5 steps to getting the medical care you want and need
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House Republicans revealed the American Health Care Act, (AHCA), a plan to replace the Affordable Care Act (ACA) with the purported goal of “giving everyone access to affordable healthcare,” says Speaker Paul Ryan (R-WI). The role of healthcare insurers, clinicians, providers, pharmaceutical and device manufacturers, employers and States is woven into the bill. But will this solution address the problem? Has anyone conducted a thorough root cause analysis of unaffordable health care costs? Obviously not. Because neither the AHCA nor the ACA address a key driver: consumers and their health behavior.

A 2012 study by McKinsey shows that 69 percent of medical costs are “heavily influenced” by consumer behaviors. Yet, consumers do not have a prominent role in reducing healthcare costs beyond facing high deductibles and managing funds in Health Savings Accounts.

The AHCA includes provisions to prevent insurers from denying coverage or charging higher premiums to individuals with preexisting illnesses. However, there are no provisions in the law that make Americans think twice about the quality of their lifestyle choices except for tobacco use.


Insurers cannot charge higher premiums to individuals with high-risk behaviors such as abusing alcohol, riding a motorcycle without a helmet, or high-risk sexual practices. And there are no provisions that keep consumers accountable for their own health.


If a patient has high blood pressure but continues to eat a high salt diet and avoids exercise, the doctor prescribes more medication — paid for by insurance, of course. If a patient is readmitted after hip replacement surgery because he or she skipped physical therapy, the outcome is damaged by the patient’s own choices, but he or she is not financially penalized for sabotaging the outcome. The hospital and doctor, not the patient, incur the financial penalties for the patient’s noncompliance.

There are some elements could be added to the legislation to make consumers more accountable for their health, and therefore their healthcare costs. Namely,

  • Revise rules regarding wellness programs incentives to allow employers to offer employees financial rewards and penalties for healthcare outcomes. Today employers can only offer premium incentives for participation.

  • Reimburse family and friends who provided legitimate caregiving services. Today, reimbursement for care is limited to licensed providers who perform CPT-worthy services and procedures. This change would expand the capacity of the system at a lower cost but also reinforce the value of community support and the importance of helping each other.

  • Allocate funding to develop K-12 curriculum on health and healthcare and offer Federal grants to States who implement and measure impact of education on healthcare costs. Today, Americans learn science, math and reading starting at an early age but only begin learning how to care for themselves after they are middle-aged, overweight and in failing health. Health literacy must begin when children are young. While this is a long-term investment, a healthy society is our nation’s single most important economic asset.

The challenge in seeing benefit from any of these recommendations is that they depend on changing human behavior and ultimately, a cultural shift. Healthcare cost will not decrease unless each of us takes some responsibility for our own health rather than depending solely on the system.

Changing the culture of care at a national or individual level cannot, and should not, be regulated or mandated. It must evolve with time, through education and awareness. The American Health Care Act is simply the next stop of a very long journey.

One way that consumers can take control of their healthcare is through The CARES Model. This five-step plan can be used to make any kind of health decision – whether it be deciding between serious medical treatments, selecting a physician, or buying health insurance. This process uses the acronym CARES, which explains how to understand your Condition, know your Alternatives, Respect your preferences, Evaluate your options, and Start taking action. The CARES Model empowers consumers to participate in making healthcare decisions. That is beneficial regardless of the healthcare legislation outcome.

Dr. Archelle Georgiou, MD is an advisor and author of the new book, “Healthcare Choices: 5 Steps to Getting the Medical Care You Want and Need.” She is the former Chief Medical Officer of UnitedHealthcare, where she dismantled many of the company’s legacy policies in order to minimize the bureaucratic hassles imposed on patients and physicians. 

The views of contributors are their own and are not the views of The Hill.