What Will Employees Accept to Lower Their Health Care Costs?

I recently looked at a Kaiser Family Foundation Public Opinion Survey that asked a random sample of people with employer insurance a number of questions about cost. The survey shows how far we have to go to come to grips with out-of-control health care costs.

The good news is that half have a reasonably accurate idea of the total cost of their health insurance. Their estimates were somewhat low, but in the ball park of reality.

The bad news is that the other half had no idea about a cost that was constraining their wages and cramping the employer they work for.

What dismayed me most were the responses to a list of possible changes to current insurance that would lower the cost of coverage. The only suggestion that received majority support (68%) was to "participate in a wellness program that promotes healthy behaviors such as losing weight or controlling your blood pressure or cholesterol." Only 30% were willing to accept paying more for brand name drugs, paying a higher deductible before the insurance kicks in, or accepting a more restricted list of participating doctors and hospitals.

So how are we going to keep health care costs from undermining public health more than is already happening?

Public education is important, but it won't do the heavy lifting. Despite lots of educational effort, something as obvious as constraining access to brand name drugs when alternatives are available still only gets 30% support.

Learning through experience is likelier to move our outlook. In the world of employer based insurance, employers and insurers should design multi-year approaches to helping us learn. We're starting to see employers offer "value-based" networks that emphasize primary care and community hospitals, with tertiary hospital care covered for services that aren't otherwise available. And as I've written about in previous posts, employers are putting more pressure on us to manage our health better (see here, here, and here).

In the current U.S. system, the majority of non-elderly with insurance get their health insurance through their employer. Employers and insurers should collaborate to make health insurance a "learning opportunity," not just a "fringe benefit." It takes us time to learn about financial responsibility in our growing up. It's going to take time and a similar concerted effort for us to learn health responsibility as adults!

Should Wal-Mart Make Smokers Pay More for Health Insurance?

A recent article about changes Wal-Mart is making in its health insurance program reports that smokers will be required to pay an extra $10 to $90 each pay period — $260 to $2,340 a year.

Is that fair?

Greg Rossiter, speaking for Wal-Mart, defends the policy on the basis of cost - “Tobacco users generally consume about 25 percent more health care services than nontobacco users.” But patients with cancer also "consume" more health care services. I doubt that Wal-Mart intends to raise their premiums.

Wal-Mart doesn't justify the tobacco penalty by cost alone, but rather by cost combined with the conviction that smoking represents a choice.

Smoking is obviously harmful, and smoking cessation will be good for the individuals who stop, the cost of the corporate health program, and the impact of secondary smoke on others. But Wal-Mart's program is wrong.

Nicotine is addictive. Addictions don't stop on a dime. Here's what I would have recommended to Wal-Mart:

1. "If you haven't done it already, involve a council of "associates" (the Wal-Mart term for employees) in developing the policy re smoking."


2. "Give associates advance notice of the financial penalties - no less than a year, perhaps two."


3. "Offer strong support for smoking cessation."


4. "Make sure the financial penalties aren't 'too large.' The aim of the penalty should be to focus attention on tobacco use and send an educational message, not to cover the incremental cost of health care. $2,390 is way too much for anyone but a senior executive."

A country with a tax-supported health system that covered all citizens would locate incentives where they belong - at the point of purchase, not as part of the health insurance premium. Tobacco, beverages with high sugar content, and other products that harm individual health, public health, and add to the deficit, would be taxed at a high enough level to create a disincentive and to account for the costs the products create for the public.

I'm entitled to smoke if I wish, but I'm not entitled to make you pay for the future costs my smoking entails.

Given our reliance on employer-based health insurance for 60% of the population, it's ideal for employers to take a public health orientation towards employees. I think Wal-Mart is right to take on smoking as a public health issue for its employees, but clinical and ethical considerations require it to modify the way it's approaching the issue.

The Good Samaritan didn't ask the wounded traveller if he'd brought on his condition by faulty choices!

Gilbert Welch's "Vision for Medicare"

The Health Care Blog just published an op ed by Dr. Gilbert Welch. It's well-written and on target. Have a look!

AARP's Misguided Medicare Advocacy

AARP has produced a strong television advertisement threatening any legislator who considers cuts to Medicare.

The ad shows an army of folks around my age marching and looking tough, while the narrator/leader intones:

"Washington, before you even think about cutting my Medicare benefits...here's a number you should remember - 50 million. We are 50 million seniors who earned our benefits, and you will be hearing from us, today, and on election day."

Here's what an ethically guided ad would say:

"Washington, before you even think about cutting Medicare benefits, think about fairness. We 50 million seniors want to do our part to ensure a healthy future for America. But we want to be part of a team, and that means everyone sharing the burden, including adding new revenues..."

I'm insured through my employer, but I'm Medicare eligible. When I'm insured through Medicare, please tell me to wash my mouth out with soap if I call it "my Medicare." It's not just "mine," it's "ours." My payments into the Medicare fund from 1965 on paid for the care of my elders, including my parents. When I'm a beneficiary, my care will be paid for by the younger generation. Medicare is a matter of communal responsibility, not the private property of the 65+ generation.

Age is supposed to be a source of wisdom. Calling for teamwork and shared sacrifice is what my generation should be advocating for. The AARP advertisement invites definition of the elderly as "greedy geezers." AARP is making itself part of problem, not the solution.

(For the Concord Coalition critique of the AARP advertisement, see here.)

The Customer Approach to Patienthood

An article about "The New Language of Medicine" in the October 13 issue of the New England Journal of Medicine makes a powerful argument against the use of economic concepts like "customer," "consumer," and "provider" for the caretaking relationship between clinicians and patients. I've never met a doctor or nurse who didn't share the authors' perspective:

The words “consumer” and “provider” are reductionist; they ignore the essential psychological, spiritual, and humanistic dimensions of the relationship — the aspects that traditionally made medicine a “calling,” in which altruism overshadowed personal gain...Business is geared toward the bottom line: making money. A customer or consumer is guided by “caveat emptor” — “let the buyer beware” — an adversarial injunction and hardly a sentiment that fosters the atmosphere of trust so central to the relationship between doctor or nurse and patient. Reducing medicine to economics makes a mockery of the bond between the healer and the sick...We believe doctors, nurses, and others engaged in care should eschew the use of such terms that demean patient and professional alike and dangerously neglect the essence of medicine.

But history is more complicated than "The New Language of Medicine" suggests, starting with the fact that "customer" language, when first introduced 36 years ago, was profoundly humanistic.

In 1975, Aaron Lazare, who was then director of the walk-in clinic at the Massachusetts General Hospital, wrote a brilliant article - "The Customer Approach to Patienthood." Lazare used the concept of "customer" to emphasize the clinical and ethical imperative for clinicians to pay close, respectful attention to their patients' requests. He and his colleagues were writing about mental health care, but their insights apply across the board in medicine:

Some professionals find the word "customer" crass. We believe it is a useful metaphor to describe a relationship in which the patient has the right to ask for what he wants, to negotiate, and to take his business elsewhere if he so desires, while the clinician has the obligation to listen, negotiate, and offer treatment that meets his professional standards. This "customer" relationship, we believe, is in the best interest of both parties.

Unfortunately, Lazare and his colleagues' superb work did not get the attention it deserved. In a recent poll, 78% of physicians said that most health care professionals provide compassionate care, but only 54% of patients said that they do.

Insofar as "customer" language construes health care as a commercial transaction governed by "caveat emptor" it's pernicious and should be fought against. But insofar as it reminds us that medical ethics and clinical excellence require top flight "customer service" as envisioned by Lazare, it should be embraced!

(For an earlier post on this topic, see here.)

Health Insurer Secrecy and Public Trust

Ten health insurers, including Aetna and United Healthcare, are suing the New York State Insurance Department to prevent publication of memos that present their rationales for rate increases. The companies argue that the memos reveal proprietary trade secrets and that making them public would cause “substantial and irreparable injury" in the competitive marketplace.

I've not seen the complaints the insurers have submitted to the court, but it's quite imaginable that the rate increase memos include company secrets that are protected by law. If this is the case, the companies may win the immediate battle. But they're sure to lose the long term war about transparency.

At the not-for-profit health plan where I direct the ethics program, rate increases reflect the cost of care delivered to members. There are no equity owners demanding dividends and improved stock prices. Approximately 90% of the health plan's revenues go out as claims payments. Among for-profit insurers the "medical loss ratio" (better thought of as the "medical care ratio," since the purpose of health insurance is to pay for medical care!) is lower - often less than 80%!

Patients and the public need to understand the drivers of health care costs. Without that knowledge we can't be part of the solution to the cost crisis. And, increasingly, consumers are demanding to know why health insurance premiums are so high compared to other countries whose health outcomes are as good or better. Transparency is inevitable, and that's a good thing.

But the kind of transparency about pricing being called for in New York and elsewhere isn't ordinarily part of the world of for-profit enterprises. Health care, however, is better thought of as a public good than as a commercial commodity. As patients, we want our doctors and hospitals to be mission-driven. Secrecy about costs isn't compatible with professionalism and public trust.

(For a New York Times article about the litigation, see here.)

Compassionate Care Requires Support from Health Organizations

An article about compassionate care in the September issue of Health Affairs identifies the core focus of this blog - health care organizational ethics - as a key determinant of whether or not patients receive compassionate care.

Beth Lown and Julie Rosen, the lead authors, are, respectively, medical director and executive director of the Schwartz Center for Compassionate Care, whose mission is "to promote compassionate healthcare so that patients and their professional caregivers relate to one another in a way that provides hope to the patient, support to caregivers and sustenance to the healing process."

The article reports on a telephone survey of 800 recently hospitalized patients and 500 physicians. Interviewees were read the following description of compassionate care before being questioned further:

“Now, I would like to turn to an approach to treating patients known as compassionate health care that focuses on improving the relationships between doctors, nurses and other professional caregivers and patients and their families. Its particular focus is to improve the communication and emotional support that patients receive from their doctors, nurses and other professional caregivers.”

Patients and physicians agreed on the importance of compassionate care, but differed in their assessment of how reliably it is provided: 78% of physicians said that most health care professionals provide compassionate care, but only 54% of patients said that they do.

More than half (53%) of the physicians reported spending less time than they wanted with their patients, and 55% of physicians and 67% of patients were worried about how changes in the health system, very much including emphasis on cost containment, would affect clinician-patient communication in the future.

The authors concluded that to achieve compassionate care, providers need (1) time to listen to patients; (2) education in the relevant skills, (3) feedback based on measures of their performance, and (4) leaders and systems that support their healing relationships with patients and families.

Health plans, hospitals, group practices, and other health organizations can't solve the time problem by printing money, but they can devote savings from efficiencies to enhancing the potential for compassionate care. Time with patients is indeed a key factor. Psychiatrists are often asked to do "medication management" in 15 minute blocks. I found that this could work for me with patients who (a) I knew well when (b) what we needed to accomplish was relatively simple and (c) I had flexibility to make more time available when we needed it. But by making my modal appointment 30 minutes rather than the 50 or 60 that was routine, I was able to meet "productivity" expectations and have more appointments available so that I could see patients sooner in followup or on short notice when urgent issues emerged. The system I worked in facilitated my doing this.

My colleagues across specialties in the group I practiced with would periodically share our clinical "pearls" for how to provide compassionate care in circumstances of time pressure. I learned important lessons not just from psychiatrists, but also from a pediatrician colleague who saw the largest number of patients and received the highest evaluation from patients for compassionate care.

Leaders are most effective in supporting compassionate care by improving tools and providing relevant education, not by preaching. The two leadership interventions I found most helpful were (1) providing individual voice mail before this was standard and (2) systematically surveying patients about their experience with their clinicians. The surveys taught me how much my patients valued being able to get a message to me 24/7 and receiving a prompt return call.

Most clinicians want to provide compassionate care. The concept doesn't require selling - it's intuitively obvious that compassionate care is the right thing to do. The challenge is getting beyond lip service. Health organizations play a crucial role in moving from endorsing the importance of compassionate care to providing it in a reliable manner!

Going to heaven with our stitches in

A team at the Harvard School of Public Health published a disturbing article in Lancet this week on "The intensity and variation of surgical care at the end of life."

The group studied the 1.8 million Medicare beneficiaries who died in 2008 to determine the frequency of surgery during the last year of life. 32% had an inpatient surgical procedure during their last year. 18% had surgery during their last month. And 8% had surgery during their last week.

This is a population study, so it doesn't tell us how often the surgery was required by the patients' true needs and wishes. But I'd bet dollars to pennies that most readers of this post have seen surgery done in situations where a better informed patient and family would have rejected the proposal.

My beloved late father-in-law was vigorous until he turned 90, at which time angina limited how far he could walk in New York City's Central Park. Early in his life he'd been in the plumbing supply business, so when a revascularization procedure was proposed to him he thought of it as a common sense plumbing repair. He didn't consult with his family before deciding to do it. The result was five months of intractable heart failure before his death.

He was a gentle, fair-minded man and forgave his physicians for a recommendation they shouldn't have made and he shouldn't have accepted: "They are young men and were thinking about young hearts, not my 90 year old heart."

Dr. Ashish Jha, leader of the Medicare study, told a similar story from experience at his own hospital:

A man had metastatic pancreatic cancer and was dying. A month earlier, he had been working and looked fine.

“No one had talked to him about how close he was to death,” Dr. Jha said. “It’s the worst kind of conversation to have.”

Instead, doctors did an endoscopy and a colonoscopy because the man had internal bleeding. Then they did abdominal surgery. “We did all of this because we were trying desperately to find something we could fix,” Dr. Jha said.

The man died of a complication from the surgery.

“The tragedy is what we should have done for him but didn’t,” Dr. Jha said. “We should have given him time to have the conversation he wanted to have with his family. You can’t do that when you are in pain from surgery, groggy from anesthesia. We should have controlled his pain. We should have controlled his nausea.”

Instead, Dr. Jha said, “we sent him to the O.R.”

Our current public concern is with Medicare costs. But the primary problem for my father-in-law and the patient Dr. Jha describes is care, not cost. More appropriate care for the patient would have had the secondary benefit of reducing cost. That's better medicine,not "death panel rationing"!

(A previous post - "Is Death Optional?" - discusses our need for a national dialogue on the goals of our health care system.)