Being a futurist is a discipline. It has little to do with what would be cool, or with new shiny objects or simplistic answers. It builds on data, it examines the whole system, its inputs and energy sources and feedback loops, to build plausible future scenarios and explore the strategies that support them.
But the core of the discipline is not the data. The core is honing the questions — finding the exact questions, the questions that give us insight that can guide strategy.
One question that is key to a great deal of strategy right now across health care: Does prevention save money? The New York Times recently asked and answered the question. (No.) But the data the article cited actually answered a quite different question, not "Does prevention save money?" but, "Does giving people more access to health care and, therefore, to preventive services such as screenings and physicals through the Affordable Care Act, without changing anything else, actually drive down utilization and so lower national health expenditures?" To which the answer should not be just, "No," but, "Of course, it doesn't. Why would anyone think it would?"
Our purposes here, though, require a different question, one whose answer can inform our strategy choices. So we need to tear this down a bit.
The "affordable" part of the ACA had two parts: Get the cost of health insurance down for the lower-income groups through subsidies and a controlled competitive marketplace. And lower the overall costs of health care by bringing better access to the millions of people with untreated and poorly treated chronic disease. Like the ACA, many of the new strategies proliferating across health care are being built and sold on the "Yes" answer to that second part: We can lower health care costs by giving people better, cheaper, easier access to health care.
Is this proposition true? The answer is becoming a matter of existential importance to many health care organizations, not only whether it is true, but in exactly what way it is true. "Existential importance" = "get this wrong and you die."
Experience So Far
What's the experience so far? Since the full implementation of the ACA at the beginning of 2014, the health care insurance market has been both more competitive and more constrained by medical loss ratio limits, "must carry" rules, and other aspects of the law. In those circumstances, rising or falling premiums represent a much closer match than they did previously for the actual costs of health care in regions and across the country, based on a two-year trailing perspective. Right now, the companies have the data from their first full year of experience with the broadened market in 2014, and are using those data to roll out their 2016 offerings.
The envelope, please. The answer from the first full year of experience with the ACA is indeed "No." Giving more people better access to health care does not by itself lower costs; so for 2016, premiums are rising, not falling.
This makes sense. If you change nothing else, people who now have easier access to health care will use it more. They will have more tests, get procedures done, use health care for all the things it is there for, and the overall costs of the system will rise.
This is true even for preventive care. Giving masses of people colonoscopies and computerized mammograms plus all the follow-up biopsies and such is a nice piece of business. So is the treatment that we give to cases we discover. The number of screenings we have to do to catch that one case early enough that it actually costs less to treat, though, is very large. In the end, those masses of tests and follow-ups cost more than the money saved by finding the rare case early.
Does this matter for your bottom line? If you are making most of your money the old-fashioned, fee-for-service way, no, not at all. It's just good business.
Still the Wrong Question
But wait. Back to the question: Notice that "our experience so far" does not exactly answer that question.
The question was not "Will doing preventive services the way we traditionally conceived them automatically result in lower health care costs overall?" To which the answer is "No."
The question was "Can preventive services, however conceived or re-engineered, save money? Can we find programs and concepts in health care that actually save money by bringing people better preventive care?" To which the answer is demonstrably "Yes."
The difference between these two questions becomes critical when you adopt any of the multiple ways that you can put your organization at risk for the costs not only of particular procedures (as in bundled payments), but actually of the health of the populations you serve (through capitated contracts and risk-based accountable care organizations, for instance). Then the critical question becomes more precise: Not only "Can we?" but "In what way can we keep the costs of disease down by providing earlier, better, smarter, more-efficient care?"
Breaking It Down
To answer this, we have to break apart the idea of prevention into its several parts. There are disease states such as diabetes and heart disease for which screening and prevention efforts are relatively inexpensive and effective if pursued vigorously — and that actually prevent the disease rather than just detecting it early.
More importantly, the populations that you serve are far from homogenous. We can break them down by cost profile. Remember how steep the cost curve is: On the bottom end, over any given period, the less expensive 50 percent of the population uses only 3 percent of the health care resources, while the most expensive 5 percent use 50 percent.
If we are in any way at risk for the costs of their health care, the people we serve fall roughly into four categories:
- Healthy people whom we would like to keep healthy, to keep them out of the more expensive categories.
- People with undiscovered illnesses or risk factors that we would like to discover and treat, to keep them from migrating up the cost scale.
- People with multiple chronic illnesses or major risk factors. These people likely are already in that top 5 percent or are apt to jump into it. We would hope to migrate them down the cost scale through some serious attention and careful medical management.
- People with serious illness such as cancer, or major trauma. They are — and should be — in the top 5 percent.
Multipronged Prevention Strategy
This suggests a multipronged prevention strategy based on market segmentation, which I often call "targeting."
Encourage healthy communities: Propagate serious community health-building efforts, such as those that have been the decades-long focus of the American Hospital Association's own Association for Community Health Improvement. The variety of the possibilities in such programs can be astonishing, from traffic safety to community gardens to healthy cooking classes to intergenerational, after-school study groups for kids at assisted living facilities. The return on investment in savings or performance bonuses in specific revenue streams can be small or difficult to show — but the investment is actually quite tiny. Various chief financial officers have characterized the cost of such programs to me as "lost in the noise" or "a rounding error" compared with their multibillion-dollar top lines.
Provide screening: Screen whole populations as well as you can, but use cheaper techniques on the front end. Why do we use periodic colonoscopies as the mass screening technique of choice for colon cancer? Frankly, because we get paid to perform them. Capitated organizations like Kaiser typically lead with prescreening through mail-in stool tests. Positive "occult blood" results on these will reliably turn up the small percentage of the population that could benefit from a colonoscopy. Some 5 percent of those actually have colon cancer.
Similarly, computerized mammograms have shown no ability to identify tumors better or earlier than regular mammograms. Mammograms in addition to periodic breast exams by a physician and teaching self-exams have shown no ability to find more tumors or save more lives than the breast exams alone, according to the massive 25-year Canadian National Breast Screening Study. We do mammograms largely because we get paid to do them and because, as an industry, we have taught women that they are necessary and important, the gold standard of finding and stopping cancer. Recent studies have gone further, showing that aggressive treatment of "Stage 0" cancer lesions — surgical treatment beyond lumpectomies, including mastectomies, that more than 60,000 women go through every year in the United States — saves no lives and prevents no invasive breast cancers.
In many categories, we can scale back the overtesting and overtreatment in the name of screening without putting our patients' lives at risk.
Target high-risk groups: Seek out vulnerable demographics for special attention. For instance, Nurse Family Partnership has made a specialty of aggressively seeking out poor pregnant women who have not been connected to the health care system. Though seemingly expensive, since they involve nurses researching the target community and making home visits, these simple interventions have a solidly established return on investment for any entity at risk for the costs of these women and their children.
Similarly, Kaiser has targeted those in its population most vulnerable to heart disease and, using standard screening and management techniques, has brought the number of heart attacks down by 24 percent, and serious heart attacks by 68 percent. Kaiser targets people with asthma, obese people and other groups for special attention.
Build trust and direct human connection into your targeted programs: The Iowa Chronic Care Consortium, for instance, managed to lower diabetes events in the rural counties it covers by 6 percent. Part of its successful formula was to reduce the number of patients managed by each care coordinator to only 250, half as many as in other programs, and to use diabetes education programs that already existed in the patients' own communities.
Target people with multiple chronic diseases: People with multiple chronic diseases (such as asthma plus diabetes plus a heart condition) occupy much of the 5 percent most-expensive bracket — and for a far longer period of time, often months and years, than those with trauma and major diseases. Aggressive, hands-on, seamless medical management can bring many of these cases under control, lower the acuity and drop the cost to the system. Boeing, for instance, is building its own captive accountable care organizations specifically for the top 5 percent of its health care users among its employees with multiple chronic syndromes. It is doing this based on the experience that it actually saves money by giving this part of the population more intensive care.
Build strong primary care relationships: The strongest prevention strategy is building strong primary care networks in the most vulnerable areas, establishing walk-in clinics, for instance, in areas that serve the poorer, less mobile populations.
In many states and regions, it is possible to pioneer nontraditional Medicare, Medicaid and dual-eligible programs that establish close trusted relationships with the less connected parts of the community.
Change practice and referral patterns: A major reason we see so little return on investment for preventive efforts is that we do those efforts in the most expensive way possible. We not only use expensive tests where simpler methods would serve as prescreening, but we tend to refer the slightest question to specialists and further tests, leaving little for the judgment of the primary care physician. This is one of the most noticeable differences between practice patterns between, say, Des Moines and Dallas — with no noticeable difference in their effectiveness in catching and tracking disease.
The answer to our more targeted question is yes, there are multiple ways that we can keep the costs of disease down by providing earlier, better, smarter, more-efficient care — and we can and will discover those ways when we are more at risk for the overall health care costs of the people we serve.
Joe Flower is a speaker, consultant and futurist based in Sausalito, Calif. He is also a member of Speakers Express, author of How to Get What We Pay For: A Handbook for Healthcare Revolutionaries, and regular contributor to H&HN Daily.