Another post about healthcare “creepware” from Opaque, Inc.

While reading the Wall Street Journal health blog, I saw this disturbing piece of information:

In a new survey conducted by Mercer, the employee benefits consulting shop, nearly half of the 428 employers polled said they plan to shift more health costs to employees in 2010.

Further, 20% of the companies surveyed said that they planned “to switch to a high-deductible or “consumer-directed” health plan.”

For many of us the term Consumer-Directed Health Plan (CDHP) means very little, if anything at all. But based on what Mercer says, we’d better find out, because the news is not cheery for anyone who plans to use the healthcare system. (That would be you.)

CDHPs plans include three basic components

• a health plan with a high deductible ($3,900 for family coverage, compared to about $680 in current plans);
• an associated tax-advantaged account to pay for medical expenses under the deductible;
• decision-support tools to help enrollees evaluate health care treatment options, providers, and costs.

The tax-advantaged account may be of 3 types:

• a health reimbursement arrangement (HRA)  or
• health savings account (HSA).
• flexible spending account (FSA).

These tax-advantaged accounts are used to pay enrollees’ health care expenses, and unused balances may or may not accrue for future use, potentially giving enrollees an incentive to purchase health care more prudently. CDHPs increased from about 3 million to between about 5 and 6 million. An increasing number of health insurance carriers and employers began offering CDHPs during 2005. The final guidance from the IRS about the deductibility of all or portion of these accounts came in 2007 and started to produce a significant growth in the number of enrollees starting in 2008.
Proponents of CDHPs contend that they can help restrain the growth in health care costs. They maintain that because CDHP enrollees may use account funds rolled over from one year to pay for health care in  subsequent years, enrollees have an incentive to seek lower-cost health care services and to limit their discretionary spending on health care by obtaining care only when necessary. The higher deductibles associated with the HRA-based and HSA-eligible plans typically result in lower health insurance premiums because the enrollee bears a greater share of the initial cost of care.

Critics, however, question whether CDHPs will help restrain the growth in  health care coverage costs, and whether they will do so by changing  consumer behavior or merely by attracting healthier individuals who use fewer health care services. If CDHPs do attract a larger share of healthier individuals, premiums for traditional plans could rise faster than they otherwise would because of a disproportionate share of less-healthy  enrollees with higher health care expenses remaining in those plans.  Critics also worry that employers will use CDHPs to shift the cost of health coverage to employees, either by failing to reduce employee premium contributions or by insufficiently funding their employees’ accounts.

Indeed, the latest data does show that CDHPs are used increasingly by employers to lower their costs, confirming the CDHPs critics point of view.  It is as though everyone agrees that there is no possibility to reform the system and the last item left is to pass on the costs & responsibilities to the employees. The results of this myopic vision, in this period of grave financial difficulties are becoming apparent. As Jane Sarasohn-Kahn wrote a few days ago: “The era of consumer-driven health has often been unhealthy for participants when co-pays and payments out of health reimbursement accounts have motivated enrollees to delay necessary care.”

But what about information seeking? Is the growth of CDHPs enrollees having an impact on information gathering? The 3rd element of CDHPs is, supposedly, the availability of tools.

These tools should allow enrollees to view:

• account details and summary information on physician visits,
• prescription drug purchases,
• treatment costs,
• a drug’s primary use, risk and benefits;
• alternative drugs and therapies / drug comparisons
• over-the-counter options; as well as, a prescription calculator to compare brands versus generics.

CDHPs are also beginning to offer data on a physician’s

• network status,
• verified disciplinary actions,
• malpractice history,
• evidence-based quality measures,
• adverse events and
• patient satisfaction survey data.

Many CDHP portals are supposed to include consumer-focused healthcare databases, online health and drug encyclopedias, e-newsletters, and even tools to evaluate whether an illness or condition necessitates a visit to a healthcare provider. Finally some CDHPs say that they provide online health-risk-assessment tools that provide consumers with a baseline of their health status and suggestions on how to improve their current condition, as well as steps to prevent future diseases for which they may have risk factors.

At face value this all looks wonderful and highly empowering. As always, particularly with any element of the US healthcare system, the devil is in the details. Many issues associated with the web interfaces, ease of use, data sources, completedness, reliability and trustworthiness have made many enrollees less than thrilled with the real offerings. As happens often with Health IT, services seem just great on paper, until you ask the patients to use them!

Until recently the number of enrollees in CDHPs (and their dependents) was small (about 6-7 million compared to 177 million with private health insurance coverage). So no one paid much attention to the potential impact of the growth of this type of health plan. With the deepening impact of the recession on companies and individuals alike this shift will likely force many people to change how and why they look for health information.

In short, if employers coerce many of their employees into CDHPs we can expect a sudden influx of a large number of Americans forced to look for health information, on their own. That can only mean that the ranks of the e-patients are going to swell, not out of choice but because of necessity. If they cannot find the necessary information & advice on the CDHPs portals they will have to use the internet to fill in the void. This expected growth could parallel what I have seen on the ACOR lists in the last year where,  after years of stagnation, the number of subscribers to a number of online communities has been climbing again, sometimes very significantly.

Medical social networks are going to have to fill in a more complex role since patients/caregivers are now, more than ever before, in need of financial advice on many health-related topics. Just like the person who, this week, avoided foreclosure by tapping into both the wisdom and the power of crowds and had the situation transformed in just a few hours. To me, besides being a sign of the times, that is an integral part of what Participatory Medicine has to offer!