10

receive the attention that they deserve in an objective sense. Even demonstrably cost-effective education may have trouble competing with quite inefficient but nevertheless “sexy” medical therapies.

These considerations complicate the picture. To my way of thinking, however, they serve primarily to rein- force the call for more serious research into the health and economic implications of health education, both in its conventional patient-counseling format and through less traditional mechanisms (such as the use of the mass media);12*13 and they echo the need for attention to the marketing of findings on the cost-effectiveness of specific health-education activities.

By contrast, Resolution 8219 lacks vision. In its all-too-ready ends justification of means, it causes APHA to fall into the trap of supporting two aspects of the status quo that the Association has criticized previ- ously, and with good reason: traditional fee-for-service and cost-based third-party coverage and restriction of reimbursement to “usual providers of care.” Both APHA and the field of health education can do better.

ACKNOWLEDGMENT

I am grateful to 0. Lynn Deniston, Scott K. Simonds, and Patricia A. Warner for helpful comments on a draft of this essay.

REFERENCES

1. Deniston OL. Whether evaluation-whether utilization. Eva1 Program Plann 1980; 3:91.

8.

2. Green LW. How to evaluate health promotion. Hospirals 1979; 53:106.

9.

3. Warner KE, Lute BR. Cost-benefit and cost-effectiveness analysis in health care: Principles, practice and potential. Ann Arbor, Michigan: Health Administration Press, 1982.

4. Warner KE. Health maintenance insurance: Toward an optimal HMO. Pol Sci 1978-1979; 10:121.

10.

11.

5. Grimaldi P, Micheletti J. Diagnosis related groups: A prac- titioner’s guide. Chicago: Pluribus Press, 1983.

6. Pauly MV. The economics of moral hazard: Comment. Am Econ Rev 1968; 58531.

7. Newhouse JP, Manning WG, Morris CN, Orr LL, et al. Some

12.

13.

interim results from a controlled trial of cost-sharing in health insurance. N Engl J Med 1981; 305:1501. Luft HD. Why do HMOs seem to provide more health mainte- nance services? Milbank Mem Fund Q Health Sot 1978; 56:140. Seidman LS. The aroman food crisis: A fable with a lesson for national health insurance. Med Care 1978; 16~417. Feldstein PJ . Health associations and rhe demand for legislation: The political economy of health. Cambridge, Massachusetts: Ballinger, 1977. Friedman M. Capitalism and freedom. Chicago: University of Chicago Press, 1962. Farquhar JW, Maccoby N, Wood PD, Alexander JK, et al. Community education for cardiovascular health. Loncet 1977; 1(8023):1192. Warner KE. The economic implications of preventive health care. Sot Sci Med 1979; 13C:227.

RESPONSE

VIEWPOINT OF THE AMERICAN HOSPITAL ASSOCIATION

recommendations as they relate to hospital-sponsored patient-education services.

Elizabeth Lee!, R.N. M.S.N.

Director, Center for Health Promotion, American Hospital Association, Chicago, Illinois

Barbara Gilotb, M.P.H. Patient Education Manager, Center for Health Promotion, American Hospital Association, Chicago, Illinois

Resolution 82 19 succinctly describes the contribution of patient education to effective medical care; however, the resolution overlooks the fact that patient-education services are often provided as an integral part of other types of medical care, for example, acute inpatient treatment. In addition, the resolution does not recognize that the appropriate method of payment for services is often determined by the setting in which services are provided and the method of payment used for other, related services.

Before discussing payment issues in detail, we want to mention recent AHA activities related to payment for patient education.

AHA ACTIVITIES

American Public Health Association Resolution 8219 The AHA established a Center for Health Promotion in recommends the inclusion of patient-education services January 1978. Its mission is to support patient, com- in health-benefit packages as well as separate payment munity , and employee health-education programs spon- for health-education services. As staff of the American sored by hospitals; expand an employee health program Hospital Association (AHA), we shall respond to those for AHA staff; assist member hospitals in developing

PATIENT EDUCATIONANDCOUNSELING

11

programs to help businesses keep their employees healthy; and develop and maintain liaisons with other groups involved in health promotion. Contracts with the Centers for Disease Control have supported cooperative activities with the Blue Cross and Blue Shield Associa- tion (BCA/BSA) and the patient-education subcommit- tee of the Health Insurance Association of America to address the financing of patient education. Publications resulting from activities with BCA/BSA include Financing for Health Education Services in the United States ’ and Blue Cross and Blue Shield Plan Support for Health Education Services. 2 Both publications are available from the Blue Cross and Blue Shield Associa- tion in Chicago.

The AHA Policy and Statement on the Hospital’s Re- sponsibility for Patient Education3 describes patient education as an integral part of patient care and states: “In order to implement planned, coordinated patient education services hospitals should provide the neces- sary staff and financial resources. Expenses for provid- ing patient education services directly related to patient care should be treated as financial requirements under third-party agreements. ”

Another important statement is AHA’s response to the proposed Revision of Medicare Conditions of Par- ticipation for Hospitals (48 Federal Register 299, January 4, 1983), which outlines a recommended re- quirement for patient education. More specifically, the AHA recommended a general standard on comprehen- sive patient-care services. This standard includes a re- quirement that “patient-education/information services be provided as an integral part of care to assist patients in making informed decisions about their use of health- care services, managing their illnesses, and implement- ing follow-up care. ”

FINANCING PATIENT EDUCATION

The method used to pay for specific services will be determined by many factors. No single method will be appropriate for all situations. The importance of the re- lationship between payment methods and patient and provider behaviors is recognized. General theoretical descriptions of this relationship can be made for various payment systems currently operating in the United States. Under capitation systems, for example, since no services are paid for on a fee-for-service basis, ser- vices would be provided if they improve enrollee health status and reduce the overall use of health services. Under retrospective, cost-based reimbursement, since the cost of services is recognized in the cost settlement, services would be provided if they contribute to the well-being of the patient as determined by medical staff. Under the emerging prospective-payment system, since payment is determined in advance for each admission, services would be provided if they contribute to more

efficient use of health services (for example, through shorter hospital stays) and can be provided at a cost compatible with established payment levels.

The last example relates to recent changes in Medi- care that will affect the health-care system for years to come. These changes provide a framework for dis- cussing the financing of patient education. An under- standing of these changes is essential when participating in efforts to ensure the effective implementation and use of patient-education services. Knowledgeable, involved advocates are needed at the state and national levels. Equally important are advocates who are able to demon- strate the significant contribution of patient education to their hospital’s financial as well as patient-care goals.

MEDICARE CHANGES

Medicare payments have been changed so that the al- lowed payment levels for acute inpatient hospital ser- vices are tied to diagnostic groups. Recent legislation, which will take effect in October 1983, will further change the payment system to include prospective de- termination of price.

As diagnosis-related payment is implemented, it will be even more important to ensure that patient education is an integral part of diagnosis-related treatment proto- cols. Many hospitals are developing patient-education plans to go along with these protocols. These plans in- clude learning objectives and recommendations for the use of educational methods, materials, and evaluation techniques. These educational plans are basic for pro- viding information to determine costs and for inclusion of patient education in the costs of a service whether it is provided as part of another service, such as ambula- tory surgery, or as a separate intervention.

For the most part, changes in the financing system that have already taken place relate to inpatient services. This is important because it means that, for inpatient settings, patient-education advocates must be able to continue to obtain financial support under existing fi- nancial constraints. For outpatient settings, patient- education advocates must determine the impact of inpa- tient financial constraints on the educational needs of patients and use this along with their knowledge of the need for primary care and prevention services to help determine new outpatient benefits and payment mechanisms.

INPATIENT EDUCATION To gain and maintain support for patient education, patient-education advocates in inpatient settings must be able to describe educational interventions and their costs and they must be able to relate them to benefits for both the patient and the hospital,

VOLUME S/NUMBER 1

12

Under the diagnosis-related payment system, patient education can be an integral part of a hospital’s finan- cial strategy. Hospitals will be paid a set price for each admission, and this price will be based on the admitted patient’s diagnosed illness. Hospital decision-makers, then, would look at patient education as beneficial if it can be related to shorter stay, appropriate use of health-care services, or any other means of reducing costs to the hospital. They would also be likely to sup- port patient education if it can help hospitals maintain markets and gain new ones, by positively affecting pa- tient and physician satisfaction or by increasing com- munity support for the hospital. Third-party payers will view patient education as beneficial if it can be shown to reduce readmission rates.

A point that must be made about prospective pricing and Resolution 8219 relates to the recommendation in the resolution that patient education be paid for sepa- rately. Given that prospective payment is based on a unit price for services provided for diagnostic groups, the argument for separate payment does not apply to this payment framework.

Lastly, we would like to stress that the implementa- tion of outpatient education services will become even more important as the results of current changes are felt. This increased importance will result, in part, from pressures to reduce lengths of stay as well as problems relating to access to care. Access to care has already become an issue for the poor. In some states, payment changes have meant that the poor can obtain services only from designated health-care providers. Of course, access to care is important when an individual is acutely ill. It is equally or more important, however, for pa- tients who need help in managing chronic diseases. One answer to access problems, then, is implementing out- reach services, including patient education, in com- munity locations such as schools, libraries, or churches.

OUTPATIENT EDUCATION

Adequate payment for outpatient services, including patient education, is an important problem that has yet to be resolved. Financing for Health Education Services in the United States’ notes that “only 56% of the U.S. population has any private coverage for physician ser- vices delivered in homes and offices and outpatient settings. ” In addition, it continues, “This coverage is likely to be less comprehensive than hospital coverage. Most of the coverage that does exist is provided under Major Medical policies that contain both deductible and co-payment requirements. Medicare Part B currently imposes an annual $60.00 deductible on physician’s services, and requires a 20% co-payment for usual and customary charges. ”

The challenge is to implement a payment system that will be flexible enough to address the outpatient care needs of a variety of populations yet one that will con- trol costs. Hospital-sponsored ambulatory care can in itself result in systemwide cost savings. Ambulatory services can be provided in a variety of organizational forms. These include ambulatory surgery units and home-care programs. These forms of care have come about, in part, from the elimination of the use of such hospital services as 24-hour nursing care. In almost every case, the hospital care eliminated has had to be replaced by an appropriate form of self-care by the con- sumer. And in almost every case, the methods of self- care have had to be taught to the consumer. Content to be taught covers a wide range of topics, from appro- priate diet to self-administration of respiratory therapy and other more complicated techniques that would ordi- narily be performed for inpatients by nursing and allied health personnel. To a great degree, then, the success of ambulatory care services and the savings they may offer are a result of effectively teaching patients (and their friends and family) to care for themselves as an integral part of these services.

There are times when patients and their families need only an educational intervention or some assistance in applying the information and skills they have learned in the hospital. Chronic diseases such as diabetes, for in- stance, require the patient to comprehend a large amount of information. While these individuals may need to be in the hospital for a diagnosis to be made, they need not ‘be in the hospital to complete the educa- tional aspect of their patient-care plan.

One option for financing education services outside the inpatient setting is to charge fees. Some hospitals are doing this, and for some patients this seems to be appropriate. Many patients who use ambulatory care services, however, cannot afford to pay for medical care let alone individualized or group patient and family teaching.

This discussion emphasizes the complexity of pay- ment issues. Payment decisions must take into account the need for the integration of patient education into all patient-care services and at the same time the need to provide services to individuals, particularly those with chronic conditions such as diabetes, when education may be their only need. The importance of patient edu- cation must be demonstrated to consumers, policy mak- ers, and third-party payers to ensure that these services are an integral part of health-care services. These financing mechanisms must make possible patient- education services that respond to the educational needs of a variety of populations and must encourage the effi- cient use of health-care resources.

PATIENT EDUCATION AND COUNSELING

13

REFERENCES

1. Blue Cross and Blue Shield Association. Financing for health education services in the United States. Chicago: Blue Cross and Blue Shield Association, 1980.

2. Blue Cross and Blue Shield Association. BIue Cross and Blue Shield plan support for health education services: A discussion of issues. Chicago: Blue Cross and Blue Shield Association, 1982.

3. The American Hospital Association. Policy and statement. The hospital’s responsibility for patient education. Chicago: The American Hospital Association, 1982.

VOLUME S/NUMBER 1