Wednesday, February 13, 2013

Isn't It Time We Got Serious About Prevention?



The United States Preventive Services Task Force (USPSTF) recently posted a draft research plan for public comment under the banner: behavioral counseling to promote a healthy diet and physical activity for cardiovascular disease (CVD) prevention in persons with known risk factors for CVD The USPSTF describes itself as “an independent panel of non-Federal experts in prevention and evidence-based medicine and is composed of primary care providers (such as internists, pediatricians, family physicians, gynecologists/obstetricians, nurses, and health behavior specialists).”

The USPSTF conducts scientific evidence reviews of a broad range of clinical preventive health care services (such as screenings, counseling, and preventive medications) and develops recommendations for primary care clinicians and health systems. These recommendations are published in the form of "Recommendation Statements."

Having previously founded, built, and sold HealthDrive, the largest medical and dental practice in the U.S. providing care to elderly residents of nursing homes and assisted living facilities, I witnessed during my tenure what happens to older Americans who succumb to chronic diseases and require constant nursing care. Spurred on by the introduction of Medicare’s Annual Wellness Visit, I came out of a short retirement almost three years ago to answer the same basic question, does counseling work to prevent disease, now also posed by the USPSTF. The Annual Wellness Visit, now only covered by Medicare, is a service in which a physician is paid to identify health risk factors as opposed to performing a routine exam or treating an existing condition.  It is an opportunity to try to prevent disease as opposed to treat it.

As a doctor who practices primary prevention on a daily basis, having last year counseled hundreds of patients to eat better and get more physical activity, I can share that success is a function of spending considerable time with patients to help them identify their motivations to live a longer and healthier life. I have found this process to be different for each patient and very time-consuming, often extending beyond an hour and sometimes more than two hours; my longest session took over four hours. Helping patients identify and articulate their motivations takes time and effort because motivation is often not the simple “I want to live.”  
True motivations range from wanting to meet their great grandchildren to seeing what gets invented next (mine).  Often they are uniquely personal.  Case in point was a patient who after considerable discussion ultimately shared that his prime motivation to live healthier was to outlive his wife so he could spend more time with the other woman he also loved.

Once I identify a patient's prime motivation, it is then critical to choose the right intervention(s).  For example, a patient who has lived a sedentary life for many years will often find it difficult to suddenly initiate physical activity on his or her own.  Extensive muscle atrophy from lack of use may require the services of a physical therapist or personal trainer (which few can afford) to start moving again. Eating healthy takes work as well. For both those who knowingly eat unhealthily or are simply confused what comprises healthy food choices because of widespread food marketing and misinformation, it is helpful for them to sit with a registered dietitian to learn how to develop healthy meal plans. 

This can sometimes be a complicated undertaking because of underlying medical conditions. For example, a patient taking Coumadin, a blood anticoagulant, cannot simply add more green vegetables to the diet as such vegetables can reverse the effect of the drug.  A plan is needed to reintroduce green vegetables while adjusting drug dosages.  A patient with fecal incontinence, a condition where bowel movements are not well controlled, must be very careful with how much fiber is added to the diet, as one of my patients recently learned as he barely made it to the toilet in time.  It requires much reassurance to overcome the fears of patients with diverticulosis, an abnormality of the colon that results in growth of out-pockets of tissue that can become clogged,  that they can in fact consume nuts and seeds after years of being told otherwise. But with patience and perseverance, I have seen the amazing happen.

One of the largest draws to my practice is our obesity counseling program.  As part of the Affordable Care Act’s new preventive measures, in 2012, The Centers for Medicare and Medicaid Services (CMS) introduced a new service called Intensive Behavioral Therapy for Obesity (IBTO). This service was introduced in accordance with the USPSTF’s conclusion that there was value in offering such a service for treating the growing obesity epidemic now estimated to affect thirty-six percent of the population, with seniors no exception.  Each obesity counseling session may last up to fifteen minutes. This limited time allotted for by Medicare has proven to be insufficient to fully address all weekly concerns as patients try to adapt new foods into their diets and change their overall lifestyle.  The hastened time often adds to patient frustration, particularly for those who need much hand holding.

But losing weight often involves more than food.

For most patents there are psychosocial reasons why they eat too much or fail to engage in significant physical activity. On the food side, there are sugar addictions or what many call “a sweet tooth,” poorly managed stress leading to inadequate sleep which stimulates increased appetite and food consumption, eating to punish one's self or gaining weight as a buffer from a difficult world, etc. Many seniors for example, suffer from depression, and food offers comfort. Excess food leads to added weight, which leads to pain which leads to decreased physical activity, which leads to little to no sun exposure, which in totality exacerbates their depression.  To change the way people with relevant psychosocial issues eat and live, a psychologist is often needed.  (Psychiatrists are often too quick to prescribe medications that don’t address lifestyle issues.) At a time when an increasing number of Americans, particularly seniors, are  suffering from emotional and mental health issues, not only are psychologists not getting their due, in 2013, Medicare further decreased their reimbursement.

The costs of entitlement programs such as Medicare and Medicaid clearly consume a large portion of our tax dollars but that is no excuse for being penny wise and dollar foolish.  For example, according to CMS provided data, in 2012, the first year of availability of IBTO services, there were only a total fifty thousand total sessions (patients are entitled to 16-22 sessions per year) provided in the entire United States.  It’s not surprising. IBTO has not been well received by the medical community because it is impractical and not cost-effective for most busy medical practices to expend their resources to schedule patients for sessions of not more than fifteen minutes to receive reimbursement which is one-third of similar reimbursement for a fifteen minute Evaluation & Management code (E&M).  For less than thirty dollars a session (national average according to CMS: twenty five dollars), a primary care medical practice must verify eligibility, schedule a patient, remind them of the appointment, greet them and process their arrival, gather biometric data such as height, weight, blood pressure, temperature, calculate body mass index, discuss progress and counsel the patient, and bill for the service.   

The realities of running a medical practice today with associated overhead costs and regulatory demands, makes it impractical for most primary care medical practices (only primary care practices can offer the service per CMS guidelines) to provide a behavioral counseling related service for which it will probably lose money.

The Centers for Disease Control has weighed in that the evidence for the power of prevention is now indisputable.  Accordingly, behavioral counseling can and will have a meaningful impact on patient's lives, as I have demonstrated with my patients. However, other doctors will not embrace preventing chronic diseases such as CVD until adequate reimbursement is available. For doctors to invest in the knowledge needed to be effective counselors for their patients will take time and for them, time is money.  Today, few physicians have meaningful knowledge of the nutritional sciences. Many physicians still graduate medical school without a single course dedicated to nutrition.  Most states don’t even mandate it in the curriculum. Therefore it is probably fair to say that if we want physicians to be motivated to educate themselves regarding their patients’ nutritional needs, we will have to incentivize them.

The bottom line is that behavioral counseling can be highly effective in altering the trajectory of patients’ chronic disease development and advancement when a practice either has the resources to address the myriad factors that affect behavior or can make appropriate referrals for critical assistance. 

Having previously built a national health care practice which I sold to a private equity firm, I find myself in the unique position of being able to experiment with my own money to prove my points.  Unfortunately, to date, even though my medical practice is the largest provider of IBTO in Florida, such services have been provided at a financial loss because of inadequate reimbursement.  This is obviously not a perpetually sustainable model for us or for anyone else for that matter. While it is not within the scope of the USPSTF's mandate to set reimbursement rates, I urge it to consider the importance of not only identifying the value of the behavioral counseling service it now is attempting to determine, but also to make clear to its constituencies that allocating enough time and resources for medical practices to fully embrace such services that can decrease the burdens of chronic disease, both for individuals and society, is of utmost importance.

About twenty-five hundred years ago, Hippocrates, the widely acclaimed father of medicine, was noted to have said that “prevention is preferable to cure.”  I know that message has never fully resonated with our sick-care oriented system, but I hope most people would agree that the time has come to shift resources from not only  treating diseases but to also preventing them. The USPSTF has wisely reached the same conclusion in the past and I trust it will do so again. I hope in this time of much needed fiscal constraint, CMS will recognize as Ben Franklin once said that “an ounce of prevention is worth a pound of cure” and fund prevention efforts accordingly by setting reimbursement rates at levels likely to encourage more doctors to act.

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