Commentary—how consumer-driven health care evolves in a dynamic market

Health Services Research, August, 2004 by Greg Scandlen

This volume presents an enormous amount of information that will take students of consumer-driven health care a very long time to read and digest. It will be tempting for both advocates and opponents of the movement for greater consumer control to browse through the work and pick out and trumpet those nuggets of information that suit their predispositions.

This would be unfortunate because the information that runs counter to our biases is the most important information to understand. Good policy can be developed only when we listen closely to honest criticism and respond accordingly--as difficult as that may be.

Still, the work presented here requires some context. Consumerism in health care is in its infancy. We do not yet know what the optimal approach is and we are in a period of experimentation and trial and error. Like most other new ideas, the initial models will need to be revised and improved. Prototype designs are almost never without flaw.

One of the marvels of any market-based system is the ability to make those corrections and revisions quickly as more information becomes available.

Too many health policy analysts take a governmental program approach to design questions--the model must be irrefutably effective before it is ever implemented. Once a program is "the law of the land" it is nearly impossible to change. Witness the protracted debate over adding prescription drug coverage to Medicare.

Fortunately, consumer-driven health care (CDHC) was born in the market and will be revised in the market. To the extent there has been governmental involvement (such as the IRS guidance on Health Reimbursement Arrangements), it has been extraordinarily flexible and permissive.

Vendors and employers are free to refine their products in accordance with changing conditions and growing knowledge. In that context, identifying problems is seen not as an attack on cherished ideas, but as a welcome opportunity to improve the product offerings. Criticism is valued as product feedback. A company that wants to succeed in the market is eager to hear what the problems may be.

Market approaches have some other advantages over a governmental orientation, as well. Government programs are essentially political. They are aimed at pleasing 50 percent 1 of the population. Opinion surveys are conducted to see how close a new idea is to achieving that goal.

Few companies in the private market think in those terms. If a new product or a new company feels it can reasonably attract even just 10 percent of a market, it views the prospects as very promising. Hertz is not the only success in the rental car business. Avis and National and Budget and Alamo and many others manage to succeed without being Number One.

Readers of the papers in this volume will likely conclude that the experience at Humana was not very favorable, the experience of the Definity-covered University of Minnesota was more favorable, and the large, unnamed Definity-covered employer was very favorable. What does that mean? Clearly different locations and different designs lead to different results. If CDHC were a government program, this might be worrisome--have we chosen "the right" model? But because CDHC is a market-oriented approach, it is not discouraging at all. Definity is doing something right and will build on it. Humana may revise its approach or drop the program altogether. It does not matter in the slightest. Humana is not disadvantaged because Definity is succeeding. And Humana's problems do not detract at all from Definity's Success.

Certainly there are things to be learned in both cases, and market-oriented companies will study these experiences closely. But no company--including Humana--is stuck with a problematic design. Humana's product did not allow rollovers and the funds in the "allowance" could be spent only on in-network provides and for covered services. These features remove the most promising elements of consumer-driven health designs--consumer choice and the opportunity to save money for future needs. It is simple enough for Humana to incorporate those features in its next round of offerings.

Market-oriented companies also know that early adopters are different than the rest of the market. The people who are the first to sign up for a new product or service tend to be risk-takers. They accept risking the unknown for the privilege of trying something new. They also tend to be younger and better educated than the rest of the market. They volunteer to be "test cases" and product developers rely on them to refine their offerings. People oriented toward government programs may view this as a selection problem, but innovators expect this to occur in the first couple of years of new-product roll out. If the product is successful at this stage, word gets out and the new idea attracts a wider market segment.

The research presented here does not address the "early adopter" phenomenon very effectively. We are told that the enrollees in the Humana program tended to be actuaries and financial service personnel. These individuals are presumably better educated than most Humana employees, and they certainly know their way around a benefits program better than the average person. It is interesting, for instance, that the studies report no end-of-year rush to consume unspent dollars in the allowance, even though Humana included a use-it-or-lose-it provision characteristic of flexible spending accounts (FSAs). This contrasts with the Countrywide Financial experience that did have an FSA-type year-end rush, even though those employees were able to roll over unspent balances. It is possible that the self-selected Humana employees understood the dynamics of forfeited balances and did a better job of spending their money through the course of the year, while less-savvy Countrywide employees stuck to their FSA-induced spending habits.