So, we will now resume development of how best to measure factors influencing the future cost of care for a patient.
In Part I, the idea was brought up of measuring patient fitness as a good surrogate of future cost of care for the patient. A simple starting point for this would be to develop a standardized exercise test, possibly on a treadmill, as one means of assessing fitness. The results of the test would be compared to one’s gender and age matched peers. If one were in the top 20%, one would be designated much better than average. The next 20% would be designated better than average, then average, then worse than average, and finally much worse than average. The quintile is important. Those who are “much better than average”, i.e. the top 20%, would have no co-pays, deductibles, or withholds. Medications would be free. With each additional quintile, out-of-pocket costs would go up proportionate to the quintile and one’s financial situation. If one were in the lowest quintile, co-pays, deductibles, and withholds would, accounting for one’s financial situation, sting a little bit. If one is in the least favorable quintile but has limited financial resources, making care or medication prohibitively expensive would defeat the purpose of cost-efficient care. Put another way, this new system would have to invest some money in this patient class to save more money down the pike. Thus, in consideration of a patient’s personal resources, medical services and related would have to be attainable for all. If a Silicon Valley billionaire were in the worst quintile and needed medication, that person would likely have to pay full price. This is because, as a percentage of income, these costs would be small.
Let us look back at the example of my patient in part I. Under this system, he would’ve had incentive to improve his health status early. As he racked up charges for medication, co-pays, deductibles, and withholds (while walking the tight rope of not making these too expensive so that he avoids proper compliance with treatment), the sting of these costs might compel him to make behavioral changes. Years before he was diagnosed with coronary artery disease, conceivably he would decide that 2 packs of cigarettes/day are not that enjoyable, after all. Possibly panting after walking up 1 flight of stairs isn’t that enjoyable either. Maybe significant obesity is not his desirable aesthetic. This list, once again, is not exhaustive.
This program could employ an additional incentive to catalyze good behavior, e.g. a 1-time monetary award for improving one’s fitness. As noted above, we will all be evaluated for our fitness status at some point and put into the appropriate quintile. However, is there no way of improving our health and becoming rewarded for it? Yes, there is. If one starts at, for the sake of this discussion, the lowest quintile and improves oneself by exercise, one could request reevaluation. If there is improvement, a one time payment of a fixed sum would be awarded. If one improves from the bottom quintile to the 4th quintile, possibly a one time sum of $250 would be issued to the patient. If one then improved an additional quintile, $500 would be issued. If one jumps from the bottom quintile all the way to the top quintile, one would be issued, ultimately, $250 + $500 + $750 + $1000 = a total of $2500. These sums issued to the patient would be issued once and not repeated if the patient dropped back to a lower quintile. The total sum of $2500 is a best guess as to what the program could afford; I believe that that sum is in the “ballpark”. Indeed, I think a return on investment in <36 months is likely.
So, the next question is, do we really have any proof that physical fitness saves money? The answer is a resounding yes. There are a number of studies that support this. The one to which this article refers is from the BMJ Open Sport and Exercise Medicine publication (published March 5, 2021), “Leisure time physical activity throughout adulthood is associated with lower Medicare costs: evidence from the linked NIH-AARP diet and health study cohort” by Coughlan et al. The issue of the study which will be discussed is leisure time physical activity of participants in middle age compared to Medicare claims at age 65 and beyond (so, the participants self-report their activity in middle age and compare that with their costs later as Medicare patients). For those who self-report no significant exercise activity in middle age compared with those who reported 1-3 hours/week in middle age, there was a reduction in costs of $1365 per person/year. For those who reported >7 hours of exercise/week, the reduction was $2079 per person/year (see Table 2 in the study).
The above noted study from the British Medical Journal article is 1 of the better ones I have reviewed but still has some suboptimal characteristics. The study uses self-reported exercise data from participants who are recalling behaviors decades before the Medicare utilization data were collected. This may not tightly correlate to actual fitness (the maximal amount of oxygen lean muscle tissue can use/minute). Indeed, the great utility of a single medical data computer for all US citizens (suggested in the above August 15, 2024 article, “The Curse of the Medical Record”) may be the ability to compare current fitness explicitly with corresponding cost data (further, this suggests that fitness as defined above may be a new “vital sign”). As one who has followed patients for decades including their level of fitness and resource use, I believe that the above figures are, once again, very conservative in that fit patients cost less because they use less medicines, have less office visits, and have less hospital visits, and so on.
Please note that some of us are born with chronic diseases e.g. cerebral palsy, congenital heart disease, cystic fibrosis, Down syndrome, and many, many other disorders which are by no means our fault. On that basis, they would be put into the “average” (middle) risk quintile.
Thus, for the majority of patients, their engagement in activities promoting fitness should be strongly encouraged and rewarded. As we age, we likely benefit even more from previous and current activities promoting fitness. This needs to be a central feature of any healthcare program.
Finally, at the end of every year, one should get a “report card” i.e. quantification of the resources one used compared to peers. This would be nice to know in a general sense and, as Americans, we are generally a competitive lot. If we know that others are doing better than we are in maintaining health, possibly we would be motivated to see our physicians to see what can be done, if anything, to approve this.