Overcome personal barriers to address patient accountability

Inadequate care coordination is estimated to have caused between $25 and $45 billion in wasteful spending in 2011. While healthcare organizations are mobilizing to correct these inefficiencies by creating team-based healthcare delivery systems, such as accountable care organizations, there’s another serious issue that needs to be addressed: patient accountability.

Patients must be able to respond to their physician’s advice, follow their treatment plans, take their medications as prescribed and often modify health behaviors that may be negatively impacting their health and wellbeing.  This requires that patients understand their providers’ recommendations, are motivated to act and able to change their health behaviors. It is well documented that advice and education are not always sufficient to bring about changes in patients’ lifestyle/health behaviors.  Most people need help and guidance to change lifestyle/health behaviors that have become integral to their daily lives.

If payers want to reduce healthcare costs for themselves and their clients, they will want to make sure that their members have the help they need to engage in healthy behavior change. This means providing access to specialists and programs that have the expertise to help people understand the factors that lead to their behaviors (for example, triggers, food cravings and stress).

Behavior Change Impacts

It is well documented that behavioral interventions save money, slow progression of chronic diseases, and improve physical and psychological health, functioning and quality of life. Key risk factors that drive poor health outcomes and higher healthcare costs include:

• Smoking. Tobacco use continues to be the greatest cause of preventable death and disease, killing more than 440,000 people nationwide each year. Self-insured employers and health plans save an average of $7,800 a year for each smoker who quits.
• Obesity/overweight. Obese workers cost U.S. employers an estimated $73.1 billion or more in healthcare costs and productivity losses each year. An intensive lifestyle intervention study of 5,000 adults with diabetes showed that behavior changes significantly reduced the number of hospitalizations, rehab, homecare and medications.
• Alcohol. Excessive alcohol consumption is the third leading preventable cause of death in the United States. A number of studies have shown that brief behavioral  interventions resulted in positive clinical and financial results. In one example, a randomized control trial in which 482 men and 292 women received a brief alcohol treatment by a physician, the total economic benefit was $195,488 in avoided emergency room visits and hospitalizations.
• Physical activity. Less than half (48%) of all adults meet recommendations for aerobic physical activity, according to the 2008 Physical Activity Guidelines by the CDC. A variety of behavioral approaches for increasing physical activity have been shown to be effective. Cost-effectiveness studies in Britain and Australia have shown very positive results.
• Nutrition. Adults consume 1.1 daily servings of fruit and 1.6 daily servings of vegetables, well below the recommended five daily servings of fruits and vegetables. Dietary interventions to reduce cardiovascular risk factors and improve diabetes control have been shown to be clinically effective. Good nutrition is linked to lower risk for cancer, coronary artery disease and diabetes, and lower blood pressure.
• Adherence. Medical non-adherence (following treatment plans and taking medications as prescribed) is a serious issue in the United States, and is associated with poor outcomes, higher utilization and higher mortality. The cost of non-adherence for all patients is estimated at $290 billion a year.

Obstacles to Healthy Change

Current approaches to behavior change,  while effective, can be enhanced by new science. As demonstrated by the studies mentioned earlier, an intensive intervention that addresses modifiable health behaviors and the barriers/obstacles to change may be the key to driving higher levels of engagement.

Healthy change is not easy. People need help identifying personal barriers that stand in their way of being able to make changes. Potential personal barriers are vast and unique for each individual. They can be psychological, logistical, socioeconomic or cultural. Here are examples of a few possible scenarios:

• Psychological: An older person with multiple chronic conditions suffers from depression.

• Logistical: A single working mother struggles with time management.

• Socioeconomic: A financially challenged person doesn’t have a car to get to the doctor.

• Cultural: A smoker trying to quit has a spouse who is still smoking.

Physicians only have so much time to spend with each patient, which makes it difficult for them to learn about these personal obstacles.  This is where payers can step in and fill the gap, by providing healthy change programs to their members and actively promoting these programs to their physician networks, so that physicians can advise their patients to enroll.

Risk Behavior

Lifestyle behavior coaching focusing on key risk behaviors across populations can have a broader impact in terms of engagement and cost savings for payer organizations, and can help drive better health outcomes for ACOs, large physician groups and hospitals. Focusing on improving these key behavior areas first can have a more immediate impact on health status than putting the first emphasis on data such as  clinical performance indicators and working backward to include the patients.

For instance, the average cost savings to a U.S. employer for quitting smoking is $7,800 per person per year. Weight loss of 7% is estimated to reduce the risk of diabetes by 58% in people with prediabetes and can achieve cost savings of $6,600 a year. It also reduces the risk for heart disease by 48% in men and 40% in women. A diabetic patient able to improve compliance by 10% can reduce medical costs from 9-29%.

Another benefit of focusing on key health risks is that the approach is adaptable to all patients or members of a population, from low-risk members just getting started to high-risk members who have chronic conditions.

Best Practices

Coaching should engage each member in insightful personalized interactions that inspire motivation to change. This can only happen if the relationship feels safe and more personal. Only then can a coach begin to understand the complexities of the person they are helping.

By taking into account each person’s history, preferences, culture and other personal variables, the coach can better guide each person to appropriate sources of help, which could include smoking cessation or weight loss counselors, nutritionists, exercise specialists, certified diabetes educators, stress management experts or in some cases, community resources.

The coaching approach should focus on the underlying cognitive and behavioral health factors that contribute to poor health outcomes through:

• Discovery of personal motivators. Members explore how a specific behavior change can positively impact their life in a way that is specific to them and their needs (e.g., losing weight for a wedding, quitting smoking to run a marathon or increasing physical activity to combat depression).

• Identification of personal barriers. Members evaluate cultural, socioeconomic and psychosocial factors with their behavior coaches that could be creating personal barriers to behavior change.  Together with their coaches, they develop plans to take steps toward dissolving barriers.

• Goal setting. Members determine what behaviors they feel ready to change based on their needs, preferences and personal desires, and develop reasonable and manageable plans for modifying their behaviors.

• Use of innovative technology tools. Members have access to mobile health solutions, at-home monitoring devices, online support services, gaming, social media and other innovative technology tools that help them stay engaged wherever they are and also make behavior change more fun. 

• Interdisciplinary care teams. In cases where members are managing a health condition, it’s important that their care be coordinated by a behavioral specialist who knows their personal situation and can connect them with appropriate services (e.g., pharmacists, physicians, nutritionists, community resources).

By focusing on healthy behavior change, organizations can prevent or slow the progression of chronic conditions, as well as reduce healthcare costs associated with specific behaviors. This is why behavior change strategies must be considered a crucial component of any system of care coordination.