Five questions about physicians’ role in CDHPs
Most primary care physicians don’t understand consumer-driven health plans (CDHP) and aren’t ready to provide healthcare financial advice to patients, according to “Are Primary Care Physicians Ready to Practice in a Consumer-Driven Environment?” a study published in the October American Journal of Managed Care, and The Impact of Consumer Directed Healthcare on Providers, a white paper published in October by Fifth Third Bank.
The findings show barriers that health plans will have to clear for CDHPs to effectively increase quality and lower costs.
Physicians play an important role because studies show patients trust their doctors more than health plans and employers, and point-of-care decision-making is a key component to containing costs and choosing the most cost-effective care.
Craig Evan Pollack, MD, MHS, a Robert Wood Johnson Foundation clinical scholar at the University of Pennsylvania in Philadelphia and coauthor of the study, says the researchers wanted to gauge what physicians think of CDHPs, adding that although previous studies have focused on the patient and consumer response to CDHPs, researchers have not explored the physician part of the equation. “I think it’s an open question about what role the doctors should play in these plans,” says Pollack.
Are docs ready?
CDHP enrollment has grown tenfold in three years. About 20% of employers offer the plans, and the U.S. Department of the Treasury estimates CDHP enrollment will reach 25 million in the next decade, according to “Are Primary Care Physicians Ready to Practice in a Consumer-Driven Environment?”
Yet only 48% percent of physicians surveyed are ready to discuss medical budgets with patients.
The study found that 43% of the 528 physicians who responded to the survey said they had “low knowledge” of CDHPs, and about one-third said they had “low knowledge” of how medical savings accounts function. (See Figure 1 on p. 2 of the PDF.)
About one-half of those surveyed think of CDHPs favorably. (See Figure 2 on p. 3 of the PDF.)
Physicians with CDHP enrollees in their practice were more prepared to discuss costs of medical care, cost-effectiveness of medical care, and medical budgeting than those without CDHP members. (See Figure 3 on p. 3 of the PDF.)
More than two-thirds of the physicians were ready to advise patients on the costs of office visits, medications, and laboratory tests, but less than half were prepared to advise on the costs of specialist visits and hospitalizations. (See Figure 4 on p. 3 of the PDF.)
Physicians with CDHP patients were more ready to discuss the costs of medications than those without CDHP members, but were no more ready to discuss the costs of services outside their practices.
On the plus side, more than 70% of physicians said CDHPs decrease care that is not clinically indicated. (See Figure 5 on p. 4 of the PDF.)
Liz Boehm, principal analyst at Forrester Research, Inc., in Cambridge, MA, says getting physicians involved in CDHPs will be difficult without health plans providing training and rewarding them for financial consultations. The variety of health insurers and plans make it difficult for doctors to sort out costs, deductibles, and bene-fit limits and simultaneously keep abreast of the latest in medicine.
“It’s unrealistic to expect physicians to play a primary role there. I think the physician can help determine quality, but the cost-quality tradeoff is something the consumer has to make,” says Boehm.
Sander Domaszewicz, principal at Mercer in Newport Beach, CA, says having physicians deliver the message of healthcare finances holds promise, but there are barriers. “It’s hard to do because there are so many other things on their plate,” says Domaszewicz.
But having educated physicians who can serve as advocates for consumer-driven care can help health plans. For example, physicians can recommend less costly alternatives, such as x-rays instead of MRIs, when appropriate. CDHPs without physician participation have marginal cost reductions, says Domaszewicz.
Can docs trust quality data?
In addition to physician involvement, another component of CDHPs is transparency, which includes accurate quality and cost information so consumers can make informed decisions.
CDHP advocates say online resources will help physicians and patients consider costs and quality at the point of care. However, the study found doctors don’t trust the information. (See Figures 6 and 7 on p. 4 of the PDF.)
The study found that:
That lack of faith could lead physicians to “disapprove of their patients’ use of quality-of-care data, potentially creating tension in the physician-patient relationship,” the study’s authors wrote. “At the extreme, physicians may attempt to dissuade patients from using such data, causing confusion and consternation for patients facing difficult medical decisions. The severe physician distrust of quality data may also present a stumbling block for third-party payers trying to use these tools to direct patients’ use of medical services.”
Pollack says the quality measures may cause physicians to “feel judged” and worry about “profiling or unintended consequences.”
“As these plans roll out and more and more patients are encouraged to use quality information, there’s a potential for a lot of confusion,” says Pollack.
Less than half of the physicians in the survey agreed that quality-of-care information from these Web sites should influence a patient’s choice of hospital or specialist. Aetna and Humana are leading regional initiatives to provide price information, but point-of-care availability is still limited, according to the authors.
In The Impact of Consumer Directed Healthcare on Providers, providers interviewed spoke out about the problems with payer information. Eighty percent called the information “problematic” because it is “inaccurate, incomplete, untimely, or unavailable.” Of the remaining 20%, half said they are just beginning to implement the process that allows them to review the information with patients, which means a mere 10% of those surveyed believe they are getting the information they need from payers. “The recurring chief compliant is that it is difficult for providers to accurately know how much of patients’ deductibles have been met at the time of service,” the white paper states.
CDHP members are usually younger and more computer-savvy, which means they expect to control their healthcare costs by viewing bills, making payments, and scheduling appointments online. But many providers, especially small ones, don’t have those online capabilities. Those with online access started with online bill payment, according to the white paper.
Having online services reduces staff labor, freeing up employees to perform other functions such as eligibility checks and additional follow-up, the researchers wrote.
The most innovative providers have kiosks in their facilities to allow patients to determine their out-of-pocket costs. The kiosks also streamline patient interactions, reduce wait times, and increase patient satisfaction. Twenty-five percent of the practices surveyed have kiosks, and another 40% plan to add the technology. Those surveyed who do not have kiosks questioned whether the technology was worth the cost.
“Some providers have reported a reduction in front desk personnel through the use of kiosks, even in a relatively small physician practice,” according to the report.
The providers interviewed said the following two products could help them in this CDHP world:
An easy-to-use, accurate price calculator that predicts expected health plan reimbursement, subtracts that amount from the expected total billed amount, and estimates the patient’s payment responsibility by factoring in copays and deductibles
Forecasting tools that predict patients’ propensity to pay their bill by referencing a credit score or key elements of credit reports
Will docs feel conflicted?
CDHPs may unintentionally create a dilemma for physicians: Should they treat patients according to clinical factors or let nonclinical factors, such as coverage, cost, and ability to pay, play a role in their care recommendations? What will this mean for low-income patients who can’t afford a higher level of care?
Pollack released a study earlier this year that looked at the effect of CDHPs and patient socioeconomic status on physician recommendations for colorectal cancer screening.
The researchers found that socioeconomic status and deductible level affects physician recommendations for preventive care, and covering preventive services and exempting them from medical savings accounts can help “mitigate the impact of high deductibles and [socioeconomic status] on inappropriate recommendations,” according to Pollack’s study.
There is also a potential legal issue for physicians. “From a legal perspective, it remains to be seen whether recommending less expensive, less effective care will leave physicians vulnerable to malpractice claims,” the authors of Pollack’s study wrote.
“I think there are many open questions for physicians taking care of patients in these plans,” says Pollack. “I think one of the goals of our study was to highlight some of the tensions that may exist for physicians and for patients who are covered under these plans.”
Are docs ready to dole out financial information?
Many physicians are not ready to give healthcare financial advice, and the shift to higher copays and deductibles is pushing patient debt onto practices and providers.
At the same time, consumers don’t understand their high-deductible plans and are miffed when their physicians’ offices ask for payment. Health plans and employers aren’t properly explaining high-deductible plans, according to the white paper.
“The general finding was that all of them believe that they needed to be prepared for the coming growing tide, if you will, of more and more consumers paying out of their own pockets, and they needed to prepare themselves for front-end processes to handle that,” explains Nav Ranajee, vice president of healthcare solutions at Fifth Third Bank in Cincinnati and coauthor of the white paper.
Ranajee says many consumers don’t understand CDHPs. They are used to their insurer paying for care and not having to fork over cash at the physician’s office. This is a dramatic shift from the managed care system that Americans have come to expect, in which the insurer pays the lion’s share of costs associated with office visits and procedures, he says.
The white paper researchers interviewed revenue cycle executives in hospitals, clinics, and physician practices to assess how CDHPs are affecting providers.
Those interviewed said revenue derived from CDHPs is increasing, with the average revenue slightly below 3%. The researchers surmised the percentage is actually higher, but offices don’t know all of the patients in high-deductible plans because insurance cards often don’t provide that information.
Another effect is that bad debt write-offs are growing and causing collection issues for practices, which leads to increased staff costs. “While some providers see very little impact, others estimate that CDH write-off experience lies between 40% and 50%,” the white paper states.
Ninety-five percent of the interviewed executives said there is a need for higher staff skill levels and training because of CDHPs, with the biggest skill upgrades needed in the areas of registration and financial counseling. Nearly three-quarters of the providers interviewed have already started that process by adding staff members and implementing training.
Will banks help docs?
CDHPs are leading to greater roles for banks. Moving beyond traditional bank services to providers, banks now offer health savings accounts (HSA) and healthcare-specific revenue cycle management services.
Along with HSAs, banks are offering online consumer management tools for quality and pricing information and looking for ways to complement practices through payment options such as HSA debit cards, online payment portals, and patient financing programs, according to the white paper.
Ranajee says providers are approaching banks about how they can improve processes. He expects banks will play a larger role in healthcare financing as consumers pay more for healthcare.
Those interviewed for the white paper agreed banks will bring about higher levels of processing and efficiency. “But they expressed concern that banks will not adequately adapt to the unique requirements, considerations, and limitations related to processing healthcare financial transactions,” wrote the researchers. In addition to banks playing a larger role, physicians can benefit from the CDHP movement by offering financial services that allow them to stand out from competitors. “Providers agree that if they do not implement best practice solutions and offer alternative payment methods, then they will soon see an adverse effect on their cash flow and bad debt,” the researchers wrote.
“The more options they have, the increased ability for the provider to collect, and it will lessen the degree of pain for the patient,” says Ranajee.
CDHP services offered by providers
The more innovative revenue cycle executives interviewed are providing some of the following services, according to The Impact of Consumer Directed Healthcare on Providers, a white paper published in October by Fifth Third Bank:
Electronic verification of insurance eligibility and benefit coverage
Manual verification of insurance eligibility and benefit coverage via telephone calls to payers when electronic verification is unavailable or inadequate
Estimates of total expected charges and calculation of patients’ financial responsibility at registration
Calls to patients as early as possible to inform them of their payment responsibility
Staff and training increases to assist with financial assistance applications
Staff and training increases to assist with Medicaid applications
Increases in skilled staff and training to assist in getting early qualifications for charity care
Postponement of scheduled nonemergency treatment until financial obligations are addressed
“[Providers] don’t want to go through three different Web sites to pull down this information. It’s very cumbersome and takes away from the patient care,” says Nav Ranajee, vice president of healthcare solutions at Fifth Third Bank in Cincinnati and coauthor of the white paper.