HWANG, Garrett, and Miller tee up one of the most important questions in health policy: what is the proper role of the consumer and patient in health care delivery? Some might ask why this is a pressing question-after all, we don't devote a similar amount of academic journal space to consumers' role in vehicle purchases or airline travel. The answer lies in the fact that health care is a significant sector of the economy with profound impacts on a family's physical and financial health-and by everyone's account, it is a market that doesn't function well. Hence, there are many ideas about how to make this market work better, often centering on the roles of providers, payers, and the patients themselves.
Hwang and colleagues do a tidy job of teeing up the competing visions for the consumer's role. On the one hand, there is an emphasis on patient engagement and patient-centered care, for example, provider incentives to engage in shared decision making or creating a role for patients at programmatic and policymaking tables. An alternative approach is increasing the responsibility of consumers at the point of shopping-aka more financial "skin in the game."
Close examination suggests these are not two sides of the same coin. The first consumer engagement approach is supported by solid evidence about the connection between patient engagement and patient satisfaction and improved health outcomes. In contrast, the latter approach-high-deductible health plans and new premium and cost-sharing requirements for very low-income families-lacks any evidence that these approaches lead to patient satisfaction or improved health outcomes (Quincy, 2016). As Hwang and colleagues note, enrollment in high-deductible health plans may reduce overall spending in the short-term but this includes reductions in both high-value and low-value services. Moreover, studies show that "skin in the game" does not result in informed patient shopping that drives value in the marketplace. Numerous researchers have concluded that patients do not treat health care as a commodity where only the price point matters (Melecki, 2014). Nonetheless, many continue to strongly advocate for this approach.
Hwang and colleagues suggest a path forward out of this morass, but I would state their case even more forcefully. Consumers, researchers, and policy makers must issue a joint call for health care policy decisions to be (1) strongly grounded in the robust evidence base about how various policy levers affect consumer and provider behavior and (2) directly tied the desired policy outcome. In health care, personal financial responsibility is not the end goal. When evidence warrants, consumer financial incentives may be a means to more important goals such as increasing the use of high-value services to achieve better health outcomes. And herein lies the path forward: various segments of health spending require different approaches. Our policy makers cannot use blunt, one-size-fits-all approaches. Some examples are as follows:
The bottom line: we must rely on our evidence base to identify and use the right lever for a given type of health spending. And as Hwang and colleagues point out, consumer and provider incentives must be aligned with the desired goal (eg, excellent health outcomes at a fair price), not at odds with each other.
High-deductible health plans are a blunt tool that does not improve outcomes, nor increase patient satisfaction or the use of high-value services. Health Savings Accounts are similarly blunt, with the added harm of the tax advantages being regressive-the largest benefit flows to the highest-income families. To impose new or higher premiums and copays on families that cannot afford them amplifies
this regressivity. In the absence of evidence that this leads to wiser health spending overall, these policies have no place in a world of consumer-oriented, evidence-based policy making.
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