Collaborating on Care: Patients Join Health Care Team
by Richard A. Sherer| Geriatric Times |  |
September/October 2000 | |
Vol. I | |
Issue 3 |
Teaching patients to be active participants in their own health care may result in improved outcomes and lower costs, according to the results of a collaborative study released last August by the Center for the Advancement of Health (CAH) and the Milbank Memorial Fund. The study cautioned, though, that effective patient involvement requires more than just telling patients what to do and what to avoid.
"Services that enhance patient self-management of chronic conditions can improve how they function and reduce pain and suffering," the report noted. "In some cases, these services can also reduce the direct costs of medical care by eliminating unnecessary and wasteful doctor and emergency room visits, hospitalizations, and medication use, and by reducing the costly consequences of poorly treated conditions."
Specifically, the study concluded, "By helping people change their behaviors and adapt to their conditions, self-management programs often increase people's adherence to medical treatments, strengthen their control of pain and symptoms, and improve their overall emotional well-being."
The study found, however, that despite the benefits, "these interventions are not routinely prescribed, reimbursed, or available to the millions of people who could benefit from their use."
In an interview with Geriatric Times, Kate Lorig, R.N., Dr.P.H., confirmed the study's findings. "People who go through these programs, compared to those who don't, tend to be more physically active, have fewer symptoms and utilize health care resources less." Lorig heads the Patient Education Research Center at Stanford University School of Medicine. She has developed an arthritis self-help course that is being offered in Canada, Australia, New Zealand, Great Britain, South Africa and Scandinavia. In the United States, programs are offered in both English and Spanish.
"In our original study, which only included about 1,000 people, we saw utilization rates drop," Lorig told GT. "We're now doing a replication study that mimics the original. There is a four-year arthritis study that shows the same data and a number of studies that are beginning to replicate the results. In a randomized study for a chronic disease program, we're seeing eight-tenths of a day reduction in hospitalization. In our arthritis study, we saw a 43% reduction in outpatient visit rates over four years."
Lorig's results were mirrored in the CAH study. In addition to arthritis programs, this study examined self-management results for heart disease, diabetes and asthma control. Collectively, it reported, these four chronic diseases account for an estimated $457.6 billion a year in health care expenditures.
The CAH study found that adding psychosocial intervention to a rehabilitation program "can further reduce the death rate the next year by 41%." It cited one study in which "rehospitalization costs for cardiac patients who received comprehensive rehabilitation after their heart attacks or bypass surgery averaged $739 lower after 21 months than those who received standard care-a net savings of $259 per patient over the cost of rehabilitation."
Patients with diabetes, who comprise only 3% of HMO populations but account for as much as 20% of HMO costs, also can benefit. The CAH study cited a program at the Oregon Research Institute that used a combination of education and group support to produce both weight loss and a reduction in blood sugar among elderly people with Type II diabetes. Significantly, neither education nor group support alone produced the same results.
The key, Lorig said, is simplicity. "There are only two or three pieces patients need to learn: how to keep up with the medical regime-exercises, medications, inhalers, glucose testing-and how to communicate with the heath care system. They need to learn how to keep doing the things in life that are most important to them-working, hobbies, cooking the Thanksgiving turkey-and, given that these are chronic illnesses, how to deal with the negative emotions.
"I went to a diabetes program where they were trying to teach the patients 127 different things, and then they wonder why [patients] don't do anything. We try to have key messages and focus on those so we don't complicate their lives."
Managing chronic conditions has become a major need of the health care system as mortality/morbidity levels associated with infectious diseases and injuries have declined.
"Chronic conditions are now a more significant cause of death and disability, and hospitals are inefficient institutions for managing chronic conditions," the CAH report continued. "A person with diabetes does not need to go to a fully equipped and specially staffed hospital to manage blood sugar, adjust insulin dosage, stop smoking, and exercise properly."
Another study, released in March by the Robert Wood Johnson Foundation and the Institute for the Future, predicted that by 2010, approximately 40% of Americans will suffer from some type of chronic illness, and 40% of that group will have more than one such condition.
Despite these findings, the CAH study found two significant barriers that prevent the widespread adoption of programs designed to increase patients' involvement in their own care for chronic illnesses: failure of physicians to prescribe such programs for their patients and failure of many third-party reimbursement programs to pay for them.
"We need a combination of things: a change in a social norm and a change in a professional norm," Jessie Gruman, executive director of CAH, told GT. "There's already been a huge sea change on the part of many people in terms of what they expect of their physician. More people are acting like consumers instead of just passive recipients of medical care. There's been a change in people's expectations, a change in the way people respond to their physicians. The medical schools and the training programs and continuing medical education are going to slowly take on these things in a systematic way.
"Patients' engagement in their care continues, in the mind of most physicians, to be an ancillary issue," she added. "It's not a central issue for most health care systems or most physicians. So far, the training programs are not being revamped to look at behavior systematically."
Gruman conceded that professional resistance to change is, in part, due to a lack of solid information. "We haven't gotten the data in order to be able to say, for instance, 'If you're only going to do three things, it's these things.' There is so much information, and it hasn't been organized well.
"While there is a lot of evidence of effective programs, it hasn't been organized in such a way that managed care plans can easily make decisions. The literature so far is uneven. For example, there is excellent research on smoking. It's very clear what a physician should do, how the triage should work, whereas figuring out what is the consensus on cardiovascular disease is not as clearly organized. We have a lot of work to do on the science side to get to [a] point where interventions would be delineated clearly enough."
There also is little in the way of systemized information on how third parties are looking at such programs. In an interview with GT, Richard Coorsh, vice president of the Health Insurance Association of America, said, "I would venture to speculate that many health plans provide or are planning to provide similar types of services so as to allow patients to get information about their conditions from trained professionals. But I don't have any statistics as to the extent of this."
Although Medicare, the largest third-party payer, is largely precluded by law from paying for nontherapeutic interventions, an official of the Health Care Financing Administration (HCFA), which administers Medicare, told GT that the government is looking for clear evidence of programs that will work. Once such programs are identified, the official added, HCFA will attempt to get authorization from the U.S. Congress to introduce them into the program as demonstration projects.
"The Medicare statute said Medicare should pay for medically necessary treatments limited to illness," the HCFA official said. "It specifically excludes prevention. Whenever we do a new preventive service, Congress has to pass a new law."
Later this year, RAND Corporation of Santa Monica, Calif., will publish the results of a study commissioned by HCFA to examine a variety of intervention programs.
"I'm completely in agreement with Jessie's statement," said the HCFA official. "We need to be doing a lot more to help people live better lives with chronic conditions. One of our purposes is helping all seniors live healthier lives; to have more independent lives. From the financial perspective, healthier seniors use fewer health care resources. It's in everybody's best interest to keep people healthy and functioning."