September 22, 2010
Make people pay higher copayments, higher coinsurance and higher deductibles and they’ll cut back on the use of unnecessary care. Give them health savings accounts where they will be spending their own money, and they will be more likely to spend it frugally.
Employers and insurers rapidly expanded use of these approaches in recent years. Yet neither made a dent in the nation’s fast-rising health care tab. Studies also suggested to the extent they did work, sick people were just as likely to cut back necessary care as wasteful services. But patients can help reduce costs if they become informed health care consumers.
A new study published this week in the New England Journal of Medicine claims there is a better way to engage patients that almost immediately achieves lower health care costs. The approach involves systematic telephone outreach to patients at high risk of serious health problems by trained nurses, who provide them with information about the risks and benefits of their therapeutic options.
A randomized, controlled study with nearly 175,000 participants found that the intervention lowered health care costs by 3.7 percent in the first year compared to those who didn’t get the calls or receive follow-up information. The main savings came from reduced hospitalizations – down 10.1 percent in the group receiving the intervention compared to those who received usual care. Pharmacy costs also fell by 3.6 percent. If this program reached the 160 million Americans with private health insurance, the savings could be huge – more than $10 billion in the first year alone.
Improve Quality, Reduce Costs
“This shows that if done well, with a total population approach, you really can improve quality and reduce costs in a way where members have tremendous satisfaction,” said David Wennberg, chief science officer for Health Dialog Services and lead author of the study. The company, whose profits are transferred to the nonprofit Foundation for Informed Medical Decision Making, sells the intervention service through 20 different health plans that cover 20 million people.
“We’re not reducing costs through increased copays or by having second opinions from doctors,” Wennberg said. “It’s saying the patients have the best second opinion. It’s a patient friendly model.”
Not everyone received the calls. The nursing staff targeted people considered at high risk of incurring new health care costs – people with chronic diseases like diabetes, chronic asthma, pulmonary disease and heart disease, for instance, or people recently discharged from the hospital. If needed, a follow-up team that included nurses, dietitians, therapists and pharmacists would visit the patients in their homes to encourage diet and exercise changes and ensure compliance with medication schedules and post-operative instructions.
In a twist on previous efforts at using call centers to monitor patient behavior, the call center staff also used electronic medical records to identify patients considering such procedures as prostate, hip, knee, back or uterine surgery, and coronary revascularization. In those cases, the medical consumers were sent web links, video and print materials before the operation, comparing the risks and benefits of surgery with options like watchful waiting, bedrest, anti-inflammatory drugs and diet and exercise changes.
“We make sure people understand they have a choice of intervention or therapy,” Wennberg said. “The second aspect is that once they have that choice, they understand the risks and benefits of each. If you choose surgery, you may get better quicker, but you face the chance of repeat surgeries and have a small chance of surgical complications.”
It turns out that when informed about the risks and benefits of competing medical approaches, fewer patients choose the riskier and more costly approach. The total cost of the program was $2 per enrollee per month. The trial showed savings of $6 per enrollee per month at the end of one year.
The results of this latest study are at odds with previous attempts by the Centers for Medicare and Medicaid Services to use call center-based coaching techniques to lower health care costs. CMS carried out 15 demonstration projections between 2004 and 2008 that used call centers and counseling. Only two lowered other health care costs and even those were by amounts that were less than the cost of the call centers.
Wennberg said his program was different from the CMS approach in a key way. “They were primarily focused on the sicker of the sick. And it makes sense in a Willie Sutton sort of way. You go where the money is.
“But it is a paradox. If you go where the money is when it’s already being spent, you’re too late. You need to focus on the next group,” those at high risk of complications or considering their medical options. “It is really important within Medicare to target the right people for the intervention,” he said.