The “Unclogging” of Healthcare Delivery
January 2019
HealthCoach- Corporate Wellness
A well-crafted Corporate Wellness Program adapts easily to the digital world of smartphone messaging, wearable biometric data, content delivery and modern wellness strategies. As we move deeper into the 21st century of healthcare delivery, it has become readily apparent that the epidemic of chronic disease will remain the primary focus of most reform measures by necessity. The United States currently spends 18% of its GDP on healthcare (4,13) and at least 70% of these costs are related to the management of preventable chronic health conditions (6). These costs are projected to double every 25 years, reaching 34% by 2040, and are largely felt to be unsustainable. To respond to this crisis, the United States enacted the Affordable Care Act which seeks to incentivize improved health at a reduced cost through the use of “Big Data” to identify modifiable risk factors in a given population. The “Big Data” approach to achieving cost-effective outcomes is being used in most other industries and healthcare has finally caught on to its potential value. According to the World Health Organization, 80% of heart disease, stroke, and type 2 diabetes could be prevented and 40% of cancer could be prevented (1). These are the major conditions that are driving increased healthcare costs within the United States. In order to harness the tremendous opportunity to save money by preventing these conditions even before symptoms have appeared, providers will need to shift resources away from costly and risky medical services to less costly and safer preventive services. The United States currently spends 96% on medical services and only 4% on prevention (6). The United States currently spends 96% on medical services and only 4% on prevention The Centers for Disease Control reports that the leading drivers of death and disability mostly related to these chronic conditions are poor diet, reduced physical activity, and cigarette smoking. Even though this information has been widely disseminated, less than 3% of the public is following all of the CDC’s recommendations for living a healthy lifestyle (25) and less then 50% are adhering to their medication prescriptions written mostly to stabilize the effects of these lifestyle “risk factors” (37). This lack of adherence to lifestyle recommendations and to medication prescriptions has resulted in poor control of disease precursors like blood lipids, blood pressure, and blood sugar (targets are being met <50% of the time, 36). To better understand why lifestyle factors are so important for health, research anthropologists report (21, 20) that the human genetic make-up has changed little in the past 40,000 years and that modern humans are genetically best adapted to: They point out that there is a mismatch between how our ancestors lived for 2.5 million years and how we began living only 10,000 years ago after the agricultural revolution (farming, domesticated animals, grains, dairy) and 200 years ago after the industrial revolution (cities, indoor living, decreased family support, decreased physical activity). These mismatches have increased dramatically in the past 30 years: The best evidence tells us that these mismatches are major contributors to the onset of type 2 diabetes, heart disease, stroke, cancer, Alzheimer’s disease, liver and kidney disease, depression, falls, disability and death (6,1,3,8,9,14,22). These conditions account for most of the chronic disease burden seen around the world and data from the CDC reveals that genetic make-up contributes only 15-18% to the causes of these conditions. The other 80-85% consists of health behaviors, psychosocial factors, and environmental exposures (6, 1). Our current healthcare system has focused resources mostly on providing care after symptoms, disease, and disability have appeared, instead of focusing on prevention (1,6,19,20,1,11). Healthcare payments tied to fee for service have incentivized care delivery to provide services after blood vessels have become “clogged” (diabetes, coronary heart disease), joints have become arthritic (osteoarthritis, rheumatoid arthritis, lower back pain), and organs have become impaired (cirrhosis, Alzheimer’s disease, kidney failure). Each year in the United States, 2.4 million angiograms, 1 million knee and hip replacements, and 51.4 million medical procedures are carried out (6). To further frame the problem in the United States: Now more then ever, we can’t afford to wait for symptoms, disease, or disability to occur before we actively and continuously engage patients in the work of self-care. We need to implement a prevention and wellness delivery system that supports patients in the work of building resiliency by self-managing conditions and lifestyle particularly in between acute episodes of care. We can’t afford to wait for symptoms, disease, or disability to occur Our emphasis on pharmaceutical and medical service prescription for chronic disease is unsustainable and has to change if we are to have the necessary resources to maintain our quality of life and our position in the world as a major power. We must now shift to a lower cost prevention and wellness model of care for chronic illnesses and this is exactly what leaders in healthcare innovation are pursuing. By improving health outcomes through this lower cost approach, we could allocate some of these saved resources to other societal problems such as crime, education, poverty and job creation (4). Our emphasis on pharmaceutical and medical service prescription is unsustainable. Lessons learned from Medicare’s pioneer ACO pilot programs tell us that we must reduce medical services by preventing “rising risk” patients from becoming “high risk” patients in order for healthcare to become financially viable in the long term (19). This is why the Institute of Medicine, the CDC (6), the Institute for Healthcare Improvement (33), the American Academy of family Physicians (34), and the Centers for Medicare and Medicaid (30) are calling for a shift in care away from reactive disease management to proactive disease prevention. These organizations are calling for a reorganization of primary care into highly functioning physician-led prevention teams like the patient-centered medical home where each member of the team takes on different responsibilities and works at the top of their license. The team focuses on prevention and wellness of their assigned population and engages patients in the work of self-management. Self-management support is a KEY intervention for preventing chronic illness (35) but physicians have received little training in team-based care and in condition or lifestyle self-management prescription (38). In addition, both providers and patients have become accustomed to the medication or procedure-based encounter pointing to the additional challenge of creating a “culture” of prevention and wellness (24, 28). Self-management support is a KEY intervention for preventing chronic illness Pre-existing models of successful self-management support programs include cardiac rehabilitation (32% improvement in cardiac mortality) (17), pulmonary rehabilitation (37% reduction in acute hospitalizations for COPD) (16), and the diabetes prevention program (70% reduction in onset of diabetes for older pre-diabetic patients) (14). The Institute of Medicine has recently called for medical education reform to meet the new demand for prevention and wellness delivery within primary care (10) but this could take many years to implement once medical schools finally embrace these recommendations. To further elucidate the healthcare “cultural” problem, patients report that they would rather take medications or undergo surgery then make changes in their health behaviors to reduce chronic disease risk factors (24). In order to change this paradigm, the American Hospital Association has called for the enactment of a “culture of wellness” throughout our systems of care (29). They recognize that the cultural disconnect between the OLD way of reactive care delivery and the NEW way of preventive care delivery. Changing culture takes time and this will be a significant challenge for 21st century healthcare. The providers who succeed in making this cultural shift sooner then later will be the winners within the NEW value-based payment system that is emerging (19). Patients report that they would rather take medications or undergo surgery then make changes in their health behavior Leaders from the Robert Wood Johnson Foundation (11), from Kaiser-Permanente (31), from Cleveland Clinic (32) and many other integrated care systems (18) are working to prevent disease at every level within the chronic disease lifecycle. They are calling for prevention and wellness integration as a primary focus for better outcomes delivery at a reduced cost. This is consistent with Medicare’s triple aim vision for the future of healthcare (18). With the shift to electronic medical records and the push to get patients “into the system”, more providers will be able to use BIG DATA to identify the right risks for prevention so that limited resources can be targeted in the right way. This is what the Robert Wood Johnson foundation calls “A Prescription for Health” (12) and this is what will sustain healthcare delivery in the long term. HealthCoach – tracks biomarker information like steps per day, weight (loss or gain), BMI, continuous blood sugar, sleep, hydration and food choices – as well as a host of other cohorts through fitness tracking technology. HealthCoach – allows doctors, participants and health coaches to use secure HIPAA messaging or video conferencing to help with better food choices, to encourage consistent steps per day, to insure safe weight loss and to communicate data back to the doctor for reassessment every 90 days.
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