Why Consumers — Not Companies — Should Make Health Care Decisions

Mike McCallister, president and CEO of Humana Inc., is precise when he chooses his words to describe the U.S. health care industry.

“We don’t actually have a health care system. We have a lot of different systems that are glued together,” he told an audience at the recent 2009 Wharton Health Care Business Conference.

McCallister began his keynote address by making that distinction, he said, because, in spite of all the political and economic talk going on, there is no single “health care system” in this country that needs to be reformed. Rather, he said, there is the health care sector — a gigantic mix of varied players — that is “broken, but can be fixed.”

Because we don’t have a system, he added, “we have the wrong objectives. We have the wrong forms of competition. The wrong geographic markets have been established, the wrong strategies and structures. The incentives are wrong for virtually everyone, including providers, payers and patients.”

Humana, headquartered in Louisville, Ky., is one of the largest health and supplemental benefits companies in the country, with more than 10.5 million medical members. No longer in the hospital business, Humana is seeking to establish itself as a leader in “consumer engagement,” or, as McCallister told his audience, in “harnessing the power of the consumer.” In other aspects of the marketplace, consumers are “very powerful because generally [they] have actionable information at [their] fingertips,” but in health care, “you can’t get the price and quality information.”

While McCallister applauded the goal of universal coverage, saying that “in a nation as wealthy as ours … everybody should be covered in some fashion,” he added that the endpoint will be impossible to achieve unless two interrelated objectives are met: “Cost and quality improvement is the dual imperative.”

Excessive use of services is at the heart of the health care crisis. “If you lie down long enough, someone will scan you,” he said, and the doctors and hospitals making money off the CT or MRI or PET scan aren’t necessarily all to blame. Patients, he noted, can’t seem to get enough medical care: The number of hospital and doctor visits increased by 20% in the past five years, and the demand for services is going to accelerate even more as 70 million baby boomers head into Medicare and the population as a whole keeps getting more and more obese, driving up the incidence of heart disease, diabetes and orthopedic injuries.

Consumers Understand Tradeoffs

But according to McCallister, there is no reason to think health care consumers would not make more judicious and cost-savvy decisions if only they had the necessary information to “choose, finance and use” health care. He noted that consumers understand the meaning of tradeoffs in other purchasing arenas. If they decide to buy furniture at Ikea, for instance, they know they will have to cart the furniture home and assemble it themselves, rather than have a delivery man do the work. But these consumers also know they will be able to save some money. Likewise, people moving out of their homes can hire a moving company to haul away their possessions or have PODS (Portable on Demand Storage units) delivered to their driveway and then pack up their belongings themselves.

When it comes to health care, he said, the concept of tradeoffs hasn’t really penetrated the minds of patients who are doing the buying. While 84% of Americans rank health care as the benefit they need most from their jobs, most people are clueless about what that benefit costs them.

“It’s coming out of our paychecks, but we don’t even know what we pay for it,” McCallister pointed out. Most employees give little thought to what health plan to join for the coming year, spending only about 30 minutes to explore their options. Even many employers, who foot much of the bill, fail to see the value in more informed decision making. He recalled suggesting to a business that it would be useful to offer a session on health benefits. The manager’s reply: “I can’t afford to have my people off the job for an hour.”

In addition to looking more closely at the options — and costs — of health care coverage, consumers need real-time, evidence-based information to act on when they are deciding what treatments to get. “The estimate is that 15% to 50% of our health care is of no use,” he stated, echoing a theme that surfaced more than once at the Wharton conference. “If we’re ever going to be able to understand what we’re doing in health care, we have to be able to understand quality.”

He noted that there are great variations in the practice of medicine across the country, and something as basic as where the patient lives can have a big difference on what care they get, or whether they get a treatment or procedure at all. In Wyoming, for instance, the rate of back surgery is 9.63 per 1,000 people, while in Illinois it is 3.39 surgeries per thousand, he said. The rate of back problems isn’t that different in the two states, so that doesn’t explain why surgery is more likely to be done in Wyoming.

“We have no methodology to judge the comparative effectiveness of new technologies,” McCallister acknowledged, although the latest economic stimulus package does include $1.1 billion to fund comparative-effectiveness research — which is a polite way of saying it’s time to get to the bottom of whether a given treatment is worth the price. He said the adoption of standards for care by doctors and hospitals can make a big difference to patients, leading to fewer complications, shorter lengths of stay, and in turn, smaller bills. Doctors at Johns Hopkins, for instance, found that they could cut the infection rate among patients in the intensive care units by 66% by following a simple checklist of safety precautions. Great strides could be made in assessing quality issues, he added, if the federal government chose to release the Medicare database, which would provide researchers and others an unprecedented look at both the effectiveness and cost of care.

Sharing the Wealth — of Information

For reform to work, McCallister suggested, doctors and hospitals also have to modernize. Despite all the medical technology that fills U.S. hospitals and doctors’ offices, both suffer from a surprising lack of information technology. “Only 14% of doctors use electronic medical records.” Even as hospitals move to implement electronic systems, their approach may be very insular. If patient care is to be better coordinated and waste eliminated, patient information needs to flow from doctor to doctor, from hospital to hospital, even from one insurer to another. “As payers, we have incredible databases. We have to be able to connect all this.” He cited the success of a joint project by Humana and Blue Cross/Blue Shield of Florida that created a web-based information exchange system that offers a full look at a patient’s medical history by pooling insurance claims information such as doctor visits, hospital stays, lab tests and prescriptions. The stated goal is to improve the quality of care, eliminate duplication of services and enhance patient safety by allowing providers to see what other care the patient has received. Patients often don’t tell their doctors that they are seeing another doctor or taking pills that another doctor prescribed, or they may simply forget when a previous illness unfolded or what medication they took and at what dose.

Humana, like some other health insurers, is making the most of the fact that consumers have become comfortable with using the Internet to comparison shop and sort through all kinds of purchasing decisions. McCallister said his company is trying to help its members get smarter right from the start about what level of coverage works best for them by providing easy-to-understand Internet tools, including a “Family Health Budget” tool that predicts their health costs for the year. After selecting a plan, members can then register on a website and do a personal health assessment. If a particular problem is noted, a Humana nurse is alerted, who contacts the patient to talk about seeing a doctor. Members can go online to look up quality information on doctors and hospitals in the Humana network, and even use a Humana-issued debit card to tap into a health savings account and pay their portion of the bill when they go to see a doctor. All the pieces related to cost and quality are tied into one Internet site.

Much of the information consumers get from their insurance companies is incomprehensible and does nothing to encourage them to make better choices, McCallister stated. The complicated “E-O-Bs” (explanation of benefits) that people routinely get in the mail from their insurance companies are “C-R-A-P,” he added. He tosses his in the trash. “We’re going to have to step up and make things simple, clear, easy to understand. The power has to be in the hands of the individual consumer.”


在最近举办的“2009年沃顿医疗卫生行业研讨会”(2009 Wharton Health Care Business Conference)上,哈门那医疗保健公司(Humana Inc)的董事长和首席执行官迈克·麦克里斯特(Mike McCallister)是这样描述美国医疗卫生行业的:“实际上,我们并没有一个医疗体系,我们有的是把很多个不同的体系粘合到了一起。”



总部设在肯塔基州路易斯维尔(Louisville)的哈门那医疗保健公司,是美国最大的提供卫生福利和补充保险福利的公司之一,在该公司医疗福利保险计划中注册的人数多达1,050多万。现在,哈门那公司已不再介入医院业务,而是寻求在“消费者接合”(Consumer Engagement)(也译为“消费者涉入”、“消费者导向”)领域建立自己的领导者地位。正如麦克里斯特告诉听众的,公司正在试图“有效利用消费者的力量”。在市场的其他方面,消费者都拥有“非常强大的影响力,因为通常而言,他们可以轻松获取可用于行动的信息。”但是,在卫生保健领域,“你就是无法得到关于价格和质量的信息。”







“虽然那些钱出自我们的薪水,但是,我们甚至不知道那些钱是用来购买什么的。” 麦克里斯特指出。大部分雇员对来年加入什么医疗保险计划都没有什么想法,他们只是花30分钟的时间查看被保险人对赔款方式的选择权。甚至连承担医疗费用账单大部分金额的很多雇主,也不知道更精明的决定到底有什么价值。他回忆说,自己曾给某个企业建议,就医疗保险福利问题办一个讲座会很有好处,可那位经理则回答说:“我一小时也不能让员工离开岗位。”



“我们并没有用于判断新技术比较疗效的系统性方法。”麦克里斯特坦承,尽管最近的经济刺激一揽子计划确实包括11亿美元用于进行疗效比较研究的资金。“现在是要弄清一种治疗方法到底是否值得我们付出这些代价的时候了。”疗效比较研究是这种探究的委婉说法。他说,医生和医院采用治疗和护理的标准,对病人来说,结果会有很大的差异,这些标准能减少治疗护理的并发症,能缩短住院时间,从而,病人的花费也会更少。比如,约翰霍普金斯医院(Johns Hopkins)的医生就发现,通过遵循一个简单的安全预防措施,就能将重症监护病房中病人的感染率减少66%。他还谈到,如果联邦政府开放联邦医疗保险数据库——该数据库能为研究者和其他人提供有关医疗护理的效果和费用的海量资料——那么,对医疗护理质量的评估就能取得重大的进步。


麦克里斯特建议,为了使改革奏效,医生和医院还必须采用现代化方法。尽管在美国的医院和医生的诊室里,医疗技术设备应有尽有,但医院和医生都深受信息技术严重缺乏之苦。“只有14%的医生使用电子病历。”甚至当医院转而采用电子系统的时候,它们的系统也可能是完全孤立的。要想让病人接受的医疗护理更好地协调起来,同时也减少浪费,那么,病人的信息就应该能在医生之间、医院之间,甚至在提供医疗保险的不同保险商之间自由流动。“作为在医疗护理服务上花钱的人,我们拥有异常强大的数据库。我们一定要把所有信息都衔接起来。”他谈到了哈门那公司和佛罗里达州的健康福利机构蓝十字/蓝盾(Blue Cross/Blue Shield)成功完成的一个合作项目,该项目创建了一个基于网络的信息交换系统,通过汇集看医生的情况、住院的情况、化验数据以及处方等保险索赔信息,这个系统能为人们提供某位病人的全部病例。建立这一系统的目的旨在提高医疗护理的质量、消除重复的医疗服务,并通过让医疗护理服务的提供者看到某位病人曾接受过什么样的医疗护理,而提高病人就医的安全性。病人往往不会告诉某位医生他们曾经看过其他医生,不会谈到另一位医生给他们开具的处方,他们也可能完全忘了上一次发病是什么时候,不记得自己曾吃过什么药、药物的剂量是多少了。

现在,消费者已经能越来越自如地使用互联网货比三家了,并能借助互联网梳理各种购买决定,就像其他医疗保险公司一样,哈门那公司也正在朝着这个目标迈进。麦克里斯特谈到,他的公司通过为消费者提供简单易懂的互联网工具——其中包括能预测消费者本年度卫生保健花费的“家庭健康预算”(Family Health Budget)工具,试图让消费者从一开始——也就是确定什么样的医疗保险计划对他们最有利的时候——就变得更加精明。选择一种医疗保险计划之后,会员可以登录一个网站,并对个人健康状况进行评估。如果消费者谈到了某个特别的问题,哈门那公司的护士就会提起警觉,随后,护士会与病人交流就医的事宜。会员可以在哈门那公司的网站上在线浏览有关医生和医院的高质量信息,甚至还可以使用哈门那公司发行的签账卡建立一个医疗储蓄账户,当他们去看医生时,可以用这张卡支付自己应付的那部分费用。所有这些有关费用和医疗服务质量的信息都集成在一个网站上。

    麦克里斯特谈到,消费者从保险公司获取的大部分信息都是很难理解的,对人们做出明智的决定根本就没有什么帮助作用。他还补充说到,人们从信箱里经常得到的复杂“利益说明”(Explanation of Benefits,简称EOB)(某些健康保险计划会直接把利益说明表格提供给登记者,说明如何支付健康利益索赔。除了索赔付款信息外,利益说明通常还包括有关上诉程序的信息。——译者注)文件,简直就是“垃——圾——废——物”,他总是把它们扔进垃圾桶。“我们必须加快步伐,必须使这些环节简单、清晰而且容易理解。权力必须掌握在消费者个人的手里。”


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