As providers heatedly debate whether providing intense patient "support" saves healthcare dollars, a study of 174,120 patients concludes that it does—by about $6 per person per month.
The report suggests that two extra efforts by health coaches to make telephone contact with higher risk patients resulted in a 3.6% reduction in costs after one-year, largely due to reduced costs of hospital admission or readmission, which were 10% less. The study was conducted by David Wennberg, MD, of Health Dialog Services Corporation and colleagues, and was published in last week's New England Journal of Medicine.
"This is the largest study done of this type," Wennberg says. He adds that interventions included helping patients navigate the healthcare system as well as providing decision support. For example, decision support includes the coach helping the patient understand the pros and cons of having back surgery for sciatica, which carries risks that may be greater than managing the pain with medications, comes with a greater time to healing and may require repeat procedures. "The goal is to have shared decision making...with a fully informed patient."
The researchers also initiated phone calls to larger percentages of patients with chronic and other high-risk conditions that put them at higher risk of being hospitalized or using a high number of expensive healthcare services.
The participants, who had similar medical costs and resource utilization at the start of the study, were divided into two groups. The usual support group received three outreach attempt phone calls from healthcare coaches who teach self-care at many levels, and make sure patients understood hospital discharge instructions and adhere to medication regimens. The enhanced support group received up to five outreach attempts, if the subjects had not been contacted with the first three.
The coaches included registered nurses, dieticians, respiratory therapists, and pharmacists.
The study participants included those who were at risk for hip, knee surgeries, prostatectomies, cardiac revascularization procedures and lumbar procedures. Patients classified as being in the top 40th percentile of high healthcare utilization, those with conditions such as heart disease, those at increased risk for surgical intervention and those with chronic conditions such as congestive heart failure or diabetes were included for the enhanced support. "
At some point (with patients at lower risk of needing expensive healthcare services) there is a point of no return. But we didn't find it in this program," Wennberg says.
After 12 months, 10.4% of the enhanced support group and 3.7% of the usual support group received the telephone intervention, the authors wrote.
The study found that after one year, costs for facility and professional services were $8.48 per person per month lower in the enhanced support group than in the usual-support group. Pharmacy costs were 52 cents per person per month higher in the enhanced support group. The program's costs were $2 per month. "The net savings was $6 per person per month."
The field of care management has been filled with controversy and debate, with many studies showing mixed results. One comprehensive study of 15 care-coordination demonstration projects by the Centers for Medicare and Medicaid Services found significant cost reduction benefit in only two, and the savings were so low they didn't cover the projects' costs.
Another meta-analysis showed that care support improves clinical outcomes, "but has mixed effects on cost or resource utilization," Wennberg wrote.
Participants were employees with one of three types of health insurance who worked in seven geographically and occupationally diverse organizations, but the authors cautioned that the results may not be generalizable to other interventions but Health Dialog has expanded it to the general population.
Care support has been proposed as one component of the remedy for runaway health care costs," Wennberg and colleagues wrote. "This study shows that an analytically driven, targeted, population-based program can decrease hospitalization and surgical procedures and thereby reduce total medical costs for the population as a whole."
One important way in which the study showed that this kind of coaching saves costs was in the way coaches assisted patients with decision support, explains Wennberg, who also is a member of the Dartmouth Atlas Working Group team.
Health Dialog Services Corporation markets its coaching program to a variety of plans. The data and trial design was reviewed by an independent third party prior to publication.