Exchanges for Everyone!

Almost a hundred years ago famed reporter/muckraker Lincoln Stephens famously proclaimed, “I have seen the future, and it works.”  Of course, he was talking about the Soviet Union and time proved that he couldn’t have been more wrong.  I hope I don’t prove equally wrong when I say that our health care future lies in exchanges.

I should note upfront that my prediction may not mean what most readers probably think it does.

I’ve written about exchanges several times in the past (e.g., the botched rollout of healthcare.gov,  the rise of private exchanges, and – two years ago – questioning the resistance to the concept) but what triggered me again was a reference I saw recently that roughly one in two new Medicare beneficiaries enroll in Medicare Advantage (MA) plans.  It seems to be an accepted truism that baby boomers like MA, so as more of them become eligible for Medicare, MA grows.  Almost 30% of all Medicare beneficiaries are now in MA.

So we’ve got the Medicare population where enrollees are able to go online to view their choices of health coverage, compare coverage and premiums, and enroll.  It sure sounds like an exchange to me. 

Of course, for the pre-Medicare population not covered by employer coverage, we’ve got the much ballyhooed state and federal exchanges established under ACA.  They are starting to pick up steam; despite issues at both levels, exchange enrollment is now around 55% of projections, according to recent analysis from Avalere. 

Finally, we have employers rushing to private exchanges: Aon Hewitt research sees 33% of employers moving to a private exchange in the next 3-5 years.  No wonder many of the big benefits consulting firms, like Aon, Mercer or Towers Watson, plus some of the larger health plans (e.g., Wellpoint), have established, bought, or partnered with private exchange vendors.  It has become a favorite way for employers to lock in costs for retiree health obligations, and increasingly for active employees as well, both using “defined contribution” approaches.

The landscape looks like exchanges all around, even though that doesn’t mean everyone actually have many choices.  For example, The Wall Street Journal found 515 counties, in 15 states, where consumers getting coverage through the federal exchanges only had one choice of a health plan, out of the counties it looked at in 36 states. The New York Times reached similar conclusions in its analysis last fall.  Medicaid recipients often lack options as well.

Surprisingly, employers aren’t much better.  According to the Kaiser Family Foundation annual survey, 87% of firms offering health coverage only offer one plan type (e.g., PPO versus HMO or HDHP).  Choices within that plan type rarely even involve multiple carriers.

Consumers say they want choice.  EBRI found that that only 35% of those with employer coverage wanted to continue having employers make the choices of health plans.  45% wanted an exchange-type approach -- where they got to pick their coverage, their employer made a fixed contribution, and they paid anything about that limit – and 21% wanted the money from their employer to either spend on health insurance or keep, as they saw fit.  In terms of health plan choice, 26% were extremely interested in more choices, with another 37% very interested. 

EBRI noted that most employees were only somewhat confident of their ability to use objective ratings systems to make their choices, but I thought it was equally important that employees’ confidence that they could pick the best plan for themselves was virtually the same as their confidence that their employer picked the best plan for them. 

Having all these different exchanges for health choices makes no sense.  It’s crazy that people’s health plan choices vary so widely based on current economic status (e.g., Medicaid or not), not only employment status but also size and choice of their employer, age/eligibility for Medicare, and geography, to name a few factors.  The commercial market and the public coverage don’t typically even use the same types of network plans: Medicaid and Medicare tend to use HMOs, while exchange plans tend to be PPOs (although often ones with narrow networks).

I’ve complained about this before (Medicaid Is Different…Isn’t It?), but the very real prospect of someone having to cycle through very different application processes, coverage options, number and type of choices, provider networks, and sources of funding as they go through common life changes is just ridiculous.  It’s administratively expensive, confusing for everyone involved, and hell on continuity of care.

In a more perfect world, one in which there had been the possibility of bipartisan agreement and some prospect of a rational approach to solving problems, ACA could have established exchanges that would offer coverage that applied to everyone.  No hidden subsidies for higher income individuals, as is true for Medicare and for employer-provided coverage.  No archaic or (literally) parochial benefit designs.  Consumers wouldn’t have to switch their coverage just because they gained or lost a job, or turned 65.  Instead of that kind of sweeping simplification, we’ve just created another kind of balkanization in our health care system.

If nothing else, though, the exchanges may help prep consumers for radically different ways of obtaining their health plan.  A recent global survey by Accenture found that two-thirds of consumers would be willing to buy insurance from organizations other than insurers; 23% were interesting in purchasing from online companies like Amazon or Google, which has created some waves in the insurance world.  The study wasn’t focused on health insurance but the lessons sure seem applicable, and health plans should be worried.

I like consumers having a choice of health plans, offered on a uniform platform that facilitates comparison shopping, but exchanges for health plans are only a first step.  What I’d like to see are exchanges for provider services. 

I hate that a provider’s cost for a given consumer is dictated by whatever health plan a he/she happens to end up in, and that the best providers for a given condition may not even be part of their health plan’s network. 

Yes, most people would agree that we have a problem with transparency of cost & quality in health care, and, yes, there is a lot of work being done on the problem (see Does Anyone Really Know What Price It Is?), but exposing health plan-negotiated prices is not enough.  The underlying problem is that using health plans to price providers’ services just makes the whole process way too opaque.

We need to get to the point where providers’ services themselves are openly offered in a competitive market. 

Imagine being able to shop for, say, heart transplants or colon cancer care through an Amazon-like marketplace, with a wide range of providers offering the service, pre-set prices, full “product” descriptions, and plenty of reviews from previous patients.   If you think that sounds far-fetched, well, you can go on the Internet now and quickly gets lots of prices for laser eye surgery or concierge medicine.  It’s funny how lack of insurance coverage for their services “helps” providers advertise their costs.

Granted, people aren’t going to shop for the best provider when they are having a heart attack or their appendix has burst, but using those kinds of emergency examples as an excuse not to try to move to a world where we facilitate consumers directly shopping for the best providers in other situations is cutting our noses off to spice our face (and I wonder how much that would cost!).

Going to such a marketplace/exchange approach would require a very different competitive mind-set from providers, which many would hate but in which I think some of the best providers could do very well, especially if it meant less interference from health plans.  And, of course, it would mean a very different, less paternalistic role for health plans, an example of which I’ve previously proposed.

To paraphrase an old spiritual, let our people go!  Let them shop for their health care openly, not just their health plans.

I'll Take My Care To Go

I have to admit that when fast food restaurants first got into drive-throughs, I didn’t really see the point.  Well, I missed that one: they now do 60-70% of their business via the drive-through, changing the architecture, menu, and consumer expectations of the fast food industry along the way.  Aside from pharmacies, I haven’t seen drive-throughs impact health care yet, but one doesn’t have to be much of a seer to recognize that that the need to actually visit providers’ offices for health care is quickly being whittled away.

Let’s start with kiosks, which are increasingly providing quick alternatives for some services that used to require consumers to visit their doctor.  For example, in the news recently was a deal higi did with Rite Aid, which will put higi’s kiosks in some 4,000 Rite-Aid stores.  higi already has kiosks in Publix and Whole Foods.  Their approach features kiosks that allow consumers to measure and track their vitals, while gamifying that mundane process.  They combine all the measures into a single “higiscore” that consumers can easily track, and also offer some community features.

higi is not alone in the kiosk business.  There’s SoloHealth, which claims 40m annual user engagements, driven in large part due to its deals with Walmart/Sam’s Club and Safeway, as well as some deals with health insurers, such as Wellpoint (Blue Cross and Blue Shield of Georgia and Anthem Blue Cross in California) and HCSC.  Indeed, Wellpoint led a $12m investment round for them in 2012.   eHealth and even HHS also like SoloHealth’s ability to target consumers while they are thinking about their health.       

Not unlike higi, SoloHealth offers quick self-service screening options, but the deals with insurers have them offering information on health plan options as well, a move that is not without critics due to the perceived privacy concerns.  

HealthSpot goes the other screening kiosks one better by also offering video visits with board-certified physicians.  They’ve been doing deals with provider organizations, including University Hospitals Rainbow Babies & Childrens Hospital (Cleveland), MetroHealth (Cleveland), Nationwide Childrens Hospital (Columbus), and Miami Childrens.  HealthSpot also recently teamed up with telepharmacy – there’s another wrinkle! – vendor MedAvail Technologies to create an all-in-one Redbox-type system. 

Other kiosk providers include StayHealthy, Computerized Screening Inc., Honeywell. 

Of course, non-office visit alternatives are broader than kiosks, especially “virtual visits” offered via phone or computer.  Parks Associates recently found over 25% of American households have used some kind of virtual care, and predict that will grow to 65% by 2018.  They also see a big market for online health and fitness tracking, as does the Consumer Electronics Association, among other forecasts.

Examples of virtual visit vendors include TeleDoc, American Well, and MDLive.  TeleDoc has been offering a telephone-based physician consult service for years, and now also offers a video consult service.  They even recently partnered with HealthSpot, adding to TeleDoc’s reach and deepening the HealthSpot physician network. 

American Well started with email physician consults, added video consults, and recently went beyond its traditional payor partners to offer a direct-to-consumer option at $49/visit.  American Well notes that its services are available via web, kiosk, and mobile – and, in fact, says that 60% of its video visits are from mobile devices. 

MDLive is the most recent newcomer of the bunch, but has a wide range of tele-services and some serious backers, including Sutter Health and John Sculley.  

Some patients (and more physicians) may be skeptical of the quality of services that can be done via a video consult, but that may be changing.  For example, a recent study in JAMA Dermatology found that the video consults produced essentially the same results as in-person visits when it came to triaging.

Kiosks themselves may end up being a niche offering along the continuum of points-of-care, as the video consults are already available on computers and mobile devices and as more and more biometric measures can be done via remote monitoring and apps – why drive to a kiosk when you get do the same things at home or on your phone?  After all, health related apps are booming, and include screening and diagnostic tools.  The stethoscope app, for example, has been around for several years and has proved popular with both consumers and – surprisingly -- physicians.  That’s just one example, but this future is happening, as evidenced by Apple’s expected interest. 

So we’ve got sophisticated bio-metric screenings at your convenience in a wide number of retail settings and, increasingly, via mobile devices, plus we’ve got physicians available literally in the palm of your hand.  That’s not all.  IBM’s Watson is teaming up with “social health management” vendor Welltok to help answer consumers’ health and wellness questions without the assistance of a physician – or any live person.  IBM is so excited about the potential that they’re actually part of an investment round for Welltok. 

Wellpoint is already using Watson on a number of fronts, including providing advice to cancer physicians and to help their pre-approval process.  We may be a long way from the holographic medical program that the TV series Star Trek Voyager had in The Doctor, but I don’t think we’ll have to wait until the 2370’s to see such applications either.  Most likely we’ll start with artificial intelligence programs assisting physicians in decision support, as computers are much better at remembering and searching vast databases than humans are.  

All these new options for receiving care and medical advice remind me again about how much behind the curve traditional health insurance and health providers are.  MobiHealthNews recently did an analysis of hospital apps, and found a lot of doctor and facility locators, but not so many trying to reinvent how/where they deliver care.

I’ve written before about how health plans need to radically reshape themselves, giving an example of them becoming more “provider brokers” for patients than network managers.  The trend of “virtual care” provides another example of a potential alternative to traditional insurance. 

As I noted in an earlier post, AHQR recently reminded us that the 50% of consumers only account for 2.8% of all spending, while the top 10% account for 66%.  I.e., a few people need lots of hands-on, intensive care, and some people may need such care occasionally, but most care for most people does not need have a physician physically present (and may not need a physician at all).  This care could be delivered through retail clinics, kiosks, and computer/mobile-based options. 

Instead of continuing to fight the good fight to increase insurance reimbursement, maybe we should be thinking about developing new products that offer consumers a prepaid package of such virtual services, carving them away from the insurance market.  Or the industry could go the new American Well consumer approach and simply offer virtual visits on a per-use basis, like most other consumer purchases.  In either case, I suspect many consumers – and providers -- would be willing to trade the convenience of the virtual options for the hassles of dealing with insurance coverage. 

Consumers might give up continuity of provider, but that doesn’t necessarily mean giving up continuity of care, such as through use of patient-centered EHRs.

One of the earliest posts I wrote, several years ago and on another platform, warned that “free” preventive care might not be as good an idea as its supporters made out (and this was before the more recent questions about, say, screenings for prostate cancer or mammograms).  One of the many things I don’t like about ACA is how it locks “essential benefits” into a more expansive and more expensive health insurance product, when what we really should be doing is finding more consumer-friendly and less expensive options for care and for paying for that care.  These various virtual care options provide the potential for such an approach.

Consumers should have the option to receive care at the time and place that best suits their condition, preferences and convenience, and that we should not be allowing reimbursement decisions to limit those choices.  It should always be about what is best for the consumer – not the provider or the health plan.

Health Care Culture Wars

There have been a number of developments in the past week that I wanted to comment on, but I kept finding myself thinking about two op-eds I read recently.  Each, in its own way, discusses the impact of culture in the health care system on our health care.  In brief – our culture of medicine may actually be adversely impacting our health.

The first was a piece by third year medical student Ilana Yurkiewicz entitled Why Rude Doctors Make Bad Doctors.  You should read the whole piece, but a couple of her thoughts really hit home to me.  Ms. Yurkiewicz makes a point of saying that ill-mannered physicians are in the minority, but, even so, their behavior adds up: she cites a study from the UCLA School of Medicine that found 50% of medical students across the U.S. experience some sort of mistreatment, such as being bullied.  She points out another study that found 17% of nurses and physicians could name a specific adverse patient outcome that occurred as a result of disrespectful behavior.

Ms. Yurkiewicz warns that communication in health care settings suffers as people worry about intimidation, fear of confrontation, or retaliation, so potential errors or warning signs may not get pointed out. 

Here’s one of her important insights: “Many in medicine actively protect the culture of disrespect because they hold a fundamentally flawed idea: that harshness creates competence” (italics added).  

As Ms. Yurkiewicz goes on to say, “bad cultures lead to bad outcomes.”

In addition to ending the culture that tolerates bullying by medical professionals, Ms. Yurkiewicz argues that the culture puts too much of a premium on saving face, which “…creates doctors who value looking like they know what they’re doing at all times more than actually doing what is best.” 

Strong stuff.  It is perhaps no coincidence that our archetype physician has gone from the kind, gentle, all knowing Marcus Welby, who was happy to make house calls, to the even more brilliant but pathologically irascible and insensitive Dr. House, who only sees patients in the hospital.

The second op-ed, which comes from a very different perspective, was by Rita Redberg and Rebecca Smith-Bindman, with the scary title We Are Giving Ourselves Cancer.  In it, they note how the use of medical imaging has soared in the past twenty years, and the resulting exposure to medical radiation has increased sixfold accordingly. 

They acknowledge that improved early diagnosis can be literally lifesaving, but point out that not enough attention is paid to the potential overuse.  According to their numbers, one in ten Americans get a CT every year, and they reference a 2009 National Cancer Institute study that projected 29,000 “excess” cancer cases – and 14,000 “excess” deaths – due to CT scans.  The authors estimate that 3-5% of all future cancers may result to exposure to medical imaging.

Their great quote: “We are silently irradiating ourselves to death” ” (italics added).

In addition to the simple overuse of scans, Ms. Redberg and Ms. Smith-Bindman mention the lack of standards about dosage, which they say can be 50 times more at one hospital than another.  Studies have confirmed the variability across institutions and even within the same institution.  

The common thread I find in these two very different pieces is the can-do, almost cowboy culture of “we can do it, so we will do it, and don’t tell me any different.” 

I find signs of this everywhere I look.  A few days ago HHS released rules allowing patients direct access to their lab results, which begs the question – why weren’t they available before?  If it was that the results were deemed too complicated for patients to understand, why wasn’t more effort made earlier to make them more consumer friendly?

Or take my personal favorite – colonoscopies.  They bring in lots of cash for GI docs, but the prep is universally reviled by patients and the procedure isn’t much fun either.  Turns out maybe they don’t need to be this bad – the FDA has just approved a pill-sized camera that patients simply swallow.  Granted, this took some advances in technology, but virtual colonoscopies have been around for several years, so why haven’t they become more the “gold standard”?  And why can’t the prep be easier – or at least less distasteful – for patients?  A consumer market, driven by patient preferences, would have addressed this long ago.

Frankly, too much of what goes on in medicine looks like it is more about protecting income or turf than about protecting patients. 

There are fights going on between physicians and their medical boards about how to demonstrate ongoing competence.  Board certification has gone from lifetime to 10 years and is moving in some specialties to 2-5 years, but not all physicians want to have to prove they know what they are doing – why not?  In another battle, anesthesiologists don’t want nurse anesthetists horning in on their territory, although they admit they don’t have proof that patient outcomes suffer (and, in fact, nurse anesthetists can claim the care is the same). 

Heck, there has been a battle going on for years about the release of Medicare Physician Payment data.  Advocates for the release have pointed out the potential for detecting fraud and overutilization and improving patient safety, while the AMA has raised physician privacy issues.  Really?  Physician privacy concerns outweigh patient safety or defrauding Medicare?  It would appear that the battle for the release has been won, but I’m not sure the war is over. 

The best example of all, though, may be medical education.  Perhaps someone could explain to me, with a straight face, why we still have allopathic (M.D.) and osteopathic (D.O.) branches of medicine, each with its own set of schools, residency programs, hospitals, licensing and oversight – not to mention chiropractic or alternative medicine.  It’s been over a hundred years after the Flexner Report and we still haven’t figured out how to take the best from each approach in terms of what works best for patients and how to best train people to deliver that care?     

As Ms. Yurkiewicz neatly concludes about our medical education process, “…we also can’t ignore a system that takes loads of formerly ‘nice’ people and churns out jaded, bitter, and gruff ones.”  Amen, although I like to believe that plenty of physicians somehow still manage to stay “nice” despite the process.

I could go on and on, but perhaps the reader will take my point.

Just when I start to get too discouraged, signs of positive culture change do pop-up.  CVS just announced they will no longer sell tobacco products, deciding they truly are in the health care business and forgoing $2b in annual revenue as a result.  They’ve already made a big bet in retail clinics, as have several of their pharmacy competitors. 

Volumes have been written about retail clinics’ potential; even hospitals are getting into the game (we’ll have to see what kind of retail experience they can deliver).  A truly retail perspective should be better at putting patients first.   

Still, even the much vaunted retail clinics haven’t severely dented more traditional practices of medicine, due in large part to the usual suspects – regulatory and reimbursement barriers.  Its distant cousin telehealth faces much the same problems, and, as a result, is having its most success in places where there aren’t many good alternatives, such as in rural areas.  Those are the underlying kinds of culture issues that are proving very hard to shake.

The culture problem really crystallized for me a couple years ago when Dr. Michael Joyner of the Mayo Clinic raised the question of whether physicians should treat lack of exercise as a medical condition.  That signaled to me that we’ve officially tipped too far from thinking about health to relying on medicine, and signified abdicating our own responsibility for taking care of our own health to the medical professionals.  They certainly should be part of our health team – just not in charge of that team.   It’s our body, our health, and we should be in charge.

At the end of the day, it is us – the patients, the supposed consumers – who allow the culture to exist.  Every time we don’t ask physicians questions or don’t demand better explanations, we allow it.  Every time we get a pill or an extra test instead of taking time to evaluate risks and risk factors, we allow it.  Every time we accept overbooking, confusing bills, inconvenient hours, or inadequate time with our health care professionals, we allow it.  And, of course, every extra pound, every missed exercise, and every missed fruit and vegetable serving, we allow it. 

Maybe we need fewer doctors like House and more patients with the attitude Howard Beale had in Network, where he famously declared “I’m mad as hell and I’m not going to take this anymore!”  We need more of that attitude to win the health care culture wars.