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"Do it yourself "may remind you of what your mom used to say about the dishes and the laundry. But "self-care" has a more serious tone these days in medical circles, particularly among clinicians who champion preventive care. A group of preventive medicine experts now says patient self-care is more commonly supported by capitated physicians than any other group of doctors. The trend suggests that a positive outgrowth of capitation may be leadership in an area of clinical practice that is crucial for both empowering patients and lowering unnecessary utilization.
Some clinicians believe self-care is growing into a significant medical discipline unto itself — so much so that the likes of the Robert Wood Johnson (RWJ) Foundation, the National Institutes of Health, and the Washington Business Group on Health are devoting significant resources to the topic.
Exactly why capitation is such a strong influencing factor isn’t clear, according to Judith H. Hibbard, DrPH, lead researcher for an RWJ-sponsored study on self-help initiatives. The research team made this discovery based on 448 surveys and 30-minute interviews with physicians in three Northwest communities (Boise, ID; Eugene, OR; and Billings, MT). Eugene has rather high managed care penetration (37%). Boise and Billings have lower managed care penetration (10%-15%).
"The findings suggests that physicians who are paid on a capitation basis have more motivation to have patients be less reliant on the formal care structure," writes Hibbard, who is also professor of planning, public policy, and management at the University of Oregon in Eugene.1 "It is unclear whether the payment mode generates this support, or if physicians supportive of patient self care self-select themselves into capitated systems of care."
Why capitated physicians? Hibbard and colleagues offer three possible reasons:
All three reasons may apply, say Hibbard and team, although based on their qualitative research, the only statistically significant predictor of self-care support was the presence of the capitation payment mode.
Less reliance on formal medical sources may stem from capitation, or it may be part of other health care trends such as the climbing prevalence of chronic disease. In a recently released Harris poll, 45% of Americans reported living with a chronic medical condition, and 72% say it is difficult for the chronically ill to obtain necessary care from clinicians, according to Gerard F. Anderson, PhD. Anderson is national program director of Partnership for Solutions, a RWJ-Johns Hopkins University joint initiative that funded the poll.
Anderson describes the poll as a wake-up call from Americans who see a need for more support in techniques such as wound dressing, bathing, transportation, and financial resources — all parts of self-care literature. Currently, 125 million Americans are living with at least one chronic disease. Paralysis, Alzheimer’s, mental health problems, high blood pressure, and HIV/AIDS are topping the list, Anderson notes.
Dissemination of information on self-care practices has increased in the past decade under managed care in particular and health insurance overall, Hibbard and team say. "It is becoming common practice for health plans and health insurance companies to distribute and make available various self-care services and products to members," she explains. They include products and services such as self-care manuals, nurse advice lines, computerized decision support systems, and other features of "demand management."
The wide range of self-care products is aimed at decreasing demand for formal health care and increasing patient empowerment, researchers point out. Also, they can act as an intermediate step to help patients determine if their problems can be managed at home or if they need to see a physician.
While these products and recommendations are available to both fee-for-service and managed care physicians, prepaid doctors are taking the lead. Physician ambivalence, however, may actually stem from the lack of clear evidence on whether self-care is effective, Hibbard and colleagues note. For example, in their review of more than 1,000 articles of self-care efficacy studies, about half of those studies cite cost and utilization savings from self-care manual dissemination, while the other studies report little if any difference.
At the same time, other influences may affect efficacy. Much evidence points to the powerful influence of physicians’ personal recommendations about most kinds of treatment (smoking cessation, for instance). "One hypothesis is that physician support for self-care makes an important difference in whether self-care manuals are effective with patients," Hibbard says.
1. Hibbard HH, Greenlick MR, Kunkel LE, Capizzi J. Mode of payment, practice characteristics, and physician support for patient self care. Am J Prev Med 2001; 20:118-123.