When I used to work in federally qualified community health centers in Central California, I was often struck by how some patients would wait out symptoms while others would come in at the first sign of a fever. I returned to graduate school to better understand how people make these sorts of personal health decisions.
Recently, I've been exposed to an entirely different type of consumer decisionmaking — asking people to help figure out how to stop wasteful and unnecessary medical care. It never occurred to me that the average person would care about the overuse of medical services and have views that could help health care leaders approach this problem. But engaging consumers through a process called deliberation has been eye-opening. It has fired my interest in how the public's voice can be brought to bear on health care policy issues that affect individuals as patients, taxpayers, and members of society.
Doing What Works session in Oakland on October 1, 2015
As part of Doing What Works, a project funded by the California Health Care Foundation and the Kaiser Permanente National Community Benefit Fund, I have been traveling around the state listening to people share their ideas on what actions could be taken to reduce harmful and wasteful health care. Health care leaders estimate that 30% of health care dollars are not used productively. With my colleagues at the Center for Healthcare Decisions, we're hosting a series of 10 half-day sessions during which we ask participants to take on the role of policymakers and consider what they would do to fix this problem, which costs Californians billions of dollars in extra health care premiums, out-of-pocket costs, and taxes for publicly funded health coverage.
Unlike focus groups, these deliberative discussions ask panelists to help solve a problem, not just comment on it. We present the group with real-life examples of overuse and misuse in our medical system — use of antibiotics for adult bronchitis, MRI scans for low back pain, cesarean sections for low-risk deliveries, and a costly cancer drug that yields minimal benefit — and asked them to choose from a list of policy actions that address the problem. Then they discuss and debate the reasons that some approaches may be preferable to others.
Racial, Geographic Balance
Participants reflect a racial and geographic cross section of Californians with low-to-moderate income. In our most recent session, held in Oakland, the dozen participants included a young white woman who is a new mom; a middle-aged black man whose wife had been injured at work; a young Asian man with four children, one of whom has a heart condition; a soft-spoken black grandmother; and a middle-aged Asian man who takes care of his elderly parents. All were Medi-Cal members, and all were glad to share their opinions.
In each session, participants discuss and consider four approaches to addressing overuse and misuse:
- Influencing demand: reducing patients' requests for this service
- Influencing supply: reducing providers' offering or prescribing of the service
- Changing coverage: reducing payers' willingness to pay for the service
- Making no changes: solutions might be worse than the problem
Not surprisingly, participants had a lot to say about reducing patient demand. One man pointed out that people may be asking for services they don't know much about. They may hear about a medical procedure through friends, news media, or advertising and be convinced that this will resolve their ailment. One man in the Oakland session explained: "As a society, we're sports fanatics. I didn't know what an MRI was until I heard about these athletes getting them. So even though we don't know what it is, we're being influenced because of what's being projected on the media."
"We Own Ourselves"
Some participants believed that if patients really want a service that is not medically necessary, they should shoulder most of the cost. One person said: "It is our health and our bodies. We own ourselves, ultimately. If we don't take more responsibility financially, everyone else will pay for it." Another summed it up succinctly: "When it comes out of your pocket, you'll think twice."
Participants reflected on reasons why patients are quick to demand treatment: "Patients will always ask for whatever they can because they want to be 100% sure." Another equated the issue with a local behavior change campaign. "Just like the bags in the grocery aisles. Now, if you want to use one, you have to pay 10 cents. The only reason why they used them is because they got it for free. If they really need [the treatment] then the doctor will give it to them. But if the patient only thinks they need it, they will have to pay for it themselves."
Participants in Oakland were inclined to reduce overuse by influencing patient demand, but in some situations they felt pressure should be put on physicians themselves. We are learning where the public feels the responsibility for reducing overuse should rest (with the patient, the doctor, or the health plan) and what strategies they believe are most appropriate. Their responses often differed depending on the problem at hand. For example, the overuse of antibiotics drew reactions that were different from the overuse of c-sections. For some, any solution will be worse than the problem.
Learning Where the Public Draws the Line
When we're done, we will have heard from residents of Fresno, Los Angeles, Oakland, Sacramento, San Diego, and Ukiah.
The findings, to be published in 2016, will be a vital contribution to two statewide efforts now underway. The first is the Statewide Work Group on Reducing Overuse, spearheaded by CalPERS, Covered California, and the Department of Health Care Services (DHCS). The second is affiliated with the American Board of Internal Medicine's Choosing Wisely initiative, a national effort to raise awareness about and prevent wasteful or unnecessary medical tests, treatments, and procedures. With a grant from the American Board of Internal Medicine, the Integrated Healthcare Association is leading a project using the Choosing Wisely campaign to target specific reductions in overuse.
Although complex health policy issues are not easy topics to bring to the general public, the Center for Healthcare Decisions has for more than 20 years been using credible, nonpartisan deliberative processes to ensure that the layperson's voice is not left out of these important discussions. Efforts like this will make it easier for public and private sector stakeholders to collaborate on policies that deliver higher-quality care at lower costs.