There have been two episodes lately that have sent me down a rabbit hole that I wanted to bring to your attention. Now, disclaimer: I know you people; you’re busy. You listen on average to, like, 26 minutes of any given episode. So, yeah … look at me being self-aware.

I say all this to say welcome to this inbetweenisode, otherwise known as The Rabbit Hole. But it’s like a 20-something-minute rabbit hole, not a day-and-a-half retreat; so just be kind if you email me and tell me I forgot something or failed to dredge into a nuance or a background point. It might be that I just could not manage to pack it in.

For a full transcript of this episode, click here.

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This rabbit hole really, really matters for anybody creating benefit design. It really matters for anybody trying to optimize the health that can be derived from said benefit design. It also probably matters for a whole lot of operational decisions involving patients or members, nothing for nothing.

But it really matters for anybody trying not to, by accident, as an unintended consequence, hammer plan members or patients with some really blunt-force cost containment measures that do a lot of harm in the process of containing costs or, flip side, accidentally cost a whole lot but don’t actually improve member health.

Nina Lathia, RPh, MSc, PhD, kind of summed up this whole point or gave an adjacent thought really eloquently in episode 426. She said there’s better or worse ways to do things and doing the worst kinds of cost containment may not actually contain costs.

You squeeze a balloon, and that works great for some, like pharmacy vendors who don’t really have any skin in the game. (See me using the “skin in the game” term for other people besides plan members? That’s some really good foreshadowing right there, by the way.)

So, squeezing the balloon works for some when they don’t have skin in the game, in the place where the air goes when you squeeze the balloon—like a pharmacy vendor who makes it super unaffordable for patients to get meds so the patient doesn’t take their meds and winds up in the ICU, or the patient’s formerly controlled with meds condition that is now newly uncontrolled and requires all kinds of medical interventions to get said condition back under control. Like, these are the reasons and the why behind why some cost containment efforts don’t actually contain costs at the plan level.

But not at the vendor level. You see what I mean? Most pharmacy vendors don’t get penalized if medical costs wind up going up. And I’m picking on pharmacy vendors a little bit here, but it’s true for a lot of siloed entities.

But, you know, balloon squeezing can also work, actually, at the plan level if where the air goes, it’s to a 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 very mercenary plan that’s running on a very short time horizon? Do they really care, that plan, if the patient’s formerly controlled condition gets uncontrolled?

Maybe not, I guess, as long as it doesn’t cost more than the max out of pocket that the patient is on the hook for, for any given plan year.

So, yeah … again, there are better or worse ways to do things; and a lot of questions kind of add up to, What kind of plan do we want to be? What are our values, and does the plan align with them?

But that’s not the rabbit hole I wanted to go down today—the aligning with our values rabbit hole—so let us move on.

The Relentless Health Value episode that kicked off the rabbit hole for me on multiple levels was the show with Bill Sarraille (EP459) about co-pay maximizers and accumulators. And don’t get me wrong, that is a complicated topic with lots of pros, lots of cons; and I am not weighing in on the inherent lawfulness or value of any of this.

I am also not weighing in on the fact that there are forthright and well-run maximizers and really not good ones, which cause patients financial, for sure, and possibly clinical harm. But not talking about that right now at all. Go back and listen to the show with Bill Sarraille if you are interested.

Where my “down the rabbit hole” spiral started was when I started noticing the very, very common main plan pushback that was given right out of the gate so often when talking about the problems that any given plan sponsor has with these pharma co-pay programs—that if these pharmacopeia card dollars count toward the plan deductibles, then the patient’s deductible gets met and the plan member will then often overuse healthcare and cost the plan excessive dollars from that point forward.

So again, if you ask any given plan sponsor what I was gonna say their main issue but a main issue that they have with these pharma co-pay programs, that’s gonna be it—that if these pharma dollars count toward the plan deductible, then the patient’s deductible is met and from that point henceforth, the patient goes nuts and overuses healthcare services and it costs the plan a lot of money.

The second episode causing this rabbit hole to open up is the one coming up actually with Scott Conard, MD. So, check back in a couple of weeks for that one.

But in the show with Dr. Conard, we get into the impact of high-deductible health plans or just big out of pockets, however they transpire in the benefit design. Both of these scenarios, by the way, the maximizer meets the deductible scenario and the very, very high-deductible plan scenario are to blame, in other words, for this rabbit hole of an inbetweenisode. So, let’s do this thing.

Let’s talk about the moral hazard of 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 cost of care to the individual, because their 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 related to having a deductible fully paid or not. Pre-deductible, the plan is not paying for a part of said care or paying a much smaller part. And after the deductible is paid for, then the plan is paying for a much larger percentage of care. So, moral hazard kicks in bigger after the deductible is fully paid, when the plan is paying for a bigger percentage or a bigger part of the care.

So, before I proceed, let me just offer again a disclaimer to the many economists who listen to this show that this is a short inbetweenisode; so I am 100% glossing over some of the points that, for sure, have a lot of nuance.

For anyone who wants a thick pack of pages for background reading, I have included some links below. Because you see, a few weeks ago, my Sunday did not go as planned. And instead of running errands, I wound up reading eight papers on moral hazard. So, my lack of groceries is your gain. You’re welcome. I am happy to send you these links if you really want to dig in hard on this.

Okay … so, moral hazard is the concept that individuals have incentives to offer their behavior when their risk or cost is borne by others. That’s the why with deductibles, actually. We gotta give patients skin in the game because once a member has their deductible paid, it’s like member gone wild and they will get all manner of excessive care.

Again, I hear that a lot from plan sponsors—a lot, in all kinds of contexts but almost always, again, whenever the conversation has anything to do with manufacturer co-pay ca