Patients

Richard Montwill, VP market strategy at Optum Health, on how improved adherence in the US can reduce waste and inefficiency.

Richard Montwill, VP market strategy at Optum Health, on how improved adherence in the US can reduce waste and inefficiency.

The US system is unable to deal with $1.9 trillion in chronic healthcare costs, according to Richard Montwill, VP market strategy at Optum Health, part of the United Health Group. This is a very large part of the forecast US total healthcare spending of $2.7 trillion in 2010. It is a global problem, driven by an ageing population.

Studies show that somewhere between $500 and $800 billion are lost to waste and inefficiencies in chronic care. Some $300 billion is related to lifestyle factors, such as obesity and smoking. Next, poor decision making by providers may generate about $300 billion of inefficiencies, while about $200 billion may be lost because of patient non-adherence.

Montwill recommends a systems approach to this complex problem. However, US healthcare is historically not a system at all but fragmented into many independent units. Some semblance of a system may be visualized by matching three main functional areas with the three components of waste and inefficiency.

Personal responsibility

This approach logically starts with personal responsibility, with patients taking ownership of their wellness. However, 85% of the population does not act on health information received and needs further measures to change behavior.

The second area is the provider system, where healthcare delivery happens. Primary care is assuming a much more prominent role here, particularly with regard to supporting patients in overcoming adherence problems. But, Montwill says, Fifty-six million Americans don't even have access to a primary care provider. And even when primary care is available, it could be much more effective if consolidated.

Montwill sees this as an integration of all the various resources surrounding the primary care physician, such as pharmacists, nurses, patient advocacy groups, and even technologies. These are important because of the shortage of primary care physicians, who can't take on the whole burden of patient engagement.

Providing the right incentives

The third component of the systems approach is incentivization of both providers and consumers, effectively rewarding them for improved adherence. Aligning consumers and providers in this way is a new concept, says Montwill.

This demonstrates systems thinking, but what about execution? Montwill explains it depends on the particular constituency. In the US, these fall into four groups: employers, Medicare and Medicaid, the states, and individuals.

A work environment enables defined processes and programs for employees, whereas Medicare/Medicaid is a mixture of managed care (closed system) and fee for service (open system). Even so, managed care does not have the mechanism needed for linking providers and consumers. So the approach has to be highly customized.

The impact of reforms

Many of these issues are within the scope of the proposed healthcare reforms, but there is not much that addresses root causes. Montwill does not think, for example, there is much there to improve personal responsibility.

Proposals for healthcare delivery, like the personal prevention plan, are much better. There is also some good thinking within the aligned incentives domain, such as linking provider payment to quality outcomes. Just the fact that they are thinking about these types of models is a step in the right direction, according to Montwill.

However the actual language of the legislation does not include anything specifically about adherence, despite this being a front and center root cause of waste in healthcare.

Marketplace mechanisms

So what marketplace activities reflect these developments? Montwill doesn't see a great deal happening in the personal responsibility space. There is much more going on in the delivery space, and there are opportunities to partner with those already in it.

There are also some innovative initiatives among the aligned incentives group. For example, Merck has offered insurers rebates based on outcomes in diabetes therapy, irrespective of the treatments used, coupled with further rebates based on compliance with the company's branded drugs.

Look at what's happening around you, advises Montwill. Reform is a combination of legislation and the marketplace, and the latter is addressing the adherence root cause, he is convinced. Overall, the systems approach seems to be working, but Montwill says it needs all three of the areas he defines to work together.