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In the News

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KSDK St. Louis: Does it work to dangle a carrot for patients to take healthy steps?

By | In the News

Patricia Alexander knew she needed a mammogram but just couldn’t find the time.

“Every time I made an appointment, something would come up,” said Alexander, 53, who lives in Moreno Valley, Calif.

Over the summer, her doctor’s office, part of Vantage Medical Group, promised her a $25 Target gift card if she got the exam. Alexander, who’s insured through Medi-Cal, California’s version of the Medicaid program for lower-income people, said that helped motivate her to make a new appointment — and keep it.

Health plans, medical practices and some Medicaid programs are increasingly offering financial incentives to motivate Medicaid patients to engage in more preventive care and make healthier lifestyle choices.

They are following the lead of private insurers and employers that have long rewarded people for healthy behavior such as quitting smoking or losing weight. Such changes in health-related behavior can lower the cost of care in the long run.

“We’ve seen incentive programs be quite popular in the insurance market, and now we are seeing those ramp up in the Medicaid space as well,” said Robert Saunders, research director at the Margolis Center for Health Policy at Duke University.

Medicaid expansion supporters celebrate victory, Portland, Maine, Nov. 7, 2017.

Medicaid patients who agree to be screened for cancer, attend health-related classes or complete health risk surveys can get gift cards, cash, gym memberships, pedometers or other rewards. They may also get discounts on their out-of-pocket health care costs or bonus benefits such as dental care.

Under the Affordable Care Act, 10 states received grants totaling $85 million to test the use of financial rewards as a way to reduce the risk of chronic disease among Medicaid patients. During the five-year demonstration, states used the incentives to encourage people to enroll in diabetes prevention, weight management, smoking cessation and other preventive programs. The states participating were California, Connecticut, Hawaii, Minnesota, Montana, Nevada, New Hampshire, New York, Texas and Wisconsin.

Medi-Cal, for example, offered gift cards and nicotine replacement therapy to people who called the state’s smoking cessation line. Minnesota’s Medicaid program handed out cash to people who attended a diabetes prevention class and completed bloodwork.

An evaluation of these programs, released in April, showed that incentives help persuade Medicaid beneficiaries to take part in such preventive activities. Participants said gift cards and other rewards also helped them achieve their health goals. But the evaluators weren’t able to show that the programs prevented chronic disease or saved Medicaid money. That’s in part because those benefits could take years to manifest, according to the evaluation.

Research on the effectiveness of financial incentives for the Medicaid population has been mixed. A report this year by the Center on Budget and Policy Priorities found that they can induce people to keep an appointment or attend a class but are less likely to yield long-term behavior changes, such as maintaining weight loss. In some cases, the report said, incentives are given to people to get exams they would have gotten anyway.

Some of the biggest factors preventing Medicaid patients from adopting healthful behaviors are their personal circumstances, said Charlene Wong, a pediatrician and health policy researcher at Duke University.

That makes administering incentive programs more complicated. Even recruiting and enrolling participants has been a challenge for some states that received grants through the Affordable Care Act.

“The thing that is most likely to help Medicaid beneficiaries utilize care appropriately is actually just giving them access to that care — and that includes providing transportation and child care,” said Hannah Katch, one of the authors of the report by the Center on Budget and Policy Priorities. Another barrier is being able to take time off work to go to the doctor.

Still, health plans are eager to offer patients financial incentives because it can bring their quality scores up and attract more enrollees. And medical groups, which often receive fixed payments per patient, know they can reduce their costs — and increase their profits — if their patients are healthier.

Standard Digital: How ‘medicines first’ HIV policy is changing sex in Kenya

By | In the News

The World Aids Day observed yesterday also marked the fifth year since the US adopted a ‘medicines first’ HIV policy for Kenya and other donor recipient countries. Titled ‘Dollars to Results’ the policy has led to what doctors are calling over medicalisation of sex through HIV.

The policy overseen by USAid since 2013, champions a model where pharmaceutical commodities represent top priority followed by treatment in which category fall health workers and medical infrastructure. At the bottom are behaviour change HIV prevention activities, which were anchored on abstention and faithfulness.

The policy has partly been instrumental in doubling the number of Kenyans on antiretrovirals to more than one million in the last five years. According to the American NGO called AVAC, today about 9,000 Kenyans are on the daily HIV prevention pill initiative called Pre-Exposure Prophylaxis or PrEP. The US President’s Emergency Plan for AIDS Relief (PEPFAR) alone plans to bring another 5,000 Kenyans into the programme next year. By 2022, the Ministry of Health targets having 500,000 Kenyans on PrEP at a cost of Sh32 billion. The US driven PrEP was launched in May by the Ministry of Health alongside a home HIV testing kit. “Our work has never been so complicated,” says Ms Karen, 43, a sex worker and a peer educator with the Sex Workers Outreach Programme (SWOP) in Nairobi.

SWOP is a project of the National Aids and STI Control Programme  (NASCOP) and the University of Manitoba Canada attending to more than 27,000 male and female prostitutes in Nairobi. “Unlike in the past where a condom was the much you need to report to work, today you prepare as you are going for war,” Karen said at her operational base, a bar along Luthuli Avenue in Nairobi. Karen explains despite many regrettable but necessary on the job risks, she is HIV-free but on PrEP to be on the safe side. Every day, she has to swallow a pill for protection against HIV infection.

Read more at the Standard Digital.

Fierce Healthcare: Humana’s wellness program features a small but committed group of wearables users

By | In the News

Of the nearly 4.5 million people enrolled in Humana’s wellness program, just 1.2% used an activity tracker.

But the majority of those that did activate a device continued using it for six months, according to a new study published in the Annals of Internal Medicine that offers the first robust evaluation of wearables within wellness programs.

In one of the largest studies of wearables usage to date, researchers at the University of Pennsylvania combed through two years of data from HumanaVitality, now known as Go365. They discovered that although initial usage of activity trackers barely broke 1%, 80% of those that did engage continued using the device for at least six months.

Mitesh Patel, M.D., an assistant professor of medicine at the University of Pennsylvania’s Perelman School of Medicine and the lead author of the study, said most estimates of wearable device usage are based on surveys that often skew toward people with an interest in technology. This study, he says, is the first objective look at usage on a national level.

“I think the rates we found better reflect actual uses than past surveys which have reported much higher usage,” he said in an email to FierceHealthcare, adding that insurers may be able to boost activation rates by offering discounts on wearable devices, tying incentives to premiums or focusing on the use of smartphones in addition to smartwatches and activity trackers.

The study also offered a peek into wearables usage among different demographics during 2014 and 2015. For example, more women activated the device than men, and activation was far more prevalent among those aged 22-49. While just 0.1% of members 65 and older activated their device, 90% continued using their activity tracker for six months, well above the younger demographics.

That sustainability may be due in part to the program’s incentive structure, which set a daily goal of 10,000 steps and used points and levels to incentivize users. Those points could be redeemed for gift cards, with incentives ranging from $0.25 to $0.40 per day.

“These findings could help inform ways to design wellness programs or other programs that leverage wearable devices by finding ways to target the types of members with lower engagement (e.g., older age, lower income) or using gamification and incentives to sustain engagement,” Patel said.

Read more at Fierce Healthcare.

Knowledge@Wharton: Can Firms Help Employees Make Better Retirement Choices?

By | In the News

Retirement savings plans have been in the news lately as Republicans eyed limits on the maximum pretax 401(k) contributions as a way to fund the cuts outlined in their tax proposal.

The 401(k) plan has over the last two decades become the dominant way that Americans save for retirement, replacing the traditional pension. But employers may not be doing as much as they can to encourage employees to use 401(k)s to adequately prepare for the end of their working years.

Many employers automatically enroll workers in 401(k) plans and set a default savings level, which puts the onus on employees to opt out. Research has shown that defaults result in greater participation in many situations, including saving for retirement. But in the case of retirement plans, a default becomes a two-part question: Firms need to consider whether or not to have one — and where to set the minimum savings rate.

New research co-authored by Wharton operations, information and decisions professor Katherine Milkmanattempts to find an optimal level for these defaults – with some surprising results. The paper, “How Do Consumers Respond When Default Options Push the Envelope?” was co-authored with Harvard’s John Beshears, Shlomo Benartzi of the University of California-Los Angeles and Richard T. Mason of City, University of London and Voya Financial.

“Companies tend to be very conservative about the savings rate they use for defaults – it’s often as low as 3%,” Milkman says. “But if people save at that rate for their entire career and retire at a normal age, that’s not nearly enough to live on comfortably.”

People tend to trust that employers are choosing the rate that is best for them, Milkman notes. Meanwhile, employers are skittish about setting a higher default rate because they fear it will shake employees out of passive acceptance and lead them to opt out from retirement savings entirely.

Finding the Right Rate

The researchers set out to find a default rate that struck the right balance – high enough that it would allow employees to adequately save, but not so high to induce the sticker shock that employers feared. In partnership with Voya Financial, a New York-based financial, retirement, investment and insurance firm, they conducted a field experiment involving 10,000 employees from one of Voya’s clients. When employees logged on to the enrollment website for their retirement plans they were randomly assigned to see a suggested savings rate ranging from 6% to 11% of their pay.

Many employers set default rates that take effect without the employee having to take any action. The researchers created a situation where the employee had to elect to continue at that rate in order to more clearly gauge acceptance of a particular default. Participants were also given access to a decision tool designed to help them determine an optimal retirement savings rate.

After looking at contribution rates after 60 days, the researchers found that not only were those with savings rates over 6% no more likely to drop out of the retirement plans than their peers, their contribution rates were 0.2 to 0.5 percentage points more than those of people defaulted into the lowest savings rates. It doesn’t seem like a lot, but the researchers note that it can add up to tens of thousands of dollars over the course of an employee’s career. While the likelihood of not participating began to inch up for those who were assigned the highest savings rate (11%), Milkman says the research shows that employers should feel comfortable moving beyond low defaults.

Read more at Knowledge@Wharton.

Fortune: How Can We Help People Quit Smoking? Pay Them.

By | In the News

Thursday is the 47th year of the American Cancer Society’s Great American Smokeout. One of the longest-running awareness campaigns in the U.S., the Smokeout involves cancer societies, health organizations, and anti-smoking advocates using social and print media to remind Americans that now is the right time to quit.

Each year Americans are subjected to over 200 national health awareness days, weeks, or months. These campaigns cover everything from autism to appropriate use of hospital linens. They are certainly effective in raising awareness over their target issues, a necessary first step in shifting our habits. But awareness campaigns can only be effective if additional anti-smoking supportive efforts—such as offering financial incentives for smokers to quit—are utilized.

Health campaigns do increase awareness. J.W. Ayers and co-authors have shown that the Great American Smokeout campaign increases cessation-related news by about 60%, Twitter posts by 13%, and Internet searches by approximately 25% on the day of the campaign. This increase is roughly 70% of the increase in similar news stories, social media posts, and Internet searches seen on New Year’s Day, which is when people generally set resolutions for the year ahead.

The question of whether increased awareness from the Smokeout translates to increased smoking cessation rates, however, has not been conclusively answered. The closest indicator to success that has been accurately measured is the use of state quitlines, which Ayers and colleagues found increases by about 40% around the time of the Smokeout. There is a positive correlation between the use of quitlines and actual attempts to quit more broadly.

While awareness and public education campaigns are well-intended, providing information alone isn’t enough to help smokers change their behavior. Campaigns should use additional tactics. First, they should introduce smokers to evidence-based approaches and groups that help people quit. This can be done by running search engine advertisements or placing direct links to vetted quitting methods on the campaigns’ social media platforms. Smokers often rely on their own Internet searches to find quitting solutions, and these can be unreliable.

Second, anti-smoking advocates should encourage smokers to set a quit date and to “pre-commit” by telling others of their intentions. Informing others of their intent to quit can be a helpful way to provide reinforcement at times when their own motivation may wane.

Third, campaigns should encourage smokers to enlist their life partners or friends to try to quit at the same time. Quitting is more likely to be successful if others in their social network also cease smoking—and conversely very difficult if others they frequently associate with do not.

Another helpful strategy would be to support anti-smoking efforts by offering financial incentives through health insurance plans. One study found these incentives to be successful in tripling long-term smoking cessation rates in employer settings. And another study found that financial incentives are the most effective approach to increasing tobacco cessation among pregnant women. These incentives offset the natural human tendency to favor immediate gratification over delayed benefits and help make more salient the health and economic benefits to quitting smoking now. In essence, insurers and employers are passing on some of their future savings from reduced health expenditures to smokers who successfully quit.

Awareness campaigns are a highly visible part of the American public health landscape and that is a good thing. But they’ll need support. Anti-smoking advocates need to disseminate advice about effective behavior change strategies and encourage health plan benefit designs that invest in preventing disease, as opposed to simply treating the health consequences of smoking. This would increase the impact of awareness campaigns in improving health.

Read the original piece at Fortune.

Reuters: Lower Medicaid fees linked to scarcer primary care appointments

By | In the News

When the fees paid to healthcare providers by the Medicaid insurance program for the poor go up, appointments with primary care doctors suddenly become more available to Medicaid beneficiaries – and the opposite happens when fees go down, according to a recent U.S. study.

Researchers found that, overall, every $10 change up or down in the Medicaid fees paid to providers led to a 1.7 percent change in the same direction in the proportion of patients on Medicaid who could secure an appointment with a new doctor.

Based on these trends, reductions in Medicaid funding that lead to lower physician fees will compromise patient access to primary care providers, the authors conclude in JAMA Internal Medicine.

“As funding declines it threatens the breadth of provider participation in Medicaid,” said senior author Daniel Polsky, executive director of the Leonard Davis Institute of Health Economics at the University of Pennsylvania in Philadelphia.

“I don’t want to overestimate its result on patient welfare, but I think it’s a good thing to have broad choices of doctors when you’re looking to make a new patient appointment,” he said in a phone interview.

For the analysis, trained field workers posing as new Medicaid or privately insured patients called physician practices in 10 states to request a new-patient primary care appointment or an appointment for an urgent health care concern. In total, 12,092 calls were made and recorded to determine whether simulated Medicaid patients were able to get an appointment at all and, if so, how soon it could be scheduled.

The 10 states in the survey were Arkansas, Georgia, Illinois, Iowa, Massachusetts, Montana, New Jersey, Oregon, Pennsylvania and Texas.

An initial survey round was conducted in 2012 and early 2013, before the Affordable Care Act (ACA), commonly called Obamacare, was fully implemented. In 2014 and in 2016, the surveys were repeated to see whether the ACA’s initial, two-year hike in Medicaid reimbursement improved primary care availability for the more than 14.5 million adults newly enrolled in the program.

The Medicaid fee bump between the first two surveys was tied to 7.7 percentage-point increase in the availability of primary care appointments for Medicaid patients, the study found. Before the ACA increased Medicaid fees, 58.7 percent of callers pretending to be a new patient were able to get an appointment, compared to 66.4 percent in the second survey.

However, in the third survey, done in 2016 when Medicaid fees had already returned to lower levels, researchers found a substantial decrease in appointment availability.

Overall, when the mean Medicaid fee for a patient office visit went from $68.58 in 2012 to $107.38 in 2014 and then $75.67 in 2016, appointment availability tracked a similar pattern. In 2012, 56.2 percent of patients got an appointment while in 2012 it was 65.5 percent and then 61.5 percent in 2016. New Jersey, Georgia and Texas experienced the largest decreases in appointment availability, with 9.1, 10.9 and 10.1 percentage-point drops, respectfully.

Read more at Reuters.

Penn Spotlight: In the Quest for Lasting Behavior Change, Two Researchers Lead the Charge

By | In the News

Have you ever made a commitment to exercise more often? You sign up with a gym and succeed for a time but soon, too soon, the enthusiasm fades. Eventually, your workout clothes gather dust and your gym membership does nothing but empty your wallet.

In the short term, changing behavior is doable, even exciting, but it’s really hard to make that change permanent. Ask anyone who has ever tried to quit smoking or eat less junk food. There’s a reason the phrase, “You can’t teach an old dog new tricks” exists within popular vernacular.

But Penn researchers Angela Duckworth and Katherine Milkman, along with more than two dozen scientists across the country, have a project they hope will turn fleeting life modifications into long-lasting habits. Called the Behavior Change for Good (BCFG) initiative, it launched this fall with an ambitious goal: to understand and improve behavior change across the lifespan, across many domains, using strategies grounded in psychology and behavioral economics.

“There are billions of people in the world, pretty much all of whom have challenges related to goals they’d like to achieve, whether it’s weight loss or medication adherence or finances,” says Milkman, an associate professor in the Department of Operations, Information, and Decisions at the Wharton School. “Pretty much everyone is looking to self-improve, and whether they have a lot of resources or not, everybody could be better. Many things get in our way, but behavior is a struggle for everyone.”

Duckworth and Milkman both felt a drive to focus on work that would have real-world implications for individuals, work that could lead to permanent shifts in the way people act.

When the University put out a call for projects for 100&Change—a MacArthur Foundation competition for a $100 million grant to solve a single, critical world problem—the pair and colleagues drafted a proposal that they argued could help with the challenge of “enduring behavior change.” The team didn’t win the grant (it was one of the top 200 proposals out of thousands), but Penn and the Chan Zuckerberg Initiative provided enough funding for an initial three years.

“We’re creating experiments to improve behavior change,” says Duckworth, the Christopher H. Browne Distinguished Professor of Psychology in the School of Arts & Sciences (SAS).

First up, the team is working on two projects, one related to gym attendance, the second to school performance. In the exercise experiment, dubbed The Step-Up Challenge, BCFG researchers have partnered with national gym chains 24 Hour Fitness and Blink Fitness, owned by Equinox. Combined, the two have memberships exceeding 4.3 million people, and the scientists are aiming for 10 percent participation, meaning hundreds of thousands of data points.

“We want people to go to gyms more,” Duckworth says. “So we’re going to deliver 28 days of support—questionnaires, videos, educational materials, and a scheduling tool, as well as incentive payments for 28 days of gym visits, along with associated text reminders about workouts—designed by scientists at Penn and elsewhere. Then we’ll look at what the gym-going pattern is after the 28 days.”

Lyle Ungar, a professor of computer and information science with appointments in the School of Engineering and Applied Science, SAS, Wharton, and Perelman School of Medicine, and Barbara Mellers, a Penn Integrates Knowledge professor with appointments in SAS and Wharton, are creating one such experiment. Based on the idea that different incentives motivate different individuals, their online tool will offer options for the type of message a user would like to receive.

“For one person, putting out gym clothes the night before works like a charm. For another, what she needs is a buddy. Maybe for a third person, something completely different might work, like thinking of this as being good for his children and grandchildren,” Duckworth says. “Rather than telling people, ‘Do this,’ the tool gives them a menu and has them essentially choose their own treatment. That is the treatment.”

 Read the original article here.

LDI eMagazine: Photo Page – 2017 Penn/CMU Roybal Behavioral Economics Retreat

By | In the News

The 10th annual University of Pennsylvania/Carnegie Mellon University Roybal Behavioral Economics Retreat convened at the Skytop Lodge and Conference Center here in the Poconos. In the Evergreen Ballroom (above), Associate Professor at Penn’s School of Nursing and LDI Senior Fellow Alison Buttenheim, PhD, MBA, leads a workshop on behavioral studies design. Two organizations collaborate in the ongoing NIH P30 Center of Excellence Roybal research program: Penn’s Center for Health Incentives and Behavioral Economics (CHIBE), and CMU’s Center for Behavioral and Decision Research (CBDR).

 

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Skytop Lodge (above, left) is a massive complex that sits atop a Pocono plateau and hides much of its bulk underground. Originally opened in the Roaring Twenties as an elegant mountain getaway for well-heeled Philadelphians, its grounds include 30 miles of hiking trails. Above, right, surveying the view from the Lodge’s observation desk is Joanne Levy, MBA, Deputy Director of the Leonard Davis Institute of Health Economics (LDI) and Associate Director of the Wharton School’s Health Care Management PhD Program.

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The two-day gathering held its main sessions in the Lodge’s Evergreen Ballroom (above, left) where CHIBE Director and LDI Senior Fellow Kevin Volpp, MD, PhD, (above, right) welcomed attendees and recapped the rapid changes now occurring across the behavioral sciences field as well as the latest work of CHIBE’s scientists, many of whom are LDI Senior Fellows. He noted that over the last year, the group members had published 349 papers on research topics ranging from medication adherence and mobile monitoring devices to weight loss strategies and end-of-life care. “More importantly,” he sad, “we’re seeing a lot of impact in the field from the work these researchers are doing.” Volpp also unveiled CHIBE’s new Annual Report.

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View the rest of the images and the story at LDI eMagazine.

The New York Times: Kept in the Dark About Doctors, but Having to Pick a Health Plan

By | In the News

It’s open enrollment season for Affordable Care Act marketplace plans, Medicare Advantage plans and many employer-sponsored plans as well. Lots of evidence suggests you should shop around, and shop carefully, though this is harder than it sounds.

When you select a health care plan, you probably consider premiums, and maybe you check deductibles and other cost sharing. But you can’t easily scrutinize the plans’ networks and the quality of the doctors in them. That’s too bad, because you may be missing something important.

Many health insurance options offered by employers or sold on the Obamacare marketplace come with narrower networks — covering treatment from a limited slate of doctors and hospitals. (Though there’s no official definition of a “narrow network,” many studies classify networks as narrow when they include less than about 30 percent of doctors or hospitals in the area.)

Narrow network plans are cheaper, and insurers say they try to maintain quality as they narrow the choices they cover. Some appear to succeed, but some don’t, and that’s hard to fully assess before you sign up.

It’s virtually impossible to thoroughly check the quality of doctors in each insurance plan. A typical plan, even a narrow one, may have a network of hundreds or thousands of physicians. It is a potentially simpler task just to know if you’re enrolling in a narrow or broad network plan. But in a study of Obamacare enrollees, for example, as many as 40 percent didn’t know this information, either.

That confusion is understandable. A study of 2016 marketplace offerings in 13 states found that only two provided indications of network size. Eight of them, as well as HealthCare.gov, provided a way to look up whether a doctor was in a plan’s network, but only two could filter plans to show only those with providers a consumer selects.

“To our surprise, we also found that few marketplaces could indicate which hospitals were in plans’ networks,” said Charlene Wong, a pediatrician and researcher at the Margolis Center for Health Policy at Duke University and lead author of the study. “In addition, none of these tools indicated network breadth by specialty.” This means that a “broad” network plan might actually be quite narrow for some specialists, without consumers knowing.

Read more at the New York Times.

Harvard Business Review: How to Reduce Primary Care Doctors’ Workloads While Improving Care

By | In the News

Not long ago, many services such as tax accounting were delivered episodically and in-person, as most health care still is today. Periodically, a client and accountant would meet, review financial materials and status and, at the end of the encounter, make an appointment for the next meeting. Increasingly, in-person accountant visits have been replaced by phone or web meetings and do-it-yourself software like TurboTax. There is still a need for accountants and face-to-face meetings, but typically accountants now require such visits for only the more complicated cases that can’t be managed with software or a call.

Health care has proved resistant to a similar transition, although everyone would benefit. While some aspects of care clearly require doctor and patient to be in the same place at the same time, many demonstrably don’t. Nonetheless, even those parts of care that could be freed from the doctor’s office remain tied to it, with schedules optimized for doctors’ productivity rather than what’s best for the patient.

In this article, we identify the barriers slowing the transition of episodic, in-person primary care to innovative models that separate care from location and that empower patients to take on more of their own care. And we describe steps needed to overcome these obstacles, lowering costs and improving quality.

Barriers to Transformation

With the rapid expansion of information connectivity, health care requires much less hands-on work than it used to. Every now and then an examination or a procedure requires physical contact between provider and patient, but many of the important elements of health care have always occurred through oral communication alone and some others — like getting your blood pressure measured or your blood tested — can now just as easily and accurately happen at home or elsewhere outside of a doctor’s office. Much of what used to be restricted to clinical settings can now, from a purely technical perspective, be handled remotely.

But let’s imagine that you are ready to video or phone chat with your doctor, recognizing the convenience of never having to leave your house or wait in a waiting room. Unfortunately, your doctor may not be that eager to chat with you. Three forces keep telemedicine from achieving its potential to transform care delivery: the excess workload created for the care provider, the likely change in patients’ health-care-use behavior, and the economics of reimbursement.

Provider workload. Much of the current thinking about new service-delivery models is based on the notion that cost and efficiency of care delivery can be enhanced by directing more patients to primary care. Enthusiasm for this approach largely derives from the appealing and perhaps nostalgic notion that more comprehensive and coordinated primary care could provide better outcomes at lower costs. Indeed, many efforts at health care transformation are built on tying patients more closely to primary care providers. The primary care community has largely embraced these ideas, perhaps because they reinforce the community’s value and centrality to the health care enterprise. The ideas have also been embraced by public policy makers, health plans, and the general public.

Primary care physicians are used to being responsible for all aspects of patients’ care. They are also among the lowest-cost physicians available. For perhaps these same reasons, there aren’t a lot of them. As a result, they are already overworked. In contrast to cardiologists or orthopedists who can limit their responsibility to heart disease or joint- and bone-related issues and triage all other issues back to primary care providers, those providers have no safe harbor. The lower reimbursement and need to provide 24/7 coverage that makes a primary-care-based system so appealing to policy makers and others has long been shown to be a source of burnout and challenges in getting medical students to choose careers in primary care. The last thing that this group of providers desires is more responsibility. Just imagine the operational demand if primary care providers also had to actively monitor their patients’ health data between office visits.

From this perspective, the enthusiasm of policy makers and health plans to simply increase access to primary care as a way to address delivery challenges is a cop-out. Rather than do the conceptually hard and convention-challenging reorganizations of systems and finances required to truly transform care, it is easier to suggest tweaking the system and encouraging patients to use more primary care — and let primary care take it from there. That cannot be the solution if, in fact, primary care providers simply can’t take it from there — either because there aren’t enough of them or because they don’t have the support to do one more thing beyond what they are already doing.

Overconsumption. The workload problem is further increased by patients’ likely response to enhanced availability, such as what tax accounting and retail customers have enjoyed through digital channels.

The old care model creates friction between the practice and the patient: the difficulties and delays in scheduling visits, the hassle of traveling to the practice and waiting in the waiting room, and the penalty of copays and coinsurance make patients think twice before seeking in-person care.

In our recent studies of how patients responded to the introduction of a portal allowing them to e-mail health concerns to their care team, we found that the e-mail system that was expected to substitute for face-to-face visits actually increased them. Once patients began using the portal, many started sharing health updates and personal news with their care teams. These new channels did not keep the patients out of the office; rather, they encouraged patients to visit the office more frequently. What doctor would dismiss a patient’s e-mail that mentioned chest pain without calling the patient for an in-person visit? Everyone has ups and downs in how they feel. As those downs become easier to report, physicians are alerted to more symptoms. The disease burden is unchanged — but now the aches and pains are given greater voice.

Without the barriers to in-person care, every skin blemish that can be photographed and sent electronically risks turning from something that patients used to ignore into a demand for medical attention. That’s good if what gets brought to attention is serious and would otherwise have been overlooked. But there is an adage in clinical medicine: “The great secret, known to internists…but still hidden from the general public is that most things get better by themselves. Most things, in fact, are better in the morning.”

Read more at Harvard Business Review.