Dr. Andrea Anderson would cringe whenever she saw the patient’s name come up on her list for the day. He had heart disease, a pacemaker, and other conditions, but never seemed to understand what he needed to do to take care of himself. “I honestly felt I wasn’t able to help him,” said Anderson, medical director of the Upper Cardozo Health Center in Washington, D.C. “He was constantly going to the emergency room.”
Patients like this one, who don’t take part in their own medical care and don’t know how to, end up costing the U.S. medical system big time. A report out Monday in the journal Health Affairs shows such patients cost between 8 percent and 21 percent more than patients who are actively engaged in their health care. Getting these patients more involved is absolutely essential to cutting the soaring medical costs in the United States, experts say.
The U.S. economy spends more than $8,000 per person per year on health care – $2.7 trillion a year or more than 17 percent of gross domestic product.
But there are some approaches that are working. The trick will be to get doctors and clinics to change their ways so that patients can do more to take care of themselves.
Judy Hibbard of the University of Oregon calls it patient activation. It’s more than health literacy, she says. “This is about feeling like you can manage your health," she says.
Hibbard has one in a series of papers in an issue of the journal Health Affairs that looks at the problem and what can be done to fix it.
“The approach that we have really encouraged is meeting people where they are,” Hibbard said in a telephone interview. “We know the low-activated patients are discouraged. They have very low confidence and they are overwhelmed. The usual approach of giving people a big long list of all they have to change about their lives is overwhelming. It’s kind of setting them up for failure.”
Studies have already shown that patients who are engaged in their own care are healthier. Hibbard’s team set out to see if they are also less expensive. They have a 100-question survey that measures how much patients know and care about their health care and assesses their "activation."
“In an analysis of 33,163 patients of Fairview Health Services, a large health care delivery system in Minnesota, we found that patients with the lowest activation levels had predicted average costs that were 8 percent higher in the base year and 21 percent higher in the first half of the next year than the costs of patients with the highest activation levels, both significant differences,” they wrote.
“More activated patients are also more likely to engage in healthy behavior and to seek out and use health information, compared to less activated patients. There is evidence that patients who are more activated are less likely to be obese or to smoke, while being more likely to have clinical indicators that fall within normal parameters—such as normal blood pressure, cholesterol, and hemoglobin A1c (a measure of diabetes) levels—in contrast to patients who are less activated.”
But how to get them there?
“It not about compliance, which is how health care providers tend to think – ‘You need to take this pill.'” Hibbard said. “It is about people taking ownership and feeling that they can.”
Dr. Mark Friedberg, a researcher at the RAND corportation in Boston, found it’s not easy, even for doctors and clinics who want to try.
“Currently, the health care system works against providers who want to make patients full partners in the medical decision-making process,” Friedberg says. “Giving patients truly personalized care will require a long-term commitment to redesigning the system.”
They studied eight different medical systems trying to get patients more involved, in part by providing what they call decision aids. “It’s usually a booklet or a CD that patient can watch,” Friedberg said in a telephone interview. “It contains information that is peer-reviewed and considered even-handed and scientifically accurate.”
Just distributing such literature takes time and would take a redesign of most medical practices to make it work, he said. Someone has to make sure the patients get the materials and understand them. And many doctors were amazingly resistant to even trying.
“Doctors and other healthcare providers are all extremely busy,” Friedberg says.
“When you ask people to do something that is complex, has multiple steps and requires time to make sure that patients understand what you are saying and to make sure you, as the doctor, are understanding what the patient is telling you, that can be tough. There’s just not much slack in the system.”
Then there is the issue of literacy. “I had a patient who was taking her antibiotic regimen incorrectly,” Anderson said. “Often patients are not able to read the label of the prescription or understand the label on their prescriptions. She complained that she wasn’t improving in her condition.”
But there are new approaches that are helping patients do more to help themselves and save money to boot.
Anderson’s employer, Unity Health Care, now offers group visits. The visits last about two hours – about the time it would take Anderson to see each of the patients individually. Patients agree to take part and Anderson said for many of the most expensive and common conditions, such as heart disease and diabetes, they’re transforming the patients’ experience.
“For example if I told a patient that eating vegetables is good for them, another patient can say, ‘Yeah, and this week they are on sale at Safeway’ and another can offer a recipe. They can add in those things that I don’t have the time to do, or the knowledge.”
Some of the patients are already beginning to take their own vital signs, weighing themselves, for instance. “They are much more invested in their own outcome,” Anderson said.
Another non-profit medical system, this one in Minnesota, has an online clinic called virtuwell, where patients can get online help for some simple conditions such as acne, flu or a bladder infection.
For example, a patient suspecting he or she may have Lyme disease is asked a series of questions about symptoms, which include a picture of the deer ticks that transmit the disease. There’s even an option to upload a digital picture of the bite. “A certified nurse practitioner reviews the information and writes a treatment plan,” Dr. Patrick Courneya of HealthPartners Health Plan in Minneapolis writes in one of the reports in Health Affairs. “The customer receives notification by text or e-mail when the treatment plan is ready—usually in 30 minutes or less. If a prescription is warranted, it is sent electronically to the pharmacy of the customer’s choice.”
The virtual visit costs $40, billable to insurance or a credit card. So far, 40,000 patients have used it and another 56,000 referred to an in-person visit if they need more help than the website can provide.
“We found that on average, acute sinusitis episodes treated through virtuwell cost $78.90 less than acute sinusitis episodes treated in our other settings,” Courneya wrote. “For lower genitourinary system infections, the cost was $127.61 less per episode; for conjunctivitis episodes, it was $69.00 less.”
Such innovative approaches are the outliers for now, but Hibbard and other experts say the current standard U.S. system must change. It’s called fee-for-service, and it encourages one-on-one, in-person visits that usually last 10-15 minutes, because that’s the only way a doctor can get paid for his or her time. Most medical practices cannot bill for a phone consultation with a nurse, even if that would be appropriate.
The 2010 health reform law aims to gradually change this, by paying medical practices for keeping patients well, not for doing individual tests or prescribing drugs.
Anderson said changing her approach eventually helped the heart patient she thought was such a tough case.
“We engaged him with diabetes educator and printed out visit summaries for him (after each visit),” she said. “A nurse was able to arrange his pill bottles in a way he could understand, with a picture of the sun for pills he needed to take the in daytime and the moon for medications to take at night.”
It worked. “I saw him metamorphize right in front of me,” Anderson said. “He started to feel more in charge. He’d care for his own condition. “
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