Health Affairs has a damning indictment of our technophilia in medicine:
Each year in the United States, nonadherence to diabetes treatment alone accounts for 699,000 emergency department visits, 341,000 hospitalizations, and nearly $5 billion in health care spending, according to a 2012 study by Ashish Jha and colleagues.
The PACT project was one of a few community health worker programs that had begun to address the complex psychosocial issues underlying the problem of nonadherence. PACT conducted a study in which a random selection of patients with type 2 diabetes at high risk for complications were paired with community health workers. Compared to the control group of similar patients who were not paired with health workers, these patients saw an average HbA1c reduction of 1.0 point at six months—a level of improvement that corresponds to a 37 percent reduced risk for vascular complications and about a 10 percent reduction in health care expenditure.
Yet in mid-2011, six months after I met Marie, PACT’s diabetes initiative was cut. Two years later the entire PACT project was closed. Our philanthropic funding had run out, and despite our demonstrating the potential for cost savings, there was minimal state or federal money allocated to programs such as ours.
A lot of talking, a lot of relationship building and a bit of organizational knowledge led to massive health improvements, better quality of life for people and lower system costs. This should be a clear win for the individual with a chronic condition and for the system as a whole. And yet, funding got cut. This is not a single isolated incident. Health Quality Partners which is a face to face care coordination entity is continually struggling to have its Medicare waiver extended despite showing amazing results:
Health Quality Partners is all about going there. The program enrolls Medicare patients with at least one chronic illness and one hospitalization in the past year. It then sends a trained nurse to see them every week, or every month, whether they’re healthy or sick. It sounds simple and, in a way, it is. But simple things can be revolutionary….
Health Quality Partners’ results have been extraordinary. According to an independent analysis by the consulting firm Mathematica, HQP has reduced hospitalizations by 33 percent and cut Medicare costs by 22 percent.
Some of the problem is our technological obsession. Some of it is a misalignment of incentives due to churn. Another Health Affairs column argues that insurance contracts with more than a year’s term would lead to better outcomes:
Insurers, too, have few incentives to invest in their enrollees’ health through wellness and disease management programs because those investments, studies show, may not pay off for up to three years. By then, enrollees may have moved on to another insurer. Thus, a greater role for exchange plans and price competition might inadvertently counteract current efforts to shift the payment system toward one that rewards providers for providing long-term health care management for their patients…A possible solution is to introduce multi-year insurance products on insurance exchanges. Under a five-year plan, for example, insurers would find it more attractive to invest in services with long-term benefits. These investments, in turn, would reduce health care costs and some of those savings could result in lower premiums for consumers.
Churn, especially in Medicare and probably in the Exchange markets argues against insurers spending money today for results that will show up in three years. Longer contracts would change that incentive structure, but we also have to confront our societal wide inclination to allow technology to solve problems instead of relying on proven, basic, social face to face “soft” solutions that deliver better results at far lower costs.
C.V. Danes
Multi-year insurance contracts would be a good strategy, but I don’t see this working when insurance plans are tied to employers. This might work on the exchanges, but how would a multi-year plan work for someone with an employer-funded plan? Would it be portable?
Richard Mayhew
@C.V. Danes: DAMN GOOD QUESTION, and I don’t know how to make it work for employer sponsored insurance… but it could work with Medicare Advantage, Medicaid Managed Care, Exchange and CHIP
Calouste
Even, say, a Republican State Representative from Oklahoma isn’t so stupid that they can’t work out the hourly rate for a community health worker. There’s not a lot of opportunity for grift there. Some shiny technology on the other hand, no one can really work out how much it should cost, so the opportunities for grift are endless.
In the “free market” of America, and the health care free market is no exception, it isn’t about cost savings or efficiency, it’s about making as much money while doing as little work as possible.
Hawise
The problem that I see is that this involves hiring people to support people and people is always the easiest cut when a politician or manager wants to show “initiative” or “responsibility”. So just because it works, shows substantial financial and health benefits, the fact that it hires people in good, full-time jobs is enough to crater the idea.
BGK
@Calouste:
I believe that goes by the high-falutin’ phrase “shareholder value.”
Capri
@Hawise:
Even deeper than that – it sounds too much like a handout to someone is not deserving. The fact it will save money doesn’t matter since it feels like giving some sick poor person something for nothing.
RSA
@Hawise:
Another problem is that while it works, it works in the aggregate by preventing bad things from happening. A short-sighted bean counter might say that some maintenance activity isn’t needed because, hey, nothing bad has happened yet. (The same perspective leads to falling-down bridges and undrivable roads…)
Gin & Tonic
@Calouste: The “shiny technology” is in many cases owned by the doctors, who then have to use it so it pays for itself. Next time you’re referred for an endoscopy, or an MRI, or if you (unfortunately) require dialysis, try to find out something about the ownership of the facility that does that. They’ll do their best to hide it, and it won’t be under the same name as the medical practice, but chances are it’s owned by a small group of doctors. And that facility and equipment and staff don’t make money if they’re sitting idle.
japa21
Yet several insurance companies are trying to build up health and wellness programs to try to insure better compliance from patients. They work both directly with the patient and with the physicinas or other care providers. Partly this id due to doing more long term contracts with employer groups and partly due to the recognition that the more insurers that get into these types of programs the better off they all are.
The company I work for is one of those. Although I am not directly involved in these programs I know several fellow employees that are, and they will tell you that when a patient and care provider agree to participate, the benefit is immense both in terms of dollar savings as well as the patient;s sense of general well-being and satisfaction.
The problem is getting patients to agree to participate. People just don’t like being told what to do, even by a physician.
And physicians have given feedback that they know what is best for the patient and the insurance company should stick to paying the bills and not bother them.
raven
@Hawise: My bride faces the same issues with her team of breast-feeding peer counselors. It’s a constant fight to keep funding.
kc
I’ve just spent several days in the ICU with a family member. Nurses and other health care workers spend more time standing at a big computer screen in the room than they do talking do or physically examining the patient.
Don’t know if that’s good or bad but it seems . . . weird.
Tenar Darell
@kc: Shot answer is: it’s pretty bad.
Longer: There’s at least one recent eye gaze tracking study that shows a 1/3 decrease in doctor patient interaction when computer in the room. From personal experience, my doctor’s laptop means she’s focused on it, as opposed to me, way too often. During a 15-20 minute annual checkup, that’s significant. She’s typing when I’m trying to ask her questions.
Steeplejack
It is amazing the number of ways we can find to do health care wrong.
Tenar Darell
@kc: Sorry, mobile here, that should be “Short answer:”
Nicole
And I think this is especially problematic with some chronic conditions, like diabetes, that involve big lifestyle changes. Type 2 diabetes runs rampant on both sides of my family and I’ve seen many a relative willfully ignore dietary restrictions, and in the case of one, really shorten her own life. And it’s not because they’re being jerks; it’s because it’s hard to take something like food and be told “you can’t.” I think more individualized guidance and support helps a lot, but we also have such a culture of so-called “personal responsibility/freedom” that we don’t really want to accept that some conditions require more assistance than others to manage. Even though it saves money in the long run.
Richard Mayhew
@Steeplejack: yep, but at the same time that gives me a lot of hope. We do so many things that are amazingly stupid and counterproductive that getting to a point of good care for all for not a lot more money does not require heroic efforts or frontier pushing innovations — we mainly need to stop being stupid and get to a solid B- in the things that we do.
Nunca El Jefe
This is not dissimilar to the whole death panels thing. It will require a culture change, which will take a long time.
kc
@Tenar Darell:
Yeah, it just seems more impersonal. I’m not complaining about the nurses, I think that’s just part of their job description these days. Maybe it makes for more accurate patient records, but it does reduce the human contact.
Soprano2
In the case of diabetes you also have to look at the cost of the medication as a reason for non-compliance. My husband started as a type 2 diabetic, he took his meds faithfully and has ended up taking insulin, and he’s not the only type 2 diabetic I know who has done that. Do you know the cost of those pens? It’s outrageous, and means my husband is in the doughnut hole by sometime in June or July! Last month he spent almost $200 for one of those pens, and that’s with supplemental coverage.He has two of those pens – one short-acting insulin that’s taken twice a day, and one long-acting that’s also taken twice a day. Luckily we can afford to pay for it, but I can certainly imagine someone who doesn’t have the money to pay foregoing the meds once they reach the doughnut hole, or if they’re on private insurance it’s possible the meds won’t be paid for, or will be in the highest tier with minimal coverage due to the high cost. Seeing all of this is what motivated me to lose 40 lbs two years ago, I never want to have to manage my blood sugar with medicine because it’s a stressful way to live. I had to call 911 once because he had a low blood sugar episode in a movie theater. If you’ve never experienced someone having a low blood sugar episode you’re lucky, it’s kind of like they’re a zombie who can hear you but can’t respond to what you’re saying. My husband says he has hallucinated when he has them, I live in fear he’ll have a bad one when I’m not with him. This is a danger of diabetes treatment that it seems to me is rarely talked about, low blood sugar is almost as dangerous as high blood sugar.
Tenar Darell
@kc: It’s not just impersonal, I think it could actually be more than a little dangerous.
Doctor: (looking at screen, typing, facing to the side/with back to patient) Do you have any questions about A, B, C, D, E?
Patient: (looking at doctor’s back, with a facial expression that says Yes!). Noooo.
Doctor: (missing the non verbal and even the vocal clue that patient confused about A,B,C, D, E). Great, see you next year! (Walks out of exam room without looking at patient, trying to update each screen correctly so the visit is recorded properly).
Patient: (muttering to self) I’m supposed to do A,C,B,E,D…..
beth
@Soprano2: Low blood sugar episodes are scary and can be mistaken for other situations. I do hope your husband has a Medic-alert bracelet. It could save his life.
C.V. Danes
@Soprano2: I had my blood sugar checked a few months ago and I was borderline Type II, which runs in my family. That was definitely impetus for me to radically alter my diet and lose weight before I have to go on insulin.
peter lopatin
The issue of churn and its relationship to insurers’ unwillingness to cover “soft” services is longstanding. I’m old enough to remember arguing with actuaries in the 90s about this very issue and how critical it was for us to find a way to value supportive and preventative services, especially in the Medicare population. Sadly, my arguments were rejected – primarily due to the perceived churn among Medicare HMO enrollees (even if the facts didn’t support it then).
tokyo expat
I gave birth to my first two sons in London. A week after being home, I had a visit from the health visitor, a trained midwife attached to my local GP who visited me at home to check on my health and the health of the baby. The health visitors also had a center open every day that I could visit at any time if I had questions about the baby, nursing, wanted to check weight, etc. etc. After son #2 was born two years after the first, I even got called by the midwife because she knew I was in England on my own without family support and wanted to be sure that I was okay and did I need anything?
I can’t explain what a difference it makes to know there is someone reaching out to you who cares how you are doing, especially if you are on your own. I wondered about how many cases of postpartum syndrome might be alleviated if such a community system existed in the US. I never gave birth or raised children in the US, so don’t know how it works there other than if your kid gets sick call your pediatrician and make an appointment.
It’s the same with diabetes. It doesn’t surprise me at all that patients who had someone checking up on them, talking to them and working with them had improved outcomes over those who didn’t.
But, best healthcare in the world, right?