By Brandon C. Maughan
U.S. health-care spending has never grown as slowly as it did last year.
Dwight D. Eisenhower was in the Oval Office when the U.S. government began recording health-care spending in 1960. Since that time, growth in health-care spending has never been lower than the 3.6 percent annual rate reported by researchers from the Centers for Medicare and Medicaid Services last week in the journal Health Affairs.
High-deductible health plans (HDHPs) are believed to be one reason for the slowdown in spending. The 2014 minimum deductible for an individual in an HDHP is $1,250. Since 2008, enrollment in the plans has nearly tripled, from 6 million to 17.4 million, and the average deductible for individuals with any type of employer-sponsored insurance has grown from $735 to $1,217. These plans are designed in part to give patients "skin in the game" and to discourage use of unnecessary services. Research from RAND Health shows that families with HDHPs spend 14 percent less on health care than families in traditional plans.
But spending less overall has also meant lower use of valuable services. We want to discourage use of low-value services (like MRI tests for most types of back pain), but if our approach to doing that also reduces high-value treatments like childhood vaccinations, then we have thrown the baby out with the bathwater.
The question becomes, how we can empower patients to value high-value care. Let me give an example from my experience.
A 44-year-old woman with hypertension, diabetes, and now, chest pain arrived in my emergency department. She described a few days of intermittent pressure in her left chest. Her initial evaluation revealed no indication for an emergency procedure, but I recommended observation overnight for continued evaluation. Despite the good news, the woman looked at me with apprehension. Money was tight, and her expenses would be paid out of pocket since her family had a high-deductible plan. If she truly needed care, she would find a way to pay for it, but these expenses would make it difficult to pay rent, purchase medications, or care for her children.
"I haven't met my deductible," she said. "How much will this cost?"
Her question seemed simple. What would she be charged for a night of observation and, possibly, a stress test? But that information isn't simple to get. Moreover, her real question - whether the recommended care was worth the price - is far more complicated. Without information on costs, risks, benefits, and alternatives, how could anyone be expected to make a reasonable decision?
Having "skin in the game" is meant to make patients more sensitive to cost. But for the 17 million Americans with high-deductible plans, having skin in the game means being faced with a set of information needs we've never faced before.
Financial incentives alone do not help patients choose care wisely; patients must also have easy-to-understand information on prices. Price data historically were difficult to obtain, but more than 30 states are pursuing legislation to enhance price transparency in health care.
However, even with price information available, patient financial obligations remain a complex mix of allowable charges, deductibles that may or may not have been met, and different out-of-pocket maxima. Determining the value of that care compared with alternatives is harder still, but everyone agrees we should try. No one thinks we should keep patients in the dark about what their care will cost or what value that care will provide.
Health policymakers face the same questions as patients, just on a population-based scale. They too want to know the cost and value of health-care programs. One approach is to measure benefits in terms of quality-adjusted life years (QALYs), units that are meant to reflect both years of life and how good they are. Comparing treatments by cost per QALY is a way to measure whether you, or someone else who is paying, is getting a worthwhile buy. The Affordable Care Act established the Patient-Centered Research Outcomes Institute (PCORI) to help patients make informed health-care decisions, but it also prohibited PCORI from using QALYs to measure cost-effectiveness or guide care recommendations.
The intense push to help individual patients understand health-care value is a stark contrast with similarly intense efforts to prevent policymakers from doing the same thing. We want patients to choose wisely, and to do so they must have information, but it is as if we don't trust ourselves enough to give patients that information or even to gain it ourselves.
Cost matters, and legislated prohibitions on considering cost are self-defeating. If we want our nation to spend health-care dollars wisely, and if we want individual Americans to avoid wasteful procedures, we must make cost, quality, and value transparent - not just to patients, but also to the people who can guide them. Unlike the woman I saw in the emergency department, who faced stress, illness, emotion, and a simple lack of facts, health-policy researchers have methods for measuring and comparing the value of different treatment options. These tools are imperfect, but they can be disciplined and rigorous in a way that avoids the uncertainty, stress, and information deficits faced by patients.
Questions on how to prioritize our health-care spending arise at the national level, at the level of physicians and health systems, and at the level of patients. Only by reducing use of low-value services will our patients - and our nation - have the resources to devote to other priorities, whether those are in health care or elsewhere. It will be hard to improve value if we won't let ourselves measure it.