I have a book sitting on my desk at home called, “Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer,” by Shannon Brownlee, a journalist who’s been writing about health care policy issues for quite some time. I’m going to read it — soon — maybe in between my kids’ games and my day job. I don’t know her — and I’m sure in her mind, my industry — and guys like me — are a big part of the problem. I’ll take my lumps. That’s okay. Because someday, somehow, we need to get over this “more” thing that dominates the way we think about health care.

Three quick examples…

1) A few years ago, Harvard Pilgrim began requiring physicians’ offices to notify us when they ordered non-emergency high end radiology services (MRIs, CT Scans, PET Scans), primarily because it was clear to us that these tests — which are pretty expensive — were being ordered without adherence to the established clinical guidelines. This decision to require notification (and a rationale), but no move on our part to either approve or deny payment, was met with a lot of unhappiness in the provider community. The basic message seemed to be that by inserting a notification process, we would be, in effect, denying access to needed services for our members in an outlandish and ridiculous way.

Three years later — we’ve learned three things. First, we were ahead of the curve. Every health plan in America does this now — many far more aggressively than we do. Second, the rate at which tests were ordered dropped — a lot — when we first required notification. Third, even after the drop in ordering, many, many tests were still being ordered outside/against the clinical guidelines. And along the way, we also learned that too much exposure to these tests was BAD FOR PATIENTS.

2) Back in 2006, the city of Boston hosted the Democratic National Convention. This was a big positive deal, but the arrival of tens of thousands of visitors to Boston scared many people who lived in the Greater Boston area, and they chose to stay out of town during that week. As a result, almost no one went into Boston that week — unless they were involved in the Convention. It was weird to see the empty highways coming in and out of the city, and the newscasts from the empty sidewalks of downtown.

Harvard Pilgrim also incurred far fewer medical expense claims from hospitals and physicians who operate in Boston during that week than we have during any other week in recent memory. In other words, the concerns about traffic and crowding not only kept a lot of people out of the city, but reduced the use of the city’s health care system by Harvard Pilgrim members during that week as well. We kept waiting for the non-use during that week to pop back up later on, but it never did.

3) Many health plans, including this one, have incorporated deductibles and tiered co-pays into our product designs in recent years, to encourage the use of less expensive services. In the pharmacy arena, it’s worked. Generic utilization when we first began our tiered co-pays for drugs has gone from 44% of all prescriptions to almost 70% of all prescriptions, and the growth in drug spending has gone from over 20% per year down to less than 10% (and in some cases, less than 5%). The “market” for drugs is working, Wal-Mart now has over 300 drugs available for less than $10, and the pharmaceutical industry competes on price in a way it never had to before tiered co-payments.

We’ve also designed plans that encourage the use of less expensive services, including our Best Buy plans, which cover most preventive services, but do encourage the use of some services over others. We think, generally speaking, that this is a good thing. More is not always better.

Anyway, some Harvard Medical School researchers (who — full disclosure — work in a department that’s funded in part by Harvard Pilgrim Health Care) studied the impact of our Best Buy plans on the use of breast, cervical and colorectal cancer screening by our members. Did the plan design — which includes deductibles — affect the use of preventive cancer screening services, or affect the choices made by members? The answers seem to be “no” and “yes.” Members enrolled in our Best Buy plans accessed breast, cervical and colorectal screening just as much as our traditional plan members did. So the answer to the first question is “no” — the plan design didn’t affect use rates. However, Best Buy members did choose FOBT (Fecal Occult Blood Testing) over a colonoscopy more often than traditional plan members did, which would imply a change in service selection. FOBT is covered with a co-pay (usually about $20), while the colonoscopy is subject to the deductible.

Some of us think this is a good thing. Faced with an economic trade-off, our members chose the less expensive, less invasive — but perfectly acceptable alternative to a colonoscopy — but continued to access the screening service as often as they had under the richer plan design.

More is not always better. I need to read that book.

Posted by Charlie Baker in Health Care Costs, Health Care Quality