Lowering the Cost of Healthcare From the Patient's Perspective

As the president of the Heritage Foundation has said, “The urgent overwhelms the important.”¹ This statement is decidedly true for those individuals with a chronic disease or disability who must forego the purchase of their medications or postpone treatments to make their mortgage payment or to purchase groceries.

In 2009, the Kaiser Family Foundation reported that slightly more than half (53%) of Americans said their household cut back on healthcare due to cost concerns in the past 12 months.² A study in the medical journal Cancer stated the more than 2 million adult cancer survivors in the United States have put off receiving medical care because they could not afford it.³

Consider this post to a Web site jointly created by the National Health Council and WebMD: “I have always been employed and carried insurance coverage. We always have lived and paid our bills, never extended our credit beyond our means. Now, I am faced with having to charge the medications knowing that I will have difficulty paying for them.”⁴

Despite having the most costly healthcare system in the world, the United States consistently underperforms on most dimensions relative to other countries.⁵

The rising cost of healthcare is a multifaceted problem. There is no single solution to bringing cost in line with the ability of Americans to pay. Whether talking about clinician efficiencies, system silos, payment structure, use of health information technology, or the overall delivery process, the economic solution must engage a varied approach.

One of the objectives of the Patient Protection and Affordable Care Act (PPACA), commonly known as the healthcare reform bill, is to reduce the problems patients experience in obtaining quality healthcare. However, we won’t experience many of the benefi ts of the PPACA provisions designed to restrain the cost of healthcare immediately (Table).

To explore the multitude of issues and opportunities central to lowering healthcare expenditures—as a nation and from the patient perspective—the Institute of Medicine convened 4 gatherings of experts in 2009. The workshops, collectively titled The Healthcare Imperative: Lowering Costs and Improving Outcomes, resulted in a thoughtful publication of the same name available on the Internet.⁶

PATIENT ENGAGEMENT

The Institute of Medicine workshops focused on a myriad of factors that gave rise to patterns of unnecessary cost, including the lack of patient engagement in shared decision- making. It is well known that patient engagement is a critical element for treatment success, but the typical patient may have limited information on issues related to outcome, value, or cost. Without meaningful and trustworthy sources of information, people with chronic diseases and disabilities are not empowered participants in the decision-making process.^6(p10)

We need more effective and efficient tools for translating technical language into accessible information for consumer use. We also need better methods for incorporating patient concerns and feedback into the decisionmaking process.^6(p54) This 2-way communication ensures that patients are better equipped to assume greater responsibility in our fragmented healthcare system by enabling creation of comprehensive care solutions that acknowledge personal predicaments at the point of care. Participants in the Institute of Medicine workshops stated that providing people with easy-to-obtain, credible information that is integrated into the healthcare experience can increase the potential for improving both efficiency and quality—2 important elements for increasing value and containing cost.^6(p48)

One participant, extrapolating from studies demonstrating the impact of shared decision making, estimated that the systematic use of shared decision making coupled with provider incentives and changes in benefit design could yield up to 5% in net savings in total healthcare spending in this country. That would be $125 billion in 2009 US dollars.^6(p17)

In various discussions, workshop participants addressed the potential of transparency in a variety of delivery system components to illuminate vital information for patients. One example of transparency in cost is the Castlight program. A start-up firm, financed by venture capitalists and the Cleveland Clinic, is building a search engine for healthcare prices. Patients using the Castlight system could find out how much doctors charge, depending on their insurance coverage.⁷

PATIENT INCENTIVES

It also was noted by many workshop participants that much of the healthcare delivery system has been shaped over the past generation with the primary convenience and interests of the healthcare provider, not the patient, in mind. For improving both patient satisfaction and patient outcomes, attendees noted that the focus has to be on patient perspectives and needs.^6(p14)

Economic strategies (eg, altering an individual’s out-of-pocket costs) can help steer people to use higher value healthcare services and remove barriers for essential, effective preventive services, thus reducing overall costs and improving outcomes.

The PPACA requires new health plans to cover many preventive services with no deductibles or copayments. It offers incentives to Medicaid beneficiaries who successfully participate in programs that promote healthy lifestyles and strengthens the preventive services program for seniors under Medicare.⁸

Geisinger Health System utilizes a “patient compact” that is designed to engage patients in ensuring favorable outcomes.^6(p41) The company’s health information technology system makes access easier for patients by providing after-hours care and Internet scheduling, and creates physician incentives to deliver evidence-based care according to treatment standards. These and other patient-focused initiatives have resulted in Geisinger achieving a 7% to 8% drop in cost growth for Medicare beneficiaries.⁹ Polk County in rural Florida instituted a program where copayments for diabetic or hypertension medication and supplies are eliminated if county employees participate in a disease management program. This program resulted in a net savings of $213,000. Although that amount reflects savings from fewer hospitalizations and emergency department visits, there also were net gains from increased worker productivity and reduced absenteeism.¹⁰

Just as the rise in healthcare costs is a multifaceted problem, the solutions presented at the workshops were equally diverse. This article cannot cover them all. However, if we first focus on ways to engage people with chronic conditions and develop meaningful incentives to help them make informed healthcare decisions, I believe we will make great strides in achieving positive, measurable health goals for our nation—including the lowering of overall healthcare costs.