Patients' Role in a High-Performing Health System

Today, more and more patients want to play an active role in their health care. As decision-makers, they are seeking detailed information about their conditions and access to their medical records. This not only benefits patients—who learn to better manage chronic conditions and adopt healthier lifestyles—but is one of the keys to developing a high-performance health system that offers better access to care, improved quality, and greater efficiency for all.

The Commonwealth Fund's Commission on a High Performance Health System is charged with identifying the keys to a high-performing system. This could include strategies to reach agreement on shared values and goals; organize care and information around the patient; expand the use of information technology; enhance the quality and value of care; reward performance; simplify and standardize; expand health insurance and make coverage automatic; guarantee affordability; share responsibility for health care financing; and encourage collaboration.

Insurers Can Promote Patient-Centered Care
Private insurers individually and through collaborative efforts can promote high performance in a number of ways, including helping patients be more engaged partners in their care. Insurers, for example, can help patients become better decision-makers by paying for efforts to promote shared clinical decision-making, through the use of patient education videotapes, booklets, and Web sites, and by offering follow-up with skilled staff to ensure that patients understand their diagnoses and the benefits and risks of treatment options. Insurers can also require shared decision-making as a condition for approving elective procedures, such as lower-back surgery.

Likewise, private insurers and public programs can collaborate on creating a multi-payer database on provider quality and resource use for different acute and chronic conditions. Such information can help patients make choices that will likely result in efficient, cost-effective care.

In addition to information about health facilities and physicians, patients want access to information about their own care. The Commonwealth Fund 2004 International Health Policy Survey showed that 37 percent of U.S. patients do not have access to their own medical records but would like it. Insurers can help here by assisting in creating patient-accessible personal health records that list a history of services utilization, patient problems, medications, and lab tests and results. Electronic patient-reminder systems that help ensure patients receive appropriate and timely preventive care and manage their chronic conditions could also improve health outcomes and help health care professionals provide high-quality care.

Expanding Coverage
Private insurers and public programs also need to develop strategies to ensure universal participation in the health care system. After all, without the bedrock of health insurance for the 46 million Americans now lacking coverage and better coverage for the16 million more considered underinsured, true patient-centered care is impossible.

The 2003 Commonwealth Fund Biennial Health Insurance Survey revealed that patients believe health coverage is a responsibility that should be shared by individuals, employers, and government. Health care opinion leaders believe affordable coverage for all can be achieved by building on systems already in place: employer group coverage, the Federal Employees Health Benefits Program, Medicare, and the State Children's Health Insurance Program.

High-Deductible Health Plans: Not a Patient-Friendly Solution
So if patient-centered care is so desirable, then what about "consumer-directed health plans?" These are an increasingly popular strategy to reduce premiums and, theoretically, promote more cost-sensitive health behavior on the part of employees. Yet, these high-deductible health plans, whether or not they come with health savings accounts (HSAs) will not make health insurance and health care more affordable for the uninsured, and will add to financial burdens on low-income workers and chronically ill patients.

Out-of-pocket expenses for patients are already high and increasing every year. According to findings from the EBRI/Commonwealth Fund Consumerism in Health Care Survey published in December 2005, patients in high-deductible and consumer-directed health plans spend a higher percentage of their income on out-of-pocket expenses than those with comprehensive coverage.

Moreover, high-deductible plans undermine access to care for vulnerable populations, as, for example, many patients choose to go without needed medications because of cost, increasing the risk of adverse events. The EBRI/Commonwealth Fund survey also revealed that people enrolled in high-deductible and consumer-driven plans are less likely to have had a choice of health plan, and are less satisfied with their coverage than those with comprehensive coverage.

It is also difficult to expect consumers in these plans, or others for that matter, to make cost-conscious decisions about health care because so little information is available about the quality and cost of physician services, hospital and health care facilities, and procedure. And given the concentration of health care costs among the chronically ill, consumer-driven plans are unlikely to have an impact on overall spending.

However, there are modifications that could minimize the potential harm from high-deductible health plans and HSAs. They include:

  • Letting employers lower deductibles for lower-wage workers;
  • Exempting primary care and preventive services from the deductible and exempting prescription drugs essential for management of chronic conditions;
  • Guaranteeing choice of a comprehensive health plan to workers covered under employer plans;
  • Permitting greater flexibility in benefit design;
  • Setting an income ceiling on eligibility for HSAs to reduce the tax subsidy for high-income individuals


Reward Performance/Improve Primary Care Access
Rather than shifting more of the cost burden of care to consumers, a better way to improve quality and efficiency in the health care system is to reward excellence in care with financial incentives, through pay-for-performance programs, and non-financial incentives, such as public reporting.

Medicare, Medicaid, and private insurers should continue experimenting with rewarding excellence in clinical care, patient experiences with care, and efficiency. Patient-centered care must be an essential element of pay-for-performance systems, particularly because it safeguards against cheap but unsatisfactory care.

For example, in RIte Care, Rhode Island's managed care program for Medicaid, the State Children's Health Insurance Program, and certain uninsured populations, quality targets and financial incentives have led to improved access and a one-third reduction in hospital and ER visits. The program also has tripled the number of primary care doctors, doubled clinic visits, and contributed to significant improvements in prenatal care, birth spacing, and infant mortality.

Another avenue to improved quality and efficiency is better access to primary care services. Primary care should be encouraged though a package of services without financial barriers, including preventive care, low-cost acute medical care, and essential medications to control chronic conditions and risk factors. And primary care payment to physicians should include bonuses for quality and accountability for resource use, such as emergency room use, medical costs, specialty referral, and hospitalization rates.

A Public-Private Partnership to Put Patients First
Truly making the patient the focal point of our health care system may seem a difficult and elusive goal, but it can be done. Private insurers and public programs can serve a leadership role in this effort, forging new and strong partnerships as they pursue strategies to build up patient education, health information technology, coverage expansion, performance incentives, and primary care. Only through public-private collaboration on policies that are really patient-centered will we achieve a high-performing health care system.

As always, I'd like to hear from you. Send your feedback to kd@cmwf.org.

chart

March 2006


Please note that this column was previously published on the America's Health Insurance Plans' Web site.

Written with the assistance of Christine Haran, web editor.