Opinion
VIEWPOINT
James A. Guest, JD Consumer Reports, Yonkers, New York. Lynn Quincy, MA Consurmer Reports, Washington, DC.
Corresponding Author: James A. Guest, JD, Consumer Reports, 101 Truman Ave, Yonkers, NY 10703 (jguest@consumer .org).
Consumers Gaining Ground in Health Care changes of their own. Many companies have introduced “narrow networks” as a means of constraining costs, but there is currently little in the way of standardized information that would signal to a consumer just how narrow or broad the provider network is. The US Department of Health and Human Services can use its authority under the ACA to develop new measures that will help consumers compare plans based on the adequacy of their networks; this would complement the new, robust methods for comparing benefits and costs. Third, states and the federal government are using a variety of approaches to implement the consumeroriented aspects of the new health insurance rules, including web-based health plan comparison tools. Going forward, a conscientious effort for tracking and assessing the different approaches can help identify those that are working best for consumers and those that fall short. Consumer testing and web traffic data should be used to see where For the first time, consumers have a these comparison tools are succeeding chance to meaningfully shop for along dimensions such as the overall “value” of the insurance plan, robust sumcoverage. This not only is more fair to mary measures of a consumer’s exconsumers but is essential for a fully pected out-of-pocket spending, new functioning marketplace. However, it is measures of network adequacy, and clinical directories that are integrated across not enough to write the rules and open plans. the doors to the new exchanges. It is Fourth, emerging consumer-friendly practices should be extended to the rest critical to sustain the momentum of of the health care industry as well. Why shifting the balance of choice and should consumers finance hospitals, phycontrol to consumers. sicians, and drug companies via health insurance without assurances that these Coverage form that standardizes the way coverage is entities, too, must operate on a level playing field with described no matter which company or organization consumers? is offering it. For example, the ACA includes important proviFirst, federal and state regulators must be vigilant sions that require pharmaceutical and device compaabout enforcing the new rules protecting consumers, nies to disclose financial relationships with physicians. such as the requirement to provide the new Summary Implementation of this “sunshine” requirement has been of Benefits and Coverage form.2 In some states, legis- slower than anticipated and loopholes in the reporting lators have prohibited or discouraged enforcement of requirements are inevitable. Professional medical assoACA protections and even blocked assistance that ciations and societies should take a leadership role in imwould help consumers understand their new rights proving this portion of the playing field. As a matter of and receive their new benefits under the act.3 In these fair and ethical practice, physicians should disclose to cases, the federal government is empowered to their patients any real or perceived conflicts of interest enforce the law and help consumers, but resource they may have. It is an essential element of profesconstraints and political expediency may mean these sional conduct to do so. Industry has many other marefforts are insufficient. To have come this far and not ket advantages, and influencing physicians and their care realize the full promise of the law due to insufficient of patients through use of financial incentives and creenforcement would be unfortunate. ative perks should not be one of them. Second, health care leaders should monitor marFifth, the ACA at long last provides access to perketplace developments and protect the interests of formance data around hospital-acquired infections, with consumers on an ongoing basis. For example, insurers physician quality ratings and more coming in the fuare busy responding to the new market rules with ture. Death related to health care associated harm is a At long last public and private initiatives are on the verge of giving consumers more information and more fair opportunities when it comes to obtaining health insurance and health care, reducing the uneven care and dysfunctional financing that have long plagued the health care system in the United States. The Affordable Care Act (ACA) is recasting the marketplace for health insurance, allowing consumers who shop on their own to make more informed choices among a better selection of health plans. Health insurers must now play by a different set of rules. Consumers with preexisting conditions are no longer denied insurance. The products for sale are more standardized, and important loopholes such as misleading out-of-pocket maximums have been closed. Private plans can be compared on an applesto-apples basis using a new Summary of Benefits and
jama.com
JAMA November 13, 2013 Volume 310, Number 18
Copyright 2013 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Ndsu Library Periodicals User on 05/23/2015
1939
Opinion Viewpoint
leading cause of mortality in the United States.4 Consumers should have better information about hospital and physician performance than they can glean from user reviews on Yelp, Zagatt’s, Angie’s List, or other such sources. It is encouraging that private efforts are also addressing the challenges consumers of health care face. The evolving Choosing Wisely campaign demonstrates that physician organizations and their members can lead efforts to reduce wasteful health services and products.5 The wide resonance of this effort underscores inadequacies in the current health-delivery systems and markets. From cradle to grave and across all disciplines, overuse and waste are common. Of most concern is when the overuse is not only wasteful and costly but also harmful to the patient. Overuse is a shared responsibility between patient and physician. For example, organizations representing practitioners who deliver obstetric services have urged an end to elective delivery before 39 weeks without medical indications and an end to elective induction at term prior to signs of readiness for delivery.6 Nevertheless, in many places in the country, the convenience of physician or patient prevails over the health of the mother and infant. Moreover, it is not just convenience that pushes patients toward questionable decisions. Patient “demand” is often driven by both subliminal and explicit advertisements in the form of highly persuasive (and often misleading) “suggestions” from hospitals, physicians, and drug companies. With the advent of digital medical records and secure online portals to those records, it is becoming easier for clinicians and ARTICLE INFORMATION Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. REFERENCES 1. Quincy L. What's behind the door: consumers' difficulties selecting health plans. Consumers Union. January 2012. http://consumersunion.org /wp-content/uploads/2013/03/Consumer _Difficulties_Selecting_Health_Plans_Jan2012.pdf. Accessed September 29, 2013. 2. Quincy L. Early experience with a new consumer benefit—the summary of benefits and coverage.
1940
patients to operate from the same information base. This year has also seen a leap forward in concepts like OpenNotes, a transparency movement that invites and enables patients to review not just their laboratory results and medication lists online, but their clinicians’ notes as well. Projects in Boston, Seattle, and rural Pennsylvania are generating impressive data of consumer benefit: patients report taking better care of themselves and feeling more in control of their care due to access to all their clinicians’ notes; they tell stories suggesting that reading notes could improve safety, costs, and satisfaction; and 99% of participating patients wanted to continue after a year of access to their clinician’s notes.7 Not one of the more than 100 primary care physicans who volunteered to participate in the initial research and evaluation phase chose to stop at the end of the trial. In light of these results, why not make this the standard of care? Such practice does not depend on technology, and for those who have electronic records, any challenges posed by technology can be readily overcome if the will is there. There will be unexpected consequences. Transparency of full and complete medical records will undoubtedly bring unexpected effects. But it is here to stay, and the benefits will outweigh any downsides. Thanks to the ACA and practitioners who prioritize patientfirst professionalism, consumers are making gains. Continued progress will require broad change in physician culture and practice, state and federal commitments to enforce and build on the new requirements, and collaboration and engagement by consumers. There is growing momentum. It needs to keep going.
Consumers Union. February 2013. http://consumersunion.org/wp-content/uploads /2013/03/Early_Experience_Report.pdf. Accessed September 29, 2013. 3. Millman J. Feds will need to enforce ACA reforms in 4 states. Politico (Pavia). March 19, 2013. http: //www.politico.com/story/2013/03/feds-must -enforce-aca-reforms-in-four-states-89041 .html#ixzz2g6DapWCZ. Accessed September 29, 2013.
6. The American College of Obstetricians and Gynecologists Committee on Obstetric Practice The Society for Maternal–Fetal Medicine. Nonmedically indicated early-term deliveries. April 2013. http://www.acog.org/Resources_And_Publications /Committee_Opinions/Committee_on_Obstetric _Practice/Nonmedically_Indicated_Early-Term _Deliveries. Accessed on September 29, 2013. 7. OpenNotes website. http://www .myopennotes.org. Accessed September 29, 2013.
4. James J. A new evidence-based estimate of patient harms associated with hospital care. J Patient Saf. 2013;9(3):122-128. 5. Choosing Wisely website. http://www .choosingwisely.org. Accessed September 29, 2013.
JAMA November 13, 2013 Volume 310, Number 18
Copyright 2013 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Ndsu Library Periodicals User on 05/23/2015
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VIEWPOINT
James A. Guest, JD Consumer Reports, Yonkers, New York. Lynn Quincy, MA Consurmer Reports, Washington, DC.
Corresponding Author: James A. Guest, JD, Consumer Reports, 101 Truman Ave, Yonkers, NY 10703 (jguest@consumer .org).
Consumers Gaining Ground in Health Care changes of their own. Many companies have introduced “narrow networks” as a means of constraining costs, but there is currently little in the way of standardized information that would signal to a consumer just how narrow or broad the provider network is. The US Department of Health and Human Services can use its authority under the ACA to develop new measures that will help consumers compare plans based on the adequacy of their networks; this would complement the new, robust methods for comparing benefits and costs. Third, states and the federal government are using a variety of approaches to implement the consumeroriented aspects of the new health insurance rules, including web-based health plan comparison tools. Going forward, a conscientious effort for tracking and assessing the different approaches can help identify those that are working best for consumers and those that fall short. Consumer testing and web traffic data should be used to see where For the first time, consumers have a these comparison tools are succeeding chance to meaningfully shop for along dimensions such as the overall “value” of the insurance plan, robust sumcoverage. This not only is more fair to mary measures of a consumer’s exconsumers but is essential for a fully pected out-of-pocket spending, new functioning marketplace. However, it is measures of network adequacy, and clinical directories that are integrated across not enough to write the rules and open plans. the doors to the new exchanges. It is Fourth, emerging consumer-friendly practices should be extended to the rest critical to sustain the momentum of of the health care industry as well. Why shifting the balance of choice and should consumers finance hospitals, phycontrol to consumers. sicians, and drug companies via health insurance without assurances that these Coverage form that standardizes the way coverage is entities, too, must operate on a level playing field with described no matter which company or organization consumers? is offering it. For example, the ACA includes important proviFirst, federal and state regulators must be vigilant sions that require pharmaceutical and device compaabout enforcing the new rules protecting consumers, nies to disclose financial relationships with physicians. such as the requirement to provide the new Summary Implementation of this “sunshine” requirement has been of Benefits and Coverage form.2 In some states, legis- slower than anticipated and loopholes in the reporting lators have prohibited or discouraged enforcement of requirements are inevitable. Professional medical assoACA protections and even blocked assistance that ciations and societies should take a leadership role in imwould help consumers understand their new rights proving this portion of the playing field. As a matter of and receive their new benefits under the act.3 In these fair and ethical practice, physicians should disclose to cases, the federal government is empowered to their patients any real or perceived conflicts of interest enforce the law and help consumers, but resource they may have. It is an essential element of profesconstraints and political expediency may mean these sional conduct to do so. Industry has many other marefforts are insufficient. To have come this far and not ket advantages, and influencing physicians and their care realize the full promise of the law due to insufficient of patients through use of financial incentives and creenforcement would be unfortunate. ative perks should not be one of them. Second, health care leaders should monitor marFifth, the ACA at long last provides access to perketplace developments and protect the interests of formance data around hospital-acquired infections, with consumers on an ongoing basis. For example, insurers physician quality ratings and more coming in the fuare busy responding to the new market rules with ture. Death related to health care associated harm is a At long last public and private initiatives are on the verge of giving consumers more information and more fair opportunities when it comes to obtaining health insurance and health care, reducing the uneven care and dysfunctional financing that have long plagued the health care system in the United States. The Affordable Care Act (ACA) is recasting the marketplace for health insurance, allowing consumers who shop on their own to make more informed choices among a better selection of health plans. Health insurers must now play by a different set of rules. Consumers with preexisting conditions are no longer denied insurance. The products for sale are more standardized, and important loopholes such as misleading out-of-pocket maximums have been closed. Private plans can be compared on an applesto-apples basis using a new Summary of Benefits and
jama.com
JAMA November 13, 2013 Volume 310, Number 18
Copyright 2013 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Ndsu Library Periodicals User on 05/23/2015
1939
Opinion Viewpoint
leading cause of mortality in the United States.4 Consumers should have better information about hospital and physician performance than they can glean from user reviews on Yelp, Zagatt’s, Angie’s List, or other such sources. It is encouraging that private efforts are also addressing the challenges consumers of health care face. The evolving Choosing Wisely campaign demonstrates that physician organizations and their members can lead efforts to reduce wasteful health services and products.5 The wide resonance of this effort underscores inadequacies in the current health-delivery systems and markets. From cradle to grave and across all disciplines, overuse and waste are common. Of most concern is when the overuse is not only wasteful and costly but also harmful to the patient. Overuse is a shared responsibility between patient and physician. For example, organizations representing practitioners who deliver obstetric services have urged an end to elective delivery before 39 weeks without medical indications and an end to elective induction at term prior to signs of readiness for delivery.6 Nevertheless, in many places in the country, the convenience of physician or patient prevails over the health of the mother and infant. Moreover, it is not just convenience that pushes patients toward questionable decisions. Patient “demand” is often driven by both subliminal and explicit advertisements in the form of highly persuasive (and often misleading) “suggestions” from hospitals, physicians, and drug companies. With the advent of digital medical records and secure online portals to those records, it is becoming easier for clinicians and ARTICLE INFORMATION Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. REFERENCES 1. Quincy L. What's behind the door: consumers' difficulties selecting health plans. Consumers Union. January 2012. http://consumersunion.org /wp-content/uploads/2013/03/Consumer _Difficulties_Selecting_Health_Plans_Jan2012.pdf. Accessed September 29, 2013. 2. Quincy L. Early experience with a new consumer benefit—the summary of benefits and coverage.
1940
patients to operate from the same information base. This year has also seen a leap forward in concepts like OpenNotes, a transparency movement that invites and enables patients to review not just their laboratory results and medication lists online, but their clinicians’ notes as well. Projects in Boston, Seattle, and rural Pennsylvania are generating impressive data of consumer benefit: patients report taking better care of themselves and feeling more in control of their care due to access to all their clinicians’ notes; they tell stories suggesting that reading notes could improve safety, costs, and satisfaction; and 99% of participating patients wanted to continue after a year of access to their clinician’s notes.7 Not one of the more than 100 primary care physicans who volunteered to participate in the initial research and evaluation phase chose to stop at the end of the trial. In light of these results, why not make this the standard of care? Such practice does not depend on technology, and for those who have electronic records, any challenges posed by technology can be readily overcome if the will is there. There will be unexpected consequences. Transparency of full and complete medical records will undoubtedly bring unexpected effects. But it is here to stay, and the benefits will outweigh any downsides. Thanks to the ACA and practitioners who prioritize patientfirst professionalism, consumers are making gains. Continued progress will require broad change in physician culture and practice, state and federal commitments to enforce and build on the new requirements, and collaboration and engagement by consumers. There is growing momentum. It needs to keep going.
Consumers Union. February 2013. http://consumersunion.org/wp-content/uploads /2013/03/Early_Experience_Report.pdf. Accessed September 29, 2013. 3. Millman J. Feds will need to enforce ACA reforms in 4 states. Politico (Pavia). March 19, 2013. http: //www.politico.com/story/2013/03/feds-must -enforce-aca-reforms-in-four-states-89041 .html#ixzz2g6DapWCZ. Accessed September 29, 2013.
6. The American College of Obstetricians and Gynecologists Committee on Obstetric Practice The Society for Maternal–Fetal Medicine. Nonmedically indicated early-term deliveries. April 2013. http://www.acog.org/Resources_And_Publications /Committee_Opinions/Committee_on_Obstetric _Practice/Nonmedically_Indicated_Early-Term _Deliveries. Accessed on September 29, 2013. 7. OpenNotes website. http://www .myopennotes.org. Accessed September 29, 2013.
4. James J. A new evidence-based estimate of patient harms associated with hospital care. J Patient Saf. 2013;9(3):122-128. 5. Choosing Wisely website. http://www .choosingwisely.org. Accessed September 29, 2013.
JAMA November 13, 2013 Volume 310, Number 18
Copyright 2013 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Ndsu Library Periodicals User on 05/23/2015
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