• Changing Patient Health-Risk Behavior Requires New Investment in Primary Care

    One Pagers | Oct 15, 2008
    Martey S. Dodoo, PhD; Lenard I. Lesser, Robert L. Phillips Jr, Andrew W. Bazemore, Stephen M. Petterson, and Imam Xierali

    Evidence supports the effectiveness of primary care interventions to improve nutrition, increase physical activity levels, reduce alcohol intake, and stop tobacco use. However, implementing these interventions requires considerable practice expense. If we hope to change behavior to reduce chronic illness, the way we pay for primary care services must be modified to incorporate these expenses.

    In the United States, the growing prevalence of chronic conditions such as obesity1 has been attributed to an escalating prevalence of health-risk behaviors. Recent studies have identified innovative practice-based approaches to help patients reduce health-risk behaviors, well described as a critical dimension of primary care.2-4 Estimating what is spent by practices that provide such services is critical for establishing appropriate payment. This was the objective of a recent study5 that estimated the within-practice expenses of providing services to change four leading health-risk behaviors: unhealthy diet; tobacco use; lack of physical activity; and risky use of alcohol. Expenditure estimates were computed for 29 representative practices that implemented risk-reduction interventions.5 Expenditures were reported after pilot testing by using standardized protocols, instruments, and a guide book (see accompanying table).

    Table. Practice Expenditure Estimates for Primary Care Interventions to Reduce Health-Risk Behaviors

    Average Expense (95% confidence level)
    Start-up (per practice)
    $1,860 ($922 to 2,797)
    $1,559 (680 to 2,439)
    $263 (8 to 519)
       Capital assets
    $37 (10 to 65)
    Implementation (per patient per month)
       Total $58 (22 to 93)
    $15 (4 to 26)
    $43 (8 to 78)

    Information from reference 5

    These are likely to be underestimates, because the practices did not have to report data on, for example, the advisory and administrative support they received from their research networks. The variation in these estimates may be explained by the diversity in the approaches taken for the 10 interventions, and by differences in staffing and organizational configuration among the practices. However, these results show that the expenses for initiatives to reduce unhealthy behaviors may be prohibitive for most primary care practices, which often lack the capital to initiate or maintain services at this expense level. Widescale adoption of these approaches will occur only if primary care compensation incorporates and fully covers these expenses.


    1. Ruhm CJ. Current and future prevalence of obesity and severe obesity in the United States. Cambridge, Mass.: National Bureau of Economic Research, 2007.
    2. Cifuentes M, et al. Prescription for health: changing primary care practice to foster healthy behaviors. Ann Fam Med.2005;3(suppl 2):S4-S11.
    3. AHRQ. U.S. Preventive Services Task Force Recommendations. http://www.ahrq.gov/clinic/uspstfix.htm. Accessed August 19, 2008.
    4. Hillsdon M, et al. Interventions for promoting physical activity. Cochrane Database Syst Rev. 2005;(1):CD003180.
    5. Dodoo M, et al. Start up and incremental practice expenses for implementing behavior change interventions in primary care. Amer J Prev Med. 2008;35(5S). In Press.

    The information and opinions contained in research from the Graham Center do not necessarily refliect the views or the policy of the AAFP.

    Published in American Family Physician, Oct 15, 2008. Am Fam Physician. 2008: 78(8):924. This series coordinated by Sumi Sexton, MD, AFP Associate Medical Editor.