Patient, Heal Thyself

By DON KEMPER

If you want a better system, support a smarter patient .

For weeks now Congress has been stymied by how to pay for extending coverage to the uninsured. While it may seem stupid to look to the patient for the answer, pumping more money into the current system would be the stupidest idea of all. Helping people to do more for their own health care may be the only thing that saves health care reform.

A lot of recent attention has gone to the medical practice differences between McAllen and El Paso, Texas—with McAllen having twice the costs and use rates of El Paso. But the McAllen/El Paso differences are tiny compared to the difference in costs between and among families—even for those living in the same town or on the same block.

Let me pose the example of two identical families, the Smiths and the Joneses, with the same medical conditions but with different approaches to self-management. How might each family deal with three possibly high-cost episodes of back pain, chest pain and dementia?

The Smiths vs. The Joneses

The Smith family is a “doctor knows best” family that relies on the excellent physicians and hospitals in their community to keep them healthy or return them to health when they aren’t, but do little to participate in the decisions or the care. The Smiths accept whatever treatments their physicians recommend.

The Jones family also relies on the physicians and hospitals in their community. But they use health care decision tools and self-management information in combination with their doctors’ advice to make sure they’re getting the best treatment for them.

When Sam Smith’s back pain flared at age 45, he was quick to accept his doctor’s recommendation for an MRI and a visit to an orthopedic specialist to make sure it wasn’t serious. The MRI showed a possible cause of the pain and (just to be sure) Sam had surgery the following week, marveling at the efficiency of the system. The cost: about $40,000 for surgery, hospital, physician care and rehab.

When Jay Jones, also age 45, had an identical bout of back pain he reviewed a back surgery decision aid on the Web—even before his first visit. He learned that back surgery is not usually needed or always successful. For him the case for surgery was not very strong.

When his doctor recommended an MRI, Jay pointed out that a decision aid helped him learn that 50 percent of back pain cases go away in four weeks, 90 percent in six months, and only 10 percent of back pain cases need surgery. Jay also learned that MRI reports often find things that can lead to surgery even though they were not the cause of the pain. With that information he asked if he might put off the MRI and the surgery while he determined if his back would get better on its own—it did. The cost: $150 for the office call and $12 for the over-the-counter medications. Back surgery is among the most overprescribed treatments.

When Sam’s wife Susan, felt some chest pain after an argument with him, she went right to the ER. While the pain went away quickly, Susan accepted the recommended EKG (just to be sure). And although she had no family history of heart disease, (just to be sure) she was also given a stress test, an echocardiogram, a mobile Holter monitor and a cardiac catheterization. She was happy to agree to anything that the doctors thought might show something. The cost was staggering—but the insurance paid most of it.

When Jay’s wife, Janice, felt similar chest pain she made a quick check with an on-line symptom guide. She self-assessed that she was not sweating, had no shortness of breath, she wasn’t vomiting or nauseous, the pain was fairly stationary and her heartbeat was steady at her normal 64 beats per minute. She also surmised that the pain could have been caused by a session yesterday on a new exercise machine at the gym. After confirming by phone with her doctor she decided to do watchful waiting to see if the pain went away—it did. The cost: $25 for the phone call to her doctor. As a bonus, her alertness to the possibility of heart pain caused Janice to renew her commitment to exercise and healthy eating.

When Grandfather Smith (Sam’s dad) and Granddad Jones (Jay’s dad) each progressed into advanced frailty  with dementia,  the pattern continued with the Smiths opting for a full medical response in their “at-all-costs” battle against death and the Jones opting for an approach which maximized family support and caring over treatment. The Smith to Jones cost difference was astounding.

The story could go on and on. If self-activated people like the Joneses are given good self-care, disease self-management and decision-support tools, they will use them effectively to avoid the overtreatment and under-caring so prominent in today’s health care system. But, how do we get more of the Smith families to step up to the same tools and philosophy as the Jones? I recommend a two-part solution: ”Supporting the Jones” and “Motivating the Smiths”.

Supporting the Joneses

Job 1 is to help the Joneses succeed in their efforts by giving them evidence-based, easy –to-use decision aids and self-management guides to implement three basic rules:

• The Self-Care Rule: Help people do as much for themselves as they possibly can. With the right tools we have become our own travel agents, bankers and investment counselors. We create our own Websites and edit our own movies. Rule #1 would bring that same innovation to health care.
• The Guidelines Rule: Help people ask for the care they need. Too often in health care there is a gap between what we know works and what we do. On average, people with chronic disease get only about half of the care they should. Conversely, we are often suggested expensive and invasive treatments when simpler treatments do just as well or even better. By giving patients easy-to-read versions of the same medical guidelines their doctors use, they can ask for and get the care they need.
• The Patient Choice Rule: Help people say “no” to recommended care that is not likely to improve their lives. With the benefit of good information people should be able to decline duplicative or overly expensive testing, unnecessary drugs or surgeries not likely to make a positive difference in their lives—particularly in the last years of life.

All three rules can be implemented quickly and effectively by implementing patient facing “meaningful use” requirements for electronic medical records and by expanding MyMedicare.gov into a virtual health home.

Motivating the Smiths

The second task is to motivate the Smiths to become more engaged in their own healthcare by offering economic and structural incentives to them and to those who serve them.

• Reduce co-pays for services that prevent complications.
• Reduce co-pays or premiums for people who use patient decision aids.
• Provide rewards when people obtain and maintain wellness goals

Clearly health care reform must include improving the provider side through EMRs, transparency, and payment reform to improve care coordination, reduce errors and hold down overtreatment. But without help from a better informed, more engaged patient that will not be enough. By giving each of us the right tools, the right incentives and the right accountability we can do much to heal ourselves and to create a new, patient-centered health care system that is affordable, high quality and better for our health.

Don Kemper is the CEO of Healthwise.

More on health care and technology:

• Meaningful Use vs. Meaningless Adoption of Electronic Health Records
• Bringing Patients into the Health IT Conversation about "Meaningful Use"
• What is the Physician's Role in a Web-based World?