The Need to Redesign Health Care
One cannot open the newspaper on any given day without seeing a headline about some study, report, committee, commission, or hearing seeking to solve a chronic disease crisis — obesity, diabetes, hypertension, pain, opioid abuse, and, most recently, depression and suicide. But the discussion rarely gets to the real cause: the very design of the health care system itself. Until we design a health care system that proactively manages risk and promotes health for the whole person and for all people, we will continue to ineffectively deal with chronic diseases and the next crises to come along.
The opioid crisis is an illustrative example. The primary responses to the opioid crisis have been to control the supply by restricting prescriptions and access; to monitor users, including both patients and providers; and to provide other drugs to manage opioid-related complications. These responses have prevented patients who need opioids from getting them, have turned providers into policemen when patients seek opioids, and have led to providers being policed themselves when they prescribe opioids. These factors have ratcheted up both the stigma of drug addiction and the demand for illegal opioids such as heroin.
While it is laudable that some city and county governments have asked the public to save lives with naloxone, this initiative is not a solution. Physicians also have been told in multiple national guidelines to provide more non-drug (complementary) treatments for pain such as acupuncture, yoga, and mind-body approaches; however, such interventions represent treatments for which physicians have not received training and for which they do not get paid.
Each chronic disease crisis is dumped on the shoulders of physicians, who are constrained by a system that does not address the root causes: It is like repeatedly mopping up a wet floor while the roof continues to leak. Those on the front lines of the opioid crisis know its cause — namely, our failure to care for pain and mental health. They know that most other diseases managed in primary care — hypertension, obesity, diabetes, heart disease, stroke, dementia — can be largely prevented. It is no surprise to them that, in the United States, costs are going up and outcomes are getting worse. The value of health care for producing health is declining.
The real crisis is how we manage chronic disease overall. We have known for at least 3 decades that most chronic diseases are lifestyle and behavior based. But our health care system and our training as doctors compel us to manage these conditions with pills and procedures rather than addressing their known behavioral and social determinants. We all want to promote health and healing, but our system makes it almost impossible to do so. The result is that we fail to provide prevention, primary care, and population health and therefore never address the underlying reasons for these epidemics.
Consider these facts: (1) Only 5% of health care spending goes to prevention practices that could avoid the expensive medical care that now accounts for 75% of health care costs; (2) primary care physicians receive only 6% to 9% of health care dollars, with razor-thin margins for wellness visits and population health management, keeping them on the treadmill of volume-based care; and (3) only about 20% of care coordination and health coaching costs are covered, thereby limiting our ability to hire team members who can help to link the office visit to the determinants of health outside the office. By the very nature of the design of our system, frontline physicians are dashed onto the rocks of volume-based care and are blamed when they don’t deliver value-based outcomes. Is it any wonder that the more dedicated an individual physician is to patient-centered care, the more likely they are to experience burnout?
True health care reform, both in the office and in our system, needs to get at the cause of these epidemics. We need a radical redesign of our approach to understanding and treating the roots of chronic disease. We need to shift both our models of care delivery and our payment structures from a transactional, pills-and-procedures approach that is primarily focused on disease management and designed around points of medical care to one that is based in a partnership that is focused on the whole person and their physical, emotional, social, and spiritual well-being over time.
Integrative Medicine and the Whole Health Approach
It is often a surprise to people that two of the largest health care systems in the country are trying to radically redesign what they do to provide more whole-person and integrative care. These two systems are run by the Department of Defense (DoD) and the Veterans Health Administration (VHA) and collectively care for over 20 million people. The nation can learn from their efforts.
The need for reform emerged after the turn of this century when leaders in the DoD and VHA began to hold informal meetings under the title “From Healthcare to Health.” Over the course of those meetings, the participants recognized the failure of their health care systems to get at the underlying causes of chronic disease. In 2009, they secured the support of the Chairman of the Joint Chiefs of Staff to change overall military doctrine and guidance to a radically holistic approach called “Total Force Fitness,” which subsequently led to health and community innovations. An example of these redesign innovations was the Defense and Veterans’ Pain Management Task Force and Report and the resulting strategy that preceded the National Academy of Medicine’s report on pain in America.
Other innovations included the Healthy Base Initiative and the Performance Triad, the latter of which focuses on the importance of asking all patients about their sleep, nutrition, and physical activity. All services — Army, Navy, Air Force, Coast Guard, and Special Forces — continue to shift to whole-person models that seek to implement behavioral and complementary approaches. For example, >6000 providers have been trained in and routinely use Battlefield Acupuncture for pain.
The transformation currently underway in the VHA, which goes under the name “Whole Health,” is also an offshoot of that leadership dialogue from 20 years ago. In the Whole Health approach, the emphasis is to empower and equip people to take charge of their health and well-being. In this approach, trained peers help veterans explore their sense of mission and purpose, and well-being programs focus on skill-building and support for self-care. These elements, in addition to person-centered, holistic clinical care, create the Whole Health delivery system. VHA facilities are shifting from a system designed around points of clinical care (in which the primary focus is on disease management) to one that is based in a partnership across time (in which the primary focus is on whole health). Clinical encounters are essential but not sufficient. This health system is designed to focus not only on treatment, but also on self-empowerment, self-healing, and self-care.
This radical redesign is built on decades of VHA work enhancing its integrative approaches with innovations such as Patient-Aligned Care Teams, Primary Care Mental Health Integration, peer-to-peer support, group access to mental health services, and the increasing use of complementary medicine approaches. These changes laid the groundwork for the kind of radical redesign now underway in the VHA and that is needed in all national health care delivery systems.
In 2011, the VHA established an Office of Patient Centered Care and Cultural Transformation to further redefine health care delivery and to oversee this unique approach. Whole Health has begun rapid deployment across the entire VHA system, starting with 18 VHA medical centers in 2018 and with a planned expansion to all VHA medical centers by the end of 2022. System-wide implementation will require an estimated $556 million over 5 years.
When fully implemented, operating costs for this shift are projected to represent 1% of the VHA annual budget. This implementation will involve hiring almost 6,400 new staff, the majority for positions that did not previously exist in the VHA, including health coaches and peer health partners, nutritionists, acupuncturists, and yoga instructors. Whole Health is building access through group visits, peer-to-peer support, and the development of Personal Health Plans for every veteran — something everyone in the country could use. In addition, new payment codes have been created, allowing providers to capture and cover their time and efforts using relative value units (RVUs) and to track productivity.
Will Whole Health help to cure what ails health care? Current models suggest that it will. With improvement in health outcomes, there will be a reduction in the need for existing clinical and biomedical services. These models predict increased access and more proactive population health management. With the addition of these new Whole Health services, we project a 24.5% increase in access when fully deployed — without the addition of a single hospital bed or medical specialist. In addition, Whole Health exceeds cost neutrality and is conservatively estimated to return $2.19 for every dollar invested over 6 years.
These returns reflect net cost avoidance and are derived from reductions in the need and demand for existing clinical health services — exactly what the nation needs in order to reduce chronic disease crises and contain costs. The per capita savings or cost avoidance is modest, averaging $535 per veteran annually over the 6-year period. Cumulatively, however, this totals over $6.2 billion in cost avoidance. Given that the Whole Health approach will improve the health of veterans, many of whom are dealing with complex issues such as chronic pain, mental health conditions, and opioid use at a cost of about $1 per day per veteran, it is a financially sound, cost-effective change from the current health care paradigm.
Making a Change in Your Organization
Can you do this in your system, even if it is non-federal? The answer is yes. In the last 6 months, one of us (W.B.J.) has been traveling around the country and conducting a series of Grand Rounds on the topic of whole-person integrative health. The number-one question asked at these sessions is, “How can we do this in our practice?” The answer is that you can implement what is needed right now in your daily practice. We recommend the following steps:
- Ask different questions: The most important thing you can do is to change the daily dialogue with your patients. This step can be accomplished quickly with the proper preparation and tools. Two tools in particular can rapidly change the normal patient dialogue from the usual focus on pills and procedures to a discussion of what matters to the patient and the importance of self-care. These tools are the Personal Health Inventory (PHI) and the HOPE (Healing Oriented Practices and Environments) Note.
- The PHI has been adapted from the VHA and involves (1) a series of questions about what matters most in the patient’s life and (2) a rapid survey of six areas of life that impact healing. This step is followed by an integrative health visit involving the use of what we call a HOPE Note. The HOPE Note consists of a set of questions specifically geared to address a patient’s personal determinants of healing in a routine office setting. It first identifies what matters most to the patient in health — a hallmark of patient-centered care.
- Using the PHI and a HOPE Note, a provider can reframe the orientation from one of disease treatment to one emphasizing self-healing together with standard medical care. For patients in chronic pain, providers can use a new pain-assessment tool called the Defense and Veterans Pain Rating Scale, which focuses on both pain and suffering by measuring the impact of pain on function as well as on sleep, activity, stress, and mood. This step is then also followed by a HOPE Note. The figure below shows the four domains of health covered by the HOPE Note and the key questions it asks.
- Support social and behavior change: This dialog can serve as the basis for the development of a Personal Health Plan, a framework also adapted from VHA Whole Health. The Personal Health Plan is personalized to the patient’s needs, personality, readiness, resources, and circumstances, including social determinants such as transportation or food.
- The goal of the Personal Health Plan is to match the patient’s current circumstances and current readiness for efforts at healing with evidence-based ways to enhance and build on those efforts. The care team helps in this process with goal-setting, group support, shared decision-making, and tapping into community services and resources.
- Usually, in order to accomplish their goals, patients need some assistance (either from a health coach or in the form of group visits) as well as ways to measure and track their progress. This assistance is largely provided by members of the team, with a lead person for each patient; the lead does not have to be a physician. When behavior change is challenging for the patient because of a lack of food, transportation, or housing, methods for integrating health care with community services to address these other social determinants of health can be provided.
- Add non-drug treatments: Even if it is not possible to ask all of your patients about their personal determinants of health or to redesign your practice to optimize behavior change, adding a few simple treatments can still help to move patients in the direction of self-care and non-drug approaches.
- Examples of such treatments include ear acupuncture (delivered by providers in 5 minutes), stress-management technologies (imagery and breathing apps), feedback devices such as Alpha-Stim, and biofeedback such as HeartMath. Lifestyle medicine training and certification is becoming more available for providers. Educational approaches that involve building experiences and skill-building together, such as cooking conferences led by certified culinary medicine specialists, offer many patients a way to engage in activities that they already love. The video Understanding Pain helps to reset patients’ (and doctors’) understanding of how pain becomes a chronic, multifactorial, lifestyle-treated condition.
- Help get it paid for: Work with your business managers to find a way to pay for this new approach to health care. Gone are the days when physicians could focus on healing and ignore costs: They now need to find their best business model.
- Studies have repeatedly shown that primary care physicians do more than they bill for in practice and that different reimbursement models are needed for primary care than for specialty care. We need to reform payment in primary care to cover care for known health determinants and integrative health.
- There are ways to help do that now, including the annual wellness visit, mental health management codes, obesity and diabetes counseling, care coordination, group and shared visits, and other methods. Why not use these in a way that really matters to your patient and their healing? Hopefully, more and better options for paying for the care of whole people and all people will emerge soon.
The nation is indeed facing an opioid crisis and other chronic disease epidemics. But we are focusing on the symptoms, not the causes of these crises. We must radically re-envision what health care is in America. We need a health system that truly promotes healing by addressing patients’ underlying personal determinants of health. We need an integrative health model for all. Most of us went into medicine because we wanted to not only treat disease, but also to help people optimize their health and well-being. You don’t have to wait for health care policies that may not come. You can change your practice now to provide whole-person care.
The views expressed in this essay are those of the authors alone and do not reflect the official position of the Uniformed Services University of the Health Sciences, the U.S. Army, the Department of Defense, or the Veterans Health Administration.