Consumer Directed Health Care Can Work!

On Thursday during a break in the cloudy/rainy weather in Vermont, I took the 3/4 mile hike up to Lake Pleiad, a mountain lake that's a favorite swimming spot. The weather was dicey and there was only one other person there, a large man with two large tattoos, who, I learned, had been a bouncer in a bar, but now now worked for a small manufacturing company.

I asked about the health insurance the company provided. Here's my reconstruction of what he said:

It's a health savings account type of thing. I have a $5,000 deductible. It's a good deal because the employer puts some money into the savings account. The deductible is a lot of money, but I'd only have to spend it all if I went into the hospital. I'd rather take that risk and have a lower monthly premium, even though a 'lower premium' is still a lot! Doctor visits and tests don't come to all that much. I don't just take a doctor's word about things - I ask a lot of questions. 'What could this test show? Would the results make us do anything different? How important is it?' Sometimes they give me a good answer, and I'm satisfied, but sometime it seems like they didn't really have a good reason, and I don't do it. You've got to ask questions!"

I asked him if the deductible got him to ask more questions. It did. "When you're laying out the money, you think about things more!"

I told him he'd made my day. He was doing just what the architects of high deductible health plans were hoping for. I said "if more people did what you do it would keep us doctors on our toes! We recommend a lot of things out of habit and they don't really need to be done. Do you encourage friends to ask questions the way you do?"

He did. A woman friend's gynecologist was recommending expensive tests on a regular basis. She didn't know why - "I just do what the doctor tells me I need to do." He said "you've got to ask!" When she did it turned out that the tests were really optional. She thanked him.

In 2009 approximately 23 million Americans had plans like the one my swimming companion had. If five percent asked questions the way he did that would be a million people. If that million persuaded five friends to do the same we'd be up to five million. To paraphrase the late Senator Everett Dirksen - "a million people here, a million people there - pretty soon we're talking real public education."

I spent thirty-five years of my practice life with a not-for-profit HMO. I think a group practice of that kind, in which patients and clinicians collaborate in planning the wisest way to use resources, is ideal. But that model didn't catch on widely, which is one reason consumer directed plans are selling like hotcakes.

I really admired and learned from my swimming companion. He was just a smart guy who thought for himself - not a health policy geek like me. If we had a groundswell of people like him who approached health care like prudent consumers it would be the strongest possible force for health reform!