Last night in the Super Tuesday open thread, Iowa Old Lady told us about her evening plans:
I go to the gym because it’s supposed to fight my depression, but lately I’ve come to believe that I’m depressed because I have to go and “feel better” part is that I’m so happy it’s over.
This morning I just got out of a meeting with an accountable care organization that is brainstorming on ways to get some of their behavioral health and co-morbidity health and cost risks under better control. The big suggestion from some of the Primary Care Providers (PCP’s) and master level clinicians was getting some of these individuals into personal training classes to do something fun. The theory of change was a combination of increased social connectives and increased physical activity will have direct and indirect medical gains which leads to better health, lower pharmacy costs and fewer infrequent but high cost acute events. Their revenue model is a modified capitation model with gain sharing, they can pay for dance classes, weight lifting classes, gym memberships and yoga instructors without having to justify the expense on a claim.
There is a long history of research that shows moderate exercise is at least as good as common Selective Serotonin Re-uptake Inhibitors (SSRI’s) in managing depression. The Atlantic from 2014 has a good summary:
Depression is the most common mental illness—affecting a staggering 25 percent of Americans—but a growing body of research suggests that one of its best cures is cheap and ubiquitous. In 1999, a randomized controlled trial showed that depressed adults who took part in aerobic exercise improved as much as those treated with Zoloft. A 2006 meta-analysis of 11 studies bolstered those findings and recommended that physicians counsel their depressed patients to try it. A 2011 study took this conclusion even further: It looked at 127 depressed people who hadn’t experienced relief from SSRIs, a common type of antidepressant, and found that exercise led 30 percent of them into remission—a result that was as good as, or better than, drugs alone…
this powerful, non-drug treatment hasn’t yet become a mainstream remedy. In a 2009 study, only 40 percent of patients reported being counseled to try exercise at their last physician visit.
Instead, Americans are awash in pills. The use of antidepressants has increased 400 percent between 1988 and 2008. They’re now one of the three most-prescribed categories of drugs, coming in right after painkillers and cholesterol medications.
A gym membership with personal trainers and potentially day by day incentives for people to go to the gym may make a lot of medical sense and even more financial sense. However under a fee for service model, reducing pharmacy costs because people were able to step down their SSRI dose or eliminate it entirely was probably a net money loser for the PCP. The doctor had to spend more time initially with the individual and talk through the program, and then there would be fewer follow-up visits to monitor progress and adjust prescriptions. Instead, it was easier to write a script, mention that exercise is a good thing in the last thirty seconds of the visit, and then schedule a follow-up in three months to see how the new SSRI dose is working for that individual. A personal trainer could not bill. and the doctor could not collect any of the savings from deferring pharmacy costs.
The incentives change on risk capitation models as the personal trainer still can not bill the insurer directly, but her salary is paid by the provider office. A personal trainer at $50 to $75 an hour in total costs is far cheaper than a PCP at $180 to $250 per hour. That $50 to $75 an hour is paid for by the savings incurred from lower pharmacy spending and fewer acute medical events. Plus the patients get into better health/wellness.
Things like this is why I am fundamentally optimistic about health care reform in the United States. This is not genius level work. It is basic work and rejiggering of incentives to avoid being stupid. We have several iterations of being less stupid before we actually have to get too smart.