Manipulating Patients and Physicians

Jul 29 2013 Published by under [Medicine&Pharma]

Humans are ornery critters. We behave in ways that thwart our own self-interests, eating and drinking things we should not while avoiding exercise and other beneficial behaviors. Even when we look to our healthcare, we do not always do the best thing(s), either as patients or providers. Broad insurance coverage can result in patients and physicians gorging at the trough of medical services, generating expenses that do little to enhance health.

Insurers instituted co-pays and other cost-sharing measures to discourage excessive use of services. The key is to make the amount just painful enough that patients think twice about dropping the cash but will not hesitate to do so when services are truly necessary. It requires a delicate balance; if patients opt out of drugs or services that prevent hospitalization or more expensive therapy, this underuse can lead to overall increases in expenditures.

Value-based insurance (VBI) links patient cost-sharing to value. High value services have reduced co-payments to encourage their use. This strategy has been used for management of a number of chronic diseases. As a physician, I get periodic notifications that a patient I follow has a certain diagnosis code, so I should consider prescribing drug X. In my case, chronic kidney disease and/or proteinuria should trigger consideration of anti-angiotensin II drugs. On the patient end of things, if I have prescribed one of these drugs in the preferred formulary, the patient may have little or no co-pay for that prescription.

In addition to reducing costs over the long run, this strategy may improve the quality of healthcare. Physicians get reminders about the best evidence-based practice, and patients get rewarded for following the treatment plan.

Does it work?

In a recent issue of Health Affairs, a meta-analysis of 13 observational studies of VBI suggests the answer is yes and no.

All of the studies showed an increase in medication adherence with VBI. The lower payment carrot works, at least for the first year. Few studies went longer than that period, with a maximum duration of 3 years.

Unfortunately, better quality of care did not reduce overall expenditures for health. This may simply be the result of the short duration of these studies. Savings have generally been estimated from "lifetime" models of spending, not the 1-3 year timeframe of these studies. Ongoing examination of these cohorts remains in order to answer this question.

VBI will not reduce healthcare spending immediately, but it does produce improved patient adherence to their treatment regimens. It has the potential to improve the care of those living with chronic diseases.

3 responses so far

  • A says:

    Notice that discussions on the health care systems tend to drift away from the core issues of health to that of money. So the money drives it, and that is the main problem of civilization, progress, and evolution vs devolution. Notice also that is a man made situation, or problem, therefore is fixable.

    Where do I find laws related to health, all of them through time???????

  • D. C. Sessions says:

    Unfortunately, better quality of care did not reduce overall expenditures for health. This may simply be the result of the short duration of these studies.

    It's not implausible that increasing the quality of care even with lowered short-term costs would increase lifetime healthcare expenditures simply by extending lifetime. It's the Smoker's Paradox: smoking actually reduces lifetime healthcare costs by killing smokers when they're young before they go into the chronic geriatric disease mode.

    That's not an argument against increasing quality of care. It is an argument against "lifetime costs" as a metric for judging healthcare measures (vaccination has an enormous cost in lifetime models after all -- nothing so cheap as a dead infant.)

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