A Call to Action
2012; Elsevier BV; Volume: 44; Issue: 1 Linguagem: Inglês
10.1016/j.amepre.2012.09.015
ISSN1873-2607
AutoresJoseph M. Smith, Eric J. Topol,
Tópico(s)Healthcare Policy and Management
ResumoIt is beyond presumptuous to attempt a conclusion to a story that has only just begun: In every real sense, the revolution in U.S. health care, though substantially overdue, is only now beginning. However, we can describe aspects of the likely trajectory of the revolution, key players in some of the turning-point battles, and attributes of the final end-state, acknowledging that, as Niels Bohr said many years ago, "prediction is very difficult, especially if it's about the future."1Bohr N. BrainyQuote.com, Xplore Inc, 2012.www.brainyquote.com/quotes/quotes/n/nielsbohr130288.htmlGoogle ScholarAs alluded to in the introduction2Smith J.M. The stakeholder imperative.Am J Prev Med. 2013; 44: S1-S4Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar and tangentially reiterated throughout the papers3Meier C. A role for data: an observation on empowering stakeholders.Am J Prev Med. 2013; 44: S5-S11Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar, 4Olchanski N. Cohen J.T. Neumann P.J. A role for research: an observation on preventive services for women.Am J Prev Med. 2013; 44: S12-S15Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar, 5Sarasohn-Kahn J. A role for patients: the argument for self-care.Am J Prev Med. 2013; 44: S16-S18Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar, 6Shah N.T. A role for physicians: an observation on cost containment.Am J Prev Med. 2013; 44: S19-S21Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 7Tuckson R.V. A role for payers: remarks on the use of data and analytics in support of preventive care.Am J Prev Med. 2013; 44: S27-S29Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar, 8Isaac F. A role for private industry: comments on the Johnson & Johnson's wellness program.Am J Prev Med. 2013; 44: S30-S33Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 9Straube B.M. A role for government: an observation on federal healthcare efforts in prevention.Am J Prev Med. 2013; 44: S39-S42Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar, 10Gottlieb S. Makower J. A role for entrepreneurs: an observation on lowering healthcare costs via technology innovation.Am J Prev Med. 2013; 44: S43-S47Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar, 11Pettigrew K.A. Senior community centers of San Diego as a preventive care model: a case study.Am J Prev Med. 2013; 44: S34-S38Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 12Yazdi Y. Developing innovative clinicians and biomedical engineers: a case study.Am J Prev Med. 2013; 44: S48-S50Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar, 13Frakt A.B. Carroll A.E. The quality imperative: a commentary on the U.S. healthcare system.Am J Prev Med. 2013; 44: S22-S26Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar, 14McDermott K. Lowering the cost of health care: the West Health Initiative.Am J Prev Med. 2013; 44: S51-S53Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar in this supplement to the American Journal of Preventive Medicine by many of the stakeholder discussants, the U.S. healthcare system is being crushed under its own weight—costlier than that of any other nation; bloated with high-volume, low-value procedures; and using a brittle, calcified care delivery model, twisted by decades of perverse incentives and resistance to change. The outrageous expense of the system coupled with the fact that Americans live sicker and die quicker than their counterparts in many of the world's less prosperous nations provide ample evidence of the need for change. The awkward, inefficient, and ineffective U.S. healthcare system is now colliding with the immovable obstacle of undeniable unsustainability based on impossible economics that threaten our international competitiveness, economic viability, and national security, and clearly indicate that, without dramatic change, by 2030 all of the average household income could be consumed by average family healthcare spending.15Young R. DeVoe J. Who will have health insurance in the future? An updated projection.Ann Family Med. 2012; 10: 156-162Crossref PubMed Scopus (47) Google Scholar And this problem is not just about the economics. Even the logistics of our current healthcare delivery system (current and projected number of providers compared to current and projected healthcare needs of an aging population with multi-morbidities from chronic diseases) are just as fundamentally unsustainable unless dramatic changes are implemented.Dramatic change in U.S. health care, therefore, must be a foregone conclusion. The operative questions are what changes are needed most, and how these changes will be enabled.An Efficient Medical MarketplaceIt is well understood that one root cause of our dramatic overspending in health care is the disarticulation between the consumer of services (most often the patient); the provider of services (physicians, nurse practitioners, physician assistants, hospitals, clinics); and the related financial transaction (typically off-loaded to some amalgam of employer- or government-provided payment systems). The insertion of this intermediary has effaced the typical market forces that govern supply and demand: value and price. To create an efficient medical marketplace, a few substantial changes are required, as detailed below.Price TransparencyEasily taken for granted in other aspects of our lives is the concept of transparency in price before purchase. Simply knowing what things cost enables competition on price and is one important enablement of informed decision making. Although it is hotly debated that price transparency in health care will allow for anti-competitive behavior (collusion, price-fixing, for example), it remains largely a theoretical, academic concern. Given the sorry state of affairs with respect to the value of U.S. health care, it seems at least worthy of experimentation.But transparency of costs in isolation may be misleading. Only when there can be assurance that lower cost is not associated with a compromise in outcome or efficacy (or freedom from complications) will cost data become particularly useful. For example, there has been growing interest in medical tourism, in which patients from the U.S. travel to countries such as Indonesia or India for specific medical procedures, operations, or treatments.16Surowiecki J. Club Med.The New Yorker. 2012, Apr 16; www.newyorker.com/talk/financial/2012/04/16/120416ta_talk_surowieckiGoogle Scholar Although this trend has risen sharply in recent years, there is a residual concern among Americans concerning the balance of lowered costs and state-of-the-art care.Consumer EngagementIt is understandably difficult to engage consumers about the price of products and/or services for which they do not believe they receive bills. Perhaps it is even more difficult to imagine broad swaths of consumers actively negotiating the price of a healthcare service when some third-party payer is picking up the tab. An efficient medical marketplace requires consumer engagement, which can be achieved through intelligent benefit design, just-in-time pricing information (i.e., information at the moment of a decision), and interoperability.First, intelligent benefit design has attracted consideration since it was proposed a decade ago.17Fendrick A.M. Smith D.G. Chernew M.E. Shah S.N. A benefit-based copay for prescription drugs: patient contribution based on total benefits, not drug acquisition cost.Am J Manag Care. 2001; 7: 861-867PubMed Google Scholar Policymakers have implemented or planned numerous programs that have sparked conceptual appeal.18Freudenheim M. Some employers are offering free drugs.The New York Times. 2007, Feb 21; www.nytimes.com/2007/02/21/business/21free.htmlGoogle Scholar, 19Fuhrmans V. New tack on copays: cutting them.The Wall Street Journal. 2007, May 8; : D1Google Scholar, 20Gavin K. University of Michigan unveils innovative medication program for employees and dependents with diabetes [news release].www.ns.umich.edu/htdocs/releases/story.php?id=230Date: April 25, 2006Google Scholar Namely, the act of altering health insurance programs to encourage high-value services and discourage low-value care promises to add marketplace dynamics to the provision and consumption of health care, cutting overall costs, and informing the ongoing debate. However, policymakers have focused most of their efforts on one side of this challenge: providing positive incentives to encourage individuals to use high-value care. The converse, imposing disincentives for the use of proven low-value services, or similar disincentives for high-risk health behaviors, has yet to make progress. Given our current predicament and impending crises, we can ill afford to rule out potentially viable options without thoughtful consideration and/or meaningful experimentation.Second, just-in-time strategies have been applied broadly in commercial settings to limit costs. To build an efficient medical marketplace, we need just-in-time information—relevant, up-to-date information about price, value, and outcome that can inform decision making at the time decisions are being made. It is of little good to have pricing and outcomes data about elective or even semi-elective healthcare products and services archived on obscure, confusing websites outside of the practical reach of consumers/patients/decision makers. Although 34 states have variations of healthcare price transparency legislation enacted, if the requirement for transparency can be met by posting a limited set of average prices on an out-of-the-way website, very little impact should be expected. Rather, if actionable pricing information can be provided/pushed to decision makers in the hours or days before a decision is made, significant savings can be expected. Payers and large employers are already exploring such opportunities to help their subscribers limit their out-of-pocket costs.21Change healthcareLatest healthcare transparency index reveals impact of provider choice in ACA mandated preventive care screenings.www.changehealthcare.com/downloads/releases/2012.03.29%20Preventive%20HCTI%20March%202012.pdfGoogle Scholar In addition, hospitals are exploring ways to prospectively commit to total out-of-pocket expenses so that patients can know in advance what their financial obligations will be for a wide range of procedures.22Financial Healthcare Systems LLCtransunion.com/corporate/business/healthcare/FHS-landing.pageGoogle ScholarThird, the majority of Americans receive care from more than one caregiver or other provider—be it from an independent physician, physician group, hospital, laboratory, pharmacy, urgent-care center, worksite clinic, school clinic, or public health site. Without integration or seamless interoperability, concerns regarding fragmentation, duplication, and error frustrate choice and elevate switching costs. In essence, the many separate and poorly communicating silos of the healthcare system create barriers to the creation of an efficient medical marketplace. Two remedies are clearly apparent: The first is integration or consolidation wherein a dominant system vertically and horizontally integrates to provide a broad set of offerings over a significant part of the market. This creates some operational synergies and removes some of the concerns of a fragmented system of separate silos, but the concentration of market presence and power can have an anti-competitive, even a monopolistic, influence.A second alternative to overcome fragmentation is smooth, seamless, and functional interoperability. Interoperability, particularly of information systems and associated medical devices, can enable smooth communication among the many disparate participants without creating anti-competitive forces. Interoperability holds the promise of making all healthcare data available to any member of the healthcare delivery enterprise whenever and wherever it is needed. In 2005, it was estimated that interoperability in health information systems would save $70 billion annually, but even that substantial estimate is likely woefully short of the true value, as it does not include the transformational effects on innovation and competition that almost certainly will occur when the fragmentation and anti-competitive influences of proprietary information systems are themselves transformed into interoperable networks.No discussion of interoperability would be complete without mention of the fact that its non-existence is no accident. Instead, it is a realization of market forces that have encouraged the development of multiple, proprietary systems. Although interoperability is an unmet need (and one that once filled, will release great value), it is not readily apparent how this value gets returned to any of the stakeholders capable of creating it. In this instance of a market failure, there may be a legitimate argument for federal intervention, particularly in light of the fact that the federal government is the largest payer for healthcare services and, as a result, stands to be aligned with the individual in achieving the greatest related benefit.Infrastructure Independence®Although novel advanced medical technology is more typically viewed as a cause of escalating healthcare costs than as part of the solution, it has become clear that innovation to enable smart, technology-enabled care coordination can dramatically improve the management of chronic diseases (that collectively make up more than 80% of U.S. healthcare costs) at much lower cost.23Darkins A. Ryan P. Kobb R. Foster L. Edmonson E. Wakefield B. Lancaster A. Care coordination/home telehealth: the systematic implementation of health informatics, home telehealth, and disease management to support the care of veteran patients with chronic conditions.Telemed e-Health. 2008; 14: 1118-1126Crossref PubMed Scopus (402) Google Scholar By harnessing innovation in ubiquitous (remote) sensors embodying actionable diagnostics, low-cost wireless communication, smart algorithms, and learning systems, ultimately linked to smooth titration of outpatient therapy, it is possible to create a fundamental shift of the paradigm in healthcare delivery and provide nearly continuous care for chronic disease, predicting and preventing costly, complex, and life-threatening decompensation.24Gary and Mary West Wireless Health InstituteInfrastructure independence.www.westwirelesshealth.org/index.php/wireless-health/infrastructure-independenceGoogle Scholar In addition to improving outcomes at lower costs, this new model can alleviate some of the tremendous stresses on the current healthcare system where the burgeoning demand of our aging population struggling with chronic disease is overwhelming our capacity to deliver adequate care using the current paradigm of office-, clinic,- or hospital-based settings. This infrastructure-independent model of healthcare delivery will foster the new era of patient-centered care and lead to significantly lower healthcare costs.24Gary and Mary West Wireless Health InstituteInfrastructure independence.www.westwirelesshealth.org/index.php/wireless-health/infrastructure-independenceGoogle ScholarRational ReimbursementIncentives matterOur healthcare system provides incentives to hospitals to be full; incentives for physicians to see patients in their offices, clinics, and hospital rooms; and incentives for proceduralists to perform procedures. Recently, with the support of the American Board of Internal Medicine Foundation, nine specialty professional organizations, including those representing cardiologists, gastroenterologists, and radiologists, provided their "Top 5" lists of unnecessary procedures and tests. This "Choosing Wisely" program represents a starting point for professional organizations, historically reluctant to take on the practice of their constituents, to reduce unneeded yet highly reimbursed procedures.25ABM FoundationAdvancing medical professionalism to improve health care Choosing Wisely.www.abimfoundation.org/Initiatives/Choosing-Wisely.aspxGoogle ScholarPatients, as it turns out, do not want to be on the receiving end of any of these behaviors. Rather, they want to be well and away from hospitals and their physicians. This obvious mal-alignment of incentives and desired outcomes is being addressed, in part, by current efforts at healthcare reform. The know-how and capability to create a far more rational and cost-effective system is within our grasp, and there has never been a more important time for the medical profession to take the lead in advocating for reform. Strategies to pay for prevention, continuity of care, and better outcomes are essential. Our current system rewards interventions for disease events and thus encourages the care we have today.26Snyderman R. Creating meaningful health reform.J Clin Invest. 2009; 119: 2855Crossref PubMed Scopus (3) Google Scholar Reimbursement for prevention, early intervention, and effective long-term management is missing. Medical homes, accountable care organizations, and bundled payments are just some of the vehicles being used to align provider incentives with desired outcomes and, in the process, elevate the practice of medicine from piece-work to holistic, outcome-driven care.26Snyderman R. Creating meaningful health reform.J Clin Invest. 2009; 119: 2855Crossref PubMed Scopus (3) Google ScholarPractical RegulationIn recent years, the U.S. Food and Drug Administration (FDA), by increasing its regulatory requirements, also has increased substantially the cost of bringing new technologies to market.27Makower J. Meer A. Denend L. FDA impact on U.S. medical device technology innovation.November 2010Google Scholar This is borne of internal issues relating to the agency's apparently growing aversion to risk and challenges with managing its review processes. But it also reflects external pressure the FDA is under to impose more stringent requirements on the review and approval of medical devices. Some consumer advocates and politicians may see regulation as a way to slow the introduction of new technology and, in turn, lower either adverse events (in some way attributed to new technology) or healthcare costs.27Makower J. Meer A. Denend L. FDA impact on U.S. medical device technology innovation.November 2010Google Scholar But it is likely that exactly the opposite is true. Increased regulation raises the cost of investment and development, which ultimately translates into higher prices for the resulting technology.27Makower J. Meer A. Denend L. FDA impact on U.S. medical device technology innovation.November 2010Google Scholar Additionally, novel technology most often represents an improvement of an existing solution or a novel solution where none previously existed, typically improving outcomes (even net of rare imperfections).Regulatory barriers also reduce competition by limiting the number of new products that enter the marketplace. Unfortunately, the high cost and temporal burden of regulation preferentially inhibit the progress of those small, innovative start-up companies whose products may offer the greatest hope of disrupting the otherwise unsustainable status quo. The larger healthcare incumbents, better able to bear the costs and time delays (and typically less interested in disrupting their own ensconced product lines inculcated within the current healthcare paradigm), are aided in their interest in preserving the status quo by a complex, costly, and slow-moving regulatory system. If we are to incentivize the needed disruption of healthcare products and services, we need just the opposite.In summary, a change in healthcare delivery and payment systems is inevitable and imminent, and every stakeholder has a separate but vital role to play in this coming transformation. This compilation of perspective from leaders across the healthcare continuum, from innovator to payer, from provider to patient, and from employer to regulator, is meant to capture the near-term steps that can be—and are being—taken as we collectively reform our nation's healthcare delivery system.3Meier C. A role for data: an observation on empowering stakeholders.Am J Prev Med. 2013; 44: S5-S11Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar, 4Olchanski N. Cohen J.T. Neumann P.J. A role for research: an observation on preventive services for women.Am J Prev Med. 2013; 44: S12-S15Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar, 5Sarasohn-Kahn J. A role for patients: the argument for self-care.Am J Prev Med. 2013; 44: S16-S18Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar, 6Shah N.T. A role for physicians: an observation on cost containment.Am J Prev Med. 2013; 44: S19-S21Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 7Tuckson R.V. A role for payers: remarks on the use of data and analytics in support of preventive care.Am J Prev Med. 2013; 44: S27-S29Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar, 8Isaac F. A role for private industry: comments on the Johnson & Johnson's wellness program.Am J Prev Med. 2013; 44: S30-S33Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 9Straube B.M. A role for government: an observation on federal healthcare efforts in prevention.Am J Prev Med. 2013; 44: S39-S42Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar, 10Gottlieb S. Makower J. A role for entrepreneurs: an observation on lowering healthcare costs via technology innovation.Am J Prev Med. 2013; 44: S43-S47Abstract Full Text Full Text PDF PubMed Scopus (13) Google ScholarAs one contemplates the enormity of the challenge, it is worth noting that in some way, we have done this before. More than 100 years ago, Abraham Flexner's report on the state of medical education and training effectively revamped all of U.S. health care. It is undeniable that another dramatic revamping is now required, and it is perhaps worth noting that Flexner himself famously commented on the economic challenge of his day, that of simultaneously affording both war and civilization. His comment then applies equally to our predicament now regarding either maintaining our current healthcare system or having one we can sustainably afford: "We must make our choice, we cannot have both."28Flexner Abraham BrainyQuote.com, Xplore Inc, 2012.www.brainyquote.com/quotes/authors/a/abraham_flexner.htmlGoogle Scholar It is beyond presumptuous to attempt a conclusion to a story that has only just begun: In every real sense, the revolution in U.S. health care, though substantially overdue, is only now beginning. However, we can describe aspects of the likely trajectory of the revolution, key players in some of the turning-point battles, and attributes of the final end-state, acknowledging that, as Niels Bohr said many years ago, "prediction is very difficult, especially if it's about the future."1Bohr N. BrainyQuote.com, Xplore Inc, 2012.www.brainyquote.com/quotes/quotes/n/nielsbohr130288.htmlGoogle Scholar As alluded to in the introduction2Smith J.M. The stakeholder imperative.Am J Prev Med. 2013; 44: S1-S4Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar and tangentially reiterated throughout the papers3Meier C. A role for data: an observation on empowering stakeholders.Am J Prev Med. 2013; 44: S5-S11Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar, 4Olchanski N. Cohen J.T. Neumann P.J. A role for research: an observation on preventive services for women.Am J Prev Med. 2013; 44: S12-S15Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar, 5Sarasohn-Kahn J. A role for patients: the argument for self-care.Am J Prev Med. 2013; 44: S16-S18Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar, 6Shah N.T. A role for physicians: an observation on cost containment.Am J Prev Med. 2013; 44: S19-S21Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 7Tuckson R.V. A role for payers: remarks on the use of data and analytics in support of preventive care.Am J Prev Med. 2013; 44: S27-S29Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar, 8Isaac F. A role for private industry: comments on the Johnson & Johnson's wellness program.Am J Prev Med. 2013; 44: S30-S33Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 9Straube B.M. A role for government: an observation on federal healthcare efforts in prevention.Am J Prev Med. 2013; 44: S39-S42Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar, 10Gottlieb S. Makower J. A role for entrepreneurs: an observation on lowering healthcare costs via technology innovation.Am J Prev Med. 2013; 44: S43-S47Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar, 11Pettigrew K.A. Senior community centers of San Diego as a preventive care model: a case study.Am J Prev Med. 2013; 44: S34-S38Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 12Yazdi Y. Developing innovative clinicians and biomedical engineers: a case study.Am J Prev Med. 2013; 44: S48-S50Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar, 13Frakt A.B. Carroll A.E. The quality imperative: a commentary on the U.S. healthcare system.Am J Prev Med. 2013; 44: S22-S26Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar, 14McDermott K. Lowering the cost of health care: the West Health Initiative.Am J Prev Med. 2013; 44: S51-S53Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar in this supplement to the American Journal of Preventive Medicine by many of the stakeholder discussants, the U.S. healthcare system is being crushed under its own weight—costlier than that of any other nation; bloated with high-volume, low-value procedures; and using a brittle, calcified care delivery model, twisted by decades of perverse incentives and resistance to change. The outrageous expense of the system coupled with the fact that Americans live sicker and die quicker than their counterparts in many of the world's less prosperous nations provide ample evidence of the need for change. The awkward, inefficient, and ineffective U.S. healthcare system is now colliding with the immovable obstacle of undeniable unsustainability based on impossible economics that threaten our international competitiveness, economic viability, and national security, and clearly indicate that, without dramatic change, by 2030 all of the average household income could be consumed by average family healthcare spending.15Young R. DeVoe J. Who will have health insurance in the future? An updated projection.Ann Family Med. 2012; 10: 156-162Crossref PubMed Scopus (47) Google Scholar And this problem is not just about the economics. Even the logistics of our current healthcare delivery system (current and projected number of providers compared to current and projected healthcare needs of an aging population with multi-morbidities from chronic diseases) are just as fundamentally unsustainable unless dramatic changes are implemented. Dramatic change in U.S. health care, therefore, must be a foregone conclusion. The operative questions are what changes are needed most, and how these changes will be enabled. An Efficient Medical MarketplaceIt is well understood that one root cause of our dramatic overspending in health care is the disarticulation between the consumer of services (most often the patient); the provider of services (physicians, nurse practitioners, physician assistants, hospitals, clinics); and the related financial transaction (typically off-loaded to some amalgam of employer- or government-provided payment systems). The insertion of this intermediary has effaced the typical market forces that govern supply and demand: value and price. To create an efficient medical marketplace, a few substantial changes are required, as detailed below.Price TransparencyEasily taken for granted in other aspects of our lives is the concept of transparency in price before purchase. Simply knowing what things cost enables competition on price and is one important enablement of informed decision making. Although it is hotly debated that price transparency in health care will allow for anti-competitive behavior (collusion, price-fixing, for example), it remains largely a theoretical, academic concern. Given the sorry state of affairs with respect to the value of U.S. health care, it seems at least worthy of experimentation.But transparency of costs in isolation may be misleading. Only when there can be assurance that lower cost is not associated with a compromise in outcome or efficacy (or freedom from complications) will cost data become particularly useful. For example, there has been growing interest in medical tourism, in which patients from the U.S. travel to countries such as Indonesia or India for specific medical procedures, operations, or treatments.16Surowiecki J. Club Med.The New Yorker. 2012, Apr 16; www.newyorker.com/talk/financial/2012/04/16/120416ta_talk_surowieckiGoogle Scholar Although this trend has risen sharply in recent years, there is a residual concern among Americans concerning the balance of lowered costs and state-of-the-art care.Consumer EngagementIt is understandably difficult to engage consumers about the price of products and/or services for which they do not believe they receive bills. Perhaps it is even more difficult to imagine broad swaths of consumers actively negotiating the price of a healthcare service when some third-party payer is picking up the tab. An efficient medical marketplace requires consumer engagement, which can be achieved through intelligent benefit design, just-in-time pricing information (i.e., information at the moment of a decision), and interoperability.First, intelligent benefit d
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