INBW42: A Philosophical Rabbit Hole of Considerations for Plan Sponsors and Others

Episode Transcript
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Stacey Richter (00:00):
Inbetweenisode, "A Philosophical Rabbit
Hole of Considerations forPlan Sponsors and Others".
American Healthcare Entrepreneurs andExecutives You Want to Know, Talking.

(00:21):
Relentlessly Seeking Value.
There have been two episodes lately thathave sent me down a rabbit hole that
I wanted to bring to your attention.
Now, disclaimer, I knowyou people, you're busy.
You listen on average to like 26minutes of any given episode, so
yeah, look at me being self aware.
I say all this to say, welcome tothis inbetweenisode otherwise known

(00:41):
as The Rabbit Hole, but it's like a20 something minute rabbit hole, not
a day and a half retreat, so just bekind if you email me and tell me I
forgot something or failed to dredgeinto a nuance or a background point.
It might be that I just couldnot manage to pack it in.
This rabbit hole really, really mattersfor anybody creating benefit design.
It really matters for anybody tryingto optimize the health that can be

(01:04):
derived from said benefit design.
It also probably matters for a wholelot of operational decisions involving
patients or members, nothing for nothing.
But it really matters for anybody tryingnot to, by accident, as an unintended
consequence, hammer plan members orpatients with some really blunt force cost
containment measures that do a lot of harmin the process of containing costs, or

(01:27):
flip side, accidentally cost a whole lotbut don't actually improve member health.
Nina Lathia kind of summed up thiswhole point or gave an adjacent thought
really eloquently in episode 426.
She said there's better or worseways to do things and doing the
worst kinds of cost containmentmay not actually contain costs.
You squeeze a balloon and that worksgreat for some like pharmacy vendors who

(01:50):
don't really have any skin in the game.
See me using the skin in the game termfor other people besides plan members?
That's some really good foreshadowingright there, by the way.
So squeezing the balloon works forsome when they don't have skin in
the game, in the place where the airgoes when you squeeze the balloon.
Like a pharmacy vendor who makes itsuper unaffordable for patients to get
meds so the patient doesn't take theirmeds and winds up like in the ICU.

(02:13):
Or the patient's formally controlledwith meds condition that is now
newly uncontrolled and requires allkinds of medical interventions to get
said condition back under control.
Like these are the reasons andthe why behind why some cost
containment efforts don't actuallycontain costs at the plan level.
But not at the vendorlevel, you see what I mean.
Most pharmacy vendors don't get penalizedif medical costs wind up going up.

(02:37):
And I'm picking on pharmacy vendorsa little bit here, but it's true
for a lot of siloed entities.
But, you know, balloon squeezing canalso work actually at the plan level.
If where the air goes, it's toa place where the member or the
patient has to pay themselves.
Like if there's a huge, I don't know,max out of pocket or deductible,
does it really matter to a verymercenary plan that's running

(03:01):
on a very short time horizon?
Do they really care that plan ifthe patient's formerly controlled
condition gets uncontrolled?
Maybe not, I guess, as long as itdoesn't cost more than like the max
out of pocket that the patient is onthe hook for, for any given plan year.
So, yeah, again, there are betteror worse ways to do things, and a
lot of questions kind of add up to,what kind of plan do we want to be?

(03:23):
What are our values and doesthe plan align with them?
But that's not the rabbit hole I wantedto go down today, the aligning with our
values rabbit hole, so let us move on.
The Relentless Health Value episodethat kicked off the rabbit hole
for me on multiple levels was theshow with Bill Sarraille about
copay maximizers and accumulators.
And don't get me wrong, that isa complicated topic with lots

(03:45):
of pros, lots of cons, and I amnot weighing in on the inherent
lawfulness or value of any of this.
I am also not weighing in on the factthat there are forthright and well
run maximizers, and really not goodones, which cause patients financial
foreshore and possibly clinical harm.
But not talking aboutthat right now at all.
Go back and listen to the show withBill Sarraille if you are interested.
Where my down the rabbit hole spiralstarted was when I started noticing the

(04:12):
very, very common main plan pushbackthat was given right out of the
gate so often when talking about theproblems that any given plan sponsor
has with these pharma copay programs.
That if these pharmacopeia card dollarscount toward the plan deductibles, then

(04:32):
the patient's deductible gets met andthe plan member will then often overuse
health care and cost the plan excessivedollars from that point forward.
So again, if you ask any given plansponsor what I was going to say their
main issue, but a main issue thatthey have with these pharma copay

(04:54):
programs, that's going to be it.
That if these pharma dollars counttowards the plan deductible, then the
patient's deductible is met and fromthat point, henceforth, the patient goes
nuts and overuses healthcare servicesand it costs the plan a lot of money.
The second episode causing thisrabbit hole to open up is the
one coming up actually with Dr.

(05:15):
Scott Conard.
So check back in a coupleof weeks for that one.
But in the show with Dr.
Conard, we get into the impact ofhigh deductible health plans or just
big out of pockets, however theytranspire in the benefit design.
Both of these scenarios, by the way, themaximizer meets the deductible scenario
and the very, very high deductibleplan scenario are to blame, in other

(05:36):
words, for this rabbit hole of aninbetweenisode, so let's do this thing.
Let's talk about the moral hazardof insurance to start us off.
In the context of health insurance,if you haven't heard that term moral
hazard before, it's an economics term,and it is used to capture the idea that
insurance coverage, by lowering the costof care to the individual, because their

(05:58):
plan is paying for part of said care,by lowering the cost of care to the
individual, it increases healthcare use.
So you could see why this may be relatedto having a deductible fully paid or not.
Pre deductible, the plan is notpaying for a part of said care

(06:18):
or paying a much smaller part.
And after the deductible is paidfor, then the plan is paying for
a much larger percentage of care.
So moral hazard kicks in biggerafter the deductible is fully paid,
when the plan is paying for a biggerpercentage or a bigger part of the care.
So, before I proceed, let me justoffer, again, a disclaimer to the many

(06:43):
economists who listen to this show thatthis is a short inbetweenisode, so I am
100 percent glossing over some of thepoints that for sure have a lot of nuance.
For anyone listening who wants a thickpack of pages for background reading, I
will put some links in the show notes.
Because you see, a few weeks ago,my Sunday did not go as planned.
And instead of running errands, I woundup reading eight papers on moral hazard.

(07:04):
So my lack of groceries is your gain.
You're welcome.
I am happy to send you these links ifyou really want to dig in hard on this.
Okay, so moral hazard is the conceptthat individuals have incentives
to offer their behavior when theirrisk or cost is borne by others.
That's the why with deductibles, actually.
We gotta give patients skin in the gamebecause once a member has their deductible

(07:25):
paid, it's like member gone wild and theywill get all manner of excessive care.
Again, I hear that a lot from plansponsors, a lot, in all kinds of contexts,
but almost always, again, whenever theconversation has anything to do with
manufacturer copay card programs, and alot when it has to do with just, you know,
high deductible plans and what happenswhen the patient meets their deductible.

(07:46):
Once a patient or family has a fullypaid deductible, their medical trend is
like a spike, I hear over and over again.
And again, this is the reason why manyinsist, and again, no judgment here,
maybe they're right, I'm just rehashingthe conversation, but this is why many
insist the moral hazard of lettingpeople have their deductible paid for
them by pharma or whatever, is thereason why some believe it is imperative

(08:07):
to have maximizers or accumulatorswhere pharma dollars can absolutely
not apply to patient deductibles.
Because then we have sick patients whonow have their deductibles reached, who
have very few financial disincentivesto go seek whatever care they want.
Right.
Moral hazard has entered the building.
I've beaten this point todeath, so let's move on.
One time, I asked a plan sponsor, whatexactly is it that these plan members

(08:31):
are going wild spending plan money ononce their deductible gets paid off?
And he said, well, you know, they go gettheir suspicious looking moles checked.
Did you hear that silence just now?
Yeah, that was my reaction.
I don't know.
I would consider getting suspiciousmoles checked, kind of, high value care.

(08:52):
There are posters all over the placesaying, if you have a suspicious
looking mole, it might be melanoma.
Cancer.
So you should get ahead of thatbefore you have a metastasized cancer.
I'm no doctor, but yeah, thisfeels like high value care.
So let's just, in arguendo,say it is high value care and

(09:12):
follow this thread for a sec.
Once members reach theirdeductible, let's say they run
around and get high value care.
Care they actually need but haven'tgotten before because they couldn't
afford it earlier or were putting itoff until they saved up enough, right?
Like, this is the other sideof the moral hazard coin.
If patients delay or abandon care, andby the way, there was a survey, it's

(09:36):
in the Wayne Jenkins show from a whileago, but 46 percent of patients with
commercial insurance these days havedelayed or abandoned care due to cost.
But if they delay or abandon carethat is high value and medically
actually necessary, and they putit off or abandon that high value
care because they cannot afford saidcare, Then yes, we have, again, the
opposite of the moral hazard problem.

(09:57):
We have members paying a wholelot for insurance that they cannot
afford to use, they're functionallyuninsured, and it's not going to end
healthfully if they need high valuecare and they're not getting it.
It's not.
Functionally uninsured patients whohave chronic conditions that really
should be managed will, as per evidence,wind up with health problems if those
chronic conditions are not managed.
I read another studyabout this just recently.

(10:17):
If I can find it, I'll linkto it in the show notes.
This is why members with chronic diseaseson high deductible health plans tend
to have worse health, by the way.
Now, I need to say, same rulesdo not always apply for healthy
patients who, at least at this point,don't need regular health care.
But do keep in mind, asit comes up in the Dr.
Scott Conard show, 30 percent of patientswho think they're healthy, they feel fine,

(10:40):
actually they are not fine and will becomesick and costly in the coming years.
So yeah, tune back in for that discussionif you are interested, but you get
the gist of this whole thing, right?
So that's scenario one as to whatpatients may choose to buy once
they're in the moral hazard zoneand have met their deductible.
They go get high value care.

(11:01):
So, let's move on from the high valuecare case study where patients reach
their deductible and get high value care,or they haven't met their deductible
and fail to get care they actually need.
I want to circle over to the othermoral hazard potential situation.
Patients who meet their deductible,and in this scenario, they again
embark on a health system jamboree.

(11:21):
But they don't get a whole lot ofhigh value care in this scenario.
They run around getting all mannerof all kinds of stuff that is well
outside of any evidence based pathway.
Like, weird example, I went to adoctor recently asking a question
about something that everyoneultimately agreed was nothing.
At which point, the doctorasked if I wanted an MRI.
I was like, What?

(11:43):
We and everyone else just agreedthis was a big nothing burger.
Why would I want an MRI?
Is there something else that we didn'tdiscuss to indicate that I need imaging?
Like, why are we going there?
And the doc said, Oh, well, everyone inNew York City has an anxiety problem.
So I thought you mightjust want to get an MRI.
Yeah, low value stuff like that isnow not financially prohibitive.

(12:07):
So someone who had met their deductible,in a similar situation to my example,
might have shrugged and said, sure, I dohave some anxiety, let's go get that MRI.
Or if they hadn't met their deductible,then the whole skin in the game,
market driven approach may work, Iguess, to prevent them from getting
low value care that was clearlyexcessive and pretty wasteful.

(12:27):
So summing up these two scenarios,the implications of the moral
hazard issue are, if it'sexpensive, people don't do it.
If it's free or cheap,they will over utilize.
And the issue with both of thesepatient choices is, patients
are not good at discerning lowvalue care from high value care.

(12:49):
And because patients are not good atdiscerning high value from low value care.
Moral hazard is not mitigated with anysort of binary kind of vote for moral
hazard or against moral hazard types ofbrute force, broad stroke tactics, like,
say I'm a moral hazard full on believer.

(13:11):
I assume all or most of the care apatient will go for is low value, right?
Because if I try to prevent moralhazard from happening, then by
default, what I'm effectively sayingis whatever they choose to buy on the
basis of moral hazard is low value.
So I make basically everythingI can pretty unaffordable, so as
not to invoke any moral hazard.

(13:32):
But right, the problem with that is thatsome of the care is actually high value.
And it's also expensive for thepatient, so they don't get it.
And patients are harmed andballoons might get squeezed.
Or the opposite, against moralhazard, right, like I'm against
the concept of moral hazard.
I don't believe in it, so I don't setup absolutely anything to combat it.
Maybe because I assume all care that apatient might want to get is actually

(13:55):
high value and totally worth it.
That's going to be a problemfor the opposite reason.
Plans can waste a lot of money this way.
Random example, in 2014, the Commonwealthof Virginia reported spending $586 million
on unnecessary costs from low value care.
I mean, they say somethinglike a third of all care is
waste and unnecessary, so yeah.

(14:16):
Planned sponsors can waste a lot ofmoney on low value care, and a bunch
of that may happen when patientshave less skin in the game because
they reach their deductible, as oneexample, and the care is not financially
prohibitive and moral hazard is realized.
So yeah, as I said, a couple of weeksago, I did not spend my Sunday as planned.
I spent my Sunday reading papersabout moral hazard in insurance

(14:40):
and how financial incentivesimpact patient decision making.
And I'm gonna repeat the grandtakeaway because this is a podcast
and you might be multitasking.
So once again, here's the sum of it all.
If it's expensive,people tend not to do it.
If it's free or cheap,they will overutilize.
And the issue with both of thesepatient choices is patients are

(15:01):
simply quite bad at distinguishinghigh value care, from low value care.
Once their deductibles are met, mostpatients will, due to moral hazard, they
will in fact go on a spending spree, andpart of what they will get done will be
really, really important and necessarystuff, like getting their unusual
moles looked at, or their heart painchecked out, or going for that follow
up visit or lab work that their doctortold them they need to come in for.

(15:24):
And the other part of what they will dowill be things that are outside the best
practice evidence based pathway guidelinesby the length of the Appalachian Trail.
You know, doing what appears tobe a tour of specialty medicine
physicians for unclear reasons,but which lead to a cascade of
testing and who knows what else.
Why do they do this, these members?
Do they do this on purpose?

(15:46):
No.
There is study after study that shows,again, members slash patients do not
most of the time have the chops tofigure out if some medical service
is high value or low value care.
And no kidding.
Most members and patientshave no clinical training.
They're not doctors, they're not nurses,they're not physician assistants.
They're humans whose uncle died of cancerand now they have a pain in their foot

(16:08):
and they're convinced it's a tumor.
Right?
Like, do we blame them when theyfinally go see a doctor because they
crushed their budget that particularyear paying thousands and thousands
of dollars out of pocket for whatever.
Earlier in the year, and now they'vemade it to their deductible, do we
blame them for taking the very rationalstep of getting the most out of those
thousands of dollars of sunk costs?

(16:30):
At that point, it's a let me get mymoney's worth situation because they
can't afford to do this again next year.
I mean, we hire employees becausethey're smart and rational, and
this is really actually a prettysmart and rational thing to do.
It's not somebody trying to commit fraud.
Okay, sure.
Some people are.
There's always bad apples.

(16:51):
But the vast majority are just tryingto live their life and not spend all
of their vacation money next year onmedical services like they did this year.
I'm saying all this becauseit's actionable, by the way.
And I'm, getting to that, but indulgeme for like 60 more seconds, because I
want to acknowledge you, listeners ofthis show, are probably nodding along to

(17:11):
this whole thing, this whole time, andthinking all of this is pretty obvious.
Well, yeah, maybe.
Except here's the reason I decidedto do an inbetweenisode about this
rabbit hole instead of doing mynormal thing, which is just ranting
about it over dinner for three daysstraight and God bless my husband for
sitting through it is the bottom line.
But the reason we are here togethertoday is the number of emails and posts

(17:35):
and et cetera that crossed my deskwhere it doesn't seem like these dots
have been connected on all of this orat least connected in magic marker.
Like fat, indelible magic marker, whichis what I think is necessary for these
dots to be connected with the ones betweenmoral hazard and patients not being

(17:55):
able to discern high and low value care.
There are so many ways andplaces these dots will show up.
Like here's another moral hazard issuewith those maximizers or accumulators,
which apparently are on my mind right now.
The not good ones.
I'm talking about now where patientsfind themselves on the hook for
hundreds or thousands of dollarsmid year if they want to pick up the

(18:15):
meds that they've been prescribed.
If you need more details on like howthat might happen to understand what I'm
saying fully, listen to the show again acouple of weeks ago with Bill Sarraille.
But even if you're a little confused, itdoesn't matter because the question is
this, do we justify having programs thatmake drugs really expensive for patients?
Do we put in place one of thesepretty darn punitive types of

(18:36):
accumulators or maximizers, right?
Like there's different kinds andI'm talking about the punitive
ones of accumulators or maximizers.
Do we justify putting one of thoseinto place and figure that if a
patient really wants the med, they'llpay a whole lot of money for it?
Because if they're willing to pay awhole lot of money for it, then, right?
It must be high value care, sothey'll figure out how to pay for it.

(18:56):
Keep in mind, as I said earlier, ifit's expensive, people don't do it.
If it's free or cheap,they will over utilize.
And the issue with both of thesepatient choices is, patients are not
good at discerning low value care ormeds from high value care or meds.
So look, pharma can be up to all kinds ofcrap and list prices are really expensive.
No arguments here.

(19:17):
That isn't the point.
The point is, what is the actualproblem that we're trying to solve
for, for our plan and our patients?
And our members.
And if that problem is making sure thatthe right patients get the right high
value meds or care, then not lettingmembers get copay assistance such
that all drugs, the good ones and thetoo expensive ones and the ones that
we don't really want our members totake for whatever reason, if we make

(19:40):
all of them way too expensive with amaximizer or accumulator designed to
make all the drugs really expensive?
Dots connected.
We wind up with the all in to preventmoral hazard issue we just talked
about where patients could easily beharmed and the plan can easily get
into a balloon squeezing situation.
All I'm saying is that there's a bigpicture view of moral hazard here

(20:03):
that we need to be looking at and overindexing into binary, moral hazard,
black and white, where we attributemalice to members, some of whom, some
of the time, may actually be trying toget high value care, or the flip side,
the plans paying too much for low valuecare and causing financial difficulties

(20:24):
and not understanding the root cause.
Going black and white or over indexingto prevent outlier kind of stuff
is probably not going to end well.
Not seeking a middle way caneasily result in a solution that
is possibly worse than the problem.
So, look, moral hazardis actually a thing.
There are lots of implications topatients not being able to distinguish

(20:46):
high value and low value care.
But if we know this, then, philosophicallyat least, how do we conceptualize a solve?
What should we be doing?
If we're not doing black and white, whatdoes the gray in the middle look like?
All right.
We don't want to be a solutionlooking around for a problem.
So let's think about the problemsthat we want to solve for.
I would start with what's the goal?

(21:07):
The goal of plan sponsorsproviding insurance most of the
time is attract and retain talent.
Also, I was at the HBCH, the HoustonBusiness Coalition on Health Conference
at the beginning of December 2024.
And there was a poll question.
There was a bunch of employers inthe audience and the poll question
asked the audience, What's yourbiggest plan goal this year?
Main answer by a mile, cut costs.

(21:29):
Okay, so we want to attract andretain, and we want to control costs.
Obviously, you can go about achievingthese three things a bunch of different
ways, and they will all be trade offs.
As Luke Prettol reminded me of theother day, there are no solutions.
Only trade offs.
And so with that, right now, I wantto introduce the second concept that

(21:51):
I have been ruminating over in myrabbit hole lately, that I've kind of
been hinting at for this whole time.
But here's a word we've been waitingfor to solve all of our problems in
a good kind of way, not the bad blackand white ways that are so often either
financially a problem or deployingbrute force and harming patients in
the name of solving something else.
Pareto optimality.

(22:12):
Pareto optimality is the state whereresources are allocated as efficiently
as possible so that improving onecriterion will not worsen other criteria.
It's essential to consider this, thatpareto optimality is the ideal we
should at least be striving for whenattempting to overcome any challenge.

(22:33):
But in particular, the moral hazardissue, when we know that patients
do not know what care is highvalue and what care is low value.
Because if we don't try to at leastpareto optimize, if that's a word, if
we try to fix the moral hazard problemand wind up with a new problem or
new problems that might be worse thanthe old problem, that's not optimal.

(22:53):
We have improved one criterionand worsened another.
So fixing the members going wild afterthey meet their deductible by slamming
the lid on the fingers of members tryingto get high value care as well as low
value care, well, not sure about this,but I'd assume, if not the attract, but
at least the retain criterion, might becompromised by member dissatisfaction.

(23:15):
But also, as I've said nine times, wemight not actually cut costs, we might
be doing a squeeze of the balloon.
Especially that could be true when,as we all probably know or suspect,
what's driving costs at the planlevel is rising hospital prices.
There's a show coming up on risinghospital prices as a primary
driver of rising plan costs andit's pretty hard to argue with.

(23:37):
So it's financially prettyadvantageous to keep patients from
needing to go to the hospital.
So yeah, I'd strongly suggestnot squeezing balloons when
hospitalizations are where the air goes.
I'm not going to belabor this.
My only suggestion is dothe pareto optimality math.
A lot of you already are,I'm sure, and do a great job.
But just, for any given policy planchange, or decision, keep in mind

(24:02):
moral hazard, and then really gothrough the whole cascade of likely
impact on other factors based onlikely member slash patient behavior.
It's so easy to get sucked into kindof these philosophical, those are my
enemies kinds of conversations thatare actually philosophically sort of
interesting, but they aren't the goal.
I mean, there's always unintendedconsequences, but not all unintended

(24:25):
consequences should come as somekind of like wild ass surprise.
They were pretty predictable, actually.
Let me also mention that when consideringpareto optimal solutions, advanced primary
care starts to get really compelling.
It's because having a PCP team with dataand a relationship to the patient, helps
patients stay on the high value care bus.

(24:45):
And that can minimize the bad that comesfrom lowering the barrier to care and
inviting in a little bit of moral hazard.
Just, just saying.
Okay.
So this has been going on a little bitlonger than I had originally intended,
but I do want to remind you of theso called theory of second best.
It's probably really appropriate here,and one of the reasons why I'm mentioning
this and not finishing the show right nowis that in a very synchronistic moment,

(25:09):
I was writing up my outline for thisinbetweenisode, and how random is this?
Dr.
Steve Shutzer wrote an email that includedsomething about the theory of second best.
Great minds and all of that.
Anyway, the theory of second best isreally aligned with pareto optimality.
It's just that sometimes yougotta be really practical.
You gotta be a little scrappy.
If you cannot achieve the best option,either because you just can't, or

(25:33):
because the best option for one thingresults in too many negative consequences
elsewhere, then don't do the best option.
Forget it.
Do the second best, i.
e.
the theory of second best.
There is nothing wrong with that.
Don't be a hero.
Okay, so in summary, moral hazard isactually a thing and so is the opposite,
and it's even more of an impactful thingbecause most people cannot distinguish

(25:55):
high value from low value care.
And if they meet their deductiblethat they have paid a lot of money
to reach, of course, they are goingto want to try to get through their
checklist of medical appointmentsthat they have been putting off.
This is not a surprise.
And it's not all bad, as long asthe care that they are trying to go
get is high value, and that mattersif we're trying to cut costs.

(26:15):
Because to cut costs for real, andnot in a squeezing of the balloon way,
we need to direct or limit somehowwhat gets done to high value care.
And we got to do that without accidentallycausing other problems, meaning think
through pareto optimality and possiblyconsider the theory of second best.
I hope this has beenhelpful at some level.
It's helped me.
I feel better having vented.

(26:37):
My name is Stacey Richter.
This podcast is sponsoredby Aventria Health Group.

Scott Conard (26:41):
This is Dr.
Scott Conard from ConvergingHealth, encouraging everyone to
listen to Relentless Health Value.
Stacey, I listen to your show every week.
I can't wait for it to come out, bothbecause I love the people you have on.
They're brave, courageous peoplewho are willing to speak out,
and that is really challengingin today's political environment.
And two, what I learned, andI, Always learn something.

(27:02):
And what comes to me as I listen tothis is, who can I share this with?
And so I will send the RelentlessHealth Value link, text it to
people, and email it to people.
And it's amazing to me how people listen,they get turned on to you, and they
change the way they're designing theirhealth benefits, they're reviewing their
contracts, they're getting their PBMscontracts, and it is so exciting to

(27:26):
be able to have you in the world doingthat because I don't know of anybody
else that has the wisdom and the visionthat you're putting forth and bringing
the people that you are on your show.

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