In 2015, the Pittsburgh Post-Gazette and Highmark Inc. cosponsored the Vital Signs Health Care Forum Series — four free, public events where a panel of experts discussed key issues impacting the U.S. health care system. Several panelists and Highmark Health experts have extended that conversation by sharing insights during and after the series on the Highmark Health blog.

After an event titled “What Is Health Care Consumerism?,” we interviewed panelist Abigail Neely, an assistant professor of geography at Dartmouth College whose research includes South Africa’s Pholela Community Health Center program, a community-oriented health care approach that began in the 1940s and influenced community health centers in the U.S. that still operate today.

Neely and other panelists raised questions about a “consumerist” mindset when it comes to health care. To get the inside view on this topic, we spoke with Tony Sciulli, a Highmark Inc. senior client marketing consultant whose roles over the past 16 years have been closely tied to efforts by the health insurance industry and individual employers to develop a more consumer-centered approach to health coverage.

Keep the conversation going by posting your comments on consumerism at the end of the article!

Don Bertschman (DB): How has your career intersected with the trend toward consumer-driven health care?

Tony SciulliTony Sciulli (TS): A few months after joining Highmark, I ended up on the team that wrote the business guidelines for the company’s first health plan member website. This involved not only thinking about what the business wanted to include, but anticipating what health plan members would be looking for on a website.

The next thing I got involved with was explaining newer product offerings, particularly health plans with spending accounts, to our employer clients and their employees. Becoming a subject matter expert on spending accounts was really my big step into what we think of as consumer-driven health coverage. That eventually expanded to include our Care Cost Estimator, the provider search directory, and all the tools and information that help individuals get the most out of their coverage.

At one point, I also did work trying to round up large retail vendors to partner with us on incentives for wellness programs. In the work I do now, we help employers to tie all these consumer-centered tactics together in a good strategy. I sometimes say our work comes down to getting people to feel better, spend better and think better.

DB: In terms of consumerism in health care, what are the most positive changes you’ve seen over the 16 years you’ve worked here — and where do you see the biggest need to continue improving?

TS: What’s funny is my answer is the same for both. The biggest development is providing individual health plan members with access to the cost of services. From our point of view, that started when our Care Cost Estimator was introduced. It initially provided cost estimates for about 160 different procedures, and it’s now expanded up to 1,600 procedures. It’s an estimate, but it’s location-specific according to the zip code, and it factors in real-time information about your deductible, so you really get a good idea of what you will owe. That information was just not available in the past.

I liken it to buying a car. In the past, people walked into a dealership to buy a car and they had no idea if it was a good deal or not. Now you can go on the internet and know exactly what a dealer paid for the car — I think that’s where we’re heading with health care.

Care Cost Estimator comparison

Highmark’s Care Cost Estimator allows health plan members to do a side-by-side comparison of a procedure at different facilities. Here we see how you can save money by getting certain tests in a doctor’s office or stand-alone facility rather than in a hospital.

Now, the other side of answering your question — more cost information exists today than even just two or three years ago, but a lot of cost information is still not accessible. What’s out there has been helpful, and it’s raised awareness about the importance of issues like checking the Explanation of Benefits (EOB) you get from your insurer to make sure it matches the invoice from the physician, and knowing that standalone facilities for X-rays and lab work will usually be less costly than the same test in a hospital. But there’s more progress to be made — so, the best improvement for consumers is also the area where we need to keep improving.

DB: More cost information may be out there, but not everyone uses it. The success of this kind of consumerism seems to depend on shopping — but how do we get people to become “good shoppers”?

TS: That’s a great question. First, what’s going to drive more people to use this kind of information and use a tool like Care Cost Estimator is that, with today’s health plans, their wallets are impacted. For so long, most people’s coverage had low out-of-pocket costs. The trend has obviously shifted in the opposite direction in recent years, and it’s going to continue in that direction.

Employers are turning toward plans with higher deductibles and cost-sharing because they are trying to cut their costs. The other side of this is that more clients are opting to use private exchanges, and there are also all the individuals now buying their own insurance on the public exchanges. That means more individuals are concerned about the upfront cost of a premium — and if people want cheaper plans premium-wise, inherently that means accepting higher out-of-pocket expenses when you need services.

All this adds up to the consumer being more involved in paying for health care services, which drives more interest in comparing costs. I should add that quality’s also important. Getting the “cheapest” price for a procedure isn’t a bargain if there’s a problem and I am readmitted three times. I think health care quality measures have to be more readily available for people.

DB: Is education and health literacy another component of this? Don’t I have to understand how the health care system works to some degree in order to use the tools effectively?

TS: We do a lot of education on the basics for clients. But let’s be honest — even people who work in the industry have a hard time understanding how this industry really works. That said, the Care Cost Estimator doesn’t require that extra knowledge — you just type your procedure in and the tool calculates an estimate of your share of the cost that even includes how much of your deductible you’ve met. The tool factors in that most people don’t understand all details of health coverage, and what they want to know is the bottom line.

Care Cost Estimator summary for knee surgery

Highmark’s Care Cost Estimator doesn’t just provide an estimate of the cost of a procedure — it uses information about your specific account to tell you what you’ll pay out of pocket. For a complex procedure like a knee replacement surgery, it details what aspects of care the estimate includes.

DB: That’s what struck me the first time that I used the Care Cost Estimator. I liked that it was specific to me, and I didn’t have to run and look at a benefits book and do a bunch of calculations.

TS: Right; we’re getting you straight to that bottom line number. If you want to know more, there are tools and resources out there, and we certainly believe in continuing to educate people. But with or without a deep understanding of health insurance, the Care Cost Estimator lets you know how much your procedure will cost, based on your plan and your standing within that plan at that moment.

DB: At the “What Is Health Care Consumerism?” event, each of the panelists expressed some reservation about applying the word “consumerism” to health care. What are your thoughts on the pros and cons of talking about health care this way?

TS: From Open Enrollment when employees make a plan choice, to choosing where to receive services, to putting money into a spending account — I don’t know what else to call this if it’s not consumerism. Individuals are consumers of health care, consumers of the services we offer, consumers of the communications we send.

Detractors might point to a definition of consumerism as a kind of movement where consumers use their power in numbers to make a difference in some way. It’s a valid point — we didn’t have millions of people launch a grassroots campaign to create our health care system. But, in the end, that’s happening in many ways because individuals are more involved in decision-making. We have more ability than ever to become involved in our health care as consumers, and if consumers take advantage of that, it could drive additional beneficial changes because the market demands it.

Consumerism is, as far as I’m concerned, the ability to make choices — and in that sense, consumerism exists in health care to the extent that so many more choices now exist.

DB: Cost is clearly a factor driving the push toward High Deductible Health Plans (HDHPs) in the U.S. The theory is that if the individual consumer bears more financial responsibility, they will make decisions that help control costs. Do we have data showing that this approach is working?

TS: In the grand scheme of things, it’s probably a little early to tell. Consumer-directed health plans can’t solve everything. But some of our employer clients have had great experiences. We have a client that five or six years ago offered a Qualified High Deductible Health Plan along with two other options. Over a couple years, they eliminated the other options, so everybody that works there now has a qualified plan with a Health Savings Account (HSA). In the early years, their cost trend was significantly better with folks in the consumer-directed health plan compared to employees who weren’t — and their cost trend continues to beat the average national trend now that everyone has switched over.

They were an early adopter, and they did some things very well. For example, they funded the spending accounts upfront for the first three years — they told everybody, after a few years, we’re not going to fund it, so get in now and we’ll give you money to build up your account.

DB: That’s a great approach. When I first chose an HDHP with an HSA, I was self-employed. It was the right choice for me — the lower monthly premium, the tax savings — but I didn’t have spare money to put into the HSA right away. This employer minimized that initial worry for its employees.

TS: Yes; if I remember right, the contribution they made was 80 or 85 percent of an employee’s deductible, which eliminated that fear of something happening on January 1 and now you have to come up with a lot of money before you’ve had time to get any saved.

DB: Some panelists also expressed concern that people will put off preventive care or early-stage care if they’re afraid of getting stuck with a high bill. So, instead of catching something upfront when it’s easier to treat, they wait — and their condition becomes worse, and drives up not only their costs, but the total health care system costs that we all share.

TS: To me, that goes back to education. Preventive care is covered at 100 percent by law now. And for High Deductible Health Plans, when they were introduced in 2003, preventive care was covered by law then — that part of the Affordable Care Act is a copy of what already existed for High Deductible Health Plans.

DB: I didn’t know that. But — there also seems to be some confusion about what’s preventive and what’s not. People go for a preventive wellness visit, which they believed is 100 percent covered, but then a doctor does some things during the visit that aren’t considered preventive care — and they get hit with an unexpected bill.

TS: Well, and that’s a shortcoming of the fee-for-service reimbursement model, right? So it’s good that Highmark, and the industry in general, is moving away from that toward a fee-for-value model where doctors and other providers are compensated based on results rather than the number of services they bill.

But that’s also an example of why education of the individual consumer needs to be a major push, and not just from insurance carriers and employers, but at the government level, too. Let’s make sure people know right away — now that you have coverage, here’s what you can do to take care of your health and manage costs, and here’s what to watch out for. It needs to be a team effort to get that information out there, and the team includes the corporate world, insurers, the government, the physicians and hospitals — everybody.

DB: That’s a great sentiment to end on. At all these forum events, and in the other interviews we’ve done, that’s one thing I keep hearing: It’s tempting to work on our corner of the health care system, and criticize other corners — but any system only works effectively if all the stakeholders align on key goals.