The United States is at the crossroads of two traditional paths in health care that don’t work particularly well for patients — fee for service and managed care. We must forge a new path, one in which transparency empowers people to make the choices right for them, and health care providers to take on the complex navigation too long borne by our patients.
This path will help improve health, lower costs and increase joy in our work.
Forging this path doesn’t require rancorous public-policy debates, but instead health care looking outside itself to work differently.
The old path
Fee for service is the health system as a pinball machine. The patient bounces around an environment optimized for reacting to short, episodic needs. We are paid for activity, creating economic incentive to do more — more tests, more imaging, more … stuff. It thwarts holistic thinking about a patient, because care is strung together across multiple events focused on sick care vs. prevention, and is driven by the allowable codes that can be used for billing.
Managed care became a fee for service’s alternative. Health care organizations took on the economic risk for the health of the individual and population as a whole. This “system” decides what patients should receive. If care isn’t deemed “medically appropriate,” permission is denied.
Managed care at its best has improved the quality of care and helped decrease the rate of cost increases by managing chronic diseases more effectively and using evidence-based care. However, its population focus can limit individual choice and create administrative barriers to care, such as prior authorization rules, and aggressive contracting approaches that force discounts in return for volume.
Traveling these traditional paths, more people have high-deductible insurance plans. According to eHealthInsurance Services, the average unsubsidized deductible in 2018 for individual plans was $4,578, and the average family plan $8,803.
Many people never reach their deductible, meaning they are paying for nearly 100% of their care.
Fee for service is expensive and doesn’t coordinate care effectively. Managed care takes away patient autonomy, limiting choice. Both paths create an inferior experience.
A new path
We can create a new path in which consumers have immediate, easy access to the information they need to understand their choices and the implications on their health and pocketbooks.
Here are several examples of how we can create a better, convenient, confident patient experience:
• Care providers and insurers must join in new partnerships to get cost and benefit information to patients upfront, so they can make informed choices rather than get surprised later, or worse, bypass care altogether.
• We need to make real costs — not estimated or general costs — transparent and part of the clinical decisionmaking process. Achieving a new level of integration between providers and payers can make this happen, reducing patient frustration.
• We must make it simple for people to navigate health care systems by providing one point of contact online or by phone, putting the onus on us to anticipate, organize and coordinate their care rather than placing the burden on patients.
• Health care must get over its love of buildings. Many things we do can be provided through technology and don’t require someone to come to us. Used smartly, technology can free up health professionals’ time for interaction and hands-on care, which led them to this calling.
• Amazon’s customer experience proves the power of transparency. Just as Amazon seeks buyer input, we must learn from patients how we are doing and respond, so we’re building trusting relationships with patients, and they see how their input is helping shape our improvement.
• We can increasingly offer care to people at home and in workplaces, schools and others places, which will add ease for people and lower care costs for employers.
Health care is largely organized for its own convenience. Instead, today’s health care consumers want the level of access, convenience and transparency they experience elsewhere. If we fail to embrace this shift and don’t change our mind-sets, we do so at our own peril.
James Hereford is president and CEO of Fairview Health Services.
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