REPORTS & SURVEYS | DECEMBER 19TH, 2013
Are Citizens Ready to Wrestle with Tough Choices?
Health care experts may assume that insurance shields most Americans from the actual costs of their care, leaving them unconcerned about cost effectiveness. And, in the past, the public seemed relatively disinterested in talking about efforts to contain cost. This research raises the question: if we help citizens learn about and deliberate over approaches to contain costs, could they contribute to policy solutions?
For "Curbing Health Care Costs," average Americans aged 40 to 65 gathered, in a series of 4 extended focus groups, to address cost containment in health care. When given the opportunity to learn about and deliberate over various policy proposals, focus group participants became not only willing but eager to consider complicated approaches for containing health care costs. And they did so thoughtfully and civilly.
The research, while modest in scope, provides substantial clues for health care leaders and policymakers regarding the approaches that the public may be more willing to accept and those that they may resist. It also provides guidance to enable leaders to better communicate with and engage the public on cost containment approaches.
Participants in the study also believed that other members of the public, as well as medical professionals and insurers could benefit from similar opportunities to deliberate. While participants didn't reach consensus, they all reported a better understanding of viewpoints different from their own. Many remarked that the civility and quality of their deliberations were evidence that health care leaders and policymakers COULD compromise.
Even insured participants were deeply concerned about their personal health care spending and the uneven quality of the care they receive. They frequently identified insurance and pharmaceutical companies as causes of rising costs. But they also blamed doctors and hospitals for greed, inefficiency and over treatment.
Participants were eager to talk about how much national spending has risen. Variations in spending and health outcomes across the country and internationally elicited considerable surprise. But the facts alone were not enough. Participants needed time and discussion to make sense of this information. They raised urgent questions about why costs have increased while Americans’ health has not improved.
Participants supported policies that would encourage providers to work together more effectively. They also saw pros and cons in various approaches to payment reform under which insurers would pay physicians some variation of flat fees—per year or per care episode, for example—rather than for each service performed. They agreed that this could reduce over treatment but raised concerns about whether it would lead physicians to skimp on care.
Participants wanted to see limits on what insurance companies, hospitals, and doctors can charge. At the same time, they were divided over how much the federal government should be involved in health care.
The idea of shifting more costs to individuals was troubling to most participants. While many acknowledged that paying more out of pocket could spur more judicious use of medical services, they were already chafing at the increased personal costs they’ve experienced in recent years. Participants worried that further cost sharing could lead people to avoid getting the care they need. They also noted the reasons that make it so difficult for patients to compare prices and shop around for medical services.
This research highlights the kinds of concerns and attitudes that Americans bring to conversations about the nation’s health care spending crisis, and the places where they may lack enough information to understand its causes and to judge potential solutions. It demonstrates what happens when citizens have the chance to consider and work through information about trends and variations in spending and health outcomes. And it begins to indicate how they may weigh various policy approaches.
State and federal agencies, insurers and employers are figuring out how to implement health care reforms, cost-saving measures and new ways of purchasing insurance. A more nuanced understanding of public perspectives can help them design policies that will work for patients and their families and communicate more clearly about pending change.
For physicians, nurses and other front-line professionals, understanding these public concerns will be crucial to implementing successful change.
If, as this research suggests, members of the public are ready to engage more thoughtfully on the challenge of health care costs, then their perspectives can play a robust role in fostering better practices and policies to control costs and improve quality. This role includes participating in how insurance plans are designed, how medical providers deliver care, and how policies encourage further change. Deliberative engagement in a range of settings could help advance this through local initiatives to improve health services.
For example, employers and unions who must deal with significant insurance and health costs could stand to gain significantly from understanding their employees’ and members’ views, educating them and working with them to use benefits and health care more effectively and efficiently.
Community-based organizations and patient advocacy organizations would also be natural places to bring people together to engage with and deliberate over cost-savings practices and policies, from preventive medicine to better use of emergency rooms to Patient-Centered Medical Homes (PCMHs) and Accountable Care Organizations (ACOs).
Local and state officials in collaboration with community-based organizations could reach out to their constituents – not only to inform them about changes in the health care system, but to give residents opportunities to share their views, deliberate and influence policy decisions.
This work can and should also inform federal lawmakers’ and regulators’ considerations and decisions, especially as the current federal role in the health care system is not well understood and any changes to that role are controversial.
While the scale of this research is small, it provides clues about the policies that Americans will most easily accept and those that are likely to elicit the most resistance.
Coordinated care and electronic medical records held wide appeal. Payment reform was intriguing but raised concerns about whether quality would suffer.
Government price setting was more contentious – and people do not necessarily understand how much the federal government is already involved in health care through Medicare, Medicaid, the military and the FDA.
The suspicions of primary care that we found among our participants mean that Patient-Centered Medical Homes may need to consider how to gain patients’ trust and respect.
Finally, participants were quite dissatisfied with the poor service they so often receive in the health care system. But some policymakers, insurers and employers want patients to act more like savvy shoppers. If they want to achieve that goal, they will have to do a better job of treating patients like valued customers.
The health care system is changing. How will public opinion change along with it? Payment reform is central to many reform efforts. But participants in our research had not encountered payment reform before; some did not seem to be aware that the current system is predominantly fee for service. Many worried about getting the right balance of benefits and trade-offs from payment reform.
Future research should track changing public views on, and experiences with, different approaches to payment reform. And because payment reform is supposed to improve quality, future research should also assess how payment reform changes patients’ experiences of care and views on cost savings.
Benefits are increasingly being designed to give Americans more financial responsibility and choice in health care. But our work suggests that citizens may not be fully ready to embrace these responsibilities. How will increased cost sharing affect when and how people seek care? How can insurance plans, hospitals, clinics and medical professionals engage people in medical decision making that is better for their health and for their wallets?
Finally, research on the perspectives and experiences of newly insured Americans who gain coverage under the ACA will be vital to helping actors across the health system adapt in patient-centered and cost-effective ways.
Public Agenda, in partnership with the Kettering Foundation, used an innovative qualitative methodology called Learning Curve Research with Americans aged 40-64 in 4 cities around the country.
In this exploratory research, participants first engaged in open discussions about their views and experiences with the health care system. Next, the groups were presented with key facts about the nation’s health care spending and listened as they asked questions and worked through what those facts meant.
Participants then engaged in facilitated deliberation, during which they considered and discussed three different approaches to getting health care costs under control. Then in small surveys and one-on-one follow-up interviews, participants reflected on the deliberations and talked about their views.
For a more detailed description about the methodology for this report, click here.
In an effort to inform policy and broaden the dialogue about controlling health-care costs, Public Agenda, in partnership with the Kettering Foundation sought answers to a number of questions.