Reducing Need and Demand for Health Care Gero 302 Jan 2011

Introduction Synopsis: 1. We have been consumed with the supply side of health care and not with the demand side. To reduce costs and improve health we need to promote self- efficacy, behavior modification, long term management of health and disease. Medical need is defined as the “medically modifiable morbidity or illness burden of defined populations” The costs of medical care are in part a function of the amount of illness in the population. Morbidity is related to the prevalence of dietary fat intake, seat-belt use, smoking, lack of exercise, and risk behaviors in the population.

Medical Demand Medical demand is the request of patient or physician or family for medical services and is often independent of medical need. Demand reduction means that informed consumers are best served by selective, thoughtful requests for medical services and the autonomy of the individual and the need for access to appropriate information. This should impact response to similar medical problems and the take up of services. Currently there is a high rate of utilization of resource intensive services, without the balance of self-management, preventive care and curative services.

Conceptual Base 80% of our present illness burden is as a result of chronic illness between 55 and death (average 75) Lifetime illness burden is often compressed into shorter periods (last five years of life) Age adjusted health status is improving while life expectancy has remained constant. Self-Efficacy-a belief that by personal behavior you may be able to affect health and other futures. It is essential in order to change health risk behavior. Favored groups are: those with regular exercise, higher socio-economic groups, higher education groups. These have decreased disability when cf to less favored groups.

Long Term vs Short Term outcomes Medicine focuses on short term outcome of particular episodic illness. E.G. Treatment of hypertension. LTG would be to increase exercise, reduce dietary fat, stop smoking, control serum cholesterol levels. This should improve duration and quality of life. Cumulative lifetime disability is a major endpoint and its reduction a major policy goal. Nature of Need-preventable illness makes up about 70% of the burden of illness. Smoking, diet and lack of exercise account for close to a million deaths in the US per year. Morbidity is associated with non-lethal conditions and is often preventable.

Nature of Demand Demand for medical services is often huge, costly, irrational, and indefensible. Geographic variations are large and linked to capacity rather than need. Hospital admissions correlate with available beds rather than the prevalence of illness. This is called “supply driven demand” Role of self-management-responsibility for health is by the individual. An educated consumer can lower service cost 7- 17%. Two variables: good consumer education and personal self-efficacy. Again-in the last year of life nearly 28% of medical costs are incurred for those over 65. The potential to reduce terminal demand equals 3% of lifetime medical costs. (30 Billion/yr in US)

Nature of Demand 70% of people do not wish to have aggressive/invasive technical treatments when they are dying. Only 9% executed their advanced directives. Often these documents are not delivered to caregivers or to medical records. The goals of health promotion therefore are: a. improve health habits, postpone and prevent major chronic illness, reduce risk factors and costs, raise personal self-efficacy, reduce low birth weight babies, have in place advanced directives, improve access to and utilization of early detection programs and screening that reduce medical need.

Three Models 1. Long Term outcome improvement on two tracks-one directed at reduction of need and demand and one directed at best possible applications of scientific medicine. Health education using mail, cable and computer and personal medical care using proven disease management principles. 2. Complete Disease Management-Ensure the use of clinical guidelines or pathways. Include prevention, optimal self-care and optimal professional care in all packages. These must function in a complementary fashion. 3. Five Lines of Health Defense-a. programs that prevent or postpone illness and promote health

Three Models 2. Second line of defense is self-management with adequate ancillary resources 3. The third line is triage which can further establish need and intervention and the urgency of the intervention. 4. Medical response to acute problems with guidelines to acceptable care and effective and efficient management of the problem. 5. Chronic Disease self-management-computer coordinated and guided by the best standards of care and integrated with all other levels.