What Matters Most in Health Care May Surprise You

Too often the public gets a bad rap for failing to understand that you can't always get what you want -- in health care. But a study released this past week by the Center for Healthcare Decisions reveals a much savvier understanding that there is a big difference being paying for surgery for a knee problem so someone can play soccer better and paying for it so someone can walk again.

The Center study was funded by the California HealthCare Foundation. They contracted with the Field Research Organization to survey 1000 people by telephone in California, asking them to rate the importance of insurance coverage for 55 different medical conditions in 87 different vignettes. In addition to the telephone survey, researchers held 15 focus groups in different regions of California,with different types of respondents, to dig more deeply into the tradeoffs.

The public was asked about a variety of medical conditions,with different levels of effectiveness and different outcomes. Here is an example:

A 50-year-old man has severe nerve pain in his shoulder following an accident. There is a medication that works well for this type of pain but it is very expensive.

A 50-year-old man has severe nerve pain in his shoulder following an accident. The
only medication for this type of pain is very expensive and often doesn't work
very well.

Then the interviewers asked:

1) On a scale of 1 to 10 (10 being highest), what priority
would you give to cover this if you were designing a
health plan for a general population in California?

2) Given that the more that health insurance covers, the
more the plan may cost you and others, would you
want health insurance to cover this service or not?

How would you predict people answered the two questions above? The first vignette received a higher priority rating than the second. And 90% of the respondents recommended coverage for the the first case, but only 75% for the second.

The only difference between these two vignettes is the effectiveness of the treatment. Clearly, the public understands that treatment effectiveness is a meaningful factor in coverage decisions. This should be a wake-up call to policymakers concerned about public reaction to wasting resources on ineffective care.

What Matters Most.

For the purpose of healthcare coverage, these are characteristics of medical situations
that matter the most to most people:
• Problems that are likely to lead to illness, disease, disability or death if not prevented or treated.
• Problems that interfere with functioning that is essential for the most important activities of daily living (work,
self-care, family care).
• Problems that may bring much higher societal costs if not treated early.
Among these high-priority situations, people support coverage when:
• Less expensive or non-medical ways of treating the problem have been tried first.
• There is medical treatment available that is proven to be effective.

What Matters Some.

Medical situations that some people also regard as important for coverage:
• Problems that cause physical discomfort but do not interfere with major activities of living.
• Problems that bring personal distress to the individual.
• Non-medical ervices that are designed to help individuals become or remain healthy and fit.

What Matters Least.

Medical situations that fewer people regard as important for coverage:
• Problems that are unsightly but not physically harmful.
• Problems that delay or prevent individuals from pursuing recreational activities.
• Treatments that are requested by patients for convenience or to feel reassured.
• Problems that are not medically significant or would resolve over time without treatment.

As national policymakers like Senators Kennedy and Baucus think about how to construct a benefit package that is comprehensive but cost effective for all Americans, they would do well to read the results of this research. This research demonstrates that the public absolutely can differentiate between what matters most and what matters least when it comes to spending our health care dollar.

Comments

[askthepublic]

The best part about this study is that the average citizen was involved. Policymakers decide "what matters most" to patients, yet they often only listen to special interests. Instead, they need to give the public a chance to weigh in. This organization actually took the time to talk with people and learn from them. Not surprising that people can wrestle with complex issues and tough decisions when you give them a chance.

[historymatters]

I realize that our resources are not limitless when it comes to this. But I'm also troubled by the subjectivity that is imbued in the results of the study. For instance, people who think a problem that is unsightly but not physically harmful and thus are least important must not have ever seen a child with burn scars being teased by classmates. Obviously the burns are healed and the child is no longer in physical danger. But does this mean we should stop research into developing better skin grafts and surgical techniques to reduce the appearance of scars? Do we only treat people until they're ambulatory and stop there? So if a person loses a leg in an accident, they can get by with crutches but are not entitled to have insurance coverage for a prosthetic leg or a wheelchair?

I think most people, when they thought of an unsightly but not physically harmful problem were thinking of moles or large ears or some other cosmetic issue. Unfortunately, that is often not the case.

One other thing, the slant of the unsightly but not physically harmful problem is an indication of a continuing disregard for the important of mental health. To continue with this example, in American society, looks matter, and I can assure you that a person who has a permanent, very visible and livid facial scar is still dealing with health problems even if they physically do not have pain anymore.

[twohearts]

The main problem as I see it is that insurance companies are not to be trusted. Are they cost-effective? Most of the times no - really covering diabetes would cost money, but if diabetics were properly treated, it would end up costing far less!
I also think that children and perhaps the elderly themselves want too much treatment to keep them alive no matter what quality of life is.
I personally could never get insurance - never - until I was over 40 years old and REALLY needed coverage - luckily (?) I was able to get Medicare Disability. Then, through marriage, I got secondary insurance, even though it costs an astounding amount. I had a heart/lung transplant. Still, insurance companies but mainly pharmacies are upping my co-pays this year especially. Why spend so much saving a life and then removing the drugs needed to sustain that life?
I am watching the single-payer healthcare bill(s) very carefully. J.

[Conk]

No, what matters most in health care is that allopathic medicine is a FRAUD! A criminal fraud that exists, with regard to treatment of dis-ease, solely as a marketing agent for Big Pharma. It's obscene.

[PlaceboStudman]

The question should have been something along the lines of finding out just what is effective vs what is the disadvantages of the same treatment.

Take the example of marijuana for medical use. Most people shirk off the idea that marijuana is effective for so many more people than is believed, because the propoganda against it has been so negative in the past. However, anyone with any real medical sense (ie those without any moral or emotionally driven agendas) , and people who are being advised by people with any real medical sense know now that marijuana for medical use is highly effective for many ailments, where the current batch of pharmaceutical drugs are actually in many cases more detrimental than beneficial to a great number of people.

Same thing goes for "alternative medicine" therapies, massages, spas, european style baths. These therapeutic, yet not exactly medical treatments have been found to be MUCH more effective in lowering the incidences of certain chronic conditions, which end up lowering the need for traditional medicine, which will in turn lower the costs.

[Konnie]

here's a thought: go to canada, france.england. sweden, et al.......ask them what they would change
about their own system if they could.

then take what is best from all those tried and true systems.......and leave out what doesn't
work in those systems.

seems like a no-brainer to me.

[Linda Bergthold - Huffpost Blogger]

Perhaps I should clarify a few things about this study. Several commenters have mentioned focus groups somewhat disparagingly. The focus groups were only used to amplify what was discovered in the telephone survey, which was administered to a randomly selected group of Californians. The telephone survey findings are the ones that are mentioned here. The focus group findings only helped researchers to better understand some of the survey findings. Secondly, in the 87 vignettes, there were many examples where the respondents' rankings differed much more strongly than in the pain medication example, showing that the public understands you can't pay for everything. If you are truly interested in this study, you should check it out on the Center for Healthcare Decisions website.

What is somewhat surprising is the consistency of the rankings among the 87 vignettes as to what matters most -- and what matters most is covering treatments that work, that avoid future illness, that help people function more effectively in their daily lives. Respondents rejected treatments that are for cosmetic improvement or can be dealt with by lifestyle changes, such as diet or exercise. People do understand that there are limits to what we can afford, and we have to take some personal responsibility for our own health and health care.

[intelliwoman]

What matters most in healthcare is that everyone has access.

Period.

(From a person with diabetes who has no access)

[PlaceboStudman]

What matters is that everyone has access to high quality care. I have a real problem with the idea of giving people care that isn't at its highest quality, and right now, our health CARE system, independant of the cost is disastrously low quality

[LeftRight]

Unless of course you are willing and able to pay the ungodly sums to get the best health CARE in the country...

[elmerfude]

The best way to cut health costs is for Americans to take some individual responsibility by cutting out the chips and fries, avoiding Burger King and McDs, walking 30 minutes a day, cutting out the sugar and eating a salad once in awhile. This would save a lot of money in the areas of chronic disease like diabetes, heart attacks, strokes, high blood pressure, high cholesterol, etc.

[historymatters]

I think that we lack accurate information about what really drives up health care costs. Your comments suggest (to me) that you think junk food and lack of exercise (and the likely resultant problem of being obese or overweight) are what cost the most. I think that cancer, accidents that cause serious traumatic injuries, and long-term nursing care for people with Alzheimer's (or other debilitating diseases that affect mental acuity much more than physical health) must be extremely expensive to deal with. It is hard to make a sound judgment of the situation without having accurate data on which to base the judgment. If that kind of data is readily available, why don't we hear about it more? If it's available, does anybody know where it can be found on the Internet?

[calibeep]

It's trendy to blame the patient, but we are spending much more per capita than any other nation does and yet leaving many of our citizens completely uncovered as well as more that are undercovered.

At least 18,000 a year die unnecessarily due to lack of access to health insurance. So where is all that money going? You don't think that the 35% or so of administrative costs that private plans run, compared to about 4% for Medicare, makes any kind of difference, do you? Ever been to a pharmaceutical company dinner? I went to one with caviar, champagne, lobster, and lectures on how there is just no way to fund care for the uninsured. The next time anyone tells you pharms need all their money for research and development, ask them what their annual budget is for marketing. At least until very recently they used to give a lot of drug samples to physicians, albeit outrageously expensively packaged, which the docs could use to help their undercovered paitents, but now those are being phased out in favor of those stupid drug commercials on tv that most of us use for our time out to go to the bathroom and get something to drink from the kitchen.

What do CEOs of insurance companies make, including stock options and perks? Oh and they couldn't possibly have made any unlucky investments which they would be charging us to get themselves out of, like the banks are doing, could they?

[ntmessage]

Until we address COST and QUALITY, none of these ridiculous focus group diversions will make any dent in the system. When we pay 18% of GDP for mediocre Health Care while other large countries pay 7%-8% for far better care in terms of outcomes, all this baloney about who actually makes the decisions is meaningless rhetoric and only meant to divert attention.

The only question that needs to be asked in advance is what will be paid for; with certainty by my insurance and what is the outcome. PERIOD.

We do not need a dopey focus group to know that.

[publicdialog]

"Dopey focus group?" S/he says tthat the only question is what will be paid for. That is one of the big conundrums and I would argue that this country needs focus groups to understand what differentiates essential coverage from non-essential. If you actually read the What Matters Most report, it raises some of the big questions about what is essential. For example, the "dopey" focus groups had lots of discussion about whether reconstructive breast surgery after cancer was a high priority for insurance coverage or low priority because it was really just cosmetic surgery.

As a society, we have a lot of work to do in thinking through these challenging questions. And if you believe we can simply cover everything that is possible, then you should not be surprised that insurance is too costly.

[ntmessage]

Dont think so.

Focus groups will only address the demand side of the issue and ignores the cost and frankly the quality. These product focused activities in a bloated system with too many products, many of which are unneeded including rehashed medicines designed to maintain patents are part of the problem. Unless we stop this nonsense, we will never get anywhere. This report is by insiders and people that really do not want to change the system for the better.

Cherry picking a success within a mammoth of a system and disastrously expensive costs is disingenuous for sure. We need hard metrics and hard decisions based on the patients, not how to parcel Health Care because we want to save an immensely archaic infrastructure, HMO’s, Insurance companies and the like that add no value whatsoever to Health Care.

This post is about administration of health care where we already know wastes 30% - 50% of every health care dollar. I know that God Complexes are an issue with some practitioners, now administrators as well? This is criminal.

As a society we must measure outcomes and costs. Large countries pay twice what we do with better outcomes.

[JohnFromCensornati]

"The only difference between these two vignettes is the effectiveness of the treatment. Clearly, the public understands that treatment effectiveness is a meaningful factor in coverage decisions."

From the example you gave, how is it clear that more than 15% of the public understands that treatment effectiveness is a meaningful factor in coverage decisions? 75% said that the ineffective medication should be covered.

[LeftRight]

He said first that people gave a higher priority, AND that 15% more people felt that it should be covered at all!

[JohnFromCensornati]

"And 90% of the respondents recommended coverage for the the first case, but only 75% for the second."