How to Reduce Health Costs: Fewer Drugs, More "Lifestyle Modifications"
The "patient-centered medical home," a new approach to primary care, is supposed to transform healthcare by enabling primary-care doctors to coordinate care, provide better preventive and chronic care, and increase patient access to care. But small practices find it difficult to reengineer themselves to achieve these goals. It takes resources and an infrastructure that most of them don't have. Insurance companies and/or healthcare systems could lend them a helping hand, but it's not clear that they will. So how can this transformation be accomplished?
In a recent interview in the New York Times, internist Richard J. Baron of Philadelphia suggests a radical solution: Take some of the money that's now spent on lifelong maintenance medications for people with chronic conditions, and give it to physicians to help patients modify their health behavior. Those lifestyle modifications could help control their conditions as well or better than the drugs do, and they're a whole lot cheaper. Here's what Baron told the Times:
When you think about what a year's worth of statins, or cholesterol-lowering drugs, cost in terms of pricing, monitoring the effects and follow-up, there are a lot of resources being used right there. But if you take those resources and put them into a program like this that achieves meaningful levels of [patient] behavior change, a lot more patients could be better off.
So what is Baron's practice trying to do that could have such a profound effect on lowering health costs? Very basic stuff, like advising patients on how to manage their own conditions, how to change their diets, and the need for more exercise. Primary care physicians have traditionally done this kind of education. But the current regime of volume-driven reimbursement makes it impossible for them to do it with the kind of depth and persistence that makes a difference, Baron explains in a Health Affairs article. To provide this kind of population health management, Baron's group hired a health educator to teach its medical assistants how to change health behavior. Then the practice found that instead of taking five minutes to "room" a patient and record their vital signs and chief complaints, the nurses took 10 minutes or more when they were educating patients in self-management. So the practice had to hire an extra medical assistant. And, to track the patients' compliance and get them more engaged in their own care, the physicians had to have a software firm write special forms for their electronic medical record at a cost of $7,500.Baron believes that this approach has made a difference to patients. But the economics don't add up, and he's not sure that the practice can continue on this path after the extra state funding for its medical home dries up. On the other hand, if healthcare resources were allocated differently, this medical home might survive.
Baron's point that paying for modifications in health behavior can be much more valuable than paying for chronic-care medications doesn't apply to everyone. Some patients do need statins to reduce their cholesterol, or anti-hypertensive drugs to bring down their blood pressure. But at this point, with "quality" incentives inducing a lockstep mentality among physicians, they're more likely than ever to prescribe these medications to patients to obtain financial rewards from "pay for performance" programs. Unfortunately, not all of the patients benefit, and the long-term cost to them and their employers is staggering.
So let's think about the best way to spend our limited healthcare resources. It might not always be a pill.
Image supplied courtesy of Rasmussen College-Green Bay at Flickr.