Let the ‘Buyer Beware’ for Health Care Purchases

Will patients ever shop for health care the way consumers do for a new mobile phone?

Injecting consumerism into health care purchasing has been the rage for the past several decades. Policy elites have salivated at the idea that if patients acted more like consumers then health care costs would plummet while patient outcomes would improve. Theoretically, the rationale sounds like a winner; however, health care is unlike most other goods or services as it is hindered by what economists refer to as “asymmetry in information.” This means that consumers don’t have all the data they need to make appropriate decisions. Physicians, pharmacists, insurance brokers, and health benefit managers, to name a few, are the ones with all the information regarding purchasing of health care services. Subsequently, this major obstacle has kept consumerism from taking a foothold in the health care purchasing ecosystem.

Now with the pending overhaul of the Affordable Care Act, it appears that discussion of patient consumerism is again gaining traction through the expansion of health savings accounts or “defined health care contribution,” arrangements which have been around for decades. HSAs allow individuals to put money into a savings account and thus manage some of their health care purchasing, including purchasing health insurance. A defined health care contribution means the employer sets the specific amount contributed but doesn’t dictate the exact health benefit an employee may purchase. For patients to appropriately utilize these plans and, more importantly, for them to succeed, policymakers need to advocate for tactics that eliminate the information gap that exists which would allow consumers to make appropriate decisions.

The best and most obvious way to eliminate the information gap is to furnish patients with as much information as possible. How? By championing transparency around access to health care benefits most valued by them — information about their physician, their pharmacy, their hospital and, most importantly, their life-saving medicines. For starters, patients need to know the most up-to-date provider, pharmacy and hospital network information, including immediate notification when a provider, pharmacy or hospital is no longer in network or accepting new patients. They also need to be advised of all the out-of-pocket costs associated with all providers, in or out of network. Access to such information will curtail situations recently chronicled in various journals where patients were saddled by significant out-of-pocket physician expenses after a visit to an emergency room because health insurers covered emergency room services through an in-network hospital while physicians that provided the care were not contracted as in-network providers.

Next, they need to provide patients platforms that allow transparent, current and readily available drug formulary information through standardized templates that include drug-specific copayment or co-insurance information that is displayed in ordinary terms. In addition, patients should know up front whether the life-saving medicines they require have some type of administrative restrictions such as a step therapy mandate or prior authorization. Patients should not end up with poor outcomes because they show up at the drug store and are informed by the pharmacist that their lifesaving medicine is not covered by their insurer or pharmacy benefit manager.

The good news is these platforms already exist. Policy makers may want to duplicate the model that currently serves millions of seniors with a satisfaction rating that is the envy of the cool new technology gadget-geeks — Medicare Part D. Medicare Part D is not only one of the few fiscally responsible government programs, as it has come under budget year after year, but one that provides the information that a senior needs when they want to make a decision about enrolling in a drug benefit plan — and all at the click of a button.

The Medicare Plan Finder is a model resource in increasing patient access to information on covered medicines. The Medicare Plan Finder allows consumers to set parameters and compare information on drug coverage across plans prior to enrollment. With the Medicare Plan Finder consumers can enter drug-specific information, conduct a general or personalized search by zip code, and find out which health plans provide the best coverage. Most importantly, seniors can identify what every patient wants to know, their annual out-of-pocket costs for prescription medicines. Medicare patients also have access to plan websites, links to plan formularies, and information on restrictions like step therapy and prior authorization.

If policymakers are serious about encouraging consumerism in health care then they need to make sure patients have appropriate and transparent information that allows them to make informed decisions. Only then will consumers be able to make better health care purchasing decisions.


Robert Popovian is the vice president of Pfizer US Government Relations. He has two decades of experience in the biopharmaceutical health care industry and has published and presented extensively on the impact of pharmaceuticals and health care policies on health care costs and clinical outcomes.

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