Wednesday, November 11, 2015

Someone Must Be On Drugs

As is probably true for many of you, I'm busy looking at health plan open enrollment options for 2016.  I have to confess that for the past few years I've been guilty of just sticking with the same plan, so it has been too long since I've had to shop.  Plus, I'm helping my mother pick her Medicare options for next year.  All in all, I'm awash with health plan options.

I'm torn between thinking that the people designing the plans are extremely clever, have a perverse sense of humor, or were under the influence of psychedelic drugs at the time.

It's not that there aren't plenty of options.  I've got different levels of HMO, POS, and PPO options, from multiple carriers.  My mother has many choices of Medicare Supplements, with Part D options, as well as Medicare Advantage options (both HMO and PPO), each from multiple health insurers.

Nor is it that having choices is bad.  Researchers have discussed the "tyranny of choice" (or "paradox of choice") for some time, meaning too many choices can be paralyzing for consumers.  I have to admit that when I go to the cereal aisle in the grocery store I feel overwhelmed, but, whether it is cereal or health plans, I'd still rather than more choices than fewer choices.  

It's just that, well, the options are so damn confusing.  I was in the health plan business for a long time, and helped develop some of the first plan selection tools for consumers,  But when it comes to evaluating some of the options now available, I find it practically impossible.

Austin Frakt recently wrote in The New York Times about this problem.  He cited a few studies specifically on point about health insurance, such as:

  • One study found that 71% of consumers couldn't identify basic cost-sharing features;
  • Less than a third of  consumers in another study could correctly answer questions about their current coverage;
  • Researchers found that consumers tended to choose plans labeled "gold" -- even when the researchers switched the "gold" and "bronze" designations, keeping all other plan details the same.  
Many consumers tend to stick with their existing choice even when better options are available, simply because switching or even shopping is perceived as too complicated.  But, hey, cable companies and mobile phone carriers have relied on this kind of inertia for a long time, so why should health insurers be any different?

I'm most frustrated with prescription drug coverage.  Not that long ago, the only variables were the copays for generic versus brand drugs.  Now there are often five or six different tiers of coverage -- such as preferred generic, other generic, preferred brand, other brand, and "specialty" -- with different copays or coinsurance at each tier, each of which can also vary by retail versus mail order, and for "preferred pharmacies." 

Moreover, the health plan's formulary, which determines what tier a drug is in, can change at any time.  Plus, as has been illustrated recently, the prices of any specific drug can change without notice, sometimes dramatically.  If either of those happens to one of your drugs, say goodbye to your budget.

It's all enough to make your head spin.  

The health plans would no doubt argue that their various approaches to prescription drug coverage are necessary in their efforts to control ever-rising costs for prescription drug costs.  Well, they aren't working.  

Prescription drug prices continue to soar, even for generic drugs.  They have become a political issue, with the Senate now launching a bipartisan investigation into prescription drug pricing and the Presidential hopefuls from both parties being forced to take positions on how they would control them.  For once, politicians are in sync with their constituents; the latest Kaiser Health Tracking Poll found that affordability of prescription drugs tops their priority list for Congress and the President.

I've long thought that the pharmaceutical industry was ahead of the rest of the health care industry.  They were doing electronic submission of claims over forty years ago.  They pushed for direct-to-consumer advertising in the late 1980's, and quickly jumped on that bandwagon.  While providers only grudgingly adopted EHRs, they quickly moved to e-prescribing.   Other health providers had to move away from discounted charges twenty years ago, whereas drug companies still mostly use that approach and are only starting to tip-toe into more "value-based" approaches, as with the recent Harvard Pilgrim-Amgen deal.  

And the backroom rebate deals between drug manufacturers and payors put a lie to any claim that at least drug pricing is transparent.  

It's not only prescription drug coverage that is increasingly complicated, what with narrow networks, gatekeepers, different copays for different types of medical services, bundled pricing, or numerous other gimmicks used in health plan designs.   The collateral damage in the ongoing payor-provider arms race is consumer understanding. 

Making things more complicated for consumers is not the answer.  

In typical fashion, the health care industry has tried to address the confusion by creating a new industry that doesn't actually solve the problem but does manage to introduce new costs.  Many enrollment sites --the Medicare plan finder, public exchanges, private exchanges, broker sites like ehealth, or health insurer sites -- offer tools that purport to estimate your costs under your various health plan options.  Yet consumers still don't understand their options.

We keep treating health care as a multi-party arrangement between providers/health plans/employers/government/consumers, which is why everything ends up so complicated.  Drug company rebates or medical device manufacturers' payments to providers are prime examples of the kind of insider trading that goes on.  It's usually the consumers that come last.  And that's the problem.  

I think back to 1990's cell phone plans.  Consumers never knew what their next bill would bring, between peak/non-peak minutes and the infamous roaming charges.  No one liked it, no one understood it, and for several years no one did anything about it.  Then AT&T came out with a flat rate plan that essentially said, "we'll worry about all those for you," and soon all carriers had to adopt a version of it.  

I keep hoping for that kind of breakthrough with health insurance. 


  1. "I keep hoping for that kind of breakthrough with health insurance." I do too. It's called single payer.

    1. Of course, single payer doesn't ensure that its structure would be any more comprehensible. If there is a worse design than Medicare, I don't know it (unless it is Medicaid).

    2. I agree with you about Medicare, a health plan designed by political influence groups - what could be worse? It's hard to believe that advocates of single payer don't understand how badly monopolies operate for consumers. And if the federal government is in charge, then we are really in trouble since politics and individual interests will drive decisions, instead of an analysis based on what's best for all of us.

  2. Good article, Kim. You are absolutely right about the growing complexity of design. They are so complicated and don't really influence behaviors in the desired end (lower cost to achieve better health). Perhaps the problem originates because the budget driven approach taken by insurance companies is to use simple equations to better budget costs. Instead, they should look at behavioral economics to find the incentives that will actually influence consumer decisions at the point of service.

  3. There are some good decision support tools out there now that help address some of the issues related to plans. But understandably it's still a complex decision.