Ian Morrison

“Consumer engagement is a real problem.” You hear that a lot. Doctors bemoan the fact that patients don’t follow their advice and are not engaged in improving their health. Health plans and employers point to a lack of consumer engagement as a key reason health costs are high and the health status of their workers is not improving. Surveys show that few consumers use cost and quality information to select health plans, providers and treatments.

Yet there is broad agreement that we are going to see a bigger role for consumers in health care in the future, whether it be individuals buying insurance though health insurance exchanges under Obamacare, or seniors buying Medicare plans through an exchange under Ryancare.

If we expect consumers to play a bigger role in health care and make more sensible decisions about their own health and the health care services they consume, then we should take some time to figure out why consumer engagement isn’t working.

You’d Think…..

In theory, consumer engagement should be improved by having a rich environment of information and incentives. American health care is awash with consumer incentives: We pay more out of pocket for health care than residents of any other country, we have large and growing deductibles and co-payments as well as elaborate cost-sharing arrangements (with more to come) in tiered formularies, skinny networks, reference pricing schemes, and so forth. Similarly, we have an entire industry of stars and bars: vendors who produce ratings and rankings of hospitals and doctors, some based on reported quality metrics and others based on organized slander, rumor and patient venting. Yet despite all the information and incentives we consumers remain disengaged. Here are some reasons:

Complexity. In other industries, consumers are readily engaged by simple, easy-to-use products and services. We are distracted by our iPhones to the point where we bump into each other in the street. The iPhone is a brilliant, complex, almost mystical device that is astoundingly simple and intuitive to use. Health care is the complete reverse of an iPhone: It makes seemingly simple things complex. In particular, health insurance is complex and becoming more so; the user interfaces are impossible to navigate, and the language and terminology impenetrable. Even Medicare (a relatively simple form of health insurance) is virtually impossible to navigate. My wife signed up for Medicare last month; after hours on the phone with Medicare agents, she stopped them at Part D worried that it went all the way to Part Z.

Confusion. Health care is not only complex but confusing and even contradictory. Is a mammogram, a PSA test, high good cholesterol, baby aspirin or a colonoscopy a good thing for me? Are three stents better than two? Does it matter which type of artificial hip I get? These are all simple questions with rapidly changing, equivocal answers depending on age and the vagaries of the latest scientific findings. Similarly, we have too many choices of plan options and insurance schemes which behavioral economists argue lead to sub-optimal choices for individuals and for society.

Gotcha. While there are enormous financial consequences of consumers’ decisions, most of these financial effects are felt as a gigantic “gotcha” after the event. Patients get shockingly high bills long after the costly decisions are made and the service delivered. Just poll your friends and family and they will regale you with stories of mysteriously large bills received long after the care happened, bills that are full of obscure mathematics justifying patient responsibility. Oh, and when providers try to make patients pay up front, they get vilified in the press as was the case with a recent front-page story about Fairview Health System in Minneapolis hiring Accretive Health to manage revenue cycle in their ER. When providers get proactive on collecting up front, they are accused of being overly mercenary.

Exchanges: gotcha on steroids. As readers of this column know, I am generally supportive of health reform, exchanges and the like, but I do have real concerns about the enormous gotcha in the making with health insurance exchanges (if exchanges are still standing by the time you read this). Here’s why. An uninsured family of four at 300 percent of the federal poverty level ($67,000 per year) will have an opportunity (mandate) to purchase a health plan through the exchange. The expected premium for this family for a silver plan (a plan that has an actuarial value of 70 percent, meaning on average patients will be paying for 30 percent of the average costs of care) will be $540 per month after the federal subsidy! As I point out to people, instead, the family could have leased a Cadillac SRX loaded with a premium sound system and leather seats. When these people have a medical event and realize they are going to have to pay a ton of money out of pocket after paying $540 a month, it is the mother of all gotchas: They are going to stiff providers on the bill. Bad debt for providers will soar.

Lack of consequences. There are obvious consequences of bad health habits (you die younger and look awful on the way), and being uninsured can surely lead to bankruptcy, but we don’t have a culture of consequences in American health care. Just today a doctor came up to me and asked “When are patients going to be accountable?” All too often, we patients behave badly (over-consuming food and beverages, under-exercising, and exposing ourselves to way too much stress at work). The American super-sized fast food environment makes it hard to be thin. Sedentary, car-loving and cubicle-based lifestyles aggravate the lack of exercise. And there is no real penalty for lack of engagement and accountability for health. Access to health services is rarely restricted or constrained based on likelihood of compliance. In many countries there is overt or covert clinical triage by age and health status. No, not death panels. But if OR time is scarce, a 50-year-old otherwise healthy male needing a coronary bypass is more likely to make it to the front of the queue than an 80-year-old smoker. Similarly, in Holland if you don’t purchase the mandatory private health insurance, you will still get admitted to the hospital, they just won’t discharge you until you pay your back premiums.

Using familiar platforms. The Internet has enabled a transformation in myriad consumer businesses, and smart phones are similarly transforming consumers’ experience on a mobile basis. Consumers are engaged by websites and apps and can deliver spectacular self-service because the platform is familiar, the user experience is intuitive, the metaphors clear. Health is not only behind because of privacy concerns but has failed to leverage existing platforms. My 27-year-old son waited five hours for an urgent care dermatological examination at a prestigious academic medical center. “Why can’t there be something like Open Table?” he asked. “Why not just use Open Table,” I replied. Seriously, why not? And Facebook for follow-up after readmissions, and Google docs for electronic interchange, and Zagat for hospitals and so on. And please don’t roll your eyes and say HIPPA. I am on record for a decade saying: “Ignore HIPPA and do the jail time, it’s easier.”

Getting Consumers Engaged

So maybe we now have some clues on how to engage consumers:

KISS — keep it simple, stupid. This is good advice. Reduce complexity by sloganeering and making things clear: good choice, bad choice. Eat this, not that. There will be a $1,000 impact if you do Plan A, a $100 impact if you do Plan B.

Presume engagement. Increasingly, self-insured employers are turning up the heat on consumer engagement. For example, they offer automatic enrollment in disease management programs if certain clinical thresholds are reached; increased premiums if health behaviors are not improved. A number of employers such as Safeway are experimenting with making health practices such as flu shots mandatory.

Learn from consumer-oriented companies. Consumers are engaged by goods and services that solve their problems: Apple, Starbucks, Expedia, Amazon and Costco can teach us the many ways that consumers can be delighted, remain loyal and stay engaged. Familiar platforms can be applied to problems. If you can use an iPhone, you can use an iPad.

Make the right thing easy. Health care needs to make it easy for consumers to do the right thing. Instead we throw curveballs, we don’t stay open during the hours when consumers want to use our services, then we complain when the patients turn up at the emergency room.

The power of brand. Consumers are influenced powerfully by great brands. We have some great brands in health care — Mayo Clinic and Blue Cross come to mind — but we need more. In many industries brand power is sufficient to engage consumers and move markets. Health care must learn to use the power of brands.

As consumers are asked to make more crucial choices about their health and health care, consumer engagement will become an ever more critical competency for health care providers, payers and suppliers. Get engaged.

Ian Morrison is an author, consultant and futurist based in Menlo Park, Calif. He is also a regular contributor to H&HN Daily.