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Managing Medicare's Costs

Patient involvement is seen as a key to cutting health care costs

It’s 5 pm and you still have 1,200 calories to burn if you want to reach your daily target. So says the dashboard on your Fitbit device, the fitness tracker you wear like a wristwatch. Not only does it tell you if you’re getting enough exercise, but it lets you know when your heart rate is in its optimal zone, how far you’ve walked or jogged today, and whether you may have sleep apnea. And if you take Fitbit off your wrist and lay it to one side, before too long it sends you a plaintive request to “Hold Me.”

With 21 million units sold since 2008 and more than 9 million users, Fitbit has an 85% share of the fitness tracker market. A dozen or so other companies are trying to whittle away at its dominance, each using a slightly different approach to help you reach your health goals.

Some devices scold you when they sense that you are slacking off too much. The new Apple Watch, for example, includes a fitness tracker that, like a Prussian schoolmarm, informs you when you’ve been sedentary too long and sends you a message telling you to stand up.

Wearables like Fitbit are an easy way to use technology to help manage your health. They are part of a much larger development in which computers and microchips are gradually shifting responsibility from doctors to patients. This trend started innocently enough in the mid-1990s when large numbers of people began reading medical articles on websites sponsored by the Mayo Clinic, WebMD, and others.

In some cases patients became experts in their own ailments, using Google Scholar and the PubMed data base to search for articles in hundreds of medical journals worldwide. They often came to know more about the causes, symptoms, and cures for their diseases than did their physicians. It was no longer unusual for patients to show up at doctors’ appointments armed with technical questions and suggestions for alternative treatments.

Next came electronic medical records, which began to be used extensively in 2011. Spurred by Medicare’s incentive payments, almost 80% of doctors now maintain your medical records in an electronic format — test results, medications, and a list of your immunizations and pre-existing conditions. More than one-half of patients can now access their electronically stored health records via online portals such as MyChart and Practice Fusion.

Another recent emphasis is to get real-time feedback on how your body is performing. Fitness trackers belong to this phase, but implantable medical devices and smart phone apps are providing the real breakthroughs. That’s according to Dr. Eric Topol, a cardiologist who directs the Scripps Translational Science Institute in La Jolla, California and who is the editor-in-chief of Medscape, a website that focuses on medical research. Dr. Topol is perhaps the country’s leading expert on using digital technology to manage your health.

In his recent book The Patient Will See You Now, Dr. Topol wonders why, if an automobile has 400 microchips to monitor its performance, most people don’t have even one. The mention of implantable devices brings to mind pacemakers the size of silver dollars. But an implantable device can be a tiny sensor no larger than a grain of rice. One sensor might detect early signs of stomach cancer or leukemia. A different sensor might send a signal when your blood sodium levels are dangerously low. And yet another might simultaneously transmit a message to your smartphone and to your cardiologist when it senses that your risk of having a heart attack in the next 24 hours is greater than 70%.

Beyond implantable devices, Dr. Topol envisions a medical era in which smartphones are at center stage. Smartphone apps can currently be used to help diagnose Parkinson’s disease, detect malaria with a simple skin test, and act as a spirometer to measure lung capacity. Dr. Topol writes of the time he was on an airplane flight and a passenger fainted. Using his smartphone, he performed an ultrasound exam, an electrocardiogram, and a blood pressure check on the passenger, who soon recovered. A layperson could have administered those same tests, says Dr. Topol.

In the future there will be fewer visits to doctors, Dr. Topol believes, because more tests will performed by patients using their smartphones. Consultations with physicians by remote communication are already replacing some office visits, saving time for doctors and patients. One study indicated that one in six patient-doctor visits in 2014 was by telephone or other electronic means like Skype and FaceTime.

Some health experts see patient involvement as the medicine’s next major leap forward. The notion that people who actively manage their health will fare better than others is only common sense. Technology, though, offers powerful new tools that enable people to assume greater control over their health. In 2013 Health Affairs dedicated an entire issue to patient engagement, which it called the new blockbuster drug.

The benefits of patient involvement have been documented in several studies. One study summarized in a Health Affairs blog found that patients involved in managing their own care reduced their medical costs by more than 5% and had 12.5% fewer hospital admissions compared to patients who were not involved in managing their care.

As people age, of course, they may find it increasingly difficult to remain involved in their own care. And that is a contributing factor to the much higher per-person medical costs for people in their 80s and 90s. For its part, Medicare has taken several small steps to keep people informed about annual wellness visits and preventive tests. On each beneficiary’s birthday, for instance, Medicare sends that person a list of the preventive tests that he or she has already taken as well as ones that may be needed in the coming year.

One area where there’s little patient involvement is health insurance. More than 17 million people in Medicare Part D stand-alone plans are not in the lowest-cost plan for the drugs that they take. They could save about $450 per person a year, on average, by switching to the lowest-cost plan during open enrollment. That $450 a year adds up over time. Even so, most people with Part D stand-alone plans remain in the same overpriced plans year after year.

Last year the Kaiser Family Foundation conducted nine focus groups in different areas of the country to determine how people choose and change their Medicare coverage. The vast majority of people in those focus groups and were not considering doing so. In principle this is no different than people selecting investments for their retirement portfolios at age 65 and never checking to see how those investments are doing or whether their portfolios need to be rebalanced. Such lack of involvement can be expensive. ◊◊

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