Scott MacStravic, PhD
The recent report envisioning an admittedly optimistic potential for saving as much as $8.5 trillion in combined sickness care and productivity loss costs between now and 2023 left out a major challenge to realizing this vision. How much can we count on consumers, as subjects or objects, to play the part necessary to achieving such savings? [R. DeVol & A. Bedroussian, An Unhealthy America, Santa Monica, CA Milken Institute Oct 2007 (www.milkeninstitute.org)]
Healthcare reformers have a strange ambivalence about consumers. This is perhaps understandable, since any reform that depends on changing the behavior of 300+ million people is necessarily very complicated by the sheer numbers involved. Changing the behavior of a few hundred thousand physicians, a few thousand hospitals, for example, is automatically much simpler because of the much smaller numbers involved.
There has certainly been a major transformation in expectations of consumers over the past thirty years. In 1977, the idea of consumers as healthcare “customers”, to be marketed to by healthcare providers, was in its infancy, with the first book on healthcare marketing, and the first national conference on the subject both emerging in that year. (I was at the conference and wrote the book.) It has been a gradual and often contentious period during which providers have gradually accepted that idea.
More recently, the concept of consumer health “self-service” has emerged as an obvious way to save money. Enlisting consumers as “virtual employees” to help reduce costs is an idea as old as the supermarket, in commerce in general. It has really taken off as the Internet, automated phone systems and websites enable consumers to find desired information by themselves, make purchases without interacting with any human, check themselves on to airplanes, etc. and thereby save billions in customer service expense.
Consumers in healthcare are being asked to complete pre-visit surveys prior to making physician visits, register themselves at emergency rooms, find their own health information, and make their own treatment choices. They are being asked, as patients or family members, to become their own “advocates” in watching out for possible mistakes that providers may make regarding treatment safety and quality in the hospital. And they are the major target for proactive health management (PHM) programs, since they largely determine the outcomes thereof. And providers often insist that they cannot be held accountable even for sickness care, since consumer “compliance” is key to those outcomes as well.
Some simplistic health reform “hedgehogs” rely on a single solution to healthcare system problems, often putting all their eggs into the basket of shifting healthcare costs and power to consumers. Through “consumer-directed” health insurance and health saving/spending accounts, consumers will get “enough skin in the game” to reform their own behaviors, becoming both prudent purchasers of their own sickness care and careful managers of their own health. This is projected to dramatically decrease the rate of increase in healthcare costs.
At virtually the other end of the spectrum are employers, and some insurers, including Medicare and Medicaid that are not only offering healthcare coverage, but are promoting the health of their “covered lives”. Rather than relying on the cost shift to motivate consumers to a new level of prudence, they are supporting, enabling, even paying consumers to become healthier. Employers are even going as far as integrating all employee benefit programs as a strategic investment in improving employee performance and value to the firm, while improving employee retention as well.
I remember when self-service was new, and seemed okay as long as it was convenient and actually resulted in improved experiences, such as getting transactions completed or finding information faster and better than using a customer service representative was. But in wholehearted pursuit of cost savings, self-service has imposed an enormous cost in time for consumers, who have little to spare, including taking time away from work as employees use working hours to take care of personal business.
Relying on consumers to do part of any job makes sense for businesses and healthcare organizations, alike. But there are limits to what consumers can and will do, before they will take their business elsewhere, or simply refuse to serve themselves, unless self-service elements are treated like products or services. This means they must be convenient, priced fairly, deliver significant benefits, to consumers, themselves, not merely save money for the business.
