ObamaCare Clusterfuck: "Patient engagement" and the privatization of public heath
he ACA era is the fourth time health care pundits have “discovered” engagement. The first was HMOs, in which doctors were supposed to help patients maintain their health (hence the name) but which devolved into a cost-containment tool. The second was disease management, which involved connecting people with chronic disease to live nurses on the phone. That didn’t engage people. Third, wellness was supposed to accomplish the same thing for a much broader pool, engaging people through a combination of bribery (called “incentives”) and coaching. That not only failed to work, but it turns out virtually all wellness vendors who claim cost savings are simply making up results. As was extensively chronicled in Why Nobody Believes the Numbers, anyone with any basic understanding of study design would find these alleged results to be hilariously transparent lies, in the case of at least one major carrier quite purposefully designed to fool benefits consultants. These vendors have invariably found that the cost of engagement exceeds the benefits.
So perhaps the fourth time, engagement will be a charm, because it involves risk-bearing physician practices and medical homes and electronic medical records. Well, that’s been tried too. On a large scale, North Carolina Medicaid has attempted for more than a decade to engage members through a statewide medical home. Following years of cost overruns and massively high per capita spending, the program – maintained until now only because the proponents paid several sets of consultants to lie for them – is being dismantled by the state if the governor’s plan goes through. Even so, physician practices should be more successful in engagement – the patients know and trust them to begin with – but they would have to be very successful in reducing utilization to cover the very high costs of one-on-one face-to-face engagement.
Engagement isn’t even always automatically the right answer. I have blogged previously about how I am a non-engaged patient because the things that my doctor has wanted me to do have been absurdly expensive and not-evidence based…and yes, I am in a risk-bearing PCMH with an electronic medical record. Sometimes the patient is wise not to engage.
Notwithstanding that type of negative experience with engagement (not my first), there is probably some marginal benefit to engagement (and in the Medicare population, probably substantial benefit) but this obsession with engagement takes our eyes off some of the bigger cost drivers of overdiagnosis, overtreatment, and expensive new technologies of marginal value.
Not to mention medical errors, which may be the most pervasive, debilitating and expensive issue of all.
Lots of linky goodness there. Use this the next time anybody tries to peddle the "informed consumer" argument. But the real killer argument is below:
Finally, there is a solution to engaging people en masse to change behaviors, and it has essentially nothing to do with the delivery system. It’s called public health and it’s the role of government. Raise taxes on cigarettes, institute taxes (collected at the producer level) on sugar, corn syrup, transfats etc. Basically, raise the price of bad behavior. To then encourage good behavior, earmark that money towards upgrading of recreational facilities, rail trails, subsidizing farmers markets in underserved neighborhoods. Basically, make it easier and cheaper to be healthy.
Instead, the current strategy, which places the onus for engaging patients in behavior change on employers and doctors, could be called the privatization of public health.
You say "privatization of public health" like that's a bad thing!