Coach, Advocate, Doctor & Counselor; The 4 Legs of an Aligned Healthcare System

So much of the national discussion about healthcare centers around getting everyone covered by health insurance. Perhaps we should address fixing a system that is badly broken economically; and where medical errors kill from 44,000 to 98,000 Americans each year (National Academy of Sciences Institute of Medicine, 1999). At the low estimate that’s equivalent to fifteen 9/11 tragedies occurring every year in our country. We spend twice as much on healthcare in the U.S. per capita than any other developed country in the world. More than half of our national debt is unfunded healthcare.

Instead of spending time talking about how we get everyone into this broken system, perhaps we should address fixing the broken system itself.

I have thirty-five plus years of healthcare experience either running hospitals (top of the food chain) or developing population health innovations. Over those years, it has become very clear to me that the perverse incentives that permeate the entire system represent one of the most fundamental weaknesses of the contemporary healthcare system in the U.S. We need to align the providers of the system with the buyers of the system and realign the healthcare system to create health. By the way, by buyers I don’t mean health insurance companies. I mean employers who buy healthcare benefits for their employees and their families. There is a perfect alignment between what employers want and what their employees want. They both want health. The problem is that the healthcare system is not aligned to create health. The system is aligned to profit from an unhealthy population and perform procedures. Everyone in the system from insurance companies, hospitals, pharmaceutical companies, doctors to even those who sell health benefits to employers make more money the costlier and more broken the system.

Too often we think the best fix is to do an analysis of the data to find where to start. That’s like driving a car in the rear-view mirror. Sure, you will find some areas to focus on, but what about focusing on the obvious blatant weaknesses of the system and building a fundamentally sound system.

This article addresses four fundamental weaknesses at the foundation of the healthcare system and suggests strategies to address each in creating a much better healthcare system that produces health not just procedures.

Leg One – Coach; Behavioral Change

The first leg of an aligned healthcare system is to address behavioral change.

According to the 2006 IPFW Study, 87.5% of healthcare costs are lifestyle related. Seventy-one percent of all cancers, 70% of all strokes, 82% of all heart disease and 91% percent of all diabetes are caused by poor lifestyle. (Stampler, 2000; Platz, 2000; Hu, 2001).

Vivian Lee, one of the forty smartest people in healthcare according to Becker’s Hospital Review (2016) said it best when asked what her biggest concern was, “..our industry has really been focused on sickness, not health, and that we’re not equipped or designed to do the single most important thing we can – prevent disease, … often related to specific behaviors or lifestyles. Yet our system, our training programs, and the ways in which we’re funded have generally not led us to be experts in changing those behaviors…”

According to a Gallup Poll (2011), 86% of full-time employees in the U.S. are either overweight or have a chronic health condition. The need to help people change behaviors is gargantuan.

A typical wellness program that hands out gift cards and other incentives for people who do simple tasks is flawed from the very start. Daniel Pink, highly sought-after author/speaker on behavioral science said it so well, “Extrinsic ‘if then rewards’ are extraordinarily effective for simple short-term tasks. However, ‘if then rewards’ are NOT effective for more complex, creative work with longer term horizons... They DON’T work! This is not a feeling, this is not a philosophy, this is a fact!” Long-term lifestyle behavioral changes are complex.

If you are going to influence complex behavioral changes, you must apply the best practices utilized by the experts from the behavioral health industry. A good therapist knows they must create a relationship of trust and meet the person where they are.

The challenge of behavioral change is a battle that goes on inside all of us. We all find ourselves in ruts that we struggle to get out of. There is not a single soul on earth who doesn’t say, “why can’t I change my behavior? Why can’t I get out of this rut?” The secret sauce of helping people change behavior is not to prescribe the change you want them to make (regardless of how true it is). The secret sauce applied by professionals is to help the person identify what they most want to change and start from there.

The solution to changing population behavior is quite straightforward. You simply need to apply best practices of change to most of the population. This can be most effectively and efficiently done through behavior-focused health coaches. These coaches don’t chase people but rather build a relationship of trust. They provide ongoing support to people who call them when they have time for a meaningful conversation.

This solution creates a whole new level of healthcare that doesn’t exist in most places. Imagine over half of an entire population having ongoing conversations with a trusted health coach focused around making meaningful behavioral changes and healthy habits. When created, this new level of health intervention becomes an incredibly effective catalyst at getting the population to engage in the other three important legs of a healthcare system that align with health.

This can be done at no cost to the organization.

Leg Two – Advocate; Help Navigating the System

The second leg of an aligned healthcare system is to offer a health advocate.

The healthcare system is not easy to navigate, and we often face it at the worst times in our lives. Everyone needs an advocate that’s just a phone call away when they don’t know where to turn but need some help:

-I need help getting in to see a healthcare provider.

-I need help understanding my health benefits.

-I need help making sense out of this EOB (Explanation of Benefits) my health insurance company just sent me.

-I’m scared. My daughter was just diagnosed with a debilitating disease.

Not only is that advocate available to give answers and help, they are also there to reach out to the person before and after a medical procedure. The patient will likely have questions, or the advocate can see how they are doing and make sure they are getting the follow-up care they need to avoid complications.

When built into a well-designed benefit strategy, they can also be helpful prior to a procedure to steer patients to the best quality and efficient providers. This can save a patient from low quality providers, avoid the risk of medical errors, and can save both the patient and the buyer from enormous healthcare costs.

The lives and cost savings far out-weigh the cost of such a program.

Leg Three – Doctor; Preventive Primary Care

The third leg of an aligned healthcare system is preventive primary care.

The current primary care system in the U.S. is badly broken and a big reason for the many medical errors. A typical primary care physician has between 3,000 and 4,000 patients in their practice. They know that they must see 30 to 40 patients every day to make a salary that’s only a third of the salaries that their specialist counterparts make. That gives them on average 8 to 10 minutes to spend with each patient. On average there are 180 computer clicks they must make on their electronic medical record for every one of those patients. They often practice at only 20% of their license and send everyone who needs more time or care to a specialist. Let’s ask, “Who is the primary communicator between the primary care doctor and the specialist(s)?” The patient. It’s no wonder why there are so many medical errors.

There is a new form of primary care growing throughout the U.S. that focuses on prevention. It is called Direct Primary Care (DPC). Instead of the doctor billing the insurance company for each procedure, the doctor receives a fixed monthly retainer for each patient in their practice and they often keep the number of patients under 1,000. Suddenly, all the incentives are changed, and the business model of the physician is to keep their patients healthy. The employee, the employer, and now the doctor, are all aligned to create health.

Because they have fewer patients in their practice, the doctor is easier to get into, takes more time with each patient, practices at the high end of their license making fewer referrals to specialists and if a referral is necessary, they communicate with the specialists. They often will take multiple hours on the patient’s first visit to understand all areas of the patient’s health history and well-being. Many times, future needs can be taken care of over the phone, or if there is an urgent need they will meet the patient at the clinic or their home rather than send them to the emergency room.

Because they don’t have to employ a large staff to interface with insurance companies to get paid, Direct Primary Care physicians are far more efficient. Often there are no copayments required by the patient to see or call the doctor.

Smart employers are building Direct Primary Care into the benefit designs they offer employees. They don’t require their employees to use the DPC physician, but for those who do, the employer pays all or some of the monthly retainer. Often employers will negotiate with a DPC physician to come to the workplace regularly to make it even more convenient for employees to see the doctor.

The insurance plan is there to cover more expensive treatments like specialist care, prescriptions and hospitalizations.

The savings from the downstream costs of traditional primary care will more than pay to provide this preventive level of primary care.

Leg Four – Counselor; Emotional Care

The fourth and final leg of an aligned healthcare system addresses emotional care.

According to the U.S. Centers for Disease Control and Prevention 2011-2012, 50% of employees are depressed or distressed. Of all health risks, none have a greater impact on overall healthcare costs than depression and uncontrolled stress. According to a study done by the Health Enhancement Research Organization, individuals who self-report that they are depressed have 70% higher healthcare claims than those who don’t. Those who self-report uncontrolled-stress have 46% higher healthcare claims. Most other health risk factors like obesity, tobacco use, poor exercise and nutrition have between 10 and 20% higher healthcare claims. Journal of Occupational and Environmental Medicine; October 1998)

Emotional risk factors tower over other risk factors. It may be the last leg of an effective aligned healthcare system in this article, but it may be the most important.

Emotional care often carries with it a stigma that, for many people, feels unsurmountable. Employers in the U.S. have for many years offered employee assistance program (EAP) services to address these emotional risk factors in their workforces. However, over time they have become very commoditized. An employer can now buy EAP services for almost nothing. They may be able to check the box that they have one, but they are often designed so that no one ever uses them, which is why they can offer them at such a ridiculously low cost. If no one uses the service, what good is it?

One of the most effective preventive healthcare strategies an employer can implement is an effective EAP that gets high levels of utilization. Typical utilization is 2-4% each year. From my experience managing population mental health for 20 plus years, the goal should be 15-20% each year.

The most effective strategies to achieve such high levels of preventive emotional care are to bring the counselors to the worksite to conduct educational workshops on a host of topics such as parenting skills, relationship issues, dealing with aging parents, financial stress and legal stress. As employees interface with the counselors, they are far more likely to take advantage of these free resources.

Another effective strategy to increase utilization of an effective EAP is training managers and supervisors on how to refer employees dealing with personal problems to the resources of the EAP.

EAP services that don’t limit the number of visits are far more effective at engaging utilization than those who impose limits. Solution focused counseling, which is offered by EAPs is often enough to address the most common sources of depression and stress. There is no need to put a limit on the number of visits. Those who need a higher level of treatment can be referred right away into the mental health and substance abuse services offered by the health insurance benefit, while the majority can get everything they need through the EAP services.

The costs of not offering an effective EAP far outweigh the costs of offering one.

Summary 

Let’s change the discussion.

Let’s fix a broken system and then let’s make sure everyone has access to it.

We can save thousands of lives and spend far less money, perhaps as much as half of what we are currently spending, by aligning the incentives to create health and building a foundation focused on prevention.

The four legs of a better foundation include:

-A health coach to support behavioral change

-A health advocate to help navigate the system

-A direct primary care physician who is aligned to create health, and

-An EAP counselor to address emotional needs.