ANNUAL EDUCATION PROGRAM

POST EVENT QUESTION SUBMISSION

In order to give everyone a chance to interact with our faculty, we are giving program participants the opportunity to email their questions after the event.  Both the questions and answers will be posted below beginning on Monday, May 12.  The deadline for emailing questions is Friday, May 16 at noon.

If you have a question for our faculty please:

• Email your question to continuingeducation@mms.org
• Type 2008 AEP in the subject line
• Identify the speaker(s) who you would like to pose your question to
• All submissions will be posted anonymously.

Questions and answers posted below.

Faculty

Eric Finkelstein, PhD
Health Economist, Research Triangle Institute’s (RTI) Public Health Economics Program

Kevin Volpp, MD, PhD
Assistant Professor of Medicine and Health Care Systems, the Wharton School of the University of Pennsylvania

Peter P. Budetti, MD, JD
Edward E. and Helen T. Bartlett Foundation Professor of Public Health and Chair of the Department of Health Administration and Policy, College of Public Health, University of Oklahoma Health Sciences Center

Carolyn M. Clancy, MD
Director of the Agency for Healthcare Research and Quality (AHRQ)

Question 1
If only 10-15% of health is due to health care, it seems that it is possible to have perfect health care and poor health.  Has there been economic modeling looking at potential health repercussions and subsequent health care costs associated with eliminating gym from schools, diet changes in schools, or even the potential savings of rolling back the obesity rate to what it was 10 years ago?

Response from Dr. Finkelstein:  It is certainly possible to have perfect health care and poor health. It is also possible to have perfect health and poor health care. One study that is relevant is by Ken Thorpe that looks at The Impact Of Obesity On Rising Medical Spending. It was published in Health Affairs. Studies that have attempted to find savings from preventive measures (such as gym class or healthy diets) have typically come up short. Although intuitive, there is little credible evidence that suggests these programs save money. This is not to say they should not be done, but only to say the evidence supporting them on purely financial grounds is weak at best.

Response from Dr. Volpp:  It is likely that preventive programs that reduce the rate of obesity are relatively cost effective even if they aren’t cost saving. Few interventions in health care actually save money nor should that necessarily be their goal. However, health-improving interventions may well improve health in a more cost effective manner than many of the interventions we currently cover through insurance that treat people once they get sick.

Question 2
I believe we could diminish the frequency of emotional and even medical problems in health care, probably reduce the cost of care, as well as improve patient compliance, if we made more of an effort to integrate good psychosocial assessment into primary care.  I have been gradually able to do that in my practice.  However, when I encourage colleagues to consider doing so, they reply, “I would love to do that, but there just isn’t enough time to do so.”  They say that, even though most insurers are willing to reimburse primary care physicians who take time to do so.   

I would direct this question to Dr. Clancy and Dr. Budetti, although I believe it is relevant to any of the presentations including the roundtable participants.  If the speakers can accept the premise as reasonable, then how has medicine gotten to such a state that many physicians are unable or don’t know they can spend such quality time with patients or families?  More important, how would the speakers suggest we go about changing the system, so that motivated physicians would be willing to spend such time?

It would be a difficult question to study but shouldn’t we undertake initiatives to accumulate appropriate evidence to validate this premise?  At the very least, wouldn’t practicing in this way go a long way towards improving physician morale as well as towards improving patient satisfaction?

Response from Dr. Volpp:  I agree that it is ironic that many physicians feel "too busy" to spend time talking with and counseling their patients. A major problem is that the amount of reimbursement for psychosocial assessments and talking to patients in general is far too low relative to reimbursement for procedural activities. Initiatives like the Advanced Medical Home, which are designed to modify reimbursement systems in recognition of the value of trying to keep people healthy as opposed to paying for treating people once they are sick, have some promise. Their potential will be limited, however, if we view them only as successful if they save money as opposed to being relatively cost effective ways to improve health.

Response from Dr. Clancy:  Multiple studies have demonstrated that a substantial proportion of patients with signs and symptoms of depression and related disorders are seen only in primary care settings -- and that detection of these issues is suboptimal. In addition, the US Preventive Services Task Force recommends that all adults over 40 be routinely screened for signs of depression. In the 1990’s the Agency for Healthcare Research and Quality (AHRQ) funded a large trial conducted in managed care organizations to improve detection and treatment of patients with depression (Kenneth B. Wells; Cathy Sherbourne; Michael Schoenbaum; Naihua Duan; Lisa Meredith; Jürgen Unützer; Jeanne Miranda; Maureen F. Carney; Lisa V. Rubenstein. Impact of Disseminating Quality Improvement Programs for Depression in Managed Primary Care: A Randomized Controlled Trial. JAMA, Jan 2000; 283: 212 - 220.) and found that patients in the intervention group were significantly more likely to comply with treatment and be symptom free at one year.

These encouraging results, however, were demonstrated in organizations with infrastructure to support primary care physicians. A clear challenge now is to determine how to achieve similar results in practice settings (e.g., practices with small number of practitioners) without additional people to support similar efforts.

Question 3:
My question is the following: Is it considered legal to give financial incentives or reward to patients to comply with their treatment plan and their follow up visits? Thanks.

Response from Dr. Volpp:  The parameters of this are still a bit unclear. It appears employers have pretty much free rein to do these programs as long as they don’t violate the Americans with Disabilities Act. Insurers can do this pretty freely in terms of incenting patients to participate in programs and for compliance but there are some restrictions in their ability to incent patients based on achievements in outcomes.