Patients need pay for performance too

The ultimate cure to the perversions inherent in U.S. health system economics is cracking the risk code – optimizing the financial risk allocation for any given disease across payer, health system, physician and patient. After years of payer and more recently health system effort, the heat is increasing on doctors and patients.

Despite vigorous effort on wellness and prevention, it’s fair to say the industry has so far missed the mark when it comes to enabling patients to take on more responsibility and risk related to their health care decisions. Payers and providers have an opportunity to make a more direct and immediate financial connection to each patient’s well-being – but must address three proximity challenges: data, money, and time.

  • Quality + cost + stakes = informed patent. Patients today are at a serious disadvantage when it comes to information about providers and services. Searching a payer-sponsored web site for surgeons you may find Dr. Smith gets five stars while Dr. Jones gets three stars. But what does that really tell you? Most likely that Dr. Smith is more cost effective for that payer. Transparency engine solutions may allow price shopping, but how much will you really know about quality comparisons? Most importantly, patients need better to tools to understand the cost vs. quality stakes. While an ingrown toenail pull vs. bypass surgery may be straightforward, most decisions are complex, and patients need meaningful decision support.
  • Connect the financial dots. Overall we need to create closer proximity between out of pocket healthcare expenses and personal decisions. Good intentions of government-sponsored care have shielded Americans from the risks of their lifestyles. Now, payers are tightening their wallets while healthcare is getting more and more expensive. Deductibles and out of pocket expenses are going up, and patients are feeling it more. However, instead of making the connection that improved health might result in less expense, many individuals will instead choose to avoid necessary care until forced to seek it in an emergent and high cost setting – exactly the opposite of what needs to happen. Shifting costs to poor lifestyle choices will never work as long as the emergency room safety net is in place. Instead, a combination of positive and negative reinforcement is needed. Direct financial incentives need to be connected to positive choices – premium savings and cash back for achieving good health milestones. In addition, the extent of safety net services must be scaled more rigorously in accordance with lifestyle decisions.
  • Make the future now. If patients are following through on appointments, wellness programs, screenings, etc., and the financial hurdle on those services is low or non-existent, they may ultimately see the reward of lower personal costs now and down the road. But in reality it takes a long time to demonstrate that. It’s challenging for Americans to think long term about their health because poor decisions and chronic pathology can be separated by decades. We need to build models that show patients the impact of making good health decisions now. High deductible plans still fail to allocate risk appropriately. With the wealth of data we now have on chronic disease, can we not build opt-in health plan models based more on variable rates of coverage for lifestyle decision related disease?

Think of it as pay for performance for patients. With everyone else in health care up in arms over rising costs, it’s time we mobilized patients more effectively for the same reason.

Matt Patterson is Senior Vice President, Business Transformation, AirStrip and a former U.S. Navy physician.

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