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Am Fam Physician. 2008;78(8):924

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.24 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).

ItemsAverage expense (95% confidence interval)
Start-up (per practice)
Total$1,860 ($922 to 2,797)
Staff1,559 (680 to 2,439)
Non-staff263 (8 to 519)
Capital assets37 (10 to 65)
Implementation (per patient per month)
Total$58 (22 to 93)
Direct15 (4 to 26)
Overhead43 (8 to 78)

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.

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

This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

A collection of Graham Center Policy One-Pagers published in AFP is available at One-Pagers are also available at

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Copyright © 2008 by the American Academy of Family Physicians.

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