BY BEN WHEATLEY
As health care continues to evolve in the direction unaffordability, policymakers are considering a range of options to reduce health care costs. The Health Affairs Committee on Health Care Spending and Value has identified four major areas for reform, including administrative savings, price regulation and support for competition, spending growth targets and value-based payment. These measures adequately target the supply of health care and the excesses that exist in the health care system.
In this blog, I would like to highlight another avenue of savings: one that focuses on the demand side of the equation. It is possible to reduce health expenditure by reducing the demand for care. This is distinct from rationing, which is the denial of necessary care. I’m referring to real health improvements that make health care less necessary in the first place. This kind of health improvement is the sweet spot of healthcare cost containment, benefiting both patients and purchasers.
In a previous blog, I asked the question: in an ideal world, how much would we spend on health care? I postulated that in a perfect world, we wouldn’t spend anything on health care because no one would be sick. Although such a perfect world may be unachievable, having the goal in mind can serve to guide our way in the present moment, like entering a destination into the GPS.
Measures that promote real health improvement can reduce the burden of disease while reducing the cost of care. They push us in the direction we want to go. In this blog, I give several such examples.
An ounce of prevention
The CDC explains that there are several types of prevention. Primary prevention occurs before a diagnosis, for example, smoking cessation that is initiated before the development of lung cancer, or seatbelt use that prevents a car accident from causing physical damage. This type of prevention occurs at a fundamental level, by preventing disease or injury from occurring. Primary prevention promotes improved health while reducing costs. However, the savings may be reduced depending on the level of involvement of the health system (for example, if rather than quitting smoking on their own, the smoker employs pharmacotherapy and counseling).
Secondary prevention involves screening to identify diseases that occur at an early stage, before signs and symptoms appear (for example, mammography and regular blood pressure testing).
Tertiary prevention involves managing the disease after the diagnosis has already been made, in order to slow or stop the progression of the disease. This includes measures such as chemotherapy, rehabilitation, and screening for complications (for example, routine eye exams to detect and treat diabetic retinopathy).
Prevention has not always been shown to reduce health costs. According to one report, “hundreds of studies showed that prevention generally increases medical costs rather than reducing them. Medications for high blood pressure and high cholesterol…as well as early cancer detection and treatment all add more to medical costs than they save. This reflects the fact that health care is expensive and that care can become expensive, even when implemented upstream. Such interventions can be beneficial, but they do not occupy the middle ground of health care cost containment.
Twelve steps
Alcoholics Anonymous now has over 2 million members in 180 countries and over 118,000 groups. A Cochrane review pointed out that “alcohol use disorder (AUD) confers a prodigious burden of illness, disability, premature mortality, and high economic costs due to lost productivity, accidents, violence, incarceration, and increased health care utilization.” In a systematic review of the literature, Cochrane found that “there is high-quality evidence that (Alcoholics Anonymous/Twelve Step Facilitation is) more effective than other established treatments, such as (Cognitive-Behavioral Therapy), in increasing abstinence.” Additionally, “AA/TSF likely produces substantial savings in health care costs among people with alcohol use disorders.” This well-known health innovation is one that has been promoted and practiced by the patients themselves, without the direct involvement of the health system.
Prevention that reduces psychiatric hospitalization
I was diagnosed with bipolar disorder in 1998. From 2001 to 2008, I was hospitalized for mania almost once a year (7 times in 8 years), including one month of hospitalization. In response, I developed from scratch a mood tracking system designed to help me monitor my condition and support self-regulation. I used the system three times a day for many years, and in doing so, I dramatically reduced both my ER use and my psychiatric hospitalization rate. This resulted in direct savings of tens of thousands of dollars. The intervention itself was free.
From 2008 to 2013, I was hospitalized at the rate of only once every three years. Today, I have only been hospitalized once in the last 10 years. I haven’t been hospitalized at all in the last seven years. These results point to the sweet spot of health care cost containment, where health improves and, as a direct result, spending decreases.
The mood tracker I developed was designed to flash red whenever I started to get manic. The system asks 10 questions (e.g., “Do you feel optimistic about the future?”) and rates mood on a 100-point scale (anything above 50 is positive mood, anything below 50 is depressed mood). My highest score was 85 the day my son was born. However, I was not at all manic that day. So I developed a second metric (on a scale of 0-10) that captured my level of mania. On this scale, any score between 0 and 5 is a green light (not manic), 5 to 7 is a yellow light (caution), and 7 to 10 provides the flashing red light.
I found that having this early warning system allowed me to take action to counter the mania. For example, I learned that eating helps. Exercise helps. Talking to people helps. My therapist and I made an arrangement that if I scored 8 or above and the system flashed red, I would take a PRN antipsychotic pill. These steps helped me stay out of the hospital.
To generate the mania score, I asked 5 additional questions (eg, hours slept and number of “big ideas”). There was a measure for “outside warnings” (for example, if a family member or friend was concerned about my mental health). I soon learned that this factor should be heavily weighted. The remaining two questions were about ‘captured manic thoughts’ and ‘raw manic thoughts’. I might have thought people were reading my emails or monitoring my calls, but the thought was “caught” in the sense that I recognized it as a manic thought. A “raw” manic thought meant that the surveillance was really going on (ie, I did not consider my growing worry to be the product of a mania).
Through trial and error, I was able to develop weights for each of these queries and tabulated them into a formula in Excel. Over time, I was able to refine the weightings until the scores gave me a very accurate representation of my manic state. If the system says I’m a 6.8 yellow, that’s the correct representation of my state at that time.
But it wasn’t just the output that proved useful, it was also the data entry process. The system forced me to monitor my own thought processes. I became aware of my own manic thinking and was then able to take action to counter it. It was this process of self-regulation that allowed me to reduce the number of manic episodes I experienced, which in turn reduced the number of emergency room visits and psychiatric hospitalizations I had to endure (at great cost to me and the healthcare system).
Drainage of the swamp
In 2022, the United States spent an astonishing amount $4.42 billion on health care. Certainly, healthcare professionals work hard to promote positive health experiences and outcomes, and their efforts should not be ignored. But I don’t think calling the health care system a “swamp” is without merit. Elliott Fisher and George Isham have recently pointed out that greed plagues the system, saying “the public perception that health care is largely about making money undermines the legitimacy and trust we depend on.”
The sweet spot of health care cost containment comes from draining the swamp, rather than trying to reform the swamp. Patients who do not need health services do not incur health expenditures. This type of demand reduction avoids other important issues, such as what psychiatric hospitals charge for an inpatient stay and what their quality indicators reveal. At a time when health care is unaffordable, demand reduction is a direction we must pursue.
Ben Wheatley has 25 years of health policy experience with organizations such as AcademyHealth, the Institute of Medicine and Kaiser Permanent (linkedin.com/in/ben-wheatley-05).
