Manage Care-Seeking Propensities to save $5 billion a year
November 23rd, 2008 by FredNavarroMedical costs are not just driven by disease and ill health, but by care seeking propensity.
Ask the question in any commercial health plan population (diseased or not) and you will find similar trends. People with a lower trigger point of when to seek care generate about double the claims compared to those who only seek care when health problems get bad. This means that the number of people at each end of the care seeking scale can have a profound influence on the cost of health care nationwide. 100,000 people at the agree end of “I only go to the doctor if I am really sick or injured” generates $72.9 million. 100,000 people at the disagree end generates $1.4 billion.
A huge part of this cost is diagnostic and not treatment related. A person could go bankrupt paying for testing, find out what’s wrong, and then not have enough money to pay for the actual treatment. Here is an example: If a Lipitor ad gets 1% of US adults to go to the doctor and get a “simple blood test”, then that will generate ($100 blood test + $60 office visit) x 2.1 million adults = $336 million in diagnostic costs, NOT including the cost of the prescription. And of course there will be medical errors that add to this cost.
Recommendation: identify adults with a low trigger point of care seeking and apply counseling that will raise the care seeking trigger point. A 1% shift from a low to a high care seeking trigger point will lower health care demand by $5 billion.
FHN
November 23rd, 2008 at 6:31 am
Funny thing is that this posting came in at exactly the same time as my “stepson” (not really my stepson–his mom had left me at the alter, but he and I stayed close anyway) wrote from college that he had all these symptoms and was planning to get tested for them (again). He is a great, really great, kid, but as far as I can tell, he accounts for about 10% of the country’s total spending on diagnostic testing.
You may be onto something but doesn’t there have to be a more tangible solution in addition to “counseling?” I can think of three. First, rasie the co-pay for diagnostics beyond a certain point. Second, switch to co-insurance (where the co-pay is a % rather than a flat figure so an MRI costs more than an Xray) so that people face a “shadow market” where the level of payment the patient makes reflects cost.
Third, information. Except in big group practices, the doctor has no idea what tests the patient has already had, and is totally reliant on the patient for that information and for the results. Many patients with test-seeking behavios, who are convinced something is wrong with them, simply don’t tell the doctor about prior tests.
November 23rd, 2008 at 6:34 am
I would add more. Testing doesn’t end with testing. Usually the doctor feels compelled to “do something” following extensive tests, whcih further drives up the costs of healthcare. After some testing which my daughter had, the ENT prescribed a dietary solution (whcih worked perfectly) and apologized, without any prompting from us, three times for not prescribing drugs.
November 23rd, 2008 at 8:19 am
his mom did what??? Do tell. It’s even worse than Fred says. A lot of time the doctor will tell you to “bring the results of your xrays.” So then you have to find them and take them and then he sees them for the first time and how is he supposed to read them right away while you’re in the office? Then you have to bring them back to your other doctor to put back in your chart.
November 23rd, 2008 at 4:54 pm
There are many tactics and strategies that could be applied to people with high care seeking propensities once they are identified. The problem is the issue of “care-seeking propensity” is not even acknowledged as a contributing cause of medical care demand. There is not one health risk assessment that asks questions about perceptual factors that influence the sensitivity of the care-seeking trigger. This is because the issue is completely off the radar of health coaching, and disease management.
As to the order of interventions, I do not agree with Al’s order. The assessment and counseling interventions should come first, and immediately. If we wait for “system changes” we will wait forever. The care seeking propensities form in the early adult years and are consistent throughout life. We don’t have to wait for a claim to occur and for each person to show up in the system before we act. We can identify each type in about 3.5 to 4 minutes. If we identify the active care seekers and intervene early, we can potentially head of trillions of dollars in unnecesary care seeking.
Consider this: If the focus was put only on the 50+ population, and through psych interventions we reduced the active care seeking group by 1% to 2%, we could shave trillions off of future Medicare spending. As I said, this focus is a “psych” one; the focus is not on health risk factors but on psychological risk factors NOT linked to any mental health disease.
FHN
November 23rd, 2008 at 7:03 pm
The Advantage of Targeting the Care Seeking Group
The active care-seeking, high cost group is defined by a complex profile of thinking patterns. The pattern of predispositions impacts health risk prevalence, disease prevalence and demand (see http://www.pathinstitute.com/Individual1.htm and “click” the link under “PATH Types At A Glance” and look at Type 7)
At this point, practically no one knows how their own pattern of thinking influences their health or care seeking. A fascinating point of luck is that this active care seeking group only differs from a very healthy, low care seeking group (path type 8) by only a couple of predispositions. Because of this I am confident that if the active care seeking group were made aware of their pattern (plus the risks associated with medical errors), perhaps 5% would change and work to adopt the pattern of the lower cost, lower demand, healthy type. The lower health care demand and reduction in spending that would result would NOT require any changes in the system, no changes in formulary pricing, no changes in co-pays structure, etc.
Let’s consider this in real numbers. The Type 7 pattern is found in about 14% of adults. That’s about 29.4 million adults in the U.S. 5% of this number is 1.5 million. In metro areas of 500,000 adults, this means getting only 3,500 to change.
FHN
November 25th, 2008 at 4:54 pm
I am not necessarily proposing an order of solutions. It’s a little like smoking. You want to tax it and provide patches and counseling. Doesn’t have to be in one or the other order, but they are all important. I myself tend to favor the systemic solutions but you have a point in that even obvious changes can take a long time
December 3rd, 2008 at 8:16 pm
i think of my 87 year old mom whenever anyone mentions our national debt problem and the ensuing health care financial crisis.
We have come up with a simple solution for 85% of the problems with the following changes to the Medicare benefit program. Pay all our Medicare members $20 per day for any days that they do not seek services but instead can produce proof of attendance at a bingo game, dance, exercise program or community outing. Converselyl, charge no co-pay for biannual check ups to pcps and $20 co-pays for every specialty care visit and a 20% co-pay on all tests. Keep all other benefits in play .
December 4th, 2008 at 12:13 am
In response to Judy, your idea is a good one, but you are kinda missing the point. ALL seniors do not need to get paid $20 to not seek care. That would be a very inefficient waste of money. In the path type framework, path types 2, 3, and 8 demand less health care and go to dances, exercise, and so forth without needing an incentive. The intervention needs to be tailored to the Type 7 health cognitive schema, and efficently targeted. Ideally, it would be done in a way that wouldn’t even be noticed by the other types.
December 4th, 2008 at 10:56 am
Judy, the only reason I wouldn’t encourage you to post that idea is that it might win and I might have to pay you. First, I would agree with Fred not all seniors should be eligible — it should probably only be for 85-year-olds and above. Second, you’d have to except certain services, like primary care or flu shots. Third, $20/day is probably way too generous. Fourth, it would have to also include not smoking on those days. Alas, I have no idea how you could police or monitor any of this but crack that nut and you’ve got yourself a contenduh.
Unlke Fred I don’t think you could “tailor” the intervention. Has to be a clear either-or point in time.
December 4th, 2008 at 2:07 pm
Al, Study up a little on schema theory, cluster-based subtypes, and “person-centered” learning and behavior change. In my opinion, one the reasons DM has not delivered and employee wellness only has an ROI of 3:1 is because both apply one-size-fits-all approaches.
December 8th, 2008 at 11:15 pm
I think the idea of working on the “care-seeking propensity” patient is a great one, but likely impractical. (I am surprised to hear the group is as high as 14% of the population). Yes, the majority of these patients have psychological issues. As a former trained therapist of many years past, I do remember that these patients are so “repressed” and removed from their feelings, much more so than many other patients, that the likelihood of reaching them on a telephonic contact is slim. They truly believe that they have some hidden condition (treasure) that some great doctor can find, and I do believe that nothing is likely to deter them in their quest. This just would be an extremely hard group to make a difference with little effect.
December 9th, 2008 at 1:31 pm
Most of the people I am speaking of do not have the traits you describe. In many ways they are the ideal empowered health care consumer. They are active health information seekers, ‘claim’ they exercise, are focused on good nutrition, getting preventive care, and putting a high premium on quality. They are health proactive, have a healthy trust in medical professionals, and put more emphasis on health care for themselves instead of family members. They try to live wellness, dabble in alternative care, and see themselves at the center of decision-making. It happens that their mix of traits actually represent a ‘perfect storm’ of predispositions, values and propensities that create higher health care spending. It is a mistake to think that these types of people are defined by their psychological issues. You could be one.
The reason why I am confident that finding and engaging these folks could lower costs is because none of them know their pattern of thinking has the outcomes it does. They believe they’re doing what every DTC drug ad tells them is good for them. You will always find this type dominating health care focus groups. These are the people who have a higher rate of sending back health care related mail surveys. They like ‘engagement’ and volunteer to be members of clinical trials and online panels. They are smart, knowledgeable health care consumers who work hard at being informed.
I am confident that, if informed about the outcomes of their type, a small percentage of them (maybe 5%) would be motivated to change. And they only need to change two things to match up with the predisposition pattern of a truly healthy type with very lower health demand. I’ve estimated that a one percent drop in the prevalence of this type throughout the U.S. would lower health care spending by $5 billion per year.
February 2nd, 2009 at 4:27 pm
Fred,
You are most likely right on this. I was probably short-sighted. I do agree there is a health-seeking type. I am sure some of my relatives would fit.
I have a brother who was in getting knee surgery with an MRI in hand a few weeks after he twisted it. Needless to say the surgery didn’t really fix anything.
I am going to read your papers on this. I think I may have found a group like this at the health plan.