetime max to $2,000,000 and $5,000,000.”
“It wasn’t possible to have $5,000,000 in medical care until HMOs had unlimited max.”
“We have a system today where 30% of care is unnecessary and wasteful. We spend far more on end of life care than anyone else already. Hospital charges are inflating at a hyper rate with minimal additional value. We are spending way more then we should and getting little for it.”
Seems private “insurance” has no concept of insurance.
“Why don’t hospitals regularly keep people alive in vegetative states when they have no hope of ever recovering,”
They already do. Thank your religious friends who think “miracles” are an everyday occurrence and “only God” can pull the plug.
it never makes sense in any realm to have unlimited liability. This will go down as one of the government’s all time colossal stupid moves. It was written by people with no concept of insurance.
We have a system today where 30% of care is unnecessary and wasteful. We spend far more on end of life care than anyone else already. Hospital charges are inflating at a hyper rate with minimal additional value. We are spending way more then we should and getting little for it. So Obama decides to remove the cap and allow people to spend even more.
Why don’t hospitals regularly keep people alive in vegetative states when they have no hope of ever recovering, no one to pay the bill. Why don’t we have 100 doctor teams of specialist hovering over flu patients to make sure they get better, the cost. We already try almost everything to treat people why not try everything even if it doesn’t have a chance to succeed, the cost.
Under Obama care, that not only gives unlimited benefits but also caps annual out of pocket, once a hospital gets someone over the out of pocket max they get 100% reimbursement for everything and anything they do. There is no restraint on spending, open check book. Why control cost when your given a financial buffet?
$1,000,000 claims were never seen, until carriers raised their lifetime max to $2,000,000 and $5,000,000. It wasn’t possible to have $5,000,000 in medical care until HMOs had unlimited max. In the HMO at least they had contractual controls.
There is no good way to reinsure infinite. Once you allow for infinite claims you will start to have infinite claims. There is no logical reason for a person to ever consume 20,000,000 in healthcare at today’s dollars. Society can’t allocate that much in resources to one person and survive.
“Done correctly, consumer-driven health care can be what everyone hoped they would be, nudging healthy behaviors and slowing health care costs with workers selecting only cost-effective therapies.”
Thanks for the thought provoking article. One missing element in the discussion is the issue of price transparency. When physicians and patients both have access to clear, transparent price information, better decisions can be made that make economic sense for all parties. As a primary care physician, I made http://www.HealthScepter.com to address the issue of price transparency so that health consumers would have access to clear prices for labs, imaging, medications and more. When prices are transparent, we can lower the cost of our healthcare system and increase access to care.
Still, the concern does make some sense: If we ban lifetime caps, then the liability could be infinite. If the goal were not for some other reason to phase out small-group self-funded programs, what else would solve that problem? A better form of reinsurance? Perhaps even government reinsurance at a certain level?
http://www.gao.gov/archive/1996/he96161.pdf
The NAIC has adopted a stop-loss model
act that attempts to define the levels of risk that can be assumed by
stop-loss carriers for determining which state insurance laws should
apply. State insurance regulators are concerned that some employers may
purchase stop-loss coverage in which the stop-loss carrier assumes most
of the risk and believe, therefore, that the plan should be subject to state
health insurance laws.7
When they pass a law saying groups under 50 lives are not allowed to self fund I think that is an intended result. Same with the NAICs studies and position papers on small groupo self funding. They are arguing against the small group self funded market specifically.
http://www.siia.org/i4a/pages/index.cfm?pageid=3417
See Self-Insurance and the Potential Effects of Health Reform on the
Small-Group Market
by Kathryn Linhan
discussing the potential negative impact of self funding on PPACA.
Interesting. Though even allowing your argument that these things make self-insurance difficult, your argument was highly intentional, that is, that government at state and federal levels is “trying” to drive companies away from self-insurance, rather than that being an unintended (possibly unnoticed) consequence of poorly-written and poorly-implemented regulations.
Do you have evidence that this is intentional?
Groups must have a minimum number of lives
minimum specific deductible
NAIC is distributing a policy paper trying to say small groups can never really self insure for lack of risk transfer
Minimum aggregate ratios
Unlimited lifetime max, hard to reinsure infiniti
Back in the day the HMO Act
NY Purchasing pool
COBRA and HIPAA regs that are administrative nightmares while failing to accomplish anything close to their goals. i.e. <2% of people take COBRA but the administrative cost and liability is huge
Medicare secondary is a great example. Self funded plans operate on 12 month reinsurance policies usually. If a hospital sends a claim to Medciare that should have gone to a self funded plan medicare has a lifetime to find the mistake then come back after the self funded plan for reimbursement, on a claim the plan never knew about. Since their reinsurance expired they are liable for the claim. It has bankrupted businesses before.
I could write a book with everything the government has done to ruin healthcare/insurance in this country
That’s a charge I have not heard before. Could you point me to some cites that show exactly what “Washington and a number of states” are doing in this attempt?
As is typical any time government gets involved, the biggest hold back is regualtion and government. The most aggresive, and I would argue successful programs are being done by self funded employers. They are free to test new ideas, quick to implement, and quick to change and improve on what works.
Instead of fostering these solutions, and maybe actually improving healthcare in America, Washington and a number of the states are trying to drive people out of self funded plans and into a few mega national carriers. The same mega national carriers they and most everyone else complain about.
> CDH oriented programs put out by payers.. are very shallow…believe that consumers don’t know that stuff and believe that telling that will bring change in behavior…make no attempt to understand what the real problems are by differing health profiles…
That is true of the programs that it is true of. There are some that are quite deep and that make serious attempts to customize themselves not only to the consumer’s health profile, but the consumer’s preferred way of communicating and interacting. And some of the best employer-driven programs are the same. And they are showing significant results — cost savings and measurably improved health markers — over periods of months, not decades.
Very interesting take and debate on this. It takes political hues as it implies people don’t have ability to deliver on their responsibilities.
While it is clear enough that results are’t encouraging, there is yet to be analysis on why it is so. Also consumer profiling for healthcare has not been performed the way it’s done in retail sector. So we get choice of imagining what the consumers are as per our convenience, just as Nate did above.
There is a very deep and reverend view about medical system. I am into many alternative things and when I share my views which are not congruent with evidence based medicine, the tension with audience is very palpitable. I don’t know what it is, but that deep psyche of intense belief and faith is driving consumer values towards healthcare.
Now regarding CDH oriented programs put out by payers- payment estimator, provider search & ratings, wellness program etc are fine. Still they are very shallow. They are shallow because they believe that consumers don’t know that stuff and believe that telling that will bring change in behavior. They are also shallow because they make no attempt to understand what the real problems are by differeing health pofiles. Just to give an example, vegetable consumption has not increased over a decade inspite of all the FDA pyramid of food ads.
Intuitively it’s right thing to do and let people take some responsibility of their care and over decades it might show some results. In meanwhile what the system needs to do is to help people who are sincere about their health. ‘On demand’ health profiles can’t be helped.
Margalit, I don’t believe I ever inquired but I would doubt it. The employers were usually the payer.
Peter, would you know what happened to those savings? Were the savings passed down to employees by any chance?
Joe, I think your numbers track well. I previously ran a national managed care program for large employers using custom built networks of care providers and our customers routinely reported reductions in medical costs in the 30 to 40 percent range when measured against prior costs.
By the way, I only trust payer reports of savings.
“Just imagine how different healthcare would be today minus medicare and medicaid and in their place some modest programs that subsidized the 13% that needed help.”
Yes, just imagine.
“One-third of children and over half (59%) of low-income children are are insured through Medicaid or SCHIP.”
“Medicaid payments currently assist nearly 60 percent of all nursing home residents and about 37 percent of all childbirths in the United States.”
“the fastest growing aspect of Medicaid is nursing home coverage.”
“Poverty in the United States is cyclical in nature with roughly 13 to 17% of Americans living below the federal poverty line at any given point in time, and roughly 40% falling below the poverty line at some point within a 10-year time span.”
Medicaid does not count the number of working poor who still can’t afford health coverage but do not qualify for assistance due to the restrictive income/asset requirements.
“Why can’t we try the simple things first, before turning the entire system on its head and handing over a few more freedoms to institutions in the process?”
So you don’t vote for Democrats Margalit? Medicare turned the system on its head for everyone over 65 instead of simple solutions for the 13% of seniors who needed help. This latest Democrat bill turned the system on its head for 300 million people instead of allowing simple solutions.
Every time Democrats turn the system on its head they make the problem considerbly worse. Just imagine how different healthcare would be today minus medicare and medicaid and in their place some modest programs that subsidized the 13% that needed help. We wouldn’t have any of the problems we have today.
Remember this next time you vote.