It is beginning to look like “prevention” — which includes the proactive management of health, risks and disease – is gathering the critical mass of support and proven success that may create a truly “disruptive innovation” effect for hospitals, physicians and other providers of sickness care.  This is no sudden event, but a stage in what has been a long and gradual development over the past 30 years or so.  It is only the growing number and breadth of its champions and results that is making it a truly major development.

Politics

Along with the takeover of Congress by the Democratic Party, there has emerged increasing attention to health policy by candidates for the presidency in 2008 – and what makes that different from the Clinton administration’s effort to create a national approach to reform is the fact that even Republican candidates are jumping on the bandwagon.  All three “major” Democratic candidates, Hilary Clinton, Barak Obama, and John Edwards, have espoused an approach to healthcare reform that emphasizes prevention and management of disease.   Tommy Thompson and Mike Huckabee on the Republican side have done the same.

Large and diverse organizations have joined in pushing the idea that regardless of proposals to restructure the “supply side” of the healthcare system, the only way we can afford to pay for sickness care is to significantly reduce the amount of such care that will be used.  The American Academy of Family Physicians, The NAACP, US Chamber of Commerce and the YMCA are examples of diverse groups coalescing around the prevention cause, in their case as members of the new “Partnership to Fight Chronic Disease” since chronic diseases account for 75% of sickness care costs. [D. Broder “A Route to Better Care” Washington Post June 3. 2007 p. B7]

The State of Vermont is already trying out the idea, starting in six selected towns, combining the elimination of co-payment barriers to preventive and disease management prescription drugs with a public campaign to promote healthy lifestyles.  The intent there is to show that reducing the need, use and expenditures for sickness care will enable the saving of enough money to pay for extending health insurance coverage to the entire population.

Demonstrated Results

While Medicare keeps coming up with equivocal results in its prevention demonstration projects, organizations unhindered by the federal government have demonstrated some dramatic results in terms of reducing sickness care use via preventive health management.  The MDVIP organization of private primary physicians, with roughly 150 members so far, but plans for thousands, has reported hospital utilization levels that are between 36% and 93% lower than those of the population at large for commercially insured patients in eight states examined. Rates for its Medicare patients are between 63% and 93.5% lower than rates for Medicare patients in general.

A rural disease prevention and management effort has offered telehealth capabilities in homes, churches, schools and senior centers to prevent or manage cardiovascular disease and diabetes.  It empowers participating patients to identify their risks and track their disease status via home devices or kiosks for general use, while providers can proactively intervene when necessary.  It is available to over 40,000 people in four rural counties, and is funded for three years.

It recently reported results in terms of reduced sickness care utilization:

* 92% reduction in hospital discharges
* 89% reduction in hospital days
* 67% reduction in ER visits
* 93% reduction in combined hospital/ER costs

These results reflect changes in an isolated and medically disadvantaged rural population, so cannot be deemed typical, but are certainly dramatic enough to suggest the potential. [“North Carolina Community Telehealth Program Achieves Impressive Results Using Telehealth Solutions from WebVMC” TMCNet.com May 31, 2007]

The Fuqua Heart Center of Atlanta at Piedmont Hospital has operated a Telehealth Monitoring Program since 2004 for congestive heart failure patients.  This program has improved the efficiency and stretched the supply of nurses, helpful given severe shortages thereof. It has improved the health status and quality of life for patients.  And it has achieved re-admission within 30 days rates of only 1.45% compated to 5.85% for patients not in the program a 75% relative difference.  Moreover, both rates are between 71 and 93% lower than the national average of 20%. [J. Mattia “How Piedmont Hospital Cut Heart Failiure Patient Readmissions by 75%” Health Leaders Extra! June 6, 2007]

An earlier program of disease management offered by CareSouth Carolina, Hartsville, South Carolina achieved a significant relative reduction of almost 50% in depression among patients with diabetes.  It also was able to manage such patients at an annual cost that was 78% lower than the average for primary physicians in the state, namely $343 vs. $1591. [R. Chaufournier & K. Reims “Hidden Opportunities for Cost Savings in Disease Management” Healthcare Savings Chronicle  (Coalition America, Inc.) Mar 10, 2005]

It has already been shown that health care providers, specifically physicians, can help overcome one of the major difficulties that prevention program vendors have – recruiting enough cooperative patients.  When patients already familiar with the physicians at Goodyear Tire & Rubber’s onsite medical clinic were counseled to enroll in a disease management program, 79% of them did so, three times as many as were enrolled without the help of physicians.  Wouldn’t it be ironic if healthcare providers turned out to be the most effective sources of prevention services, once they are paid enough to make it worthwhile, despite their also being the ones most negatively affected in terms of sickness care use and revenue?

Popularity

A recent survey of 300 benefits decision makers in small (25-100 employees), mid-sized (100-1000) and large (1000+) businesses found that 82% of the small, rising to 99% of large employers see value in wellness programs.  57% of small and 90% of large employers offer such programs to their employees.  Moreover, 37% of small and 71% of large have absence management programs that also tend to include prevention as one way to reduce worker absences. [“Benefits and Behavior” GuardianBenefits.com 2007]

The CVS Caremark Corporation is aiming to reach a half a million people, offering a free online wellness and health improvement program.  The program includes health risk assessment (HRA), online diet and fitness programs, medical history management and interactive fitness and wellness library access.  And it pays “cash dividends” to participants in the program. [“CVS Caremark Corporation Signs Advertising Agreement with flexSCAN to reach 500,000 Wellness360 Enrollees” Press Release, June 6, 2007]

Humana has begun guaranteeing to self-insured employer clients that it will cap annual increases in claims costs at 9%, with 40% of its typically $350 per employee per year administration fee at risk if it fails to deliver.  The savings from this “Smart Results” program have been promised to be achieved through wellness and disease management efforts, rather than any change in handling of claims.  The employees covered by this program will be asked to complete and HRA to identify risks and diseases needing to be managed, and to lean more toward generic vs. more expensive brand-name drugs. [U. Karkaria “Humana Promises Savings to Employees’ Florida Times- Union June 1, 2007 (cgi.jacksonville.com)

The increasing interest in and adoption of prevention may simply be an example of what Winston Churchill described as an American trait: “You can count on America to do the right thing – after it has tried everything else first.”  But as more of the burden of sickness care is shifting to consumers, they are beginning to join with businesses, insurers, and governments, along with an increasing number of providers, in preventing rather than paying for or merely treating sickness, particularly chronic disease.

The extent of the consequences are as yet difficult to predict.  The examples cited above range from merely holding sickness care utilization and expenditures to less than double-digit inflation all the way up to reducing them by 90% or more.  But the handwriting on the wall seems clear enough.  There continues to be need for hospital and physician capacity to handle the sickness care that will still be used, plus potential epidemics, disasters or terrorist attacks.  But projected increases that do not take into account the effects of the growing move to prevention may turn out to be overly optimistic, both in the amount of sickness care that will be used, and how much will be paid for it.

Moreover, these projected increases may are being significantly reduced by the actions of sickness care providers themselves.  A growing number of primary physicians, as well as many hospitals, are investing in their own preventive initiatives – many for their own employees as part of their cost-savings efforts.  Many are also doing so as a mission commitment, and a balanced approach to their future as a way to generate revenue that is likely to be far more generous and profitable than sickness care revenue is now or ever likely to be.   The fact that they seem to be so good at it means it would be a shame if they ignored the potential and merely suffered from the success of others.