OP-ED

New Study Proves Reducing Healthcare Costs While Improving Care Is Achievable

The results are in: population-based care management doesn’t just improve patient satisfaction – it also can significantly reduce medical costs.

It is widely known that chronic disease accounts for 75% of the total cost of healthcare in the United States. In the late 1990s, the care management industry grew out of the need to combat this problem, by increasing medication compliance, reducing gaps in care, and helping individuals become more empowered to actively manage their own health.

Care management programs have long been shown to increase medication compliance and use of other preventative services, and individuals who participate in care management programs find them extremely valuable. Yet the care management industry has always faced challenges in verifiably demonstrating the effectiveness of its programs in  reducing medical costs. Several methodologies have been created to attempt to reverse-engineer a calculation of savings delivered by care management programs, but the gold standard of healthcare effectiveness measures, a randomized controlled trial, has rarely been done and none in a large population.

I’m pleased to say that this is no longer the case. A study from Health Dialog appearing in the New England Journal of Medicine today, uses a randomized controlled trial to definitively show the savings delivered by an enhanced care management program. The trial looked at 174,120 individuals over twelve months, measuring those individuals’ health outcomes and the total savings as a result of an enhanced care management program. The program included chronic condition management and patient decision support programs, and these services were delivered telephonically as well as online.

After twelve months, the average monthly medical and pharmacy costs per person in the trial group were shown to be $7.96 lower than the control group. A 10.1% reduction in annual hospital admissions accounted for the majority of the savings. With the cost of the programs at less than $2.00 per member per month, the net savings to the health plans who participated in the study came to $6.00 per member per month.

There were four unique factors in the success of this particular program.  The first was a coaching approach that focused on empowering individuals to participate in medical treatment decisions across a wide range of conditions – not just chronic – with their doctors. It is important to recognize that people are not diseases (or collections of diseases). Every person possesses a unique set of strengths and faces individual barriers to a healthier life.

The second factor was Shared Decision Making – decision support through multimedia decision aids combined with coaching. Third, the program achieved a high level of engagement by utilizing unique analytic models for risk-scoring individuals, customizing outreach, and predicting receptivity to coaching. Lastly, unwarranted variation analytics allowed us to incorporate local healthcare system factors and practice patterns into our outreach strategies.

As the U.S. healthcare system continues to strain under the weight of the costs associated with care, population-based care management will play an increasingly important role in helping to manage those costs.  This research proves that supporting patient involvement in the decision-making process through scalable interventions can be an effective component of a better healthcare system, now and in years to come.

David Wennberg, MD, is the Chief Science and Product Officer at Health Dialog, a care management company based in Boston, MA that serves over 20 million lives. David is also a member of the Primary Project Team of the Dartmouth Atlas Working Group at the Dartmouth Institute for Health Policy and Clinical Practice.

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37 replies »

  1. I would really like to know just how these savings are determined. I am an enhanced case manager in a large for profit health insurance company. The administrative overhead, from what I see and experience, would more than eat up any “real savings.” Now with the shift to consumer driven health plans, causing plan members to absorb ever higher deductables, co pays and co-insurance, the members are cutting back on their utilization, not because they are using good health judgement, but because they cannot afford the increased cost passed on to them. I hear this every day. Ultimately, this leads to more ER and hospital utilization, the most expensive care. Most providers consider our ECM programs a bother and resent talking with us. For profits take their profits and give big salaries and bonuses to the top management echelons and their shareholders. The not for profits just coat their bank accounts. The real issues here are that providers are not reimbursed adaquately for their services, cannot spend enough time with their patients and do ineffective teaching and explanation with their patients which then leads to more ER and hospital care use. I can’t tell you how often I call a provider office to have a member seen on an urgent basis and am told to send them to the ER. Let’s get real here. Managed care is adding to the cost of care, not making it less costly or more efficient.

  2. Great post John!
    If two percent is not the thirty percent and the NEJM study is correct, how is the industry ever going to achieve enough savings to stop the run-away health care train?

  3. @Maggie Mahar
    From your own 2007 article in Dartmouth Medicine, The State of the Nations Health
    “Can waste help fund reform?
    With its decades of data, Dartmouth has exposed the incredible waste in the U.S. health-care system. Sizing up the evidence, Wennberg estimates that up to one-third of the over $2 trillion that we now spend annually on health care is squandered on unnecessary hospitalizations; unneeded and often redundant tests; unproven treatments; over-priced, cutting-edge drugs; devices no better than the lessexpensive products they replaced; and end-of-life care that brings neither comfort nor cure.
    As Dartmouth’s 2006 paper, “The Care of Patients with Severe Chronic Illnesses,” points out, if this waste were eliminated, “the Medicare system could reduce spending by at least 30% while improving the medical care of the most severely ill Americans” (emphasis added).”
    Maggie, both you and Dartmouth said that “the Medicare system could reduce spending by at least 30%…” Your quotes, not mine. (Emphasis added again and again and again!). Refresh yourself by reading your entire script in Dartmouth Medicine.
    So was it said only for the emphasis, or did the researchers mean what they said? And when they influenced policy from all of the emphasis, at what point did they realize that achieving a 2% savings was not going to approach the proposed “up to one third” that they sold to the lobbyists and the rest of the circuit on Capitol Hill? We all know the origin of much of the hype that helped to create the structure of PPACA, from value-based purchasing to reduced reimbursement for physicians, hospitals and more. Where is the accountability and responsibility in academia (or media) when an adult needs to stand up and say “hey, when we commercialized this, we couldn’t get near the “up to one third” that we found in the laboratory, so maybe you should re-think what we told you”?
    Let’s be clear, this piece of research (a RCT no less) that David has gotten published is certainly good news for many folks, and a testament to the hard efforts of his team. It is a move in the right direction, and is only marginally better than the CMS disease management demonstration projects that were less successful and forced at least one vendor into Chapter 11.
    But Coaching is NOT new so I wonder if they can eclipse the 2% savings over time, or will it end up being a one time savings…and only for those that most qualify for being most influenced? Anecdotes don’t define health policy, so this trial will need to be re-published with more longitudinal results over time. I also hope that the true savings can begin to address the spending so eloquently promoted in your piece above…maybe then, more savings can be realized, perhaps enough to bend the curve.
    Lastly, I can’t leave without stating the obvious…that there is an inherent risk that withholding, delaying or deferring care (like the profile for the uninsured and indigent) could end up having massive unintended consequences as these members end up deferring what might otherwise be prudent medical care…as determined by licensed attending physicians. The cascade of cost cuts both ways. We are going to need a good bit of clinical effectiveness research published and peer reviewed before we can have a reasonable debate about which protocols, methods and services should be withheld, discouraged or shared in any form of decision making…no matter how you look at it!
    I want the saving more than anyone, I just want to know that the methods are sound and the science behind the provider and condition selection are well vetted. Thus far, I see many too many contradictions between the research and the commercialization efforts…and I am quite transparent about my bias toward commercial applications to help improve performance.
    Sorry, maybe 2% is good for you, but it just feels like lunch to me and it will never help fund PPACA.
    TRG.

  4. I think there are significant chunks of healthcare that have wide price variance among providers but narrow quality variance or none at all. This includes prescriptions drugs, including the brand vs. generic issue as well as which pharmacy charges the least, expensive imaging and many routine tests and procedures. The work that Nate and others like him do in trying to guide patients toward the most cost-effective sources of care makes an important contribution toward controlling healthcare costs. Indeed, this is probably the lowest hanging fruit in the sector. Price and quality transparency tools as well as tiered in network insurance products could contribute even more to this effort.
    Whether a particular drug, service, test or procedure for a particular patient constitutes necessary care or not is a different issue. Here, we need mechanisms to differentiate among providers that order lots of tests with no outcomes benefit and those who don’t and then communicate that information to both patients and referring doctors. Tort reform would also be helpful here including robust safe harbor protection for doctors who follow evidence based guidelines where they exist. I recently asked my cardiologist (and primary care doctor), who practices with several other doctors in NYC, how much of the utilization that he and his colleagues drive constitutes defensive medicine. His answer: in virtually every practice in the region, it’s about 15%-20% and he is perceived (correctly) as a cost-effective practitioner. The recent study published in Health Affairs on this subject is far wide of the mark, in my opinion.

  5. Of course you can, Nate. But just like you are able to show me cost savings down to two decimal points, you will need to show me how many of those folks actually renewed their Rx and how many actually kept that preventive care appointment and how many went to the more cost effective hospital after you called them and how does this compare to a control group you didn’t contact.
    You do have the data. Just aggregate it and do the calculations. Otherwise it’s nothing more than anecdotal evidence.
    Ideally you will also show me that their health is better, by some accepted quality measures, like Boeing did.

  6. If I call someone and remind them to fill an Rx they didn’t can I say I improved care?
    What if I call and get someone to schedule a routine exam they didn’t plan to?
    What if my website shows them hospital X has better outcomes and lower cost then Y can I claim it then?

  7. Strategies like filling prescriptions at less expensive pharmacies or getting routine procedures done at less expensive hospitals that can do just as good a job as the AMC with the marquee name and huge fees can make a significant contribution toward improving the cost-effectiveness of care defined as outcomes per dollar spent. We should be encouraging as much of that as we can which is why I keep pushing for price and quality transparency tools and tiered in network insurance products.

  8. i was curious what your responce to Joe’s peice would be. Lot of employer involvement there. There are things that MDs can do to help lower cost, and they should be taken advantage of. I don’t understand why you would limit yourself to just those opportunities and ignore all the others though.
    If I call a member and get them to fill their Rx at Wal Mart instead of CVS and we save 15% does that really require me measuring their health outcome to justify claiming care was not negativly impacted? Can I really not claim we saved 15% while maintaining quality of care based on the logic that the same Rx was filled just at a different store? Not everything has an effect on care quality.

  9. And I’m sure Victor Fuchs is correct. As far as I know the definition of a team is a bunch of people working together to achieve a certain goal.
    Where was the team in this study? There were phone coaches and separately there were doctors or nurses or whatever at the patient’s regular clinic.
    There is no indication that these two separate agencies coordinated anything. Is this the optimal model?
    Jo Flower has a new article here describing how Boeing did it. That model sounds really good and somehow they managed to collect health metrics and save 20%. Maybe they are…. liberals too.

  10. The esteemed health economist, Victor Fuchs, tells us that the best way to manage diabetes is with a team, most of whom are not physicians. Lots of routine primary care and chronic disease management doesn’t require day to day physician involvement. There is an important role to be played by NP’s, PA’s, nurses and pharmacists and we shouldn’t be afraid to utilize their expertise when and where it’s appropriate.

  11. “I don’t happen to believe that phone coaching which is totally separated from a patient’s clinical team can be very effective.”
    And you base this on years of experience with phone coaching? Did you even read what he wrote? Compare what he said to what you wrote;
    “by increasing medication compliance,”
    Why does someone need to schedule and consume the time of a medically trained provider to be reminded to take their medicine? Not to mention the delay in catching the problem and relying on the person being honest with their doctor.
    Now lets look at the terrible, ineffective, won’t work employer/insurer solution. Person doesn’t refill their Rx within 30 days of their last Rx. We call and tell them we notice they have not filled it, remind them of the importance and offer to call it in and order so they can pick it up. Can you come up with a more effective clinical based solution?
    ” reducing gaps in care,”
    If they aren’t going to the doctor how is a doctor going to remind them to go to a doctor? Again something I can easily tell from my data and accomplish with a phone call. Can you come up with a better clinical based solution.
    ” and helping individuals become more empowered to actively manage their own health.”
    Has Cleveland Clinic ever told anyone CC is overpriced and they could cut their cost in half by going to another provider not praticing in the Clinic? Again accomplished very easily by a phone call.
    In regards to better care do you want to argue medication compliance and getting your routine care is not better care? I think we can safely assume those two actions can be considered better care, if you need to spend millions to measure that….well you must be a liberal.
    Have you been proven wrong or do you still not want to admit maybe us evil and stupid free marketers might just know what we are doing?

  12. Nate, here is my problem in a nutshell: The title of this article is misleading. Yes, there was measured reduction in cost. No, there was no measured improvement in quality of care. The key word here is “measured”.
    I don’t happen to believe that phone coaching which is totally separated from a patient’s clinical team can be very effective. If you feel otherwise, I would very much want to be proven wrong.
    All we need is a study that actually Measures the outcomes of such intervention in terms of quality not just dollars spent by employers.
    Granted, it is harder to measure quality of care than it is to add up claims, but this is not a good enough reason to assume that quality was better, just because we previously assumed that “less care is better care”.
    This is not very scientific reasoning, IMHO.

  13. “The question is how to reduce costs while improving quality,”
    Not all quality needs improved, we could afford to lesson quality in some places if we could improve it in others.
    For example in Cleveland the Clinic runs adds saying every life deserves world class care, true for rare conditions, overkill for a cold. This area 99213 bills out around $80-$100 and they net $40-$50. Clev. Clinic bills $180 and nets $120-$150. For a flu, sprain, or all the other routine care do we really need that level of quality? Assuming their quality is even better to start with and not mearly marketing perception.
    “This is a far cry from a stranger, who knows next to nothing about this particular patient,”
    Margalit I guarantee you on the majority of my members I know more about them then their PCP does, if there even is one. At this point in time I have invested far more then most PCPs in collecting data and the tools to do something with it. If your goal really is improved results I would be careful who you deride and dismiss. You eliminate a lot of valid solutions with bias like that.
    I would prefer we solve our physician shortage before we go sumping a whole new line of work on them. Also nurses are much cheaper then doctors why would they not be a logical point of contact? They are quicker to train, more affordable, and sufficiently trained. Why do we need someone with an M.D. for wellness? It’s as logical as hiring a world class chef to pour you a glass of milk.
    “If I understood correctly, the coaches in this study were acting solely on behalf of employers and insurers and there is no mention of care coordination, or any communications, with the patient’s treating doctors or nurses. I question this approach.”
    Margalit are you just going to ignore the tens of millions of people that don’t have a PCP or regualar physician? Your limiting yourself to a small portion of the population with your assistance on clinical base. In some ways reaching those without doctors is even more important.

  14. I don’t know if reducing medical costs is really that effective. I would understand why most readers would disagree. What matters in the end is the quality of care patients get out of what they’re paying for.

  15. Maggie,
    I am certain that you are correct about coaches being valuable resources in a medical setting like the ones you mention. They would probably be very valuable in any clinical setting where their work is done in conjunction with the clinical team and basically supplements medical care provided by physicians.
    However, after reading the NEJM article, including the Appendix, very carefully, it seems to me that the coaches described in this study, although trained and probably very qualified individuals, are not part of a clinical setting. There is no mention anywhere that the coaching was somehow coordinated with the patient’s physician(s) or hospital(s).
    If I understood correctly, the coaches in this study were acting solely on behalf of employers and insurers and there is no mention of care coordination, or any communications, with the patient’s treating doctors or nurses. I question this approach.
    And again, the article clarifies several times that the only outcomes measured were costs of care (based on claims). Nothing there about measuring the effects on quality of care. Perhaps I am missing something.

  16. Margalit–
    Thanks. Let me just say that “decision-making coaches” at places like Dartmouth, Mass General and breast cancer centers throughout New England are nurses especially trained to do “shared decision-making.”
    I have interviewed some of them. They are excellent. They understand that it that their job is not to “lead” the patient to a deicision, but to follow the patient.
    They have more time than doctors have. (Some say that coaching requires 3 meetings.)
    Patients are not just given a pamphlet and a video. The doctor (or the coach) gives them the pamphlet and the video, explains that they should take it home, view the video–often with their family– read the pamphlet, and then come back to talk about their decision.
    Some M.D’s are very good patient counselors–and would make excellent decision-making coaches. Some aren’t–and in many cases would prefer to have a nurse-practioner who works with him or her do the coaching.
    (I think doctor-nurse-practioner teams working together can be great, in part because doctors who work that way tell me that they and the NP can divide up the patients, each doing what he or he (these days, more and more NPs are men) do best. Some are better at working with older patients. Some are better at dealing with chronically ill patients who need to learn how to help manage their disease. Some are better at dealing with well-educated patients who have done a lot of Googling, and have a zillion questions about recent medical research. And presumably some would be better at explaining “odds” to patients– understand risks vs. benefits is all about comprehending “odds” the way a gambler does. For many people, this is not intuitive.

  17. Com mon all you high rollers. You think you can save money on your own? Your to busy rolling in it to make any substancial gains! oh,yes!! we know it is so hard to save anything with these bubbling useless excuses that doctors are annoyed with and insurers who find more ways to part money from members to boast their benefit package. Yes: it is the Member/Patients
    Oh Blame your problems on these knuckleheads that buy into the premise of paying more for a ponzi scheme that bearly holds its own. Yes, these are your targets of green backs. that have been lining your pockets for years. Get real folks! You are the largest part of the problem.Each of you, providers and insurers come to the table with the sole purpose to exploit and misuse patients to maximize Profits for the industry.
    As long as patients are excluded from these High Roller decisions you Can’t in five lifetimes lower Costs!Its impossible for two for profits to cut cost with rate increases to accomodate huge egos and milky way size pay scales. Greed demands waste and what gets wasted are the patients.
    It is a clearly unique situation that the health Industry has the full protection of the Federal and State Laws that serve as protectors and collobrators of Health Care policy. It is this Protectionist policy that has created more waste,gaps in coverage,limited coverage, mediocre care,sky rocketing drugs and medical appliances.
    The facts are Health Care would be very different if it was a Free Market Model.A model that focused on Good services and reasonable pricing. Alot can be said if a marginal hospital found themselves going broke and used that experience, to turn themselves around.As it is their are no real incentives for Hospitals to do Better. They can fester in their cesspool of infection and disease without any reason to worry. It is all kept secret from Public View. So the patient dies from hospital acquired infections its a Big secret. Patients beware death is in the air.

  18. Maggie,
    I don’t disagree with anything you wrote above.
    My only point is that quality of care was not measured in this study and therefore cannot be postulated that it was better, worse or even the same during the 12 months period of the study. In my opinion this makes the study incomplete.
    Obviously health care costs can be reduced, by more than 2.7% if we so choose. The question is how to reduce costs while improving quality, or at the very least keeping it constant. I don’t think this study answered this question.
    As to shared decision making, I don’t know that there was any observed in this study. Sending a bunch of brochures out and referring the patient to “employer resources” does not qualify in my mind as shared-decision making. I sort of have this vision of a doctor and a patient (and family) sitting down and talking things through slowly and deliberately.
    This is a far cry from a stranger, who knows next to nothing about this particular patient, calling at 6PM and purporting to give one advice about life changing events.
    If we must have “wellness” programs, I much rather they are administered and run by a Patient Centered Medical Home, overseen by physicians, than anonymous telephone coaches working on behalf of insurers and employers. And in any case, if it is an “wellness” program, we must measure the “wellness” as well as the dollars.
    Looking forward to your full writeup.

  19. Margalit& John Morrow
    –If patients undergo an operation or a test that they don’t want (or wouldn’t want if they understood the balance of risks and benefits before hand), this is, by definition, a bad outcome (assuming you believe in patient-centered medicine, which says that everyone should get as much care as they want and need–no less, and no more.)
    Studies show that patients who go through shared decision-making rarely regret the decision to go through a procedure. Those who don’t have a chance at shared decison-making are far more likely to regret — and of course, these are the people who are likely to sue.
    Maybe, from the point of view of the surgeon, the patient SHOULD want the procedure. Their might be an excellent chance that it would prolong his life. But the patient might be more concenred about qualify of life. Or the risk of dying on the operating table. Depepending on his or her age, longevity might not be the patient’s first priority.
    Jack WEnnberg suggests that operating on a patient who doesn’t really want the operation is malpractice–“it’s like operating on the wrong leg.”
    I recently talked to palliative care specailist Diane Meier who pointed out that the majority of people in their 80s or older approach death with equanimity–not all, but many.
    I think of the wife of the senile man who had a pace-maker in that NYT magazine story a few months ago. She did not want surgery that might leave her impaired.
    A friend recently turned down hip replacement. It might well relieve his pain, but the pain isn’t that bad. He leads a busy, active life, and for him, the benefits don’t outweigh the risks and the amount of time that surgery and rehab would take. (His doctor thinks he’s crazy.) Ten years from now, he might change his mind–it’s up to him.
    I interviewed David W. about this study, and will be writing about it soon on HealthBeat
    John Morrow–
    It’s now just the $72 per patient saved now, when the patient doens’t have hte operation. It’s the money saved down the road, when the patient decides to try medication instead of surgery for his back pain. (DAvid W. tells me that patients who have back surgery once often have it twice.) More more younger patients (under 50 or 55) are underoing joint replacement. That means that if they live to 75, they’ll probably have to replace the worn-out part. Patients who have PSA tests that tell them they have early-stage prostate cancer, and then go on to treatment often have to have further treatment as they battle side effects (incontinence and impotence.)
    I could go on. Frequently, medical tests and procedure lead to a “cascade” of events. You go into the hospital for the back surgery–and develop an infection.
    This is why each patient who isn’t admitted to the hospital saves us more than $72. And if patients and doctors in our medical culture began to think of medical interventions as something that patient and doctor should agree on–taking into account the patients hopes, fears, lifestyle, temperament, etc., we would have a less aggresive medical culture. This would be less costly, and, in many cases,kinder.
    Too often, older patients in particular, are pushed into doing something they really don’t want to do.
    Finally, we’re never going to save the 1/3 of health care dollars that are wasted. No one at Dartmouth has said that we will. The 1/3 number simply tells us that there is plenty of waste, much low-hanging fruit. And to make health care affordable, all we need to do is rein in health care inflation–“break the curve”–by brining annual increases in the nation’s healht care bill down from 6% to 7% to roughly 2% (assuming GDP and workers’ wages are growing by 2% a year–less if they are growing by less.) It’s the inflation that is killing us.

  20. You naysayers are wound pretty tight on this one. Given that the whole notion of health coaching is still in the development stage, I felt these results were promising. And no one is talking about the potential for long-term health benefits that can result from sustained coaching and health management from a medical home. (By the way, there are other health professionals that can do this under the direction of a primary care physician–does not have to be the doc doing this “without pay.”) The Health Dialog measurement was over one year, presumably involved with patients with acute issues. The big bucks will be saved when Americans begin to equate their behaviors with their own well-being, and in turn with the bucks being spent on their care. We are talking about culture change on a major scale–and to simply keep doing what we have been doing since Medicare was invented is not going to cut it. Health coaching–around acute episodes, and getting society to connect their behaviors to ongoing health status, can and will make a big difference. Everything else is external and additive to the process of improving health and reducing expense. If you don’t think this will help, what is your solution? Just keep the fee-for-service treadmill clipping along and hope for the best?

  21. @ John M – excellent challenge; @ Brad – well said
    30% may be too high an estimate, but unwarranted care and variation do exist, at times for good reason (i.e. when the local physician’s intimate understanding of their patients’ needs allow for deviation from protocol – a fact not well accounted for in the Dartmouth studies) but also unnecessarily. Relying on the BUCAs, providers or policymakers to address it is untenable. Consumers (i.e. organizations that purchase healthcare for their employees, not the employees themselves) are best situated to influence both the cost and quality of medical services by wielding their purchasing power.
    Also, the use of employee engagement programs (since they are the DMUs for medical consumption) are vital to cost control, and get the best leverage and immediate ROI when they address acute care (i.e. surgeries) versus wellness (i.e. weight loss).
    Despite the perceived weakness of this study, there is merit to helping individuals better understand and utilize the medical system. Cost is not the only driver, but it is an integral decision factor to all health improvement pursuits. Beyond that, and what is not captured well, is the value of patient and provider satisfaction when everyone is fully informed and expectations are better leveled.

  22. “More specifically, once the affected patients have learned to take better care of themselves, how long does this benefit last? ”
    That’s a great question, but it is based on an assumption that was not measured. According to the article,
    “The primary outcomes were total health care expenditures and utilization of health care services during a 1-year period.”
    Nobody measured health care outcomes, so we don’t know if the 2.7% cost savings came with better care, or possibly worse care, or no change at all in quality of care.
    We also don’t know if all those folks who decided against hip replacements this year, will stick with the decision next year.
    Another item I found peculiar was the description of how the coaches referred those patients who needed more help:
    “After assessing an individual’s needs, coaches may refer to other resources as appropriate, including health plan case managers, home health, community resources, behavioral health providers, or other health plan or employer resources.”
    No doctors???

  23. I agree that the net savings are modest over a twelve month period, but the near term results of savings four times greater than the cost of the intervention acrosss the targeted population at least justifies that health plans and providers should undertake such programs.
    The unanswered question from this study is how much of the improved health and treatment compliance is maintained over time.
    More specifically, once the affected patients have learned to take better care of themselves, how long does this benefit last?
    What additional outreach and care mgt interventions are needed to maintain this?
    Do they continue to perform better (lower health care costs, fewer hospital admissions, and higher employee productivity) over time?

  24. A) The model can be potentially refined and improved as more as learned and patients are better targeted–this was just a start.
    B) The intervention is cost reducing. How many studies are published that cost more than they save?
    C) One cannot disparage this study, yet advocate for PSA, Mammo’s <45 yo, etc. With all the waste in medicine, this is a mode of care worth refining. Again, it saves, not spends.
    D) In terms of ROI, to knock this intervention, also knock wellness programs. Last time I looked, corporate America has taken to them like a bee to honey. Not a condemnation for sure, but demonstrating a variation on the same theme, ie, prevention strategies that (may) work.
    Brad
    Brad

  25. Once you can figure how statistics—applied as decision driver vs individualization—dictate care, tell that to malpractice bar and get them out of a doc’s mental calculus…or have all the mid-levels purchase their own malpractice policies.
    The Obamacare debate recently concluded by lawyers, lobbyists and ‘stakeholders’ left this issue out because it is a ‘republican’ issue….

  26. CalPERS, who buys insurance or self insures 1.4 million lives, did a study a few years ago that found that prescription drug costs were the largest contributor to high health insurance costs. What Obamacare ignored was this fact. They could have outlawed prescription drug advertising and adopted patent law reforms saving $billions yet they settled for industry political support in return for a modest closing of the Medicare donut hole.This is a sad result of reform politics gone ammuck.

  27. The total family premium for my company’s PPO product is 15,588. Since the company is fully insured, the program would save $432 for my insurer if my family achieved the same success. 2.7% savings on a premium with CAGR of 15%+ does not seem to move the needle for the consumer, though it could scale nicely for the BUCAs.

  28. $12,536,640 straight into the paycheck of the CEO of the average non-profit insurer? Not such small beer!

  29. @ Keith
    Sorry, I am not your kind of mathematical savant. I am sure the $72.00 means something to you, but on a Macro economic level it is really small beer.
    AHIP’s 2009 national average insurance cost for individuals is $2,985. Add deductibles and co-pays and the number is well north of $3,000 per person in 2010. 155 million insured through employers, 85 million insured through gov’t, Medicare, Medicaid and the VA, 26.5 million with individual insurance plans and 50 million uninsured. Before you know it we should be talking serious money, but still barely bending the cost curve…if you haven’t read the daily health reform debate.
    Yet, compare that to the “up to 30% potential savings” that the folks at Dart_mouth say they can save from reducing unwarranted geographical variation and we have a basic but big disappointment in commercial execution of the Dart_mouth Atlas Group’s hypothesis.
    Most savants know why, but since Health Dialog (Study author and Dartmouth Atlas participants) is the offical exclusive commercialization entity of the Dart_mouth Institute and pay royalties to Dart_mouth for using their intellectual property in products licensed to insurance companies…many of us savant pundits were expecting so much more. And, only because we were told to expect more!
    Since this seminal randomized controlled trial found only a 2% savings, and because it also included three other major forms of gate keeping/influence of patients; 1) empowering individuals, 2) Shared decision making, 3) …risk scoring individuals to determine receptivity to coaching…, we can’t relate all of the 2% saving to the last factor of 4) unwarranted variation analytics.
    So, call me bad at math or whatever you want…I can’t get my pick-up truck from 2% to 30% without an awful lot of blind ambition. Sorry, I was hoping to be proven wrong by what the world now knows is the best independent and objective documentation of savings from reduction in unwarranted geographical variation 2%! OK 2.06%
    Thanks for bringing my math to my attention. It’s a good start, but I remain unimpressed. You should demand more too.
    TRG

  30. $72 is a start but not anywhere near the finish. Yes, chronic diseases need to be considered in any reform designed to cut costs. Mandatory preventive testing coupled with increased utilization of Health Savings Accounts will provide big savings. Rather simple concept as well.

  31. And John Morrow is bad at math
    174,120 x $72 = $12,536,640 – yes I can see where you’d say that $12M/year in savings is nothing.
    At least pcp has a valid objection based on methodology.

  32. Every “case management program” I’ve come across has been based on the assumption that docs are willing to spend countless hours without pay reviewing and following up on endless reports generated by “case managers.” No true cost savings, just using physicians as free labor. Count me out.

  33. Wow, how unimpressive! If this is the best you can do…save $72.00 per member per year on typical premiums in the thousands per member per year I suspect you are wasting your time… and that of the employers, employees and governments who are subject to this form of rationing. Call it shared decision making, but it really sounds like a gate keeper that doens’t really keep many back. $72 bucks is maybe a single view chest x-ray.
    You may want to study the human behaviorial effects of gate keeping in high tech and white collar industries and the negative impact of gate keepers. $72 bucks is lunch no matter how you look at it.
    After a decade, it is a shame there isn’t any significant benefit to these gatekeepers as there wasn’t found with MCOs.
    Lastly this just proves to everyone that deployment of the supposed unwarranted geographic variation analysis doesn’t prove very effective in the real world!
    A 3X retun on nothing is…nothing.

  34. “It is important to recognize that people are not diseases (or collections of diseases). Every person possesses a unique set of strengths and faces individual barriers to a healthier life.”
    Brilliant statement, yet the movement to computerize medical care with CPOE pre ordained disease specific order sets for treatment and diagnosis of collections of diseases is being trumpeted as an improvement?? Such gimmicks have no proof of cost effectiveness. They are the latest craze to make money off of health care while offering no proven benefit.
    I would prefer to utilize the patient specific coaching rather than the orders and edicts being generated by companies whose expertise may be limited and whose intelligence and judgment may be less than that of the patients’ attendings.
    It is all about doint the right thing at the right time for the specific patient.

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