Teaming up for wellness, prevention -- and saving money

A message to all physicians from AMA President Cecil B. Wilson, MD.

By Cecil B. Wilson, MDis an internist in private practice in Winter Park, Fla. He served as chair of the AMA Board of Trustees during 2006-07 and was AMA president during 2010-11. Posted Feb. 7, 2011.

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When I was a medical student, I never dreamed that my work as a physician would have anything to do with the federal budget or the cost of health care to the nation. Yet that's exactly what's happening today as we find ourselves trying to figure out how to help Americans with preventable diseases and chronic conditions help themselves.

We all recognize that here in the U.S., controllable behaviors -- obesity, smoking, alcohol abuse and sedentary lifestyles -- are a major determinant of a person's health. Even so, the numbers from the Centers for Disease Control and Prevention are sobering.

Of the determinants of health in the U.S. population, 10% relate to access to care, 20% relate to genetics, 20% relate to the environment (clean air, clean water, etc.) and 50% relate to a person's health behaviors.

Those things also are expensive: More than 75% of health care spending in the United States is devoted to individuals with chronic conditions to a great extent associated with controllable behaviors -- conditions such as heart disease, diabetes, lung cancer and stroke.

Obesity-induced type 2 diabetes and associated complications accounted for approximately 10% of all health care spending in 2007, and heart disease accounted for more than $143 billion in U.S. health care spending in 2008.

Kathleen Sebelius, the nation's secretary of Health and Human Services, points out that solving the obesity epidemic -- which is larger than breast cancer and HIV combined -- is one of our most pressing public health priorities. It is also one of the most pressing financial problems in this nation.

Moreover, these difficult economic times have taken their toll on physicians' opportunities to steer patients toward wellness. Patients facing even a $20 co-pay have been less likely to seek out preventive care and wellness checks -- and it's no secret that over the past several years businesses have been increasing co-pays and deductibles.

This shows up in the numbers, too. While spending on physicians and clinical services in 2009 did increase, it did so at the lowest rate -- only 4% -- in a half-century.

That's why it is important that the Patient Protection and Affordable Care Act has taken wellness and prevention into account. The law requires private health plans created or changed after September 2010, plus Medicaid and Medicare, to fully cover most preventive care -- i.e. no co-pay and no coinsurance required. The care includes many vaccines; colonoscopies; annual exams for Medicare patients; prevention care for children and women; and screenings for hypertension, depression and HIV testing for high-risk candidates. Final guidelines will be released by Aug. 1.

Not unexpectedly, this is not as simple as it sounds, since not all preventive care is included, nor at this time are all insurance companies. This year, an estimated 31 million people are expected to be enrolled in health plans affected by this rule, with 78 million covered in 2013 and 98 million more still to be included.

Additionally, if a physician handles problem-oriented services during the same visit as the wellness services, the patient will have to make a co-pay for the acute services.

It is confusing, and it will cause headaches in recordkeeping, but it is a good start.

Also under the health reform law, the CDC was authorized to start a National Diabetes Prevention Program. Working with the National Council of YMCAs of the USA, the agency has developed a program to help overweight, pre-diabetic people exercise more, eat better and be more aware of body metrics related to diabetes.

These steps are important, because there is mounting quantifiable evidence that by making health care more accessible -- in this case by reducing costs -- patients are more likely to participate in programs and take charge of their own health.

As an example, Olathe, Kan., is one of three Kansas City-area communities that operates a free health and wellness clinic for city employees. Thanks to employee use of the clinics for both health and preventive measures, Olathe anticipates saving more than $2 million in health care costs this year. Kansas City, which followed Olathe's lead in establishing a free clinic for city employees, says its clinic saved $5 million in 2010.

The business community has been a leader in understanding the value of wellness programs. Health Affairs recently reported that when an employer in Orlando, Fla., cut co-pays for diabetes medications, the program paid for itself in three years through fewer hospitalizations and lower disability payments. This was the subject of a study by the Florida Health Care Coalition in Central Florida.

A recent survey by the human resources firm Hewitt Associates found that employers are looking hard at wellness programs to help keep group insurance costs from going higher. According to Hewitt, many of the employers they surveyed either plan to or already are penalizing employees who do not participate in wellness and disease maintenance programs.

The good news that comes from all of this is that major chronic diseases are amenable to changes in behavior. The AMA's Healthier Life Steps tool kit can help jump-start the necessary behavior changes that lead to a healthier lifestyle and a reduced risk for chronic conditions. The tool kit is online (link).

The bad news is that while our role as physicians is important, the truth is that changing behavior ultimately is up to the individual. It is also difficult. It takes time, concentrated effort and even a certain amount of courage.

Likewise, if we are really serious about wanting to turn around the health of this nation, physicians alone cannot do it, one patient at a time.

It will take a combined effort and years of total engagement by physicians, yes, but also patients, business and the government to change attitudes and behaviors across our whole society -- and lower the nation's health care costs in the process.

Cecil B. Wilson, MD is an internist in private practice in Winter Park, Fla. He served as chair of the AMA Board of Trustees during 2006-07 and was AMA president during 2010-11.

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External links

"Value-Based Insurance Plus Disease Management Increased Medication Use And Produced Savings," Health Affairs, January (link)

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