Let's look at all the things carriers and employers have done over the last 40 years to try to curb the increase in both health care costs and utilization. They include (but are not limited to):

1) The creation of networks

2) Implementing deductibles

3) Various forms and severity of medical management

4) Wellness programs

And when those didn't work, the carriers and employers (and their consultants) had the following bright ideas:

1) Narrower networks

2) Higher deductibles

3) Increased medical management and intervention

4) More wellness

And these continue to be the same strategies implemented today, some at an even more rapid pace.

Einstein once said "We cannot solve our problems with the same thinking we used when we created them.” Nowhere is this more true than in health care and health insurance.

So if what we have done isn't working, wouldn't it hold true that we must either do something different? I propose that all of these strategies were put in place with (mostly) good intentions, but a very important step was missed that would make all these strategies more effective.

We often talk about "consumerism" and "consumer driven health plans," but the only thing the consumer is driving is continued cost and volume increases. Before any of these can ideas change behavior, I believe there needs to be a fundamental shift in how we think about health care and health insurance.

First, we need to understand that those two terms describe very separate and distinct things. The first is how we consume and interact with the health care system; the second is simply how we pay for it. And we think about the latter completely different than we do any other kind of insurance.

Allow me to provide a few examples. Have you ever been in a small fender bender where you were at fault? Let's say you have $1,000 worth of damage and your deductible is $500. Would you ever consider just paying the full repair instead of making a claim on your auto insurance for fear of your rates going up or the carrier possibly dropping you? Most would at least consider the option. But how many of you have ever said, "It's just a cardiologist appointment. I'll pay the $250 instead of making a claim because I don't want my health insurance company knowing I may have heart disease"?

Another example is when we have employees from our employer partners call our office to complain. After happily paying a $10-$15 copay for a generic drug, one day they realize it has been on the Walmart $4 list all along and, had they paid cash, they would have paid less. Yes, they get mad at their insurance company, because the pharmacy charges more when using insurance. Where else do we get mad at someone paying the bill for us because the vendor charged us more, simply because they know someone else is footing the bill?

In the same line of thinking, patients also direct frustration at the insurance company when their prescription copay goes up, failing to realize that this is usually in response to what is often a doubling or even tripling of the drug price by the manufacturer and, in most cases, the insurance is picking up a larger percentage of the cost even at the higher copay.

The American patient wants to do whatever their doctor suggests, and feels that cost (and quality) shouldn’t be an obstacle or consideration. And I wish it weren’t. But now that we have the most expensive health care system in the world, and one that is ranked last among industrialized nations (and some third world nations too), isn’t it time we considered this?

The strategies listed above have had other negative impacts, as well. The leading cause of bankruptcy in the U.S. is medical bills, and nearly two-thirds of those filing for bankruptcy had health insurance. If insurance doesn’t protect us from bankruptcy, what good is it? It is still necessary because without it, we would never get treatment for many conditions like cancer, or heart disease (a heart attack, yes, but not ongoing treatment and care). Further, the deterioration of benefits has led many covered Americans to delay care, thereby increasing the likelihood of major diagnostics or procedures being required.

The most common reaction to the rising costs (both premiums and out of pockets) or the worsening of benefits, or the increase in the insurance company meddling with the care we receive, is to get angry at the insurance company, or in some cases, our employer. But rarely do we ever look to the health care system, and even less frequently, to ourselves.

I think a major shift in thinking has to occur before we can get to the root of the problem. And if we don’t do it soon, the government will have no choice but to step in in a way that makes Obamacare look like child’s play. I believe our current system is the right one. I believe in the employer-employee relationship for health insurance. I think this type of market provides for the greatest opportunity for advancement, innovation, quality and efficiency. So why are none of these things occurring now? Simple: The consumer (in this case, the patient) is not making demands before allowing any money to be spent (either by them or their health insurance company). Conventional wisdom was that the creation of networks would reward the providers that met these metrics, but here is the problem with that thinking: The patient did not stop using those providers, and if their carrier didn’t have the provider they wanted in the plan, they would switch to another carrier that did. And if the carrier tried to drop the provider after members were enrolled, the members yelled and screamed at the carrier and threatened to switch.

Please do not take my message as a defense of the insurance companies. Our health insurance system is also of relatively low quality and very high cost, which is simply reflective of what it is paying for. My theory is that the health insurance we all deal with is a result of the problem, not the cause of the problem. I propose we need to fix the health care system first, then we can fix the health insurance system. Most of what the government, the employers and the country has done has been the opposite.

Let’s start a revolution. Let’s put even half of the effort into determining total cost and quality of a hospital, surgery, or MRI that we put into buying a new refrigerator, or finding a new restaurant on Yelp. Admittedly, doing this in the current environment isn’t easy. And it won’t be until the information required to do so becomes more readily accessible; but that information will not become more readily accessible until we demand it, and refuse to have money spent at providers that do not share that info. But once we demand and reward providers for not only sharing it, but excelling at raising quality and lowering costs, this can have a profound impact on our healthcare system. A recent article by Leah Binder, CEO of Leapfrog Group, that publishes data for free on quality of hospitals, highlighted a hospital in Seattle that’s already doing this. And the data shows that this hospital excels in both quality and efficiency.

I know that when a health event occurs, we are vulnerable, and susceptible. And when this happens, we have the most on the line, both financially and physically. I say it’s time we take responsibility for that and make better, more informed choices before the ability, and the benefits of doing so, are completely removed from us.

Instant Insights /

Health insurance is a result of the problem, not the cause

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