In recent years, the idea has spread that forcing consumers to pay more for healthcare — giving them “skin in the game” is the usual mantra — will prompt them to become more discerning medical shoppers.
The goal is to improve the efficiency of the healthcare system by saddling consumers with higher costs if they opt for less useful or more overpriced services. Experts have identified numerous flaws with this concept, as we’ll get to in a bit.
But a new paper by Michael D. Frakes of Duke, Jonathan Gruber of MIT and Anupam Jena of Harvard raises an important and oft-overlooked point: Even if consumers have better information about the efficacy of particular treatments, will they be any good at using that information?
The answer is: probably not.
There really should be 100% consumption of high-value and 0% of low-value care. On those benchmarks, doctors don’t do a whole lot better than non-doctors.
The authors tested the theory behind “consumer-driven healthcare” by examining the behavior of the best-informed consumers of all: doctors. (Their sample of physicians as patients came from the massive Military Health Service.) What they found was that doctors are better at picking high-value treatments and avoiding low-value care — but “not by much and not always.”
The message is that “purely relying on consumer cost-sharing and high deductibles won’t get us to the best outcome,” Gruber says.
The authors’ examples of low-value care included caesarean sections, which are judged by experts to be vastly overused; and pre-operative diagnostic tests for low-risk surgeries, such as chest X-rays prescribed for patients undergoing eye operations. The high-value examples included comprehensive diabetes care, statin use for patients with cardiac risk, and child vaccinations.
The finding is important because it suggests there’s a limit on how much more efficient the healthcare system can become by making consumers better informed. If doctors, the best-informed medical consumers, can’t consistently be steered to the most cost-effective treatments, then obviously average consumers will do much worse.
“If our approach is just to get more information to patients,” Frakes says, “that may not give us a great deal of return.”
This study isn’t the first to cast doubts on the theory that high deductibles and co-pays alone will lead consumers to make better and more cost-effective choices on healthcare. In 2015, a team from UC Berkeley and Harvard examined what happened when a large company shifted from an all-expenses-paid health plan to a high-deductible plan in a single year.
They found that total medical spending fell by as much as 13.8%, but that consumers cut spending on “potentially valuable care” such as preventive services as well as potentially wasteful care, such as X-rays and scans. They found “no evidence of consumers learning to price shop after two years in high-deductible coverage.” That confirmed a 1993 study by the Rand Corp. that also found that consumers reduced spending on good treatments and bad alike.
The latest study found that physician families did reduce their rate of C-sections, but only modestly and not enough to bring the rate into line with what medical experts say is proper. (Medical professionals say the rate, which is about 30%, should be only 10% to 15%.) Physician patients received unnecessary pre-surgical diagnostic tests nearly 20% of the time, less than non-physicians but still much too often.
As for high-value care, physician patients failed to receive comprehensive diabetes care 30% of the time. There was virtually no difference between doctors and laypersons in receiving post-cardiac care, or in vaccinations for diptheria/tetanus/pertussis and hepatitis. There were “small improvements” in compliance for child vaccinations for chicken pox, polio and measles/mumps/rubella.
The findings don’t show that there’s no place for deductibles and co-pays in the U.S. healthcare system. “There’s no step forward in healthcare that doesn’t have pros and cons,” Gruber says. “Absent any consumer cost-sharing, healthcare will be overused; the potential con is that people will forgo both more valuable and less valuable care.”
That points to a more nuanced system of deductibles and charges, he says. Often this is termed “value-based healthcare,” in which flexible cost-sharing steers consumers to more effective care. That means lower co-pays for generic drugs, higher charges for unnecessary tests or higher-cost treatments not shown to have better results than lower-cost alternatives.
“The right answer for our system is not to tell patients they can’t have service X,” Gruber says, “but to say service X isn’t cost-effective — if you want it you have to pay for it. That’s controversial and hard, but the lesson from this paper is that we should bring expert analysis into cost sharing, rather than relying on consumers to figure it out.”