Consumer-Driven Health Care: The Changing Role of the Patient

Policy Reports | Health

No. 276
Tuesday, May 10, 2005
by Devon M. Herrick, Ph.D.

Monitoring and Treating Chronic Conditions

Treatment of chronic diseases is one of the factors driving up health care costs. Nearly half (45 percent) of all Americans have a chronic condition, and half of those (60 million) have multiple chronic conditions.96 A Yale University study found that one-quarter of Americans have one or more of five chronic conditions: mood disorders, diabetes, heart disease, high blood pressure and asthma. Moreover, patients with these conditions account for almost half of all health care spending.97

“Nearly 45 percent of all Americans have a chronic condition, and half of those (60 million) have multiple chronic conditions.”

Patients with chronic illnesses can use the Internet to obtain information on specific medical conditions, clinical trials and the latest drugs. They can also share their experiences with and learn from others suffering from the same conditions. Once patients inform themselves, they can manage their conditions and control their health care in ways unheard of only a few decades ago. Following are some examples of how patients with some common chronic conditions can take a more active role in their own care.

Heart Disease . Heart disease, the most common chronic condition, is America’s number one killer. According to the American Heart Association, 65 million Americans have high blood pressure, resulting in 5.4 million strokes per year.98 In 2005, hypertension will cost nearly $60 billion ($59.7 billion). The cost of strokes, which are frequently a complication of hypertension, costs an additional $56.8 billion. The average cost, in present value dollars, of treating cardiovascular disease for the duration of life for the average 45-year old is $30,000.99

Patients with high blood pressure have opportunities to reduce their cost of treatment by shopping. For example, those on the anti-hypertensive drug Cardura (Doxazosin) can split double-strength tablets for a savings of 46 percent.100 In addition, research has found that an inexpensive “water pill” (diuretic) is more effective than many newer, higher-priced antihypertensive medications such as ACE inhibitors and calcium channel blockers.101 For this reason, experts say low-cost diuretics should be a hypertensive patient’s first step in controlling high blood pressure.102

“Some 65 million Americans have high blood pressure, resulting in 5.4 million strokes per year.”

In addition to shopping, patients with hypertension can take a more active role by administering their own tests. A controlled study of more than 300 patients with high blood pressure found that patients who monitored their own blood pressure and adjusted their own medications had 27 percent fewer physician office visits than those who did not.103 Those who self-medicated were given a $40 blood pressure monitoring device and a formula to adjust their medication. They achieved blood pressure control similar to those who depended on a physician to adjust their medication.

There are also cheaper medication options many hypertensive patients can use to reduce the risk of stroke, a major complication of hypertension. A recent study in the Journal of the American Medical Association found two daily aspirins were as effective at preventing recurrent strokes in African Americans as a daily 500mg dose of the drug Ticlopidine.104 This is a significant finding, given the fact that Ticlopidine can easily cost patients almost $65 per month.105

“Nearly $2.5 billion in annual hospital costs for diabetes complications could be averted with appropriate care.”

Diabetes. More than 16 million Americans have diabetes — the sixth-leading cause of death by disease in the United States.106 The mortality rate for people with diabetes is 11 times the rate for those without the disease.107 In addition, diabetics spend four times more money on health care than nondiabetics.108 There is much to be gained from better disease management. By one estimate, nearly $2.5 billion in annual hospital costs for diabetes complications could be averted with appropriate care.109 Numerous studies have shown considerable benefit from self-management training for Type 2 diabetes.110 Patients can be trained to inject insulin, monitor and maintain a log of blood glucose levels, and use the results to adjust their dietary intake, activity levels and medicine doses.111

There are approximately 20 different monitors to test blood glucose available in a variety of shapes and sizes.112 Occasionally monitors are given away free — but some only work with a proprietary brand of glucose test strips and therefore are more costly in the long run.113 Costs for test strips vary considerably. A diabetic patient could pay $69.99 for 100 Ascensia Microfill Blood Glucose Test Strips at Devine Medical’s Web site.114 However, the same 100 count box is sold on eBay for $59.95.115 If patients who check their blood sugar four times a day could save 25 cents per test strip, the savings would add up to $365 for the year.

In the past few years several new oral medications for diabetes became available.116 Savvy consumers will also find the price of diabetic medications vary considerably.117 Some are available in generic form while some are not. In addition, many diabetics can reduce reliance on medications and control their diabetes completely by adhering to a meal plan, losing weight and exercising.118

Asthma Self-Management. From four to six percent of the population of Western countries has been diagnosed with asthma. Uncontrolled asthma imposes economic costs on society.119 The Asthma and Allergy Foundations of America estimates nearly 20 million Americans suffer from asthma — resulting in 500,000 hospital stays each year.120 More than 2.5 million school-age children suffer from asthma, missing nearly 15 million school days per year. The economic loss averages out to nearly $800 per child per year.121 A Dutch study comparing self-management to usual care found that those monitoring their own asthma achieved a savings of about 7 percent the first year and a 28 percent savings the second year compared to those in standard care with a primary physician.122

Patients should develop a self-management plan with their physician or asthma nurse. An asthma plan is essentially a list of established guidelines indicating which actions to take in response to various symptoms.123

Asthmatics can use a software package called Asthma Assistant to monitor their condition.124 This computer program helps patients measure their condition on a daily basis, including peak air flow, medication and events that may trigger symptoms. Such biometric data can be transmitted over the Internet from a patient’s computer to a physician’s office computer for evaluation by a doctor or technician (a process called telemonitoring). The software program analyzes airway obstruction data gathered by the patient using a spirometer, which measures the speed and volume of exhalations. A recent study of asthma patients trained to perform in-home asthma telemonitoring found that the results of self-testing were consistent and met established guidelines. Moreover, participation in telemonitoring did not require that patients have extensive computer knowledge.125 Some 87 percent of patients in the study were “strongly interested” in continuing to use this method.

Bleeding and Clotting Disorders . A variety of conditions cause patients to bleed too freely or their blood to clot too readily. A study of Veteran’s Administration patients found that home self-monitoring of prothrombin time (clotting) while taking Coumadin (Warfarin) to reduce the formation of blood clots is superior to standard monitoring by physicians. The “bleeding rate” was 11 percent for patients monitored monthly at a clinic, but only 4.5 percent for patients who monitored their own prothrombin time at home on a weekly basis. The rate of blockages caused by blood clots, known as thromboembolism, was four times higher with standard follow-up therapy than with self-monitoring (3.6 percent each year versus 0.9 percent). Serious cases of bleeding (and/or thromboembolic events) occurred in 2.7 percent of cases per year in the standard-monitoring group but there were none in the home-monitoring group.126

“Self-monitoring saved asthma patients about 7 percent the first year and 28 percent the second year compared to physician monitoring.”

Migraine Headaches . The National Headache Foundation estimates that 28 million Americans suffer from migraine headaches each year, resulting in the loss of 157 million workdays.127 The cost of migraine headaches on the economy is estimated in the billions of dollars.128 One of the ways patients can help doctors with migraine management is by keeping detailed records, including a diary to identify triggers of migraines, time, duration, frequency and severity of attacks.129 Some patients find they can effectively treat themselves using low-cost over-the-counter drugs. For instance, a multicenter trial of an over-the-counter therapy containing acetaminophen/aspirin/caffeine (AAC) provided significantly better (more rapid and more sustained) relief than the prescription drug sumatriptan.130 Sumatriptan, sold under the brand name Imitrex, costs around $16 per tablet, regardless of the strength of the dose (25mg, 50mg or 100mg).131 Individuals suffering from the onset of a migraine headache can take up to 200mg of Sumatriptan per day.132 Patients who try AAC treatment may find they can save hundreds per year, and possibly see the doctor less frequently.

Economic Incentives . Because chronic disease is so costly, insurers and public health advocates hope that chronic disease management (CDM) will reduce costs and improve quality of life in chronically ill patients.133 The goal is to identify expensive-to-treat patients and reduce costs through better management of their disease before costly complications occur.

Patients may not be able to rely on their health insurers for disease management.134 The reason is that, for the most part, insurers and providers don’t benefit from the results. The efforts of health insurers to use disease management generally don’t pay off because patients do not stay enrolled in their plans long enough to recoup the investment. Furthermore, a recent study in Health Affairs found that when disease management was provided to broad populations of patients with chronic disease, overall costs generally rose rather than fell. The only group who benefited from disease management was the small subset of patients not following treatment protocols.135 For patients already adhering to protocols, additional expenditures to better manage their conditions generally result in higher marginal costs with little marginal benefit. But when patients control their own expenditures, and benefit from any savings they realize, they have an economic incentive to adhere to treatment protocols.

Patients also may not be able to rely on their doctors to manage their conditions. Physicians’ compensation is based on the services they render, rather than evaluations of their performance based on patient outcomes.136 Consequently, physicians have little incentive to counsel patients on disease management and follow up to see if recommendations were followed.

“When patients manage their own health care dollars, they have an economic incentive to adhere to treatment protocols.”

Patients benefit the most from disease management in terms of better health. If patients tend to reap most of the benefits, they should bear the cost and control the funds necessary to manage their chronic conditions. Since chronic conditions increase patients’ out-of-pocket costs, controlling the funds to manage their conditions is a step towards motivating them.137 Patients with health savings accounts would reap financial rewards (beside the reward of good health) since they would be at liberty to use fund for prevention rather than acute care.

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