WASHINGTON -- The whole idea of giving patients financial "skin in the game" so they'll be motivated to shop around and lower their healthcare costs hasn't been working and needs to be rethought, several experts said here.
"Maybe we need to rethink the value of the high-deductible health savings account," Tara O'Neill Hayes, deputy director of healthcare policy at the American Action Forum, a right-leaning think tank, said here Tuesday at an event sponsored by the National Coalition on Health Care. "Maybe we put a little too much in that basket."
Paul Ginsburg, PhD, director of the USC-Brookings Schaeffer Initiative for Health Policy at the Brookings Institution, a left-leaning think tank, agreed. He noted that when it comes to the idea of having consumers shop around to get cheaper care, "[Our] experience [with] providing good pricing [data] to consumers is not encouraging at all; they don't go there. They don't use it ... Just having consumers be in high-deductible health plans and giving them price information is not the most effective way to get them to be better consumers."
What would work better, Ginsburg said, is capping the amount of money for health insurance premiums that workers could exclude from their taxable income. That would force people to buy less expensive health plans from their employers "without all the bells and whistles," he told 51˶.
At the event, the coalition presented its on strategies for improving healthcare affordability. The report identified six drivers of healthcare costs:
- Chronic illness rooted in non-medical determinants of health
- Poorly coordinated, inefficient care delivery
- Misuse of provider market power, caused in part by providers who demand guaranteed inclusion in contracts
- Barriers to drug price transparency and competition
- Insurance and reimbursement rules that promote cherry-picking of healthier patient populations
- Cost barriers to high-value care, such as increasing deductibles
When it comes to that last item -- barriers to high-value care -- John Rother, the coalition's president and CEO, pointed out that "not all healthcare has the same value. Certain procedures and interventions offer high value and there are others that offer low value, and yet we don't distinguish [between them] and people with coverage often don't understand the difference. By removing barriers to higher-value care, we could definitely make a positive impact on healthcare."
The coalition offered several suggestions for improving affordability:
- Focus on the non-medical determinants of health. This would probably offer the best value, said Rother. "Investments in children in particular have a long-term payoff. There's no question that dollar for dollar, investments in child health through Medicaid and through [the Children's Health Insurance Plan] is the single best investment we can make"
- Make healthcare more efficient by promoting value-based care. "We need to build the infrastructure [for that], including more emphasis on primary care and a common set of performance measures that tell us how we're doing and where investments have the best payoff," he said
- Curb misuse of the market power of providers. "There is tremendous consolidation in healthcare going on today as providers look to enhance their own market power," and fixing the problem will require leadership from the Federal Trade Commission as well as state lawmakers, Rother said
- Eliminate barriers to transparency and competition in drug pricing. "Drug pricing has gotten a lot of attention lately and I think deservedly so," he said. "We're seeing the price increases for brand-name drugs overwhelm the savings we get from generics, and it's likely to increase in the future as more and more new drugs are very expensive biologics that run six figures a year." Promoting more competition among drugmakers and a better pathway for biosimilars would help, as would broader formularies and a greater ability for Medicare to negotiate prices based on comparative effectiveness, Rother added
- Promote increased use of high-value healthcare. "We could exclude primary care from deductibles, and also exclude chronic care services. We need to think about what works and measure it, and perhaps implement it more broadly"
Gerard Anderson, PhD, of Johns Hopkins University in Baltimore, gave a historical perspective on the issue; he noted that in 2003, he and several colleagues, including the late Princeton University health economist Uwe Reinhardt, PhD, wrote a paper entitled, "," which explained that the reason for the high cost of healthcare was payers' willingness to put up with high prices.
"We were looking at the reason for these higher costs -- we looked at defensive medicine, higher educational costs for physicians, the aging of the population, the administrative burden, and [the fact that] Americans were sicker," said Anderson. "But [for each one] we said, 'Yeah, that's not the real reason' ... We found that it was the prices."
Some of the researchers involved have redone their analysis "and most everything remained exactly the same in the last 15 years," he continued. There was one difference: when the group wrote its original paper in 2003, the private sector and the public sector were paying about the same rate for healthcare, but now the private sector is paying much more.
"You can talk about cost-shifting, but for me, one of the main reasons for growth in last 15 years ... is the willingness of the private sector to continue to pay ever-increasing prices for goods and services," said Anderson. "The question is, can we mobilize them ... or do we have to give them some government help?"