Healthcare Consumerism

Opposition Party Health Reform

 

Shifting From Irate to Ideas

 

 

Regardless of party affiliation, the American people are angry with the policies and politics of Washington, D.C..  The Tea Party movement has led the way uniting the “silent majority” giving renewed voice to American principles of limited government, personal responsibility, and self-reliance. In the elections of 2009 and again in early 2010 their votes spoke loud and clear against the corrupt process pushing extravagant health reform, special interest payoffs, and higher tax policies by a tone deaf Congress. The masses opposed health reform that did not lower costs, increase access to care, improve quality, or solve the uninsured problem for 45 million citizens. 

 

People recognized that health reform proposals of 2009 were not about health or healthcare.  They were about centralized power, increased bureaucracies, and expanded political control.   With a single election the public removed a “Democrat controlled filibuster proof Senate” and let every incumbent politician (Republican and Democrat) realize that they work for the citizens and not the other way around. 

 

But, being against something is always easier than knowing what ideas and initiatives to be for.  The challenge for the Tea Party movement and others is to shift from irate to ideas. From success to significance.  The Tea Party Patriots can remain a movement against selected policies or grow into a movement that promotes common principles and/or specific policies.  It does not need to detail solutions.  It can stand ready to choose among options and specific ideas from others.  However, a stronger political position would be to understand the possibilities and direct policymakers to take specific actions.

 

For example, polling indicates that the American public recognizes that there are problems with health and healthcare, but there is no national consensus on a common vision for going forward.  It is now time to lay out basic principles, desired outcomes, and general legislative proposals to deal with real health reform.  Reform can be accomplished if we first establish a common vision through citizen input, coalesce around shared values, promote American ingenuity, and value bipartisan debate.

 

Establishing Basic Principles

 

A uniquely American solution must be founded on basic American principles and values.  Before any specific policies are promoted, the following principles are suggested for discussion and debate.  Any health reform proposal including private coverage, Medicare, Medicaid, SCHIP, and others aspects of the current health system should be measured against a common set of basic principles:  

 

1.   Market-based – The U.S. Congress and States should establish a supportive legal and regulatory environment that will allow a creative open competitive entrepreneurial market to develop the health insurance products and services that will meet the needs of every citizen.  Significant legal and regulatory barriers exist that must be brought down to establish the framework for real market-based solutions. 

 

2.   Increased Competition – Competition in an open free market is the best solution to lower prices, better services, higher quality, greater convenience, and more choices. New legislation and regulation is critical to increasing competition among insurers, providers, agents, and other providers and vendors of care.

 

3.   Maximize Insurance, Minimize Third-party Reimbursements – Third-party reimbursements foster an environment of entitlement and unlimited demand for healthcare services. A system based on personal responsibility minimizes third-party reimbursements by putting financial power in the hands of consumers. A comprehensive system allows everyone to have insurance coverage, regardless of their current or future health status. 

 

4.   Security for the Sickest – No one can be left behind. Health insurance is about financial security when sickness or accidents strike. Solutions must help the sickest patients get the best care, treatment, and understanding of their condition through financial and information empowerment. Any system that works only for the young, healthy, and wealthy is a solution destined for failure.

 

5.   Behavioral Change, Not Cost-shifting – Behavioral change includes wellness, prevention, early intervention, and compliance with proven care and treatments.  It means providers delivering evidence and outcomes value-based care.  It’s about encouraging personal involvement in altering health and healthcare purchasing behaviors.

 

6.   Personal Responsibility –Personal responsibility means taking ownership for good and bad health and healthcare decisions.  Personal responsibility cannot effectively occur without information and support tools for increasing self-reliance.  Support programs include patient financial involvement with incentives for participation, rewards for compliance, and educational support for better personal health management. 

 

7.   Ownership – Ownership means control of the key decisions affecting coverage, choice of treatments, and selection of providers. Ownership means possession of financial assets, choice of how to spend personal funds, the right to information regarding one’s own health, and ownership of a personal health record.

 

8.   Portability – Portability allows individuals to continue coverage regardless of employment status and/or job changes.  Policies that do not rely on employer-based insurance should be encouraged and expanded.  Health insurance should not be dependent upon a job or lost when one changes jobs.

 

9.    “Wholistic Care” (Physical, Mental, Spiritual, and Social) – Health should be viewed as a dynamic state of well-being within an individual that includes physical, mental, social, and spiritual balance.  A focus on health recognizes the potential to improve the status of an individual in need regardless of the diagnosis or condition.

 

Achievable Outcomes

 

American ingenuity can solve any problem and achieve any goal. By creating supporting policies based upon the above principles, the positive outcomes will include the following:

 

1.   Transformation to Quality– If followed the principles will lead to improved quality in a transformed system. Simple reform of the current health system will not work. With a common vision, transformation will emerge - one that is a uniquely American system that builds on existing strengths and transforms for the better the policies and processes that do not work.

 

2.    Empowerment of Consumers/Patients – Empowerment will come from financial and information sharing.  Market-based systems engage consumers in meaningful ways to understand options available to them and the risks and rewards associated with choices.  The individual has both rights and responsibilities when it comes to their health and healthcare.

 

3.   Healthcare Consumerism – Healthcare Consumerism will develop by putting economic purchasing power—and decision-making—in the hands of individuals. It’s about supplying the information and decision support tools they need, along with financial incentives, rewards, and other benefits that encourage personal involvement in altering health and healthcare purchasing behaviors.

 

4.   Reduction in Costs & Increased Affordability - Affordability is not just the dollars paid as premiums.  Affordability will be achieved through health choices and behavior changes.  We are generally used to individuals paying less if they are non-smokers (or quit smoking).  Similarly, healthcare and insurance costs can be more affordable for individuals if they maintain healthy metrics for blood pressure, cholesterol, and body mass index.  Affordability can also be achieved by rewarding Americans with serious health conditions for adherence to disease management standards or compliance with good lifestyles, diet, and exercise standards that stabilize chronic and persistent conditions.

 

5.   Increased Access & Choices –Choice means personal options for insurance coverage, care, treatment, providers, participation, lifestyle, wellness activities, disease/condition support programs, service conveniences, and educational resources.  A choice not to be covered by insurance should be allowed, but getting care (even emergency care) without participation in an available insurance pool will have potential treatment and financial consequences.  Once a viable robust market-based system exists, government-based programs of Medicare, Medicaid, and SCHIP should allow individual choice for transitions to market-based alternatives.

 

6.    Elimination of Diversity in Outcomes – Whether it is social, racial, geographic or other categories, the diversity of outcomes will be mitigated once the segmentation of the existing insurance system is eliminated and all Americans are covered in the same system, treated by providers who practice best standards of care, and empowered with the same information and decision support tools.

 

7.   Expanded Use of Technology – Health, healthcare, and health insurance will  get an infusion of technology to lower costs, improve efficiency and effectiveness of coverage, and appropriately identify and distribute information.  Whether it is personal care devices, personal health records, electronic medical records, or e-prescribing the world of health is lacking in adoption of new technologies.  Encouraging American ingenuity will advance the use of healthcare technology to lower costs and improve health.

 

8.   Movement to A Culture of Health – A culture of health focuses on wellness and prevention rather than on disease, sickness, and treatments.  Health activities should measure and reward participation in wellness assessments, compliance with a condition management programs (e.g. taking medications, diet, exercise, office visits), and maintenance of good health characteristics (e.g. blood pressure, cholesterol, nicotine use, body mass index)

 

The time is right for developing a consensus based on common principles and desired outcomes.  The need is great. The foundation blocks are bipartisan collaboration, support at the federal level, reform at the state level, creative product development, and citizen involvement in their own health and healthcare empowered financially with information and choices.

 

Ideas from the left, right and middle will have to meet a common set of accepted principles.  Only then can we have a rational discussion of ideas such as: tort reform, cross state selling, expanded HSAs, high risk pools, federal regulations, coverage mandates, consumer protections, state/federal responsibilities, national insurance, etc. 

 

The mission is clear – Insure all Americans in a market-based affordable comprehensive health and health care system.  The questions are: Who will help? Who will hinder? And who is willing to give power to the people over their most precious asset – their health?  Let the people speak, let the collaborations begin!

Healthcare Math:2+2=4

Healthcare Math: 2+2=4

 

How will healthcare reform affect you? Healthcare reform may be confusing and complicated but it does not take a degree in mathematics.  At an early age we are all taught certain basic truths, like 2+2=4.    Even those who learned “New Math” know that 2+2=4.  It may at times be an inconvenient truth, but nevertheless, no one can claim that 2+2=5!

 

There are three key changes and challenges mentioned in all healthcare reform proposals:  Access, Quality, and Cost.  In the debate process, look for answers to these simple questions.  See if it all adds up for you.

 

Access:  If 47 million currently uninsured lives are added into the system, will you find it easier or harder to get an appointment with your primary care physician?  With a specialist?  Supporters of current Congressional proposals are saying that that you will have increased access to care.  To many, that doesn’t sound logical.  Those with the most to lose from less access to care are the Medicare beneficiaries.   Many doctors today limit the number of new Medicare patients. Medicare beneficiaries know 2+2=4; they aren’t buying into the political rhetoric that more coverage will mean less waiting.  It just doesn’t add up.

 

Quality: The proposals include $500 billion taken directly out of Medicare. Will you find the quality of medical treatments under Medicare be improved or lessened?  If doctors are paid less, will the quality and time spent with your physician increase or decrease?  Supporters of current Congressional bills are saying that quality of care will be improved.  For many, it makes no sense.  Supporters have not explained how a negative (reducing Medicare by $500 billion) will create a positive (improved quality).

 

Cost: The Congressional Budget Office has estimated the several leading proposals will cost an additional $700 billion to over $1,000 billion (a trillion).   Plans proven to lower costs by 12-20% with health savings accounts are likely to be prohibited or greatly inhibited under current proposals.  Under proposed bills, cost effective comprehensive catastrophic coverage cannot be priced at less than 30% below a government determined acceptable plan, even if current generation products are 40-50% lower.  It doesn’t take a math whiz to figure that advocates of the current proposals are not seeking real cost containment. Citizens can’t understand how increasing expenditure by over $1 trillion will lower healthcare costs.

 

In a story that may be apocryphal, a king once objected to a mathematical factor called pi that showed up frequently in formulas.  Pi is the ratio of the distance around a circle (the circumference) to the distance across its middle (the diameter).  The value of Pi is approximately 3.14159…, but its actual value has an unending string of numbers to the right of the decimal point.  How inconvenient!  The king declared that the “governmental value” of pi would hence forth be equal to 3.0!  The result was that citizens could no longer draw perfect circles and round columns could not be built to hold up buildings.  The empire eventually collapsed.

 

American’s are not stupid.  Politicians and kings can try to force the public into believing 2+2=5, but “fool me once, shame on you, fool me twice shame on me.”  The public trusted the government with bailouts, takeovers, cash for clunkers, and stimulus programs that don’t seem to have worked.  This time they are insisting that 2+2=4 and will not accept answers that are more or less.     

 

Ronald E. Bachman FSA, MAAA is an actuary and Senior Fellow at the Center for Health Transformation, an organization founded by former U.S. House Speaker Newt Gingrich. Nothing written here is to be construed as necessarily reflecting the views of the Center for Health Transformation or as an attempt to aid or hinder the passage of any bill before any state legislature or the U.S. Congress.

The Road to "Hellth" Reform

 

 

Clink on Link Below for an Audio Only Discussion of Health Reform

 

08/28/09 Host Richard Smith

 

08/24/09 Host Bill Bennett

 

 

Government “Hellth” Reform

Health Reform or Hellth Reform? Health reform in Washington has never been about health or healthcare.  It is about power.  Controlling $2.5 trillion dollars gives politicians control over election results.  The bill passed out of the Senate HELP Committee is loaded with new controlling councils, agencies, boards, departments and other entities all with the power to spread tax dollars around to cronies through “planning and establishment” grants. The word “grant” shows up 421 times in the bill.

We already have the largest national health care system in the world.  The government controls 50 cents of every healthcare dollar spent in the United States.  Federal programs of Medicare, Medicaid, CHIP, VA health, and Tri-Care are responsible for half of the healthcare in the country.  Yet, these government controlled programs exemplify out of control spending, waste, fraud, abuse, and the lack of modern technology that the president so confidently states that the federal bureaucracy will change once all healthcare is under their control.

The reason Congressional health reform proposals make little sense to the general public is that they inherently know that the federal government cannot solve the problems that are created by current government ineptitude. Many citizens are confused by the proposals because they believe that the political class is trying to improve health and healthcare for all.  They are not. 

If improving health and controlling healthcare costs was the goal, why would the president and Congress ignore the non-partisan study by the American Academy of Actuaries which identified an approach where “total savings generated could be as much as 12 percent to 20 percent” and future “trend rates (are) lower than traditional plans by approximately 3 percent to 5 percent.”  Importantly, the Academy report also concludes that in these plans “recommended care for chronic conditions (are) at the same or higher level than traditional plan participants” and the “studies reported a higher incidence of physicians following evidence-based care protocols.”

The basis for these remarkable results is the use of consumer-directed health plans. Healthcare consumerism has been developing in the employer and personal insurance market for nearly a decade.   The report is an unbiased view that shows amazing results.  New generation plans are being developed and implemented by employers and purchased by individuals that show even higher levels of savings. Healthcare consumerism encourages personal responsibility with rewards and incentives for healthy choices and adherence to physician treatments.  They are good for both the healthy and those suffering from chronic conditions.  But consumerism is rejected by the proposed bills.   The president speaks many of the words and uses the language of consumerism, but the Senate bill would make illegal rewards and incentives for those who take the initiative to control their blood pressure, lower cholesterol, stop smoking, or improve other health related standards. 

Changing federal and state laws to support the growth of healthcare consumerism by promoting personal responsibility can lower the uninsured by 15 million without any government expenditures.  If Obama and Congress have better ideas proven to control costs and improve quality of care they should start by changing the 50 percent of healthcare already under government control.  Mr. President, show the country, employers, and voters how to successfully implement health reform before the 180 million with private health insurance who are moving towards healthcare consumerism suffer from your political Hellth Reform. We all know that the devil is in the details.

Ronald E. Bachman FSA, MAAA is a Senior Fellow at the Center for Health Transformation, an organization founded by former U.S. House Speaker Newt Gingrich. Nothing written here is to be construed as necessarily reflecting the views of the Center for Health Transformation or as an attempt to aid or hinder the passage of any bill before the U.S. Congress. Mr. Bachman was an outside expert to members of Congress and the Clinton administration during the 1993-94health reform.

Senate H.E.L.P. Committee Health Reform Bill

111

TH CONGRESS

1ST SESSION ll

To make quality, affordable health care available to all Americans, reduce

costs, improve health care quality, enhance disease prevention, and

strengthen the health care workforce.

IN THE SENATE OF THE UNITED STATES

llllllllll

llllllllll

introduced the following bill; which was read twice

and referred to the Committee on

llllllllll

A BILL

To make quality, affordable health care available to all Americans, reduce costs, improve health care quality, enhance disease prevention, and strengthen the health care workforce.

Be it enacted by the Senate and House of Representa

tives of the United States of America in Congress assembled,

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

(a) S

HORT TITLE.—This Act may be cited as the ‘‘Affordable Health Choices Act’’.

(b) T

ABLE OF CONTENTS.—The table of contents of this Act is as follows:

 

Download 2009 Senate HELP BAI09A84_xml[1]

Emerging Data on Consumer-Driven Health Plans

 

Consumer-driven health (CDH) products have been marketed in various forms since the early 2000s. While emerging data is not entirely conclusive, general directional conclusions can be drawn from the studies published to date. This monograph summarizes the results of some of those studies, focusing on the ones that are based on historical claims data, that use credible methodologies, and that provide reasonably detailed and relevant results.

The studies reviewed were:

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Making an Impact—Aetna Health Fund (2008)

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CIGNA Choice Fund: Two Year Experience Study, 2005-2006 (March 2008)

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Reden & Anders—Consumer Directed Health Care: A Look at Current Experience (November 2006)

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Uniprise—2008 CDHP Results Discussion (March 2008)

This monograph focuses on the most recent version of each study identified above, but it should be noted that many of the studies included have been repeated multiple times for growing data sets over the past few years. In general, the previous versions of these studies show similar results as the ones that are discussed in this monograph.

The observations of this monograph are organized around four main questions that are frequently raised regarding CDH plans:

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Do CDH designs result in any first-year cost savings and/or favorable effects on cost trends beyond the first year?

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Are the apparently positive results presented by market participants real or the result of favorable selection?

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Are cost savings generated at the expense of necessary care or the result of delayed or inappropriate avoidance of care?

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Are CDH plans merely a device for employers to shift more of the total benefit cost to employees?

With regard to first-year cost savings, all studies showed a favorable effect on cost in the first year of a CDH plan.

CDH plan trends ranged from -4 percent to -15 percent. Coupled with a control population on traditional plans that experienced trends of +8 percent to +9 percent, the total savings generated could be as much as 12 percent to 20 percent in the first year. All studies used some variation of normalization or control groups to account for selection bias.

For savings after the first year, at least two of the studies indicate trend rates lower than traditional PPO plans by approximately 3 percent to 5 percent. If these lower trends can be further validated, it will represent a substantial cost-reduction strategy for employers and employees.

Generally, all of the studies indicated that cost savings did not result from avoidance of inappropriate care and that necessary care was received in equal or greater degrees relative to traditional plans. All of the studies reviewed reported a significant increase in preventive services for CDH participants. Three of the studies found that CDH plan participants received recommended care for chronic conditions at the same or higher level than traditional (non-CDH) plan participants. Two studies reported a higher incidence of physicians following evidence-based care protocols.

Finally, the studies indicated that while the possibility for employer cost-shifting exists with CDH plans, (as it does with traditional plans) most employers are not doing so, and might even be reducing employee cost-sharing under certain circumstances.

Further research will need to be performed to further validate many of these conclusions. The most significant areas for further study include:

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Additional validation of ongoing trend differences, including more studies, years of experience, and members;

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The factors that contribute to enrollment elections in a “choice” environment;

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How the utilization of wellness services is affected by first-dollar coverage and the impact wellness utilization has on total health costs; and

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How trends and cost levels for underwritten CDH plans in the individual coverage marketplace compare to those for employer-provided coverage.

Download 2009 AAA CDHC Experience Study

Sample Summary Plan Descriptions - SPDs (NBGH)

 

Overview: 46 clinical preventive service Summary Plan Description (SPD) language statements designed to assist benefits staff as they design, discuss, negotiate, and set benefit structures and coverage guidelines with a health plan, union, or consumer group. Sections include:

• The Purpose of Comprehensive and Structured Clinical Preventive ServiceBenefits

• An Overview of Employer-Sponsored ERISA Healthcare Benefits

• Communicating Health Benefits to Beneficiaries

• Federal Regulation and Preventive Services

• Clinical Preventive Services and High-Deductible Health Plans: A Unique Opportunity to Promote Use • Clinical Preventive Service Summary Plan Description (SPD) Language

• Current Procedural Terminology (CPT) Codes

Download 2007 NBGH Preventive Services Guide.Chapter 2 SPDs

Web 2.0 and Employee Engagement in Next Generation Healthcare Consumerism

Participatory information technology platforms can enhance the effectiveness of next generation Healthcare Consumerism. New Health Advocacy Program (HAP) strategies use various participatory Web-based approaches—aimed to engage end-users and accelerate behavior change. Innovative Web 2.0 aggregator/navigator platforms can engage participants to optimize Healthcare Consumerism savings of 9-21% and separately provide additional value-added savings of 2-4%. Web 2.0 and next generation “Health Advocacy Programs (HAPs)” can enhance financial successes as well as achieve better participant engagement and overall satisfaction...  Download 2009 Web 2.0 and Next Generation Healthcare Consumerism

Mental Health Racial Disparities

Health Disparities for Racial and Ethnic Minorities

 

Miranda, Jeanne, PhD, Lisa A Cooper, MD. MPH. (2004). “Disparities in Care for Depression among Primary Care Patients.” J GEN INTERN MED; 19:120-126

 

·        A cross sectional study of identification and treatment of depression among diverse primary care patients using self reports of system and care

·        Found no ethnic differences in patients reports of primary care provider recommendation of depression treatment

·        Significant ethnic differences in rate of actual receipt of treatment

·        Latinos (31.5%), and African Americans (44.1%) are less likely to receive antidepressants than whites (56.6%)

·        Latinos (31%) are less likely to receive specialty mental health care than African Americans (44.5%) and White patients (68.8%)

·         A lower percentage of depressed Latino and African American patients receive treatment for depression that whites.

For Full Report:

Download 2005 MH Disparities for Racial and Ethnic Minorities1

HSA Bank Account Reports (Canopy)

 

Q4’08 showed slight increases in average High Deductible Health Plan (HDHP) deductibles over Q3’08 both for individual and family HDHPs, coupled with decreases in average monthly employer contributions. However, decreases in employer contributions were offset both in individual and family HDHPs by increases in average monthly employee contributions, with average Health Savings Account (HSA) balances remaining relatively unchanged quarter-over-quarter. Average individual HSA balances were down a modest two percent quarter-over-quarter, while average family HSA balances were unchanged from the previous quarter.

Due to continued weakening in the financial markets, average Health Investment Account (HIA) balances realized further sharp declines. On average, individual and family HIA balances decreased from Q3 to Q4 24 percent and 29 percent respectively. Even with continued declines in HIA balances quarter-over-quarter, average transfers into individual and family HIAs were more than double average transfer amounts from HIAs.

Individual and family HIA accountholders age 51+ continued to hold the highest average account values, nearly triple individual HIA accountholders age 25-40, and almost fifty percent higher than the value of family HIA accountholders age 25-40. However, in Q4 average overall account values of individual HIA accountholders age 51+ surpassed the average overall account values of family HIA accountholders age 51+, with average account values of $12,010 and $11,684 respectively.

In terms of spend, Q4 ’08 again showed card payments lagging behind every other spend category with the majority of spend derived from Reimbursements and Bill Payments, and with Wednesday and Friday being the primary days for sub-deductible account spending (ie. spend incurred before HDHP plan coverage kicks in).

In Q4 ’08 the top three spend categories realized by individual HSA accountholders were Hospital, Dental, and Vision related expenditures respectively, whereas the top three spend categories for family HSA accountholders were Hospital, Dental, and Mental Health Services related. Hospital expenditures represented one-fifth, and in the case of family HSAs nearly one-quarter, of total HSA accountholder expenditures for the quarter.

Finally, due to end-of-the-year enrollment periods, customer service call durations crept up with more time spent on enrollment type calls, and basic how-to questions of newly enrolled individuals. Looking forward, we anticipate a slight increase again in the first part of Q1’09, as tax forms are generated and account audits become more prevalent.

Download HSA_MarketReport 2008_Q4

Download HSA_MarketReport 2008_Q3

Download HSA_MarketReport 2008_Q2

Download HSA_MarketReport 2008_Q1

Healthcare Consumerism for Children (NBGH)

 

The purpose of this toolkit is to help benefit managers understand consumer-driven health care benefits as well as to provide a road map and resources for addressing child and adolescent health care in consumer-driven benefit designs.

 

Advocates for one new benefits model — the consumer-driven health plan model — state that it may result in improved employee health and satisfaction while moderating increases in costs. One model pairs a high-deductible health plan (HDHP) with a personal health care savings account to provide consumers with expanded choice and access. It also places a greater emphasis on preventive health care.

 

These added benefits come with added responsibilities: consumer driven health care requires a greater level of employee involvement, decision-making and risk-sharing.

 

This shift of responsibility will require employees to more actively manage their family’s health care service use. Parents will have greater decision-making responsibility for determining medical care for their child and adolescent dependents. Parents will also have to increase responsibility for managing the costs of care.

 

As a result of concerns that consumers lack the education and skills necessary to do this effectively, benefit managers will be challenged not only to educate employees to appropriately use consumer-driven benefit plans, but also to educate employees to improve the overall health of their families...

Download 2006 Healthcare Consumerism for Children

Healthcare Consumerism Er 's Guide (NBGH)

 

The purpose of this tool kit is to help benefit managers understand the developing concepts of health care consumerism as well as to provide a road map and resources for addressing consumer-directed health care benefit designs and implementations.

As we know, health care costs have continued to rise despite large employers’ best efforts to curtail increases. This trend is projected to continue, forcing employers to develop innovative ways to address costs while providing maximal benefits to their employees and beneficiaries.

Traditional plans have led to an “entitlement” mentality with the utilization of health care services without regard to cost and quality. Health care consumerism is a new approach to lowering costs by empowering participants with information and financial incentives that support greater personal responsibility in health and purchasing health care services.

 

The overall goal of health care consumerism is to assist individuals in making more informed health and health care decisions which will favorably impact clinical outcomes and lower the cost of health care.

Involving participants more, through greater financial responsibility, will create the normal economic demand for price and quality information.

Download 2007 CDHC Healthcare Consumerism Tool Kit FINAL