"Audiences in the Washington area have been erupting in whoops, whistles and applause when actress Helen Hunt, playing the single mother of a chronically ill child, denounces HMOs with a string of unprintable epithets," the Washington Post recounts in a story in 1998. "Hunt's character quickly apologizes for the outburst, but actor Harold Ramis, playing a physician, assures her that the apology is unwarranted. 'Actually, I think that's their technical name,' he says."
While most people may not remember this movie, "As Good As It Gets," they certainly are familiar with HMOs — and how unpopular they were with the public in the Clinton era, as embodied by this scene. Today, most purchasers and payers who once championed HMOs as the next great answer to health costs and quality are much more cautious about them: Less than 38 percent of employers offer an HMO benefit to their employees, almost always as one among many plan options.
Yet the basic principles behind HMOs remain appealing to employers. They can realign payment systems to incentivize prevention. If a procedure appears unnecessary, they don't pay for it — or they can require clinical evidence that it is indeed necessary. They can pivot services around the needs of the patient and coordinate care.
Employer reliance on HMOs has receded, but the problems HMOs were designed to address have only grown exponentially larger in recent years. Health costs exploded since "As Good As It Gets" debuted, and the persistent problems of fragmented services, inadequate prevention and unnecessary care waste at least a third of all money spent on healthcare, according to the Institute of Medicine (IOM). But consumers hated HMO restrictions on choice and resented interference with the doctor-patient decisio-nmaking, and that doomed HMOs, however good their intentions may have been.
So purchasers moved in a new direction, aiming to uphold the original principles behind HMOs without interfering with patients' choices. Instead of tightly managing the services provided to employees, purchasers would take a hands-off approach and give consumers more information so they could make their own decisions about the right care at the right price. Instead of managed care, we'd have manage-your-own-care. The manage-your-own-care philosophy ultimately led to the accelerated growth of high deductible health plans, now the fastest-growing form of health insurance, in which employees and dependents enjoy a high level of choice of doctor and procedure but pay for much of it out of their own pocket. This gives consumers the incentive to "shop" for the best provider, search out the right prices, and make sure that the procedure and the costs are warranted.
In line with this development is a trend among purchasers to call for price transparency, including a demand for plans and individual providers to publicly report on how much employees must pay for services they seek. I support price transparency, with an important caveat: Price reporting must be interwoven with quality reporting, in all venues, every time. By contrast, price reporting decoupled from quality reporting could inspire the same backlash HMOs did. Here's how:
- Your costs will grow. Anyone who has worked in healthcare knows that the current pricing and chargemaster scheme are nonsensical and are in no way correlated to the quality of care. What that means is you can't predict the quality by the price. But consumers don't understand that, and studies show that given the pricing options, they will select the highest priced provider — assuming that's automatically the highest quality provider. When you only show pricing, without coupling the dollar figures with an easily comprehended indicator of quality, consumers will head toward the highest priced option, especially after they have already satisfied the deductible and it's the purchaser's dime (i.e. during an inpatient stay). If a purchaser or plan tries to restrict choice of hospital, it will be perceived as a cynical effort to cut costs at the expense of patient quality — since the employee does not see for themselves that price is unrelated to quality.
- Your company CEO will appear as the villainous businessman sweating on 60 Minutes. Employees will accuse their companies of choosing "cheaper" providers rather than the "best" providers, without any information on whether the less-expensive options are actually lower in quality. Comparing pricing information with quality information allows employers to make informed choices, and in turn, inform employees, too.
- Your health plan will be treated as evildoer. If your employees continue to shop services by price alone, they will not appreciate any efforts by health plans to restrict choices of hospitals or otherwise make demands on hospitals. Health plans that try to do this on behalf of purchasers or as part of the exchanges will be subject to Helen Hunt-style vitriol for sacrificing quality as soon as the employee exhausts the deductible.
In the new movement away from managed care and toward manage-your-own-care, purchasers and payers are at a crossroads. They must take steps to educate their employees on how to select the best provider, including the weirdness of a market in which price tells you nothing about quality or vice-versa. Only by assuring full transparency of both quality and pricing — always coupled together — will the public learn the strange truth about getting the best care for themselves and their families. Purchasers and payers deserve credit for pushing for higher quality care, so they should insist on giving employees what they need to work toward that same goal. Don't be cast as the villain again.
