Personal Responsibility

Consumers’ personal choices and behaviors are significant determinants of their overall health, and those who fail to take personal responsibility for their health can cost the system billions of dollars each year. For example, a 2010 study from the UnitedHealth Center for Reform and Modernization found that more than 50% of Americans could have diabetes or pre-diabetes by 2020, carrying a cost of $3.35 trillion over the next decade. According to the Centers for Disease Control and Prevention, smokers cost the community more than $193 billion annually in lost productivity and healthcare costs. 

William M. Jennings, president and chief executive officer of Bridgeport Hospital in Connecticut and executive vice president of Yale New Haven Health System, says that while much of the debate surrounding the Patient Protection and Affordable Care Act (PPACA) has focused on the insurance exchanges or Medicaid eligibility, many healthcare stakeholders are bypassing a greater conversation that needs to take place about personal responsibility.

“It’s irresponsible for us to continue to focus on costs, to continue to focus on access, when no individuals are being held responsible for their poor decisions or their lifestyle choices that affect the cost long-run,” Jennings says.

It’s a broad issue most noticeable in individuals’ upcoming responsibility to obtain coverage under PPACA, responsibility to spend wisely, and responsibility to take preventive measures on behalf of their own health and quality of life. Healthcare stakeholders know the behaviors patients should adopt to achieve the optimum health outcomes and reduce costs. However, without the patient’s buy-in, even the best evidence-based methods can go nowhere.

SIGNING UP FOR COVERAGE

Under PPACA, the individual mandate requires most legal residents to either obtain health insurance coverage by 2014 or pay a penalty tax. Despite the regulation, healthcare experts say participation in the healthcare system still isn’t guaranteed. 

Robert Zirkelbach, spokesman and vice president of strategic communications for America’s Health Insurance Plans (AHIP), says there are several provisions of the law-including the new health insurer assessment tax, costly benefit requirements and age rating restrictions-that could increase the cost of coverage for consumers and employers. The potential cost increase could prompt many younger, healthier people to forgo coverage, he says.

It creates a premium death spiral.

“If you don’t get proper participation in the system, particularly among young and healthy people, costs are going to go up for everybody else,” he says. “If the only people who sign up are those who are older and have very high healthcare costs, then coverage will be unaffordable for many people. And that incentivizes more people to drop their coverage, and costs go up even more.” 

He says consumers’ ability to pay for coverage will be the biggest determinant to whether or not they will ultimately sign up for coverage. In an attempt to better align coverage policies, Zirkelbach says, AHIP is talking to states and legislators about adopting incentives that would drive consumers’ personal responsibility. 

For instance, one suggestion is restricting open enrollment to once a year. The policy would prevent people from waiting until they’re sick to sign up for coverage and incentivize them to sign up when they have the chance. Other ideas include charging late enrollment penalties or charging higher rates for those individuals who have gaps in coverage. 

Zirkelbach believes the priority should be working with regulators to establish clear rules to guide the insurance exchanges before the industry can begin to focus on fostering participation in them.

“You want a regulatory process that is going to maximize choice and competition for consumers and employers, so you need to have the infrastructure in place, and an infrastructure that works, before even trying to get people to participate in that system,” he says.

Enroll America is taking a more community-based approach to promote coverage and prompt personal responsibility. Anne Filipic, president of the not-for-profit organization, says the first step in getting Americans to sign up for healthcare coverage is making sure they are aware of the benefits that will exist through PPACA, such as online enrollment and subsidized coverage. 

“Our research has shown that there’s a very high percentage of the uninsured population that aren’t aware of the opportunities that are coming their way,” Filipic says.

To increase awareness, Enroll America has designed a community-based education and enrollment campaign that will reach the uninsured population through local radio and newspapers. Avoiding overcomplicated messaging will also be essential.

“Part of this is just making sure that folks have some basic information because, fundamentally, most people do want health coverage,” she says. 

Filipic says the task will be a team effort by the diverse Enroll America board of directors, which includes representatives from the insurance, hospital and pharmaceutical industries. Providers can play a role by providing information on the law and the opportunities that now exist to patients they treat, and health plans can be prepared to answer questions and develop resources to specifically address concerns of the uninsured, she says.

“While I do think there are some simple messages that go a long way, we know this is going to take more than one conversation or more than one touch,” she says.

SAVING FOR FUTURE EXPENSES

Once members have signed up for coverage, many will be obligated for the out-of-pocket expenses associated with that coverage. A 2012 report from the Kaiser Family Foundation indicates that individuals in the non-group market could expect much higher cost sharing amounts in 2014 than typical employer-based coverage or current non-group market plans. 

For example, those signing up for bronze level exchange plans, with a standard 20% coinsurance and an out-of-pocket cost sharing limit, would have an estimated deductible of $4,375 for individual coverage. The figure is significantly higher than the average single deductible for non-group markets in 2010 of $2,498. By comparison, the average deductible in 2011 was $675 for employer-sponsored PPO plans.

“The crucial thing is that the changes that are taking place in plan design really have exposed people more to the front-end cost of care, and since 2007, you’ve seen the number of people in high-deductible plans roughly quadruple, from 5% to 19%,” says Jeff Goldsmith, president of Health Futures, a consulting firm, and an associate professor of public health sciences at the University of Virginia. “Those numbers are only going higher.”

Research has shown that some Americans are increasing their efforts to save for healthcare. According to the Employee Benefit Research Institute, the asset levels in health saving accounts (HSAs) and health reimbursement arrangements (HRAs) are growing, from $873.4 million in account assets in 2006 to $17.8 billion in 2012. The average account balance is also on the rise and was $1,534 in 2012, up 4% from the year before. 

But healthcare experts say getting members to put away adequate amounts of money to cover healthcare expenses remains a challenge, especially in a struggling economy. Goldsmith says even with healthcare coverage, many Americans are unable to pay their medical expenses.

“There are a lot of people that already have too much exposure to the cost of care,” he says. “If they are not filling prescriptions that their doctor gives them because they don’t have the money to pay the copay, if they are not following up with a specialist visit to resolve a problem their doctor has identified, maybe we’ve pushed too far in the other direction.” 

Alexandra Drane, co-founder and chief visionary officer at Eliza, a healthcare communications company, says she believes the healthcare system has broken down over the years in that it doesn’t necessarily solve health problems the average person would want solved. 

“The perception is we in the healthcare space are selling wellness-everyone knows we are not,” Drane says. “We are basically selling a system that fixes people once they are sick. The reality for the average individual out there is they don’t think they’re ever going to get sick until they are.” 

She believes health plans need to invest more time in finding out what the average person with no healthcare experience would be willing to pay for and then determine based on that knowledge how they can encourage preventive services and a healthier lifestyle.

“One of the ways to get people to start saving is to get them to prioritize that their health is worth the money, and that’s a marketing challenge,” she says.

Once health plans and providers can demonstrate the value of paying for healthcare, Drane says the next step is to connect patients with the financial tools that can help them save for out-of-pocket expenses and lessen overall financial stress. 

“We need to get in front of that and position the assistance that we can give in terminology that resonates with the average person, who, quite frankly, is not sitting around stressing that they can’t get their high blood pressure medication,” she says. “They are stressing that they are going to lose their job, or that their mom calls them 12 times a day, and they don’t know how to help her.”

GETTING PREVENTIVE CARE

In 2011, more than 54 million additional Americans received preventive services with no out-of-pocket costs under PPACA, according to the Department of Health and Human Services (HHS).  Services ranged from immunizations and pediatrician visits to mammograms and colonoscopies. 

There was some debate over whether polyp removal was part of the no-cost colonoscopy or not. At first, plans separated the service and applied regular cost-sharing. In February, HHS clarified that plans must also pay for polyp removal, which should promote greater patient use of the free preventive service. 

Those who work daily in the healthcare arena know that preventive services such as colonoscopies are high-value services. However, getting the average American to act on the advice is often a struggle for payers and providers.

Goldsmith says the biggest challenge for health plans trying to inspire personal responsibility in their members is establishing credibility with consumers, many of whom could be wary of a health plan’s motives. To improve credibility, Goldsmith says, plans and providers need to invest resources to address the root causes of unhealthy lifestyle choices, whether its financial stress, personal stress, mental health, or a lack of time or resources. 

Drane agrees that the definition of healthcare needs to expand to include factors that affect people’s everyday lives. The upcoming insurance exchanges will offer an opportunity to do just that with effective marketing strategies. 

“You know what it takes to be a good brand?” she says. “You have to sell something that people want.”

If health plans help beneficiaries with the problems they want solved, Drane says, it will add authenticity to the brand and give health plans a more persuasive voice. The voice could work to their advantage when members need to schedule a mammogram, visit their primary care provider for follow-up or improve medication adherence.

“They listen to you because you have added value in a genuine way that builds credibility,” she says. 

To create authentic, non-paternalistic messages, Goldsmith says, managed care needs to move beyond mass-produced member materials based on traditional demographic data.

“You can’t rely on blunt demographic categories like age and sex to frame the message,” he says. “You actually need to understand what people’s hot buttons are, and in order to do that, you have to listen to them.”

For instance, Drane says, one health plan’s mammogram campaign used humor. Automated calls told women their local mammography machine “missed” them. The program took the plan from the 25th to the 75th percentile in Healthcare Effectiveness Data and Information Set (HEDIS) measures. 

MEET THEM WHERE THEY'RE AT

Tracy Langlais, the vice president of medical affairs operations for CDPHP, an upstate New York health plan, says it has also focused on personalization. CDPHP, which serves approximately 425,000 members, offers care management services with shared decision making tools. 

While providers want to address issues from a clinical perspective, it’s more important to find out the individual member’s treatment priorities, she says, adding that sometimes there might be a social issue that needs to be addressed before focusing on a physical one.

The company also offers a shared health program to help their large employer groups develop wellness programs at work sites. As part of the program, CDPHP mines their clinical data to identify preventive care opportunities. 

“It has to remind people on a regular basis in a kind of user-friendly method that is not too intrusive,” Langlais says. 

Jennings says individuals could be forced into taking a greater responsibility for their health by employers who are fed up with the cost of care. Economic consequences, he says, could be the only way to prompt change. 

“It’s money,” he says. “It’s going to boil down to money because that is where the pain comes. As long as people are able to come into the emergency room without consequence or any economic impact, they aren’t going to change.”  MHE