With Health Reform, Medicare Now Covers a Prevention Visit With A Doctor: A Look At the Scientific Evidence, Part 2

In yesterday's post, the pernickety Disease Management Care Blog contrasted Speaker Pelosi's victory speech description of the newly passed health bill's prevention provisions with the actual legislative language. While her characterization bordered on bombastic, it's clear that there's a lot of grant money and new government being devoted to prevention. What really caught the DMCB's attention, however, was the decision for Medicare to now pay for an annual visit devoted to the creation of a "personalized prevention plan."

Sounds good right? Imagine being ushered in from the waiting room and huddling with your personal physician, Dr. Nowpaidenuf. Dream about reviewing, sharing and discussing how little you exercise, how much you eat and how unwilling you are to get a colonscopy. Then visualize exiting the clinic with a plan, being thankful that your version of Medicare is under the stewardship of an enlightened political leadership and resolving to eat more vegetables. And fruit.

Sound too good to be true? There's plenty of research to say that it probably is.

While there are plenty of studies (for example) that show that physicians could do better when it comes to counseling their patients about prevention, it turns out that lack of payment has been only a small part of the story, compared to other issues, such as their own lack of confidence or patient barriers that include socioeconomic issues, competing medical conditions, and the lack of motivation. If physicians wade in anyway, their advice can be wrong and, even if they're right, the benefit that patients may get typically decays over time. No wonder the U.S. Preventive Services Task Force has concluded there is no evidence that primary care counseling works to meaningfully increase physical activity and that a very thorough review of the medical scientific literature found no evidence to support the notion that counseling alone has any sustained impact on obesity.

While the DMCB is thankful, that's because a certain Ms. Anderson has thrown her hat, plus ample amounts of fruit, into the ring of Dancing With The Stars. Armed with that inspiration, the DMCB thinks it's ironic that, just when Medicare is emphasizing value based purchasing, Congress has created an additional entitlement that, by itself, has little apparent value.

But all is not lost. The DMCB ultimately thinks that there is plenty of value to be had in prevention counseling. More on that in a Part 3 post tomorrow.

What 'Cash for Clunkers' Teaches Us About Health Club Sponsorship for Wellness by Employers or Government

The Disease Management Care Blog, like Casablanca's Captain Renault, was shocked, SHOCKED (not) to hear on NPR's All Things Considered that there are some economists who doubt whether the United States' 'cash for clunkers' program is a wise investment. These must be the same guys that told the DMCB years back that insurer or employer-based incentives for fitness club memberships was also a silly idea.

How can this nattering naysaying be possible given the widespread belief in the promotion of healthier lifestyles? What about the luster of financial incentives that can transform indolence to healthiness? What gives these self-appointed oracles an insight that's been missed by almost a third of the U.S. corporate employers that financially sponsor club memberships?

The arguments are simple and convincing. While financially supporting fitness clubs is associated with superficially gratifying uptakes in membership, there are two problems:

1) many of the persons qualifying for financial support would probably join a fitness club anyway; all you're doing is using precious premium to unnecessarily subsidize it. This was the same argument on today's NPR broadcast: there are probably many car owners with an old set of wheels that are destined for a trade-in anyway. Cash for clunkers merely helps make it happen sooner at an additional cost of up to $4500 to the U.S. Treasury, er, make that to us taxpayers.

2) many of the persons qualifying for financial support may not necessarily need to join a fitness club; the joiners are far less likely to find exercise a distasteful chore and are already active. In the meantime, the persons who could really use some exercise are unlikely to be motivated by any financial incentive. The same may be true in the 'clunkers' program: the cars being destroyed arguably still have some value, and many have acceptable if not optimal mileage. In the meantime, many other persons will have plenty of reasons - like not taking on the debt of new car payments - to keep enough really bad clunkers on the road for years to come, not help Detroit's doldrums and not reduce their carbon footprint.

The DMCB did a literature search to disprove either of these arguments. It was unable to find any.

And then there is the inevitable gaming that can go on. Persons may 'join' a fitness club, not go and keep the money, requiring the insurer to impose requirements with or without monitoring to make sure the letter and spirit of the initiative is being met. That may be one key difference vis-à-vis a Federally-run program: the 'clunkers' program seems to be quite game-able.

Cash for clunkers... meet cash for slackers.