Cost to Patients Barrier to Counseling for Obesity and Smoking

Researchers Urge Healthcare Policy Makers and Payers to Consider Coverage

San Diego, CA, February 2, 2010 – Reducing obesity and smoking have become national priorities in the United States. Research has shown that intensive counseling can positively impact each problem. However, because such counseling is typically not covered by medical insurance, cost can be a barrier. In a study published in the March 2010 issue of the American Journal of Preventive Medicine, researchers from Virginia Commonwealth University, Richmond, Virginia, found that when primary care clinicians and community counselors collaborated to offer free counseling services to patients, there was an overwhelming positive response. Yet, when the same services were offered at a cost to the patient, there was a significant drop in participation.

An electronic linkage system (eLinkS) was used to prompt healthcare providers to suggest intensive healthcare counseling for adult patients with unhealthy behaviors. eLinkS then helped to facilitate and automate referrals and communication between primary care practices and community programs. During a 5-week period when funding was available, 5679 patients were evaluated, 1860 had at least one unhealthy behavior (triggering an eLinkS prompt), and 407 (21.8%) were referred for intensive counseling.

In a 3-week period after funding was exhausted, 2510 patients visited the practices, 729 triggered an eLinkS prompt, but only 5 (0.7%) were referred for intensive counseling. Compared to the coverage period, the overall referral rate for patients with an unhealthy behavior decreased by 97%. Practice nurses asked 22% fewer patients about health behaviors (37% vs 29%). When prompted by eLinkS, clinicians offered referrals to 79% fewer patients (29% vs 6%). If a referral was offered, 81% fewer patients accepted (76% vs 14%).

Patients confirmed that costs introduced a barrier to counseling. Some patients were explicit that charges would prevent participation while others who had deferred counseling in the past were motivated to enroll because it was free. Clinicians reported that removing cost as an impediment, combined with an easy means to refer patients, allowed patient discussions to focus on behavior change. The heightened patient interest reversed when charges were reinstituted. Fewer successes also diminished motivation for the counselors.

Alex H. Krist MD, MPH, Virginia Commonwealth University, Department of Family Medicine, and his co-investigators comment, “Our quantitative and qualitative data underscore that clinicians, not just patients, are influenced by costs. Despite prompts, nurses were less likely to record patients’ BMI and smoking status during the no-coverage period, triggering fewer eLinkS prompts. Clinicians were also less likely to discuss health behaviors with patients. However, even when clinicians did offer a referral, 81% fewer patients accepted. …This study indicates that policymakers and payers should support clinical–community partnerships and eliminate cost as a barrier to intensive smoking cessation and weight loss counseling. Modifying health behaviors is daunting enough for patients and clinicians – cost can be the tipping point in their decision to forego the effort.”

The article is “Patient Costs As a Barrier to Intensive Health Behavior Counseling” by Alex H Krist, MD, MPH, Steven H Woolf, MD, MPH, Robert E Johnson, PhD, Stephen F Rothemich, MD, MS, Tina D Cunningham, Resa M Jones, MPH, PhD, Diane B Wilson, EdD, RD, and Kelly J Devers, PhD. The article appears in the American Journal of Preventive Medicine, Volume 38, Issue 3 (March 2010) published by Elsevier.

Full text of the article is available upon request; contact eAJPM@ucsd.edu to obtain copies. To schedule an interview with the authors, please contact Anne Buckley, (804) 828-6052, or albuckley@vcu.edu.

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Notes for Editors
Authors are:
Alex H Krist, MD, MPH
Department of Family Medicine
Virginia Commonwealth University, Richmond, Virginia

Steven H Woolf, MD, MPH
Departments of Family Medicine and Epidemiology and Community Health
Virginia Commonwealth University, Richmond, Virginia

Robert E Johnson, PhD
Departments of Family Medicine and Biostatistics
Virginia Commonwealth University, Richmond, Virginia

Stephen F Rothemich, MD, MS
Departments of Family Medicine and Epidemiology and Community Health
Virginia Commonwealth University, Richmond, Virginia

Tina D Cunningham
Department of Biostatistics
Virginia Commonwealth University, Richmond, Virginia

Resa M Jones, MPH, PhD
Massey Cancer Center and Department of Epidemiology and Community Health
Virginia Commonwealth University, Richmond, Virginia

Diane B Wilson, EdD, RD
Massey Cancer Center and Department of Internal Medicine
Virginia Commonwealth University, Richmond, Virginia

Kelly J Devers, PhD
Urban Institute
Washington, DC

About the American Journal of Preventive Medicine
The American Journal of Preventive Medicine is the official journal of The American College of Preventive Medicine and the Association for Prevention Teaching and Research. It publishes articles in the areas of prevention research, teaching, practice and policy. Original research is published on interventions aimed at the prevention of chronic and acute disease and the promotion of individual and community health. The journal features papers that address the primary and secondary prevention of important clinical, behavioral and public health issues such as injury and violence, infectious disease, women's health, smoking, sedentary behaviors and physical activity, nutrition, diabetes, obesity, and alcohol and drug abuse. Papers also address educational initiatives aimed at improving the ability of health professionals to provide effective clinical prevention and public health services. The journal also publishes official policy statements from the two co-sponsoring organizations, health services research pertinent to prevention and public health, review articles, media reviews, and editorials.

The American Journal of Preventive Medicine is ranked 12th out of 105 Public, Environmental & Occupational Health titles and 16th out of 107 General and Internal Medicine titles according to the 2009 Journal Citation Reports© published by Thomson Reuters.

About VCU and the VCU Medical Center
Virginia Commonwealth University is a major, urban public research university with national and international rankings in sponsored research. Located on two downtown campuses in Richmond, VCU enrolls more than 32,000 students in 211 certificate and degree programs in the arts, sciences and humanities. Sixty-nine of the programs are unique in Virginia, many of them crossing the disciplines of VCU’s 13 schools and one college. MCV Hospitals and the health sciences schools of Virginia Commonwealth University compose the VCU Medical Center, one of the nation’s leading academic medical centers. For more, see www.vcu.edu.

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