Professional Point

In the absence of any organized health-care reform effort by Congress, "consumerism" appears to be gaining traction in the health-care marketplace. This concept means different things to different people, but it usually means empowering consumers to make decisions about their health care rather than deferring to a "third party." It also generally entails providing consumers with information and decision-support tools, along with financial incentives, rewards and other benefits that encourage involvement in decisions about their health care.

"Consumer-driven health care" is, to date, the label most frequently attached to employer-sponsored benefit plan designs that attempt to incorporate principles of consumerism. An estimated six million individuals (of a potential 180 million) in the employer-based health system now participate in consumer-driven plans, but significant increases are predicted for the next few years. The jury is clearly still out as to whether these plans can lead to optimal, cost-effective care. It is important, nonetheless, for practitioners to understand what is happening with consumer-driven plans and how best to assure the inclusion of psychological services in whatever form consumerism takes.

Proponents see consumer-driven health care as a way to bring the power of informed consumer decision-making to health care in order to remedy the distorted purchasing decisions and uncontrollable inflation in a system where someone other than the patient is paying the bill. Some think consumer-driven health care offers a way of replacing managed care's efforts to limit the "supply side" of health care with incentives that influence and control demand for services.

The version of consumer-driven health care most often seen today relies on a health savings account (HSA) combined with a high-deductible insurance plan. In most instances, both the employer and employee contribute tax-free dollars that can accumulate from year to year. Money in the account can be used to pay for plan deductibles,co-insurance or co-payments, which the employee historically has paid with after-tax dollars. Money in the HSA can also be used to cover nonplan expenses recognized by the IRS as "qualified medical expenses." The employee is responsible for all expenses up to the deductible, typically $2,000 or $5,000. In theory, this structure positions the employee to control decision-making about how to spend his or her health-care dollars and, importantly, to choose the desired health-care services.

Opponents of consumer-driven health care point to significant problems with HSAs. They are not curbing health-care costs. They are of no help to low-income or uninsured individuals. HSAs are built on fatally flawed assumptions about consumer behavior regarding health care. For example, people diagnosed with a life-threatening disease would not look to price as their first concern. People do not "shop" for emergency care. And research on cost-sharing shows that when people have to pay more out-of-pocket, they either delay or forgo treatment altogether.

Opponents of HSAs believe they will cause further fragmentation in the health insurance market. The healthiest individuals will gravitate to HSAs, while sicker people will remain in traditional insurance plans, causing premiums to rise and employers to stop offering plans. In the end, critics say, HSAs drive people out of the group insurance market and into an individual insurance market that is ill-equipped to handle the shift.

Even supporters of consumer-driven health care agree that the individual insurance market needs alteration if it is to be part of any effective health care system transformation. But they are also quick to point out that high-deductible plans with HSAs are far from the whole story with consumer-driven health care. Supporters say consumer-driven health-care is about changing incentives that influence all participants in the health-care system. It is intended to meld with other anticipated health-care reforms, such as increasing information technology, not to be implemented in isolation. And its ultimate focus is behavior change leading to wellness, prevention, early intervention and better disease management. It is here that psychology's unique expertise in the link between health and behavior must be primary as consumerism unfolds.

Whether consumer-driven health care can mature beyond the limited HSA version seen today and whetherit can have a positive impact is yet to be determined. Meanwhile, strong forces are converging that will likely propel its continuing adoption. Clear realization of a broken health-care system, baby boomers' demand for consumer empowerment, and employers desperately wanting to shift their responsibility for employee health care are all contributing to the growth of consumer-driven health care. Add the fact that those who oppose government control as a way to solve the health-care system's problems view the consumer-driven approach as the last opportunity to stave off a government-driven solution, and the stage is set for a development with which our profession must contend.