Module 4: Improving Treatment Outcomes and Lowering Healthcare Costs with Outpatient Care

The failure of patients to comply with medication regimens and medical directions contribute significantly to the high medical costs and poor treatment outcomes in the U.S. and elsewhere.  The New York Times columnist Tina Rosenberg writes: “Many doctors are uncomfortable wrestling with adherence.  They may even believe that it is not their problem, that their job is done when they write the prescription or hand the patient a diet plan.  But even concerned doctors would find themselves helpless in a 10-minute office visit.  They are too removed from their patients, too much the authority figure to really get to the bottom of why a patient isn’t doing what he is supposed to.”(1) With the high demand for doctors in the U.S. and in many other countries, patients have limited face-to-face time with physicians.  This distance between doctor and patient can hinder patient understanding of the importance of behavioral modifications and treatment adherence.  Moreover, there is limited follow-up care or monitoring of patients once they have left the doctor’s office. For patients who experience such exceptional barriers to care as chronic health problems, poverty, homelessness, and unemployment, the lack of outpatient support and preventive measures can lead to the drastic progression of illness and, ultimately, to the need for expensive emergency care.  A variety of outpatient care measures have been applied in different settings from Haiti to New Jersey to test whether prevention of the progression of illness and the removal of barriers-to-care can both result in improved health outcomes and lower escalating healthcare costs. 

Intensive Outpatient Care

Some researchers, economists, and businesses have found that increasing healthcare coverage can actually lower healthcare costs.  One large IT company sought to reduce employee health costs by raising their employees’ insurance copayments, believing that employees who had to pay more would take better care of themselves and therefore have fewer medical visits and procedures.  Although doctor visits, E.R. visits, hospital visits, and prescription costs went down, the medical costs continued to climb.  An economist analyzed the employee health costs and found that the higher co-payments resulted in a reduction in lower-cost preventive care and an increase in more expensive treatment costs.  For example, one employee with high cholesterol and diabetes started refilling his prescriptions only half of the time and had fewer doctor visits because he could not afford the new co-payments. As a result, he had a heart attack that required emergency surgery, and was left with chronic heart failure.(2)  Providing free or low-cost preventive care would have prevented this more severe stage of illness, which necessitated greater expenditures than standard prescriptions and doctor visits.

There are often a select number of patient outliers who have complex health problems or severe barriers to care and contribute the highest healthcare costs. For example, in Camden, New Jersey, one % of the patient population accounts for one-third of the city’s healthcare costs.  These patients are often the ones receiving inadequate and low-quality care.  In 2007, Dr. Jeffrey Brenner sought to reverse this situation by providing more patient-centered and comprehensive care not only to reduce healthcare costs but, more importantly, to help marginalized and neglected patients.  Brenner recruited a staff of primary care doctors, nurses, and social workers and built the Camden Coalition of Healthcare Providers to try to improve the health outcomes of these “worst of the worst” patients and to decrease their hospital visits. In this program, the nurses call the patients to keep updates on health issues, insurance or housing problems, and on adherence to medication regimens.  Before participation in this program, the 36 patients who contributed the most hospital visits averaged 62 hospital and E.R. visits per month; after the program they averaged 37 visits, a 40 % reduction. The program, accordingly, decreased their hospital bills by 56 %, from an average of $1.2 million per month to slightly over $500,000. While the results do not account for patients who have improved their health on their own or who have died, the costs are undeniably reduced.(3)  Preventive care can provide tremendous returns. 

This system of responsive outpatient care has proven particularly effective in reducing hospital visits and medical costs in Denmark.  In 1990, Denmark had approximately 150 hospitals.  Over the past two decades, the country has expanded the availability of outpatient primary care services to include after-hours consultations, email access to physicians, and nurse management of complicated cases. This has resulted in improved patient quality of care.  As a result, only 71 hospitals needed to remain open in 2011, down from 150.  The New Yorker columnist Dr. Atul Gawande notes that now “An important idea is getting its test run in America: the creation of intensive outpatient care to target hot spots, and thereby reduce over-all health-care costs.”(4)  It appears that providing higher quality preventive care - especially for those with complex health problems - can deter the onset of severe illnesses that necessitate expensive procedures, hospital stays, and tests. In order to save money and improve health outcomes, perhaps both public and private health insurance schemes should begin reallocating money from emergency care to preventive care.  It seems that everyone would benefit, except for those who treat healthcare as a business.

Community Health Promoters

In order to be even more cost-effective, some programs use community health workers (CHWs) rather than nursing staff to support patients. The NGO Partners in Health (PIH) has been especially successful in improving treatment outcomes through the employment of community health workers.  In the 1980s, PIH in Haiti implemented a program for patients infected with tuberculosis (TB) in which community health workers, called accompagnateurs, were assigned to certain patients to ensure adherence to rigorous drug regimens and to provide psychosocial support.  This program was later adapted for HIV/AIDS therapy.  The accompagnateurs are respected community members who serve as liaisons between community members and clinics. They are trained in the provision of emotional support, patient confidentiality, clinical management of HIV infection, administration of drug regimens, and HIV prevention.  They visit patients more than once per day to observe medication administration and to assess a patient’s health status and needs.  Social workers or their assistants visit patients to assess factors influencing treatment adherence, including the family’s social situation and the patient’s social support network.  Patients also meet monthly to share information and problems in order to strengthen the responsiveness of the program, to learn how to prevent transmission of HIV infection, and to form a support network with other patients.  Between 1999 and 2004, the “HIV Equity Initiative” contributed to the drop in HIV prevalence in PIH prenatal clinics from over 5% to 2.8% in Haiti.  Compared with a group of HIV-positive patients not in the PIH program, the 10 HIV-positive patients with accompagnateurs experienced fewer opportunistic infections, hospitalizations, tuberculosis infections and lower mortality.(5)  Because of its cost-effectiveness and success, this model has been replicated in other regions of the world.

In 1995, the Division of Social Medicine and Health Inequalities at Brigham and Women’s Hospital and Partners in Health collaborated to implement a similar program entitled the Prevention and Access to Care and Treatment (PACT) Project.  The program worked with over 100 HIV-positive patients living in inner-city Boston who failed to comply with conventional anti-retroviral therapy due to confounding problems such as disability, homelessness, mental illness, substance abuse, and domestic violence.   Similar to the program in Haiti, PACT hires community health promoters to visit patients in order to ensure adherence to medication regimens and to provide social support and counseling.  After the first and second years of the program, 85% of the HIV-positive patients who participated in the program had higher CD4 levels, lower HIV loads, and reported an improved quality of life.  For the other 15% of patients, the DOT-HAART (directly observed therapy – highly active antiretroviral therapy) program was offered in addition to PACT and saw positive outcomes.  A vast majority of these DOT patients have maintained high rates of adherence, effectively decreased their HIV loads, and improved their quality of life.(6)  Moreover, this program has decreased medical costs.(7)  TheNew York Times columnist Tina Rosenberg writes:
“PACT’s methods work.  A study of AIDS patients found that the patients’ use of appropriate medicines rose — they were becoming adherent.  At the same time, spending on hospitalization dropped by nearly two-thirds.   Overall, patient costs dropped by 36 %.  Even taking into account the $6,000-per-patient cost of PACT, patient costs dropped 16 %.”(8) While the clinical improvements support the moral incentive to treat those who might otherwise have died, the financial savings serve as the practical incentive to continue this program.

As in Haiti, the community health promoters are often community members who have faced similar problems and barriers to care.  Ayesha Cammaerts, the Director of Operations at PACT, notes, “Especially with patients who suffer from substance abuse and mental health issues, they need someone they feel comfortable letting into their environment.  Sometimes patients don’t feel they can connect to clinicians from outside their community.”(9)  This aspect helps the health promoters provide more appropriate advice to patients on the methods to overcome barriers to adherence, and also helps the community health promoters build better rapport and trust with the patients.  In turn, the patients are more likely to follow advice from the promoters, to comply with treatment regimens, and, thus, to experience improved treatment outcomes.  The community health promoters accompany their patients to their appointments, assist them with social problems, and provide emotional support.  They also provide education on medication and the management of side effects.  The DOT health promoters visit patients daily to check on them and to observe the patient’s ingestion of their medication.  They build even stronger relationships with their patients.  As a result of their own experiences and their relationship with patients, many health promoters advocate for better mental health, substance abuse treatment, and HIV/AIDS services for marginalized individuals.(10)  This program initiates a virtuous cycle in which marginalized individuals are given the intensive care necessary to stop the reoccurrence of emergency health problems, and the voice necessary to represent their needs.

The PACT Project model is now being adopted in other cities in the U.S. and for other chronic diseases.  In Boston, PACT is now providing community health promoters for patients suffering from diabetes.  Tina Rosenberg notes that another program based on PACT is being implemented in New York City under the Care Coordination Program.  It is an initiative that operates at 28 sites in various hospitals throughout New York.(11)  A similar program of “intensive outpatient care for complex high-needs patients” has been established by Dr. Rushika Fernandopulle in Atlantic City, New Jersey for casino and hospital workers with the highest healthcare costs.  Based on the promotoras, or community health workers, model in the Dominican Republic – a model similar to that of PIH -  Dr. Fernandopulle has employed “health coaches,” who are non-medically trained, to check on patients and encourage them to practice healthy behaviors and to adhere to medication regimens.  The program and the health coaches are patient-centered and highly responsive to patients’ needs.  This program has proven highly successful.  Dr. Atul Gawande notes that “After twelve months in the program, he found their emergency-room visits and hospital admissions were reduced by more than forty per cent. Surgical procedures were down by a quarter.  The patients were also markedly healthier.  Among five hundred and three patients with high blood pressure, only two were in poor control. Patients with high cholesterol had, on average, a fifty-point drop in their levels. A stunning sixty-three per cent of smokers with heart and lung disease quit smoking. In surveys, service and quality ratings were high.”(12) This study demonstrates that peer health promoters are able to achieve high quality, comprehensive treatment management at a low cost.  Investing in the front-end of healthcare ( prevention) rather than in the back-end of high-cost surgeries and emergency treatment may be the key to improving health care systems and health outcomes around the world.

Mobile Communication

Many healthcare organizations and physicians are beginning to use text messaging and mobile communication as a potential method to increase adherence and provide more outpatient support.  Much like how email is now being used by doctors in Denmark and elsewhere to communicate rapidly with patients, text messages can be used in non-industrialized countries by patients to ask doctors and nurses various questions on managing health problems.  Thus far, however, there have been few studies demonstrating positive health outcomes resulting from these mobile communication interventions. More research is needed to evaluate the impact of mobile technology on healthcare before it can be widely adopted.  To see examples of community health workers applying mobile technology to improve patient care and adherence, see Mobile Technology in Community Health Workers Course.

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Footnotes

(1) Rosenberg, Tina. “A Housecall to Help with Doctors Orders.” New York Times, 28 February 2011. Accessed on 6 April 2011.

(2) Gawande, Atul. “The Hot Spotters.”  The New Yorker 24 January 2011. Accessed on 4 April 2011. 

(3) Ibid.

(4) Ibid.

(5) Behforouz, H. L., P. E. Farmer, and J.S. Mukerjee. “From Directly Observed Therapy to Accompagneurs: Enhancing AIDS Treatment Outcomes in Haiti and in Boston.” Clinical Infectious Diseases 38(2004): S429-36. Accessed on 6 April 2011.

(6) Behforouz, H. L., P. E. Farmer, and J.S. Mukerjee. “From Directly Observed Therapy to Accompagneurs: Enhancing AIDS Treatment Outcomes in Haiti and in Boston.” Clinical Infectious Diseases 38(2004): S429-36. Accessed on 6 April 2011.

(7) Ibid.

(8) Rosenberg, Tina. “A Housecall to Help with Doctors Orders.” New York Times, 28 February 2011. Accessed on 6 April 2011.

(9) Ibid.

(10) Behforouz, H. L., P. E. Farmer, and J.S. Mukerjee. “From Directly Observed Therapy to Accompagneurs: Enhancing AIDS Treatment Outcomes in Haiti and in Boston.” Clinical Infectious Diseases 38(2004): S429-36. Accessed on 6 April 2011.

(11) Ibid.

(12) Gawande, Atul. “The Hot Spotters.”  The New Yorker 24 January 2011. Accessed on 4 April 2011.