Accountable Health Communities
 
               CMS has announced a new program of grants designed to generate information that will lead to “accountable health communities.”[1] The authors note that 95% of the trillion dollars spent every year for health care is spent on direct services, although estimates are that “60% of preventable deaths are rooted in modifiable behaviors and exposures that occur in communities.”
               The authors cite some experiments where investment of resources in social services have reduced demand for direct medical care services. They note:
 
“We still lack expertise, however, in the best ways of scaling these approaches across myriad settings; we remain unsure whether broad-based investments improve health care utilization and costs; and we need to develop and test a template that allows a wide variety of communities to undertake transformation efforts.”
 
               The notion that prevention of disease and disability will lead to cost savings is inherently plausible and psychologically attractive. The experience with sanitation and refrigeration in reducing deaths of young people from infectious diseases informs much of our current public health discussions. Just get people to eat right, exercise, stop smoking and using other addictive drugs, and we can save all sorts of money and people will leave longer, healthier (happier) lives, the argument goes. While it is a sort of “Mom and apple pie” argument, there is a lot of reason to be skeptical that this approach will alleviate our financial crisis.
               At one level, the issue is philosophical. If solving the problems of poverty and unhealthy behaviors was simple, we would have resolved these issues already. I am not expert in this area, but it strikes me that we are at risk of changing our focus from one tough nut, health care, to another, poverty and social ills. If the politics of the former are difficult, the politics of the latter are worse.
               Coincidentally, a paper was published this month in Health Affairs by Patel and associates,[2] whose title states the conclusion: premium-based financial incentives did not promote weight loss. This was a study of 197 obese subjects in a workplace wellness program who were divided into four groups. For the control group, no incentives were offered. The other three were given premium relief, either delayed, immediate, or randomly. Over the study, the control group gained 0.1 pounds, which means most of the subjects were stable, while in the groups receiving incentives, the range was a loss of 1.0 to 1.9 pounds. The authors concluded:
 
 “The apparent failure of the incentives to promote weight loss suggests that employers that encourage weight reduction through workplace wellness programs should test alternatives to the conventional premium adjustment approach by using alternative incentive designs, larger incentives, or both.”
 
               This paper was reported by Kaiser Health News and picked up by NPR and sent out on its network.[3] As reported by Michelle Andrews,
 
“Eighty-one percent of employers with 200 or more workers that offer health insurance also offered weight loss, smoking cessation or lifestyle coaching programs, according to the 2015 employer health benefits survey by the Kaiser Family Foundation and Health Research and Educational Trust. About two-thirds of large companies offered workers cash or merchandise for participating in these programs, the survey found, with 34 percent offering lower premiums or cost sharing.”
 
               Clearly the notion of prevention as I outlined above has been widely accepted, but the payoff, so far, has been small. Dr. Patel was appropriately cautious in his conclusions, noting that other benefit designs or amounts might have changed the outcome. While true, it does not seem likely. I have previously discussed the issue of risk and rewards and their impact on patient behavior when the result of ignoring medical advice is likely to be death in the near future, yet some patients don’t act on the advice. All practicing physicians can think of other examples. So if people can’t make behavioral changes when the consequences are large and the time frame is short term, I am skeptical they will do better when the consequences are uncertain and the time frame is long.
               Given this skepticism about our ability to induce patients to “behave” the way we want them to for optimal health outcomes, what should we do? The short answer is I don’t know. But I note that the website post by NPR included a vigorous response by the “vox populi.” Some think all of this is a good idea and we should press on. Some recognize the issues I have raised. Some don’t see why employers should be involved in the issue at all, and criticize what they perceive as public shaming that frequently accompanies attempts to get group support for behavioral change. The public, in short, is all over the map on this one issue, so I can’t imagine we can garner public support for the sort of intensive community-based interventions favored by CMS. I guess the best I can hope for is that my skepticism is wrong. What do you think?
 
10 January 2016
 


[1] Alley DE, Asomugha CN, Conway PH, Sanghavi DM. Accountable Health Communities—Addressing Social Needs Through Medicare and Medicaid. N Engl J Med 2016;347(1):8-11. doi:10.1056/NEJMp1512532.

[2] Patel MS, Asch DA, Troxel AB, Fletcher M, Osmann-Koss R, Brady J, Wesby L, Hilbert V, Zhu J, Wang W, Volpp KG. Premium-Based Financial Incentives Did Not Promote Workplace Weight Loss in a 2013-15 Study. Health Aff 2016;35(1):71-79. doi:10.1377/hltaff.2015.0945.

[3] http://www.npr.org/sections/health-shots/2016/01/08/462380096/why-employers-incentives-for-weight-loss-fall-flat-with-workers. Accessed 9 January 2016.
                                                      

Further Reading

Readmission Penalties
 CMS is in its third year of applying penalties to hospitals with excess readmissions, but almost 75% of hospitals were penalized this year.  Is this a quality improvement or a surtax?  

Risk, Reward, and Other Reasons Patients Don't Follow Medical Advice
 Patients often don't do what their doctors recommend.  The problem is important and contributes to "bad" outcomes, yet we have little insight into the problem.

What Hospitals Are Doing
How are hospitals and health systems responding to change? An AHA survey provides some insights, but suggests few are really working to improve the function and resiliency of their teams, and are thus likely to fail in attaining their strategic objectives.