And it is talking combined with trusted social engagement.
Medicare recently authorized a creative new diabetes prevention benefit that leads to better health results and significantly lower costs. The core technological driver is talking and coaching at the YMCA. The Incidental Economist/New York Times has details:
That feeling shifted last week when Sylvia Mathews Burwell, the secretary of health and human services, announced that Medicare was planning to pay for lifestyle interventions focusing on diet and physical activity to prevent Type 2 diabetes. It’s an example of small-scale research efforts into health services that have worked and that have expanded to reach more people….
The Diabetes Prevention Program grew out of extensive research on weight managementand behavioral learning. More than 3,200 patients age 25 to 75 with pre-diabetes were randomized to one of three groups. The first group was given an intensive lifestyle intervention. By focusing on a low-fat, low-calorie diet with the addition of exercise through brisk walking or a similar intensity activity, it encouraged people to lose at least 7 percent of their body weight and maintain that over the course of the trial.
The backbone of the intervention involved 16 one-hour face-to-face meetings that helped each individual participant set and achieve goals to improve health habits. The second group was treated with metformin, a medication that can lower blood glucose, and the third was the control group, provided with a placebo medication.
The trial was ended early because the results were so compelling. Those in the medication arm had a 31 percent reduction in the risk of developing diabetes. More important, those in the lifestyle intervention saw a 58 percent reduction in their risk. Moreover, if you were 60 or older at the beginning of the study, your reduction was 71 percent. A later meta-analysis confirmed that these results for lifestyle interventions were replicable across numerous different studies….
the behavioral expert, Mr. Marrero worked with the Y to reshape all 16 core intervention lessons and several maintenance lessons into a group-based format led by instructors who were Y employees. The new intervention was about $205 per person, a fraction of the original cost.
They estimate that if the Y program were expanded to all Medicare beneficiaries, the government might save about $2,650 per participant over 15 months, much more than the program cost.
This is a big deal. And the core component of the program is frequent coaching sessions by a trusted coach who gives actionable feedback and course correction guidance.
Talking and trusted coaching is the killer app of population health management, not a new set of pills or ever more doctoral level providers, although doctors are critical as they are the most trusted information conduit. Payment reform is part of the package but it is just an enabling feature. Payment reform without trusted coaching to achieve behavioral change is massively insufficient.
My employer is working on a coaching initiative that is showing very significant results in terms of health improvement and cost avoidance. We had tried for years to have a call center staffed with nurses and nutritionists and pharmacists to harass people into making behavioral changes. The problem was the probability of someone staying on the phone for more than fifteen seconds after the caller identified themselves as coming from the insurance company. We were getting a lower retention rate than cold-callers selling steak knives. However as soon as primary care physicians were told to write an actual prescription to call the insurance company for help, response rates quadrupled and preliminary results are showing some awesome (and statistically significant) changes.
Under the old fee for service model, good health coaching made no economic sense for the primary care provider. A good health coach provided by an outside entity meant office visits avoided, it meant tests avoided, it meant hospitalizations avoided. Those are all great things for the patient, those are all great things for the payer. They are bad things for the primary care physician’s revenue. However the movement towards accountable care organizations and risk adjusted capitation means these are opportunities for better member health and better profits for the doctor. They don’t have to see their frequently visiting patients as often or at as high level of care, they are ordering fewer tests and seeing fewer hospitalizations. Since they are getting a flat fee for their entire practice and their more expensive patients are getting cheaper to manage because they are getting healthier, they make more money and more importantly according to a few focus groups I’ve observed, they’re happier practicing medicine instead of writing scrips.
From a system perspective, a significant fraction of healthcare costs, especially for the Medicare population, have roots in modifiable behaviors. Changing those behaviors through trusted talking and coaching is usually more effective and efficient than prescribing brand name prescriptions or in-patient admissions. We’ll see more talking and less cutting in the future.