Helping our patients make better health decisions can be a challenge. Whether we aim to get them out of bed in the hospital or off of the couch at home, factors contributing to follow-through may be complicated, and the best strategies to facilitate the right choices are seldom clear.
As providers, we would hope that a long and healthy life would serve as the most powerful incentive for behavior change, but with health decisions, consequences are not often direct or immediate enough for patients to always draw the right connections. In our system right now, it’s not explicitly understood who should be most responsible for helping patients stay healthy, but it is clear that individual accountability is slim. With bundled payments per care episode on the horizon, it makes sense to ensure that each party understands their role.
Incentives are powerful tools as long as they’re focused on the right groups and the right behaviors. When a patient with congestive heart failure returns to the hospital shortly after discharge, shouldn’t they have some stake in the penalty that’s assessed by Medicare? After all, CHF exacerbation and intermediate-term management is highly dependent upon the choices of the individual: dietary indiscretion, daily weight, medication adherence. We don’t want to pressure them to avoid the hospital; instead, insurers should implement financial incentives (like reduced premiums) for patients who can demonstrate vigilance managing their chronic conditions. Penalizing hospital systems may help stimulate the creation of more urgent care clinics or expansion of home and outpatient services, but the incentive is still aimed at the wrong party, and that makes it less effective than it could be.
In contrast, if one hospital is discharging their 80-year-old pneumonia and UTI patients to skilled nursing facilities at a rate much higher than their geographic peers, it might make perfect sense to penalize that hospital for overutilization. In this case, the risk of losing reimbursement for admissions would stimulate better practices during those visits: more attention to nutrition, better physical activity for inpatients, improved focus on minimizing delirium. These factors are directly within the hospital’s control, and so financial incentives should affect them directly.
Behavior change is a high-value focus: We can derive substantial improvement in patient outcomes at very little cost. On the part of providers, the barrier has been that our administrators don’t fully understand how much help we can do here because it’s difficult to capture in terms of billable services and productivity, which leaves us with few opportunities to impart meaningful education in an actionable manner. Instead, we give informational print-outs and hurry on to the next service.
If we instead had the time to learn from our patients what separates them from the behavior changes they need, we could better help them. A gap of knowledge is rarely the only obstacle: Many patients underestimate the likelihood of some diseases or how significantly they can actually affect their risk through lifestyle modification. We won’t ever achieve perfect adherence, but we can do better, and the coming changes to payment structure make this the right time to revisit our approaches.
John Corsino is a physical therapist.
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