There is a massive untapped resource in health care: consumers. Like a sleeping giant, unaware of its size and power, consumers have yet to realize what effect they could have on the system simply by asking questions or making choices. It’s not certain when, or if, consumers will awaken.

Consider this finding from our recent online survey of consumer opinions (1). The survey asked a national sample of about 3,000 employed individuals about where they get health information and how they use it. Only half of all respondents ever remember a doctor offering them multiple treatment options from which they could choose. Let’s remember the evidence: individuals who participate in medical decisions have better outcomes, better recovery, lower costs and higher satisfaction than those who don’t (2). Against this backdrop combined with national agencies promoting shared decision making with their “Questions are the Answer” campaign (3), and the new Physician Ethics Manual (4) insisting that the patient should be the primary decision maker about options, this answer is disturbing. But not surprising.

The subtle distinction is this: consumers remain recipients of care rather than participants in care. Sitting in an examination room, waiting for a doctor, possibly half-naked, not feeling well, patients are more inclined to say “ok, whatever you say” than “tell me what my options are.”

Despite huge advances, the environment is still not conducive to active participation. For most consumers, the information revolution in health care has not yet arrived. By and large, most consumers still get their recommendations from friends and family and don’t spend much time or energy making comparisons. We surveyed and interviewed consumers about where they get their information, how much they know about price and quality, and what would make them choose a different provider. What we learned tells us a lot about the ways consumers are and—perhaps more importantly—are not actively involved in care decisions and what factors get them more involved.

Our observations do confirm the obvious: there is no such thing as a “typical” consumer. Opinions vary dramatically on everything from desired control over decisions, satisfaction with care, use of information, and loyalty to a specific provider. Consumers’ level of health literacy also varies. We conducted random interviews of “people on the street” about health care topics to hear what typical responses sound like. One look at these video interviews asking about price (5) or what quality means (6) reminds us just how unique each person’s perceptions and preferences can be. Their feedback also reveals how much our own experiences shape our views and our decisions about care.

The results also expose gaps between what consumers suggest they want and what actually happens. They tell us that the health care landscape is full of contradictions. Here are some examples:

• Most consumers want to play an active role in their health care decisions, but few are confident they can find information to select better quality or lower prices.
• Most say they would be comfortable asking about the price of care, but fewer than half have actually done so.
• Consumers agree that the quality of care varies across providers, but a minority have actually compared quality.
• When asked if they would switch providers to save money, the vast majority of consumers say they would, but, once again, very few have actually switched for that reason.
• Three-in-ten have experienced a medical error, but most still report they are satisfied with the care they get.

To the extent that we can generalize, these findings describe a population that often has interest in playing an active role in care and are willing to consider changing providers to save money and get better care. However, few take action to get information or make a choice based on what they learn. It is as though we are poised for a shift toward greater consumer involvement, but have not reached the tipping point.

Adding to the possibility that such a shift may occur in the future, the demographic attribute that was most associated with active information-seeking and choice making was age. More than one’s gender, marital status, region, or education, being younger made a person more likely to report higher use of online comparisons, greater desire to play an active role in care, and a greater interest in choosing different or better care options.

Besides the energy and curiosity of youth, there appears to be several contributing factors to why consumers often don’t take action:

• lack of confidence (few felt confident they could find better or less expensive care if they tried);
• discomfort with the role of a consumer (some were not comfortable asking their doctor about price);
• lack of experience (fewer than one-in-five had ever looked online for information); and 
• lack of motivation.

In the motivation category, financial incentives do matter. One of most striking findings was how much the amount of a consumer’s deductible influenced his or her likelihood of asking about the price of a service. For those with little or no deductible, about 35 percent had ever asked about the price of care; of those with a high deductible, over 60 percent had asked. When we combined all these factors in a model, we could predict who would ask about the price of care. For an older, lower-income person with a low deductible who feels uncomfortable asking the doctor about price, 15 percent would ask. For a young, highly paid person with a high deductible who feels comfortable asking, 75 percent would ask.

Still, the general rule seems to be a hypothetical desire to participate in one’s care, but limited actions to actually make that happen.

It’s difficult to predict which factors and messages are most likely to prompt widespread participation in care, or shift the norm from expecting answers to expecting options. Will it slowly occur in parallel to the observed generational difference in using mobile technology? Will it happen sooner as the wave of baby boomers demand better service in the face of declining health? Or will there come a point where care is sufficiently expensive for consumers and information sufficiently accessible that individuals realize they can choose a better, safer, or less expensive option right now, and do so?  We don’t know.

But, whether it happens sooner or later, slowly or quickly, it does seem to be the direction we’re headed.
 

References

1. Lynch, W. D., & Smith, B. (2011, fall). Altarum Institute survey of consumer health care opinions. Retrieved from http://www.altarum.org/files/imce/CCCHC_Survey_Extended_Report_123011.pdf.
2. Lynch, W. D. (2011, September 27).  Why advocate for consumer choice in health care? Retrieved from http://healthpolicyforum.org/post/why-advocate-consumer-choice-health-care.
3. Agency for Healthcare Research and Quality. Questions are the answer: Your health depends on good communication. Retrieved from http://www.ahrq.gov/questions/.
4. Emanuel, E. J. (2012, January 3). Review of the American College of Physicians ethics manual, 6th ed. Annals of Internal Medicine, 156(1 Pt 1), 56–57. Retrieved from http://www.annals.org/content/156/1_Part_1/56.extract.
5. Altarum Institute Center for Consumer Choice in Health Care. (2011, December 13). Care is costly. Retrieved from http://www.youtube.com/watch?v=c4E-SifFrh0.
6. Altarum Institute Center for Consumer Choice in Health Care. (2011, December 13). Considering care. Retrieved from http://www.youtube.com/user/AltarumInstitute?feature=mhee#p/c/4/2gARz-BUAso.

All postings to the Health Policy Forum (whether from employees or those outside the Institute) represent the views of the individual authors and/or organizations and do not necessarily represent the position, interests, strategy, or opinions of Altarum Institute. Altarum is a nonprofit, nonpartisan organization. No posting should be considered an endorsement by Altarum of individual candidates, political parties, opinions, or policy positions.