by Zhenya Abbruzzese

Fall 2015 – Imagine patients who actually get worse the more care they receive, instead of better – suffer more symptoms, require more care, rack up higher medical bills and become more dissatisfied with their care.

Take, for example, Anna P. She’s a 46-year-old accountant who’s been feeling dizzy. One day, she’s dizzier than usual. Anna recalls a story about a friend of a friend of similar age who had a stroke, and drives to the ER. After an evaluation, the stroke is ruled out, and Anna is advised to follow up with her primary care physician (PCP) if her dizziness does not get better.

Anna’s no better, so she visits her PCP who refers her to an ENT, suspecting an inner ear disorder. An extensive ENT evaluation does not reveal an inner ear problem, so Anna is prescribed antihistamines to see if controlling her allergies relieves her dizziness.

As her dizziness persists, Anna develops headaches. Concerned that her symptoms may be caused by a brain tumor, Anna makes an appointment with a neurologist, who in turn orders an MRI (largely at Anna’s insistence)—which shows no abnormalities. Anna begins to experience fatigue, muscle twitches and leg pain, so when a new round of testing shows an elevated white blood cell count, Anna undergoes a spinal tap–but that’s normal too.

Anna is miserable—not only from her ongoing physical symptoms, but also from the growing concern that she has a serious, as yet undiagnosed disease. She‘s frustrated that her physicians are incapable of finding the real cause of what’s going on with her. And her bills are now topping $20,000 for expensive, largely unnecessary care that hasn’t delivered any meaningful relief.

Anna’s not alone. Approximately 15% of all primary care patients and at least 25% of patients seen by specialists seek care for persistent symptoms that do not have an adequate medical explanation. Physicians term patients like Anna somatizers—patients with symptoms unaccounted for by objective physical findings. The symptoms these patients experience are real—however, the way in which they experience their symptoms causes them to become amplified and resistant to treatment.

Physicians are frustrated when caring for patients like Anna. Feeling an obligation to do something for these patients, many order additional medical tests or authorize specialist referrals– even when they themselves do not expect to find any helpful information from this additional workup. But ultimately, the reassurance provided by negative test results is not only fleeting but actually counterproductive: the more reassurance these patients receive, the more they need.

The excessive workups associated with somatizing patients adds up to very serious dollars. One study estimates that more than 10 cents of every healthcare dollar is spent on the pursuit of persistent symptoms that will not have an adequate medical explanation. This extensive testing is not only costly but also can be quite harmful, as it often leads to over diagnosis—finding a condition that would never cause the patient any symptoms or serious disease, and overtreatment, which might very well be worse than the condition itself.
So can patients like Anna find real relief? The answer is a resounding yes. What’s surprising is how few physicians know how to effectively treat somatizing patients, even though there is treatment that has been demonstrated effective using one of the most rigorous type of study design—a randomized controlled trial.

The treatment is not a pill or a procedure—instead, it is a highly specialized form of cognitive-behavioral therapy (CBT). This specialized treatment teaches patients how to “turn down” the volume of their persistent symptoms—while learning how to think about their health in more realistic and less catastrophic ways. As patients learn new ways to think, react and respond to bodily symptoms, they begin to seek medical care in a more adaptive and productive way. A randomized controlled trial published in 2014 found that patients treated with this form of CBT had a 15% reduction in utilization—which would amount to over $100 billion per year savings to the healthcare system.

Since CBT is so effective for this common condition, why hasn’t it been adopted? Several barriers have prevented its widespread use. The first challenge is identification—many patients like Anna seek care from multiple providers, so no single provider gets a clear picture of what’s going on, and which workups have already occurred. Another key obstacle is patient reluctance to engage in a behavioral health treatment—a referral to a therapist is often seen by patients as a suggestion that their symptoms are in their heads. Finally, there is a critical shortage of providers trained in the specific CBT approaches that are optimally effective for this patient population. Conventional depression/anxiety treatments fail to address the root causes of symptom amplification that plague these patients.

The shift toward value-based care makes it imperative to find a solution to this problem—both from the clinical and the financial perspective. As payers and providers begin to share the risk for the clinical and financial patient outcomes through the formation of ACOs, it is vitally important for payers and physicians to work together to connect patients like Anna to evidence-based treatment that provides relief for a fraction of the cost of ongoing fruitless medical workups. Payers can use their bird’s eye view of the patient’s total utilization history to identify patients caught in this loop of unhelpful and excessive medical workup. Physicians can use the power of their patient-physician relationships to prescribe CBT as an intervention to help manage patients’ ongoing symptoms—while still continuing to care for the patients; and specially trained CBT therapists equipped with the specialized protocols can deliver care that provides meaningful and lasting relief.

Recently, a patient who completed a pilot program using this evidence-based approach observed, “This program has completely changed my life—I only wish it were available 15 years ago when my problems started”. Let’s hope that it won’t take us another 15 years to bring relief to the estimated 16 million Americans who are suffering today.

About the Author

Zhenya Abbruzzese develops effective solutions to some of the most pressing problems in healthcare delivery. She founded Enigma Health to offer a novel, life-changing intervention for people suffering from troubling, persistent physical symptoms. Ongoing physical symptoms of uncertain medical origin affect as many as 1 in 10 adults, disabling them, frustrating their physicians and generating escalating costs for payers.

Enigma Health works with health plans, employers, and ACO providers to deliver an evidence-based telehealth program specifically designed to relieve persistent physical symptoms and symptom-related stress. More than 90% of participants report clinically significant improvements in symptom severity, health-related anxiety and health-related quality of life. Physician-patient relationships and patient satisfaction improve and payers see an immediate ROI – a 15%+ reduction in utilization.

Prior to launching Enigma Health, Zhenya worked to identify and reduce ineffective healthcare spending in a wide range of populations including spinal surgeries, knee surgeries and births by cesarean sections. Her efforts saved Cambia and its members over $60M to date, and earned Zhenya the CEO Excellence Award for Regence BlueCross BlueShield in 2012.