This article was originally posted at Forbes.com on May 29, 2018.
The idea behind Health Savings Accounts (HSAs) is a simple one: Instead of giving all our health care dollars to a third party (employer, heath insurance company or the government), we can put some of those dollars in an account that we own and control. When spending from that account, we become fully empowered consumers in the medical marketplace – reaping the full benefits and bearing the full costs of every decision we make.
Even if people don’t have money set aside in a Health Savings Account, patients are paying for more and more of their own medical expenses. Half of employees who get their insurance at work have a deductible of $1,000 or more. The average silver plan deductible in the Obamacare exchanges is almost $4,000. In response to patients paying with their own money and making their own decisions, a supply-side revolution has already taken place:
- Walk-in clinics provide timely care at affordable and transparent prices – meeting best practice guidelines more often, on the average, than traditional primary care physicians.
- On-line prescriptions drug firms are competing on price with local pharmacies and they have a lower error rate.
- About 11 million people have access to telephone and email consultations – something that still isn’t covered by Medicare, Medicaid and most commercial insurers.
- Using an iPhone app, people on the East Coast and the West Coast can summon a doctor to their homes at nights and on weekends — one who usually arrives within 30 minutes and costs about $100. That way, patients avoid a $500 bill and several hours of waiting at a hospital emergency room.
Yet as I previously wrote, we have barely scratched the surface in reaching the full potential of HSAs. Right now, HSAs are being used to pay small medical bills below the deductible because that is all the government allows for those accounts. But they have enormous potential to control costs, increase access and enhance the quality of care if only the government would allow it. In fact, the HSA concept could and should be used in just about every aspect of medicine. The following are some examples.
Chronic care. There is mounting evidence that patients suffering from diabetes, heart disease, cancer and other chronic illnesses can (with training) manage a lot of their own care as well or better than through traditional doctor therapy. If they are going to manage their own care, they will do an even better job if they are also managing the money that pays for that care.
Primary care. Patients should be encouraged to manage almost all the money used for primary care, including routine doctor visits and most diagnostic tests. If patients are controlling the money, everything will cost less. They will substitute less expensive phone and email consultations for doctor office visits; they will shop for better options for everything from blood tests to mammograms; and they will opt for walk-in clinics and free-standing emergency care instead of hospital emergency rooms when appropriate.
Concierge care. Concierge (or direct pay) doctors used to cater to the rich. These days, almost everyone can afford one. Atlas MD in Wichita, Kansas charges $50 a month for a middle-aged adult and $10 for a child. For that you get 24/7 access to a doctor by phone or email, all routine primary care and generic drugs for a lower price than what Medicaid pays. Strangely, the HSA law won’t allow the use of HSA funds for this service. That needs to change.
Expensive elective surgery. Employers and insurers should be able to deposit a fixed sum of money in an HSA for such expensive procedures as knee and hip replacements. This would let patients gain financially if they secure the service for less money. The experience of WellPoint with CalPERS (the health plan for California state employees, retirees and their families) shows that patients armed with their own money are much more effective than insurance companies at controlling hospital costs.
Medical tourism. Employers and insurers should be able to deposit funds to an HSA for patients who agree to travel for their care, with the patients gaining financially from the lower cost of the surgery. A company called MediBid has organized a national market in which patients willing to travel have access to transparent prices (well below what commercial insurers pay) and quality information about the doctors who submit bids.
Care for the disabled. Employers and insurers should be able to deposit funds allowing the disabled to manage more of their own care – especially custodial care, much as is now done in Medicaid’s highly successful Cash and Counseling program for the home-bound disabled.
Palliative care. Are we spending too much on patients at the end of their lives? We would get better results if we left those decisions to families. Private and public insurers should be able to deposit funds to an HSA so that patients and their loved ones can make their own decisions with respect to custodial care and palliative care, a practice that is widely followed in Europe.
To take advantage of the full potential of expanded patient power, we need three policy changes in addition to the changes described above: (1) HSAs need to be completely flexible, wrapping around any health insurance plan, without any requirement of a deductible, and paying for any services the plan does not pay for; (2) HSAs need to be encouraged by providing tax relief equal to the tax benefits of paying premiums for third-party insurance; and (3) insurers should be able to deposit unrestricted amounts into a patient’s HSA without any tax penalties.