Information is a word that's bandied about in no small measure in this country when the subject of health care comes up. It costs too much, some say. Too many people go without it in any given year, others add. Health care costs gobble up any boost in wages, statistics show. Medicare and Medicaid threaten to consume the national budget, still others cry out.
Several factors contribute to the woes of the U.S. health care system, a system that costs more than any other in the world without exhibiting a higher level of quality or better outcomes. One factor is employer fatigue with rising costs. General Motors once said it spends more on health benefits for its employees and retirees than it does on steel for its vehicles. Employers are tired of the increases.
Another factor is the fragmented way in which the system runs, which leads to a lack of coherence on clinical guidelines and even definitions of what constitutes effective care. There are many other factors contributing to the health care system's woes, but the last that will be covered here is the need for comparative information that consumers can use to make informed decisions.
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If health care consumers are going to be expected to make wise decisions about where to get their care and how much it should cost, one argument says there ought to be a place that compiles just such information and makes it available to brokers, benefits managers, employers and consumers — and to do so in a transparent and unbiased manner. Can it be fixed? If so, what will that require?
Brokers and benefits managers can play a crucial role in creating the answers.
Heart is willing
Employers want to help, even if they don't want to pay more into an already burdensome system that saw its first single-digit rate increase in three or four years in 2006. According to researchers at the Center for Studying Health System Change, 66 percent of all firms say all employers should share in the cost of employee health coverage. That number is consistent across small firms (those with up to 199 employees) and large firms (those with 200 or more employees), a hopeful statistic.
"It certainly is an encouraging finding," says Heidi Whitmore, a researcher at Washington-based HSC, "given the concern over the cost of health insurance and annual rates of increase in premiums, which have consistently outpaced inflation for quite a few years now. The study shows that employers still view health benefits as important in recruiting and retaining good employees."
Employers, especially small firms, HSC found, are willing to take on a number of administrative-type tasks if it means expanding health coverage. Most of the tasks are changes that need to be implemented legislatively, but the promise of change exists, and brokers are in the right place to help employers and their benefits managers along the way. One approach that found large support among employers involves a tax credit to low-income workers. Employees use the credit to buy their own insurance or pay a premium obligation to their employer. Eighty percent of firms say they would be willing to reduce workers' withholding taxes by the amount of available tax credits. Slightly fewer employers, 70 percent, say they are willing to collect the tax credit and apply it to the employee's premium share.
Come together
One model of togetherness is being tested in Washington, the Minneapolis-St. Paul area, Detroit and Wisconsin. The groups are known by various names, but their goals essentially are the same: to use input from the spectrum of the health care world to provide comparison reports, implement evidence-based treatment guidelines, offer information consumers can use and create incentives that reward quality care. In Washington state, the group is known as the Puget Sound Health Alliance, and since its inception, it has brought together public and private employers, health plans, doctors, clinics and hospitals, consumer groups, and unions to work toward a better health care system.
"I think it was key that from the beginning all groups were represented at the table," says Diane Giese, director of communications and development. "We didn't start with a few groups and expand," which can lead to mistrust from the groups that are brought to the table after some recommendations have been made or a direction has been chosen.
The alliance's foremost goal is to produce a comparison report on the quality of care provided at local clinics and hospitals by doctors that will be available to everyone. But where the group really hopes to make a difference — and this is something that can be developed into a national model — is in the area of adopting evidence-based treatment recommendations and guidelines, guidelines that could affect the way benefits packages are created. "We want to make sure that every dollar spent on health care is a dollar that helps people get better or helps them avoid getting sick," Giese says.
To do that, the Alliance plans to listen to doctors and medical groups to develop treatment guidelines. "The definition of quality care is coming from the medical community," Giese says, "not from employer groups saying this is what we think is quality. The medical community tells us what a person with diabetes or back pain needs."
For example, according to the medical community, someone with diabetes — one of the first five ailments the Alliance is studying — needs an annual foot and eye exam. He also needs to regularly test his blood sugar. The Alliance will recommend that benefits packages have a plan that covers the foot and eye exams and the medically necessary test strips, because the medical community thinks it is advantageous to be proactive in the treatment of diabetes, which ultimately will save costs. Instead of paying for an amputation down the road, the health plan can pay for less expensive yearly exams. Using the medical community's input, and a little common sense, the Alliance plans to create definitions for quality care across a broad spectrum of illnesses and diseases, with the hope that all of the clinics, hospitals, doctors and especially plan providers will adopt the guidelines.
And consumers will be able to see which health care providers have adopted the guidelines and measure up to the definition of quality in the report, but that's going to take some time. Once the report is made public, especially in future years when the information will be more comprehensive, some clinics and hospitals are going to have below-average numbers.
"Moving from theory to reality is making some people nervous," Giese admits. But it is something that must be done if the health care system is to move toward greater transparency and effectiveness, especially on a national level with the growth of consumer-driven health care.
Comparative effectiveness
As consumers are given more and more responsibility for managing their health care costs, it becomes imperative they have access to quality comparison information. Consumers easily can find out where to find the least expensive HDTV, car, computer or almost any other retail item. That's often how retailers are measured against each other. With health care, cost is an issue, but so is quality and effectiveness. Gail Wilensky, a senior fellow at Project Hope in Bethesda, Md., and the former administrator of the Health Care Financing Administration under President George H.W. Bush, says there should be a Center for Comparative Effectiveness Information.
Such interest exists for pharmaceutical information, but Wilensky says that's not enough. Interest is growing, however, and it's growing in the right places. "There does seem to be interest from diverse parts of the health care world that this makes sense," she says, adding that the support comes from supporters and opponents of administered pricing. "But it has to include more than just pharmaceuticals, since that accounts for just 10 cents of every health care dollar."
Even the comparative information that exists for pharmaceuticals is based on performance against placebos, not the other drugs on the market, and Wilensky says that has to change. Measuring the effectiveness of something against nothing is not the strongest measure that can be found. Procedures, technologies, plan designs, hospitals and more must be measured against other technologies, plan designs and hospitals for the information to be as strong as it can and should be. While the structure and location of such a center is open for debate, what the center undoubtedly should offer is information consumers, brokers, health plan providers and employers can use to make informed decisions. And anyone worried about the center making decisions that affect large swaths of plan providers and the consumers they cover need not worry.
Wilensky sees the function of such a center as providing objective and credible comparative effectiveness information on technologies and alternative therapies; she says it will not be a centralized location for making coverage decisions. The creation of a comparative effectiveness center is probably a long way off, as it would have to win legislative and executive approval, but brokers and benefits managers have the chance to do their homework and prepare themselves and their audiences for a time when transparent, unbiased comparative effectiveness information is available.
It will affect how plans are designed and employees are covered. Even if a national center like Wilensky envisions never appears, comparative effectiveness is on the way. Through organizations like the Puget Sound Health Alliance and its brethren, the health care systems symptoms are being diagnosed and solutions are being created and presented. As more of the programs experience local and regional success, chances are more programs will be implemented nationwide.
Health care's future in America is not dependent on the actions of one or two large organizations; it is dependent on the actions of hundreds of large and small organizations working together to draw conclusions, make recommendations and give consumers the information they need to be the kind of buyer in the health care arena they are in shopping for other goods and services.
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