Editor’s Note: This is part one of a two-part blog by several of the 2006-2007 Commonwealth Fund Harkness Fellows. The post below describes the extent to which these international scholars felt able to make meaningful choices in their interactions with the American health care system. In part two of their blog, which will appear on October 17, the authors propose changes to strengthen the ability of consumers in the United States to make health care choices.
Vidhya Alakeson (United Kingdom) is the lead author. Other authors include Mark Booth (New Zealand); Robbie Foy (United Kingdom); Bruce Guthrie (United Kingdom); Richard Hamblin (United Kingdom); and Ruth Lopert (Australia).
In November 2006, health ministers, senior policymakers, and academic experts from Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States gathered in Washington, D.C., for the Commonwealth Fund’s annual international health policy symposium. Reflecting striking differences in how health care is funded and organized, their discussions nevertheless shared a common theme: the role of choice.
With the exception of New Zealand, choice was high on the political agenda across all the countries present. It was portrayed as a way of giving patients greater control and, in doing so, driving up the quality of their care. Whether in the British National Health Service, in German sickness funds, or in the U.S. private insurance market, ministers agreed that encouraging patients to exercise choice would empower them, giving them greater confidence and control over their treatment options. In addition, it would drive out poor performers, force mediocre ones to improve, and reward high performers with a greater share of the market.
We attended the symposium as recently arrived Harkness Fellows in Healthcare Policy. Each year the Commonwealth Fund awards Harkness Fellowships to a group of mid-career professionals from Australia, Canada, Germany, New Zealand, and the U.K., enabling them to spend a year in the United States, studying the health care system and working with U.S. health policy experts.
By and large, we were used to health care systems that have traditionally offered less choice than the U.S. offers and where freedom to move between different providers has not been a policy priority. By providing us with comprehensive health insurance, our fellowships gave us the opportunity to experience at first hand a health care system where choice is paramount. We were curious to find out whether we would be motivated to take greater control of our care in the U.S. system than in our own systems, and what our U.S. experiences could teach us about the likely outcomes of expanding choice in our home countries.
It soon became clear that our opportunities to exercise choice were less straightforward than we had been led to expect. At times it seemed as if we had a lot of choice, when in reality we had very little. In Washington, D.C., for example, our health insurer’s Web site provided a list of over fifty in-network primary care physicians, but when we called to make an appointment, most were not taking new patients. We got to number twenty-five on the list before someone agreed to see us. By this point, the need to find a physician — any physician — overrode any consideration of the quality of the provider.
Even when choice was possible, it was difficult to exercise in a rational manner. Over on the West Coast, faced with a dauntingly long list of potential providers, one of us set out to choose a high-quality physician. Two hours of Internet browsing turned up limited data about health plans, health maintenance organizations (HMOs), and large provider groups — all irrelevant to the choice at hand. There was minimal information available on individual doctors’ registration and disciplinary history, both of which are markers of minimal competence rather than high quality; what information there was had to be paid for. Since none of this was particularly meaningful, the tried and trusted U.K. method of finding a family practitioner was employed: choose the one closest to home.
We also quickly found that the fragmented nature of the U.S. health care system, with plans having relationships with certain providers and not others, created unanticipated costs and financial risks to exercising choice. One of us was ambushed by an unexpected bill, after failing to check that a radiology examination was being done in-network. The assumption that it must have been since an in-network physician had made the referral to a provider in an adjacent office proved to be simply naïve.
Elsewhere, a compatriot arranging an immunization required by the school system had two options: a local family doctor who insisted on providing a well-child check before vaccination, or the local public health department, which offered the immunization alone. Being cautious, he checked the potential costs of each option. Depending on the extent of coverage, the cost of going to a family practitioner could vary by $150, and depending upon income, the cost of visiting the public health clinic could vary by $70. It took a thirty-minute phone call to the health plan to determine the full extent of coverage. Even with this “clarification,” neither provider could give sufficient information to weigh this small, but not insignificant, financial risk.
Indeed, we found that choice was typically accompanied by a level of bureaucracy and micromanagement that belied the rhetoric of market efficiency. At every stage, our choices were strictly governed by which providers were “in” our health plan’s network, which medications were on the formulary, and which procedures required preauthorization. Strictly speaking, preauthorization was the physician’s responsibility, but the financial risk of not checking fell on us. The bureaucratic burden of choice not only created uncertainty about coverage, despite being comprehensively insured, but also, as we discovered, imposed both financial and time costs.
To date there has been little in our collective exposure to U.S. health care to suggest that greater choice has increased our sense of control. More often than not, we found we were making choices to knit together different providers and fragmented parts of the system to guarantee access and continuity of care. Frequently we had to choose between different options, even when the choices offered were of little value to us, and often with little information to support informed decision making. Rather than giving us a sense of greater control, these forced choices served only to create a sense of uncertainty.
Part two of this blog will appear on October 17.