Medicine's Most Perplexing Challenge: Addressing Unhealthy Behaviors
New demands on health care systems to be holistic patient health coaches in addition to being traditional treatment providers raise a number of complicated questions that have yet to be answered by either the government or the medical profession. The need for guidance on this issue assumed greater urgency in the wake of the Centers for Medicare and Medicaid Service's new drive to convert 30% of its fee-for-services reimbursements to value based payments by end of this year, and to 50% by the end of 2018.
So, it was no surprise that the issue was made a major discussion theme in the first of the New England Journal of Medicine's new "NEJM Catalyst" online webinars bringing together top authorities in the field of patient engagement and health behaviors.
New multimedia venture
In January, the Boston-based NEJM, which publishes one of the world's most influential medical journals, launched a new multimedia division to focus on the sweeping changes and disruptions now in progress throughout the country's health care industry. The goal is to foster collaboration and more effectively disseminate the latest developments in medical knowledge, practice and education as they relate to three rapidly changing areas of health delivery: care redesign, changing business models and patient engagement.
The organization has appointed national "Lead Advisors" and a committee of "Thought Leaders" in each of these three areas. The Lead Advisor for the Patient Engagement core is Kevin Volpp, MD, PhD, who heads the University of Pennsylvania's LDI Center for Health Incentives and Behavioral Economics (CHIBE). Two of the seven Thought Leaders in that same behavioral sciences core are also from Penn: David Asch, MD, MBA, Executive Director of the Penn Medicine Center for Health Care Innovation and LDI Senior Fellow, and Scott Halpern, MD, PhD, Deputy Director of CHIBE and LDI Senior Fellow.
Insurance Benefit Design as Behavioral Tool
Another theme of the NEJM Catalyst "Health Behavior and Habits" panel session was how insurance benefit design can be more effectively used as a behavior changing tool.
"One of the greatest levers we have in terms of existing flow of funds to improve health are people's health insurance benefits," said Kevin Volpp, who heads one of the country's largest health-related behavioral sciences research centers. "But these are really underutilized as a driver of behavior change. We need to think about how to use benefit design to drive greater use of cost-effective therapies and lower use of low value care."
"There's been a lot of interesting research work on value-based insurance design that has focused on medications and lowering cost-sharing on things like statins to reduce barriers to utilization," Volpp said. "But we need to think more broadly about ALL the medical services we provide and their value in terms of improving health."
"It's generally recognized," he continued, "that benefit design has become very complicated with consumers getting a 20-plus page description of what's in their health benefits. It's pretty clear they're not going to really learn what they're being incented to do or not to do. We need to make benefit designs shorter and more understandable."
Practicing what he preaches, Volpp and his research team recently worked with Humana to design a health benefits plan whose description was only one-and-a-half pages long (See the document).
"Research told us that co-payments were what people actually understand much better than 'co-insurance' or 'deductibles,'" he said. "All medical services were broken into five tiers of pricing. So, the impossibly complicated world of medical service delivery was distilled down to let the consumer actually see the cost of different kinds of services. And once you had that, you had the potential to inbed within it a value-based framework whose goal was to shift people based on how you set those cost-sharing levels."
"As health care leaders and clinicians see more and more how the pressures to improve patient outcomes are driving health care organizations' interests, it's important to think broadly about how we influence patient behavior and how that helps to keep people healthy," said Volpp, who is also a Professor of both Medicine at Penn's Perelman School of Medicine and Health Care Management at Penn's Wharton School.
Unhealthy behaviors' cost
Backgrounding the webinar session's discussion is the fact that one of the key drivers of the country's runaway health care costs is the unhealthy behaviors of patients themselves.
Leading the NEJM Catalyst session entitled "Health Behavior and Habits," Volpp estimated that unhealthy lifestyle behaviors cause as much as 40% of premature deaths. The Centers for Disease Control and Prevention (CDC) estimates that unhealthy lifestyle habits and the chronic diseases associated with them ultimately account for "most health care costs" in the U.S.
So, the central question and quandary faced by those who must identify ways to lower the nation's long-term health care costs is this: how do you get millions of people to cease smoking, avoid unhealthy foods, engage in regular exercise and take the medicines prescribed for them? Once a health care provider observes one or several of these unhealthy behaviors in a patient, what should that institution do about it?
Health care vs. health
"We know doctors and hospitals excel at providing health services but don’t always do as well in terms of improving health," said Volpp. "Consider that while we spend far more than any other country on health services, life expectancy in the US is not in the top 20. There are many social and behavioral determinants of health and until recently, health plans tended to pay for health services and not health, per se. This raises the question of whether health care delivery systems should be thinking about broadening their product offerings."
But how would that work?
"Health Behavior and Habits" panelist and NEJM Catalyst Thought Leader, David Kirchoff, pointed out the obvious: "It's easy to see everything that HAS to happen to make our health system more robust, efficient and less costly as well as make consumers adopt healthier behaviors that can prevent disease."
"But," said Kirchoff who spent 14 years as a top executive in one of the country's largest commercial behavior modification companies -- Weight Watchers, "all this involves getting a patient to adopt new habits and, generally speaking, we really haven't made a lot of progress in that."
"One insight I offer from my many years of experience is that patients don't care as much about their health issues as their physicians do," Kirchoff said. "Even when they have chronic disease and would be directly affected by healthier lifestyle habits, they don't change."
Panelist Wendy Wood, PhD, NEJM Catalyst Thought Leader and Professor of Psychology and Business at the University of Southern California sees some progress in the way more clinicians ARE asking patients about their smoking, exercising and other habits.
"But the conversation typically stops there," she said. "It does not explain to the patient how to change his or her behavior. We need to start these conversations in the doctor's office with follow up questions about what health behaviors would be easy for that particular patient to adjust and what features of home environment could be changed to trigger healthier behaviors."
How paternalistic should doctors be?
But how paternalistic should physicians be and what are the logistical and economic mechanics of changing their office practices to become health coaches?
"It's hard for me to imagine that it will ever be considered cost effective for a doctor to spend hours and hours working closely with patients to counsel them about their health behavior," said Volpp. "That doesn't abdicate them of responsibility, but I don't think from an economic standpoint they're equipped or positioned to be the primary lever here."
"They're going to need a lot of help and support in this," Volpp continued. "They're going to need a lot of programs that are designed at the health delivery system level. Things like predictive analysis to help them figure out who's the right patient to be offered a specific kind of behavior-related program? It's not the kind of thing that the doctor can just figure out on the fly when the patient walks into the office."
"There IS a crucial role for clinicians to play in this," said Kirchoff. "People listen to their doctors and doctors have a lot of sway on what patients do. They can create a sense of urgency like no one else."
Beyond the physician's skill set?
"At the same time," Kirchoff continued, "This can't be put purely on the clinician. If you look at behavior change technique, you can see that these are things that would be difficult to train for in a medical school context; learning skills like motivational interviewing and facilitating group support and related methodologies are not traditionally the realm of the doctor."
"The most potent combination for achieving this new service is in the medical home context," Kirchoff said. "In that mode, the primary care physician is able to connect a patient with a community-based program than can actually BE the delivery mechanism for behavior change techniques, incentives and the support needed to produce healthier habits."
Wood agreed: "The idea of having the problem flagged by the clinician and then having the patient going elsewhere for treatment is a very reasonable model that could be adopted; psychologists would certainly be very well positioned to provide those sorts of behavior change strategies."
Complex collaborations required
She also noted that a clinical system capable of achieving broader care of the whole patient rather than only his or her episodic ailments would likely require a complex collaboration of various professionals.
All three panelists concurred that there is no single approach or answer to exactly which behavioral modification methodologies might work best in providers' expanded "whole patient" services. The reason for this is that individual patients' social situation, financial circumstances, living environment and other characteristics can be dramatically different in ways that require very different holistic approaches aimed at fostering better health behaviors.
Kirchoff took issue with the concern about being too "paternalistic" in directly addressing patients' obvious behavioral issues.
"Right now," he said, "we have a paternalistic society that is favorable to junk food because we subsidize certain crops that lend themselves to highly processed food. So, it's not like we're not already being paternalistic -- it's just that we're doing it in ways that are not good. Is there any reason we should facilitate people drinking a high-test Coca-Cola in a 64-ounce cup in a movie theater? If a patient's A1c is high, you can't shy away from a serious conversation about the fact that he or she is on the verge of developing a chronic disease that is, by the way, very expensive to care for."
Taxation and social policy
"I would take a harder line than you suggest," Wood told Kirchoff. "I think (as a society) we need to be informed by the health data. We have enough data on lifestyle behaviors and the diseases linked to them. And having tax and other broad social policies set based on those data seems like something we should have been more in line with at this point.
"One of the biggest challenges for behavioral change interventions," said Wood, "is that as scientists, we've put a lot of emphasis on immediate, short-term change. If you exercise for two weeks, that's fine. But it may have little effect on your long-term health. I see a very strong focus on short-term change and little value placed on understanding what changes people's behavior in the long run.