Wanted, an informed health care consumer-300 million openings

One of the basic assumptions about health care costs for many economists is that if you force the patient to pay more they will use less.  That is the logic behind the so-called Cadillac excise tax on high cost health plans.,  In other words, if you tax these excessively generous benefits, employers will trim the benefits by raising deductibles and co-payments thereby shifting more costs to employees who in turn will become more prudent and efficient buyers of health care thus lowering health care costs.  

This is not a new idea of course, the high deductible health plan with a Health Savings Account was supposed to do the same thing but with the added incentive of being able to roll unused money from year to year for future expenses.  That idea never caught on and where employees were given that option which in the process lowered their payroll deductions, enrollment was modest.  

The great majority of private employers do not have plans that will hit the limits for the high cost plan (and many who do is a result of being in a high cost area not necessarily because of generous benefits), at least not before future inflation takes its toll, and yet the more typical plan still suffers from high costs and high cost growth rates each year.  Employees already pay on average 25% or more of the premiums among even large employers, more for smaller employers.  Especially in the self-insured plans of large employers where costs are determined solely based on the benefits used by that group of workers and dependents you would think there would be a strong incentive to use health care efficiently, apparently that is not so. 

The problem with forcing less use of health care by increasing its cost to workers is that the first people to be affected are the lowest income people.  I can afford a $2,000 deductible, my administrative assistant cannot. 

In addition, while in one way we see higher out of pocket costs as the answer, at the same time pending reform legislation seeks to lower out of pocket costs via the essential benefits package and improvements in Medicare benefits. 

So which is it, define a benefits package with prudent cost sharing until it makes people think twice about going to the doctor or accepting the suggestion for a second MRI or promote the use of co-pays instead of coinsurance and add an array of services (largely things that should not even be insurable) with 100% reimbursement that sends a message that cost sharing is bad?  

To agree with the idea that cost sharing affects medical care use I believe you have to accept the idea that buying health care is no different than buying a new television, which is objective and price driven with an end goal of pleasure in some manner.  Is that how people view the next office visit or surgery?  My years of working with thousands of people and their health benefits tells me no, it is not.  Health care is emotional, scary and certainly not pleasure driven. While some people may think twice about the initial office visit if it comes from their pocket, once in the health care system cost decisions are extremely difficult and even more so when the patient is a loved one, especially a child.  

In my view the long term answer is not driving the patient to make cost benefit decisions, but rather a delivery system that makes those decisions automatically, invisibly through a well coordinated care approach and reimbursement driven not by fee-for service or volume, or interlocking health care system investments. 

You know, kind of like a well run staff model HMO… the concept we killed a few years back because patients wanted more freedom to seek out the best care and, of course, we all know that HMOs skimped on care just to save money…you mean like what we now want individuals to do?

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