Thursday, June 20, 2013

Price and Value in Health Care

Oscar Wilde wrote in The Picture of Dorian Gray, “Nowadays people know the price of everything and the value of nothing.” (Yes, I know he also used that as the definition of a cynic in Lady Windermere’s Fan, but Dorian Gray was earlier. Isn’t Google wonderful?) That was the thought that occurred to me as I read in my local paper, “Consumers may not be using health savings accounts as expected.” The reporter wrote, “A new research report suggests that consumer-directed health plans — which give employees more control over how they spend their employer-subsidized health care dollars — are getting the opposite of the results intended.”

The article points to a study published in Health Affairs titled “Consumer-Directed Health Plans Reduce The Long-Term Use Of Outpatient Physician Visits And Prescription Drugs.” (Paul Fronstin, MartĂ­n J. SepĂșlveda and M. Christopher Roebuck: Health Affairs, 32, no.6 (2013):1126-1134) The study compared employees of two large companies over a period of five years. One company offered consumer-driven health plans (CDHP) that included a health savings account (HSA) to which the company contributed. One plan was high deductible and another low deductible, with related differences in premium costs but no differences in the company’s contributions to the HSA. The other company offered a Preferred Provider Organization (PPO) fee-for-service insurance plan. Employees were matched between the two companies based in their demographics, etc.

The results were not what the investigators expected.
Although no significant effects were detected for inpatient hospitalizations and days, the CDHP was associated with an increase in ED visits… after three and four years, respectively. For outpatient visits and prescription drug fills, CDHP had a significant negative impact that persisted over the four years after the CDHP’s adoption. Specifically, numbers of physician office and clinic visits were lower…after one year (in 2007) and… after four years (in 2010). Moreover, enrollees filled… fewer prescriptions after one and four years, respectively, under the CDHP..



That is to say, employees with CDHP’s didn’t spend fewer nights in the hospital than PPO employees. On the other hand, they made fewer outpatient visits and had fewer prescriptions filled. The study also showed that employees with CDHP’s had fewer screenings for certain cancers in the first year, but that effect equaled out or reversed over the five years of the study.

These results were not expected because CDHP’s were supposed to result in fewer nights inpatient and fewer emergency visits, and increased outpatient visits. The expectation has been that with more control and also more personal money on the line employees would make wiser and less wasteful decisions. That is, they would choose more carefully and focus on “essential” care, without spending money carelessly. With that in mind, the thought was also that they would choose preventive care so as to avoid the hospital or the Emergency Room.

My regular readers will be well aware of my own concerns of making too much of one study. This is a very preliminary study, albeit with a large study pool. The authors are conscious of important limitations of the study. Among those is the fact that this only involves two companies, and only one offering CDHP’s. Within that one company, too, there were differences between those in the high deductible and low deductible plans. The results may not generalizable.

At the same time, in their discussion they offer some interesting reflections for public policy and employer decisions. Among other issues they raise are whether specific preventive measures are or are not subject to the deductible. If annual physicals and preventive screenings are subject to the deductible, even with the resource of a health savings account, patients may avoid the out of pocket expense – only to find that a medical need catches up with them when it’s more developed and more serious. That, then, could result in more ER visits and more, or at least as many, inpatient stays.


Which gets at a concern I have about how we talk about health care spending in this country. “Nowadays people know the price of everything and the value of nothing.” In the public square there’s an assumption that spending wisely would mean spending less. The point is for the patient to focus on health care that is essential, and not be wasteful. But for the longest time we’ve focused our health care on paying and reimbursing for interventions. That begs the question of what we mean by “essential.” Many of us would think “essential” could include preventive care; but preventive care might actually mean spending more now with an expectation of spending less later – like, in fewer ED and inpatient visits. If, on the other hand, there’s a focus on the price and expense rather than the goal of care, “essential” can mean “when you can no longer put it off” – which all too often means once you’re already seriously ill or injured.
This individual study won’t resolve the question of whether CDHP’s are ultimately better or worse for the health of employees, or whether they really reduce costs. At the same time, the authors are alert to just these issues. They write,

If CDHPs are to succeed in getting people to make more cost-sensitive decisions about the use of health care services and to engage in health-promoting activities such as using recommended preventive services, plan sponsors will have to design plans to provide incentives for primary care and prevention, intensely educate members about plan coverage, and provide needed information to assess options. Employers and insurers will need help from public policy makers to allow employers more discretion over health savings account–eligible plan designs. For example, primary care coverage could be exempted from the deductible, so that high-value preventive services not subject to the deductible would not be affected by changes to coverage of other health care services.


In other words, it’s not enough to think about the price of health care, especially when that’s simply an excuse to shift the burden of the price from the employer to the employee. It’s not enough to think about the price if we don’t also think about the value.

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