She discusses the regulatory changes that are contributing to a changing marketplace that positions employees and health care consumers and offers hot tips for employers on how to best help their employees manage their health care. Oldenburg also talks about which health and wellness approaches work best and which may not be as successful for employers.
Jan has focused on digital transformation in healthcare for more than 20 years. Her experience includes senior roles in several advisory firms as well as digital health leadership roles at Aetna, Kaiser Permanente, and HealthPartners. She’s the former co-chair of the HIMSS Connected Health Committee and a board member of the Society for Participatory Management. She is also a member of the Patient Advocacy & Ethics Group for the Datavant COVID-19 Research Database.
This is the second episode in our series about the consumerization of health care with Jan Oldenberg of Participatory Health Consulting. In this episode, we’ll hear Jan discuss the regulatory changes that are contributing to the changing health care marketplace. She’ll also share hot tips for employers on how to help employees manage their health care. And she’ll share what typically doesn’t work in a consumer economy. So let’s take a listen.
Overall, all of this is based on the premise that health care is what I would call, again, in quotation marks, a “normal market.” Because if it were a normal market, then price would actually respond to shopper demand. And we can argue that while it doesn’t respond, because not enough people are doing cost comparisons or cost estimations. But the fact is that there’s so many complexities in how organizations set their prices and how they negotiate them with a wide variety of payers, that it actually is really hard for consumers checking costs to make a difference or that difference be apparent in changing the price.
You’d also think that cost would correlate to quality. You know, in pretty much every other consumer purchase, when you pay more for the service, you can be assured that you’re getting the higher quality of some sort. You know, I might buy a Coach bag because I feel good about the quality associated with that brand. But in health care, unlike pretty much other places, cost doesn’t really directly correlate. You might get the best service from the lowest-cost provider. But we really haven’t taught people how to think about that, how to make that judgment, how do we evaluate the quality of the service that they’re getting? And you’d also get an estimate for every service.
I mean, think about if you go out to a restaurant to eat. I know that’s a long foreign experience, but let’s imagine what it used to be like. You had a menu and it had prices associated with and for the few things that said market price, you could ask your server and they’d give you the date. Today’s price in health care, it’s sort of like you go to the restaurant and you buy the meal and you don’t get the bill until maybe three months later. And at that point, the pleasure of the meal and what you had and how high the quality was is sort of disappears for you.
Same thing is true if you think about getting an estimate on a car repair, which is perhaps a little closer, you get an estimate upfront. And if that estimate changes in the course of the service, you could ask about it and you can make a decision about how far you want to go. So think we’d also see true comparative pricing much more readily available and much clearer associated with the type of insurance and your deductible, et cetera.
And you’d be in a normal market much clearer if you use an intermediary like, say, a broker to help you buy a house. You know what? You’re paying for those services and how they affect the total price. And perhaps most of all, you know, yes, it matters to us to trust people we’re buying things from. But I think that’s kind of amplified in health care in terms of the relationship with your doctor and the importance of trusting somebody with your life and your care, that is sort of takes you in a different director direction than being hard-nosed about the cost.
Who’s Accountable for the Ills of the System?
And perhaps most importantly, asking individual consumers to control costs makes individuals accountable for the ills of the system as a whole. Lots of things are misaligned in the health care system that are not corrected when people ask for cost. So we’ve got to look at systemic change rather than only consumer behavior change.
And Joyce, thank you for asking some questions. She’s asked, “How we can raise their competency in doing cost comparisons?” And I think there are a couple of things. Certainly, if we’ve got cost comparison tools, we can promote them. We can make sure that we’re talking about them as employers. We can show training sessions, we can model the behavior. But we also need to demand that those cost transparency tools actually are easy to use, to cover a variety of services are easy to find comparable services. So you really know that you’re doing an apples-to-apples comparison.
Quality of Care
And she also asks this really tricky question that I raise about what tools are available to help consumers evaluate the care that they receive since it doesn’t correlate with quality. And this is a I think, a multidimensional problem.
One aspect of it is, is that it’s a place where I’d say both employers, to some extent, and health plans, to another, try to sort of act in the role of the adults in the room. Sort of like the way that your college acted as if they were your parents in setting rules in the dorms. And so they’re trying to implement programs that control costs that get you, and we’ll talk about this a fair amount more, get you to a lower-cost program or get you to a provider that mixes high quality and low cost. But because there’s not a lot of trust between providers and health plans and maybe to a degree, to their employers on this topic, they tend to see that not as a service that’s helping them find that right mix of cost and quality, but just an effort to provide them with lower-cost care.
So if we’re going to gain their trust in some of those mechanisms, I think we’ve got to open the kimono. We’ve got to be more transparent about what are the things we look at that determine quality. Why did we suggest this provider over that provider? What is it about quality that they should be looking at? And so it’s really an education process we could treat and consumers still. I think that you go to the doctor, you don’t ask questions, you don’t challenge the results.
And as a consequence, it’s hard behavior to learn and to take up when you’re an adult. So all of those factors, I think, have an impact. But I’m a big fan of the more transparent we are about what goes into those decisions, about what does constitute quality, the more likely we’re going to bring them along with us and increase their trust in the market.
Consumer Expectations Have Changed
So all of this is happening around health care costs in an environment where consumers’ expectations are changing about all of the kinds of services that they purchase. And they expect health care to work a lot more like the other consumer goods and services that they deal with than they currently do.
So when people find out what I do, I can’t tell you, and this was back, of course, when I was actually having real conversations with new people. But how often I get questions like, “Well, if I can do X, if I can see all my banking information in one place, why can’t I see all my health care records in one place? If I can get my dog’s whole veterinary record, why can’t I get my whole health record? If I can schedule my hairdresser appointment online, why can’t I schedule my provider appointments online?”
And you think of it, think of the ways in which our expectations have changed over that same ten years of the graph I showed you earlier about all of the goods and services we work with and people are expecting health care to work like those they expect it to be convenient.They expect it to be connected and interconnected. Expect it to be personal and engaging. And they expect it to be effective. And those expectations color their judgment of the quality of the care that they get and their expectations about how convenient and digital the services that they receive should be.
Democratization of Information Impacts Expectations
And that, along with all of these digital tools in other aspects of their lives, we’ve seen a democratization of information. And that, too, affects expectations. So everybody’s a creator. You’re not just watching a performance, theatrical…sports…and waiting for the next day to read the pundits evaluation of it. People are providing commentary in the moment.
And Twitter and other social media tools are getting interactions. They’re getting likes. They’re relying on expertise a little bit less because they can get access to a lot of that information. It’s not protected in silos. In the same way, experts aren’t the only source of information. You can also potentially read the journal article or do a lot of research on your own. You can get evaluations from your peers. And while there are potential problems with that, I think we’ve seen some of those play out both in vaccination hesitancy, and certainly in our politics, there are also some benefits to it. And we need to figure out how to provide trusted information that gives people access to this, just, deep stuff and then help them understand whether they’ve interpreted it correctly and not.
What Does Health Care Consumer Partnership & Participation Look Like?
And so as they enter into this world, they’re expecting, in their health care endeavors, more partnership and more participation than they’ve had in the past. And this has an impact on the strategies that are effective for them in working with health care.
And as I talk about what partnership and participation look like, I have to say I am on the board of the Society for Participatory Medicine. I do have a book out that’s entitled Participatory Health Care. You can tell this is an area that I am a champion of. And that’s where I think it really does matter to consumers health, that we help them understand what it means to participate in their own health and give them the tools to do so. And frankly, train providers to understand what that care looks like and provide that kind of care.
So it means a lot more shared decision-making. It’s not, “I recommend you do X,” but, “Let’s explore what your options are and what the benefits and detriments are of each of them.” And there are certainly curriculums around shared decision-making and training for doctors. But maybe we need to think about developing those kinds of training tools for consumers as well, or for our employees.
Health Care Consumer Goals, Wishes, Lifestyle Choices
Patient goals, wishes, and lifestyle choices are respected. I’m on an HL7 committee that’s looking at advanced directives and, you know, one of the problems with advanced directives is that there’s a huge issue with getting, even if you do have one as a consumer and expressed your wishes, making sure that that’s actually available at the point of care when critical decisions are being made. And until we solve some of those problems behind the scenes, that are indeed systemic problems, we’re going to have a hard time really listening to and understanding what people’s goals are for their care.
Coaching and Education
In addition, they’re looking for more coaching and education rather than having an authority figure to tell them what to do. And again, this changes over time. It changes based on age. It changes based on severity of illness.
I remember interviewing a woman who was somebody I really admire in terms of her decisiveness and her taking charge of almost any situation. And I interviewed her about an experience she had with, again, grandma syndrome, where if you don’t know about this, it’s a situation where you get paralyzed. And she’d been diagnosed at a doctor’s office and he said, you know, I’d advise you to go to the hospital right now because you’re going to end up there anyway. But he didn’t insist. And she was like, “Well, of course, I need to take make arrangements for my children. I need to take care of a variety of things.”
But by the time she got home, she couldn’t even lift her two-year-old, she couldn’t climb the stairs, and she realized and I realized interviewing her that it was a moment where she needed the doctor to be sensitive. He had information she did not about what the course of that illness was. And she needed to be further educated about what kinds of choices might make sense.
So, in that moment, she needed a more decisive provider than she would at almost any other point in our lives. And that’s a sensitivity skill that, again, we can train people, we can train people, physicians, and motivational interviewing. We can train their staff to recognize some of these things so that we can respond to people where they are in the moment.
Digital Tools Are Expected
And people expect digital tools, access to digital tools, being able to do things outside of normal business hours. And, actually, they’re beginning to vote with their feet for the kind of care they want. And that includes digital care. Accenture has been studying the digital health market for at least since 2008 with serving a set of consumers every year and in 2020. Well, there wasn’t it was not all good news by any means, and it was their 2019 survey that was published in 2020. So this wasn’t affected by the pandemic yet, but they found that for the first time, 25% of people said that they would change providers for a better digital experience. 50 percent said a negative digital experience with their provider affected their whole perception of the care received, and 40% said a positive digital interaction had a positive halo effect in all of their care.
Care and Treatment is a Collaboration
So we’re starting to see these behaviors emerging in terms of really having those expectations about convenience and frictionless care and participation affect the choices of providers that people make. And when we think about the cost control strategies that we talked about earlier and that are the ones that as employers we’ve tended to use to reduce costs, many of them are focused on controlling consumer behaviors more than educating and partnering with them.
Cost Control Strategies
So narrow network strategies reduce the choices of how many providers that you can see. But they may also break long-established physician-patient relationships, and the trust that’s part of that with some negative impacts.
Pre-authorization requirements, again, intended to reduce the cost of care or make sure that care is really necessary. But it adds a lot of friction to the process, and it uses providers’ time, expensive time, and not necessarily in productive ways.
We’ve talked about high deductible plans and some of those perverse incentives that they introduce. And this whole idea that trust is lacking in their cost control measures are really aimed at getting the person the best and most effective care rather than just the least cost care.
Strategies That Match Expectations
So these strategies need updating for a consumer economy. Think less about these high-control procedures. Think less about policies that limit your access to information in your decision-making. Think about introducing fewer things and approaches that don’t respect my choice as an individual for the kind of care I want to receive.
And let’s think about taking other kinds of market action to affect the broader health care market, rather than asking consumers to make choices that don’t really have as big of an effect as we would hope. So strategies that match these experiences are much more likely to work. So more access to data and digital tools for me to understand my own health. I’m a firm believer that having access to my own data is a foundation point in my ability to really participate in my own care.
Employer and Employee Collaboration
Let’s focus on changing things together, bringing your employees into the decisions that you’re making about the kinds of plans that you offer, the kinds of networks you offer, work with them in partnership in these changes. Think about shared decision-making, not only in how you build the benefits that you’re looking for, but also in what you ask for, in the providers that you’re contracting with, or that your health plan is contracting with on your behalf.
And think about how to make all of these things integrated in a way that makes it seamless, easy for employees to do so, and in a way that actually gives them the tools to match the behaviors that we hope they’ll engage in. And I will also say, and I’ll say this a couple of different times in the next couple of slides, there’s something very powerful in employer leaders talking about their own experiences and what they encountered and how they dealt with it.
I remember when I worked for Aetna, Mark Bertolini, who was the CEO at that time, talked about the experience he’d had with having to change much of his behavior around his health. I think it was a closed head injury he received and the way he used yoga and other strategies even in the office, to calm himself down and reduce his blood pressure. And that was very powerful as an employee in that setting. So you can have an impact.
New Regulations Increase Access to Price Information
I’m also going to talk briefly about, there are new regulations that are going to help you. So the ONC, over the last couple of years put ou,t actually most recently, some regulations that will affect price information. Now, they’ve been put on hold by the Biden administration while they evaluate them, but I do expect them to move forward.
One set was for providers, was supposed to take effect this past January. That said they had to provide both a consumer readable tool and a machine-readable tool that explained their prices for a market basket of services.
And in 2022 and 2023, payers are going to be subject to some of the same things in terms of publishing their discounted rates and the information that they actually pay, in and out of network, and for prescriptions. And all these things not just make it easier for consumers directly to do it, but for third parties to get access to this information, to provide better tools.
New Regulations Increase Access to Health Records
Similarly, we’re seeing some of the same kinds of things take effect for access to health data for consumers. So these rules have been delayed slightly due to the impact of COVID. But in April of 2021, this coming April, providers are required to provide API access to consumers and any tool of their choice to their full health record. And that’s everything from the provider notes to all aspects of their records.
Similarly, taking place in July, health plans are responsible for providing the same information about claims or the same kinds of information. So again, this is going to provide more tools for third parties to provide access to the requisite information and to be able to give tools that make it easier for consumers to make these choices and for you to support them in making these choices.
Employers Can Accelerate Change
But you can help accelerate that change. You can hold your provider organizations to account for how they are responding to these kinds of mandates. You can look for third-party apps and tools that provide these capabilities, and you can educate your consumers, your employees, about why it matters that they use them, why they should get access to their health record, why it matters to look at the costs and how they think about that intersection that still matters about cost and quality, and then why you’re making some of the recommendations that you’re making.
These are the components of owning your own health that I think we really need to re-educate people about. If I had my way, we would teach this in schools from kindergarten on. But since we’re not and there’s a workforce element of making these changes, and making them available.
Other Ways to Drive Change
There are other levers of changes that you can use as employers. You can think about these cost control tools that you might have been accepting and you can push for approaches that are more transparent, that give employees more access to the thinking behind those tools and that provide them with better decision making support than not.
And that may not just be digital tools. That also may be concierge services that help walk them through the options and the path that they have. And again, you can tell your own health story about how you work with these things and how you use them.
Change is Coming
So some key takeaways. Change is coming. It’s already here actually in many respects. And you can help drive, you can make a difference in your community for your employees.
You can band with other employers to have better impact. And there are a lot of opportunities to do this in terms of looking at local markets, thinking about employer purchasing coalitions. Thinking about the way that you can help integrate the care that your employees are receiving by the marketplace, pressure that you can bring, and then model the behaviors that you want to see in your employees as a leadership team.
And that’s partly what it means to be an informed and activated consumer. It’s telling stories about how you navigate difficult health issues yourself and what kinds of participation in decisions you expect. So I talked to provider groups all the time, and I tell organizations that it’s hard for providers and nurses to model the behavior of being engaging and participatory with their patients if they’re not being engaged and living in an environment where their opinions on how the environment is run are respected. And the same thing can be true in employer settings.
So you may want to think about those changes in the consumer market and think about how it might need to be reflected in your management styles, in some of your policies and your rules.
How Employers Can Help
Very good. Well to wrap up Jan, I’ve got a really good question for you, and I think the timing of this is perfect. What’s the best place to start or the single most important thing I can do?
First of all, if you’re not already follow these behaviors around your own health, because actually it’s really hard to advise people to do something that you’re not already doing yourself. So make sure you understand what’s happening with the providers that you’ve recommended to them, with the health plan that you’ve established for them, with the tools that you’ve established. Be an active, informed consumer of health yourself and then talk about that. Talk about it as a part of your leadership in the organization because it models of behavior that I think it’s really important for people to see and they will start behaving in those ways as well.
That wraps up this episode of For Your Benefits. We’d like to thank Jan for great insight. And we hope that you’re able to take some key takeaways home with you. As always, if you’d like to learn more about SentryHealth. Visit our Web site at www.sentryhealth.com. And don’t forget, if you like what you heard today and you want to hear more. Don’t forget to subscribe to our podcast. Thanks for joining us.
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