Scott MacStravic, Ph.D.
It has long been a major tenet of health care that everyone should get equal quality of care, regardless of race, education, income, or other individual differences, including whether or not they can pay for the care they need. This does not obligate every provider to welcome every patient, regardless of ability to pay, nor does it preclude providers from offering “boutique” or “VIP” levels of service to wealthier patients, but the medical care is supposed to vary only by provider, not by patient.
This tenet turns out to apply only to half of medical care, the half that applies to reactive treatment of sickness, where the primary criterion for success is that patients should be cured, or at least given the best chance to survive and be restored to as close to a normal level of health as possible. By contrast, the other half of medical care (by definition, not in terms of how much medical care falls into which category) – namely proactive health care, aimed at preventing disease and injury in the first place, or managing existing chronic conditions to minimize their crises, complications and worsening, violates this tenet.
In reactive sickness care, it is the mission or health care organizations (HCOs), and the professional commitment of individual clinicians, to do whatever is necessary and appropriate for each sick patient. The assumption, or at least hope, is that someone, any combination of patients, themselves, employers, insurers, governments, or charities will cover the costs of what is needed, even if some patients pay nothing at all. The benefits of care are measured in terms of patients’ health; only the costs are measured in dollar terms.
But in proactive health care, the mission of providers -- whether traditional HCOs and clinician practices, or the new “vendor” organizations specializing in proactive health – is to minimize reactive sickness care costs to payors. If commercial or government insurers are the payers, this means reducing reactive sickness care utilization and expenditures such payors must pay for. If employers are the payers, this often means reducing the total economic impact of employees’ (plus dependents’ or retirees’) unhealth on those payors’ financial performance.
So, where reactive sickness care delivers treatment for money, proactive health care delivers money for money, not mixing apples and oranges, but apples and apples. This makes it a relatively simple matter, at least conceptually, to determine how much should be invested in not just proactive health strategies overall, but even in individual patients’ cases. The best way to be sure that an overall proactive health program delivers the desired results to both provider and payor is to ensure that the return on investment in each patient is positive.
While controlling costs based on the probable cost savings achieved with each patient may be too complicated, doing so for different patient segments is both logical and common. Patients with the same health promotion, risk behavior change, risk condition reduction, or disease management challenges, for example, can be handled differently from those with other challenges. And perhaps even more important, patients with higher-risk reward potential because they seem more likely to succeed may logically be afforded more attention, effort, and investment than those with less potential.
This has usually been reflected primarily on the risk side, with patients having the greatest current and predicted levels of costs to payers, either just from sickness use and expense or total costs to employers, are given more attention. But it makes just as much sense, at least in planning investments, to consider the probability of success, not merely the potential savings. In fact, if potential savings can be predicted in dollar terms, and the probability of achieving them in percentage terms, the “value” of each patient, and therefore the maximum amount that should be invested in each, is simply the product of savings amount times the percentage probability.
Rather than go to all the effort of making individual patient-specific predictions of potential savings times probability of achieving them, the common practice is to categorize and segment patients according to “tiers” of risk or value. Using three tiers, representing high, medium and low levels of risk or value seems to be the most common practice, though any number that makes sense and improves the efficiency of investments and overall returns can work just as well.
Once tiered, by particular problem or goal, then by risk/value within each such category, patients are accorded different types and levels of attention. Those at the high level may be assigned a personal coach, for example, to be contacted by face visits on an individual or group basis, or phone coaching sessions. Those at the medium level could be assigned to group vs. individual sessions, to less frequent or shorter coaching sessions. And those at the low level may be sent mailed or e-mail messages, written materials, or asked to visit a website for self-initiated interactions.
Traditional HCOs and practices may have difficulty deliberately varying the intensity and “quality” of their interventions for such a crass, commercial reason as predicted risk or ROI. But it only makes sense if proactive health intervention programs are to be profitable. Delivering the “best possible proactive care” to everyone, regardless of risk and value differences, would simply guarantee that proactive health care would be a money-losing business, fitting into “community benefit” or charitable services missions, rather than business logic.
When there are such clear and consistent success criteria as money spent in proactive care investments compared to money saved for payors in reduced sickness care or total labor costs, it simply makes sense to use these in planning and implementing efforts. It amounts to simply making proactive health investments meet the same criteria as capital and operational investments providers make within their own organizations. And it will surely be the only way that proactive health investments will pay off for providers, as well as payors.
