Reverse our attitudes and values to control health costs

by John Kaegi

We all complain about the cost of health care and health insurance.  Ours is by far the most expensive health care system in the world.  And for the money, our health isn’t so hot either.  On the world stage, the U.S. ranks 37th in health care efficiency (a measure of health outcomes such as infant mortality, incidence of chronic disease, etc.) as reported by the World Health Organization.  America ranks behind virtually every EU country and Canada.  What can we do about it?  Ration health care?  Control doctors?

The answer begins with that which we want to retain.  Most Americans enjoy unlimited access to health care.  And despite the world rankings, it is generally accepted that the quality of American health care is unsurpassed.  Let’s not throw the baby out with the bath water, right?  But, if we are going to continue to enjoy our access and quality, then we need more than information and empowerment.  We also need a little push.

As in most things, health has interconnected, but contrary forces — its “yin and yang.”  Could it be that wide access to quality care after we get sick may be the culprit creating growing indifference to the consequences of poor health behaviors?  It is so easy to rationalize super-sizing our cheeseburger and fries when we have Lipitor, liposuction and a litany of care providers watching our backs.  As important as it is that we have convenient and transparent health cost and outcomes information to control health care costs when we need it, I assert that it is equally critical that we avoid poor health in the first place as the ultimate means to reducing the cost of health care.

The crux of the problem is found in our attitudes and values toward health.  To reverse high health cost inflation will require us to reverse our attitudes and values first.  Incentives as well as information can play a role.  Many large employers now provide their employees (and often their spouses) with on-site health management clinics, staffed primarily by nurse practitioners who are generally better trained than doctors to engage patients in health management dialogs.  Coordinated with these clinics are health risk assessments in order to identify potential health issues so that individual health management plans can be created.  They often include wellness programs and incentives to make behavior changes.  Some even include disincentives to motivate participants to change, such as increased deductibles for those who persist in smoking or over-eating.

Driving these employers is sensitivity to the root causes of high health care costs.  We hear a lot about the aging of the population, about the contribution to cost by new technologies and drugs, and of course, about defensive medicine and malpractice costs.  However, those are just the symptoms.  The root causes of high health costs are:

  1. poor health behaviors,
  2. misaligned provider incentives, and
  3. disconnected health information.

Poor health behaviors accounts for about one-half of the $3-trillion we spend on health care annually.  Three years ago, in 2008, every annual health insurance premium included an additional $1,405 to compensate for smokers, $1,280 to compensate for lack of exercise and obesity and $1,070 for uncontrolled hypertension and cholesterol.  Three years of uncontrolled inflation makes it even worse now.

It would be helpful if doctors took the time while we see them to explore the root causes of our illnesses, to counsel with us about our health behavior choices, to create health management plans and to follow-up with us on our progress.  But, don’t count on that in the fee-for-service reimbursement system.   Because the FFS system pays for procedures delivered, it incentivizes physicians to overutilize medical services.  It is extraordinarily inflationary as it seemingly justifies overutilization in order to avoid malpractice litigation.  It creates an assembly-line culture among providers that results in an average of 7 minute appointments, clearly not enough time to engage in wellness counseling.

Wellness counseling will only occur when providers are incented to do so.  But to add more financial incentives on top of FFS is not the answer – it only exasperates the problem.  Rather, a system of salaried providers combined with liberal bonuses for improving the health of their patient panels is the ideal solution to refocus practitioners on taking the time to know their patients, to engage them in wellness and to follow-up.  Most employer clinics use salaried providers and often feature average appointments of over 25 minutes.

Finally, even those providers who are wellness focused are still ineffective without data, information and health history.  Yet, only 20% of hospitals and about 10% of doctors use electronic medical records in their everyday practices.  Less than 1% of doctors are interconnected with one another, sharing information about common patients.  That leads to errors, misdiagnoses and even deaths.  Over 90,000 patients die unnecessarily in hospitals every year according to the Department of Health and Human Services.

As we fight for greater transparency of information, we should also fight for a change from an illness to a wellness model; from FFS to outcomes-based reimbursement; from intuitive medicine to data-based care plans.  With that, we also need that push to do better; incentives (and poor health behaviors disincentives) to engage in wellness as vigorously in the future as we do now in poor health behaviors.

John Kaegi is Chief Strategist, Healthstat Inc.

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  • Katherine Levine

    I think my managed care provider does a great job in all three ares–my provider Kaiser Permanente–Colorado. Others should follow their lead.

  • drdarrellwhite

    While I don’t necessarily agree with your solutions I DO definitely agree with your premises, as well as your keen observation about the underlying problem. What we have is a HEALTH crisis in America, and it is this that is the underlying cause of our Healthcare Finance crisis. It’s been grinding along like this for several years; decision makers, those with their hands in our wallets, do not care to agree with you.

    Here’s what I’ve written:

    Not much has changed in 2 years, unfortunately.

  • John Kaegi

    Dr. White, I agree there are other solutions than the salary-plus-bonus idea that I offered, but the encouraging point is that more and more of us agree with the premise about what the problem is and that a wellness solution is needed. Thank you for your response.

  • e-patient

    It doesn’t make any sense to send a doctor to medical school for 7+ years and have that doctor spend the day giving out lifestyle advice. Doctors are trained to diagnose and treat illness. Once the lifestyle problem is identified, it makes sense for someone trained to deal with the lifestyle issues.

    • drdarrellwhite

      I like that! I see diabetics all the time. If I ask them if they’ve given any thought to seeing a dietician they respond “I guess so”. If I REFER them to a dietician they go; the MD referral has weight. Same thing with exercise (I’m a fitness wonk. Every Crossfitter is.) Diagnose the problem, identify a solution, enact the treatment.

      I like the way you are thinking.

  • Prevention Institute

    It’s true—focusing the majority of our resources on medical treatment while ignoring root causes contributes to America’s poor health and soaring healthcare costs. Still, having doctors individually counsel patients on healthy lifestyles can only go so far when the social and physical environment—the places people live, work, learn and play—does not support healthy behaviors. Health is intimately tied with social factors like socioeconomic status, ethnicity, and geographic location. Those who suffer the most from a wide array of chronic diseases and injuries are largely poor minorities who live in marginalized communities that lack access to services, infrastructure, and social cohesion. Real improvement in population health will require changes to the environment, including (but by no means limited to) access to healthy food, safe places to be active, and protection from environmental toxins like car fumes and cigarette smoke. Every dollar invested in building healthy communities will reduce the burden and demand on our health care system, and ensure that more people will be healthier for longer periods of their life.

    This means that physicians have a role to play even beyond educating individual patients. While these changes may seem like the work of public health professionals, planners, and community organizations, physician support is vital to convincing lawmakers and the public that environmental change is critical to achieving better health outcomes. Their expertise and first-hand experience can also help us learn more about the specific conditions that contribute to poor health in a given community. Learn more here:

    • drdarrellwhite

      “Those who suffer the most from a wide array of chronic diseases and injuries are largely poor minorities who live in marginalized communities…”

      Do you have a source for this statement? While it may be true, and the “8 Americas” article certainly finds that some communities suffer more of these “lifestyle-driven” diseases than others, it is a rather universal finding that crosses all socio-economic strata. Indeed, it crosses all education level strata and is not geographic.

      I practice in an affluent suburb. My patient population covers the ENTIRE spectrum of income, education, lifestyle, and community. LIfestyle-driven health issues that cause increased health expenditure are equal across all boundries in my practice experience.

      Some people are just better dressed and arrive in fancier cars.

  • John Kaegi

    Yet, one of the problems with fighting behavioral health issues is that everyone thinks it is someone else’s problem to solve first. In fact, most Americans — not just the poor minorities — engage in poor health behaviors. That’s what’s fueling the epidemic of obesity, diabetes, hypertension, etc. Over 51% of American children under 18 are now considered obese. Clearly not just the poor minority.

    The article makes the case that doctors ARE NOT the right providers for the wellness work. It advocates for engaging nurse partitioners in the work of counseling and following up on patients who need help changing their health behaviors and developing healthy habits. We know that education alone does not work; neither do positive incentives. The work requires a “village.” Employers are in the unique position to be able to guide their employees through a holistic, centralized system of rewards, penalties, on-site nurses and telephone wellness coaches, etc. No one physician office is in the same position to orchestrate health behavior changes.

    • Prevention Institute

      Employer practices are absolutely a part of the picture; in fact, every one of us has a role to play. We need collaboration among a diverse set of groups, including medical professionals, businesses, local and federal government, city planners, educators, etc. Employers are in a unique position to change organizational practices to make it easier for their employees to adopt healthy behaviors, and doctors are in a unique position to influence Americans’ understanding of what health is and how we improve it, since their advice on health is regarded more highly than anyone else’s. We love both the farmer’s markets established on the campus of our local Kaiser Permanente clinical offices that make access to fresh fruits and vegetables easier for patients advised to eat more healthily, and we also love their wellness benefits for employees. And you’re right: poor communities are affected disproportionately, but we are all seeing and feeling the impact of unhealthy eating, which makes it even more critical that we all become part of that ‘village’ to put community prevention in place. Thanks for reading and responding to our comment!

  • Justin

    Instead of subsidizing corn, we should be subsidizing free community gymnasiums.

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