Fragmented. Inefficient. Episodic. These terms are frequently used to describe the U.S. health care system, which was not designed to handle the fact that three out of four Americans aged 65 and older are living with multiple chronic conditions. If we want this system to effectively handle the chronic disease epidemic, we must evolve our clinical mind-set and fee-for-service reimbursement structure from the episode-driven “one-and-done” system to a consumer-centered, integrated care approach supported by value-based reimbursement. And doing so requires us first to remember how we were trained.
For many doctors — myself included — who started practicing medicine a few decades ago, our education was influenced by this fee-for-service methodology that emphasized volume over value. Fee-for-service encouraged us to take a linear, simple approach: make the clinical diagnosis, write the script, and give some basic instructions. We believed we had done our part as physicians because we identified the problem and “fixed” the immediate issue.
Yet what we failed to realize is that our work should not have stopped with “take two and call me in the morning.” That’s where our real work should have begun.
Today’s Population Presents Complex Challenges
Patients today receive clinical care through this extremely fragmented and complicated health care delivery system that’s neither consumer centric nor easy to navigate. The development of employer-sponsored health care insurance benefits to counter wage-control regulations during World War II was aimed at a young, working population with episodic injuries or infrequent infections, not seniors with multiple, complex, and chronic conditions.
As the U.S. population has aged, we, as a society, have spent the past 35-plus years developing unhealthy habits, from our sedentary lifestyles to our massive consumption of sugar and processed foods, all of which have combined to fuel a higher prevalence of chronic conditions such as diabetes, coronary artery disease, congestive heart failure, and chronic obstructive pulmonary disease.
The collective increase in disease burden during this time brings us to the point where 86% of our country’s health care spend is for patients with one or more chronic conditions. Most important, our system is not equipped to deliver the holistic approach required to manage complex chronic conditions because many of us are still mired in the fee-for-service approach. And nowhere is this more evident than diabetes, a disease that’s primarily driven by the adoption of an unhealthy lifestyle over decades.
Today, 10 million Americans aged 65 or older have been diagnosed with diabetes. Being diagnosed with diabetes can be a very unsettling experience. And I can tell you, from discussing with physicians who treat our Humana members living with diabetes, that adjusting to the disease is daunting.
From necessary lifestyle changes, to new medications, to tracking blood sugar, a diabetes diagnosis presents a tremendous amount of new information for the patient to process. Developing a detailed understanding is essential for preventing diabetic complications such as eyesight problems, kidney diseases, a need for dialysis, and peripheral neuropathy. When it comes to diabetes and other chronic conditions, the time has come to evolve to a long-term, patient-centered and outcomes-based care model.
Helping older adults who are living with chronic conditions to improve their health requires us to recognize that many of these chronic conditions are the result of decades of unhealthy behavior. This leads to the realization that instead of plugging holes in a leaky dam, our approach must be built around holistic and preventive care, fueled by the embrace of value-based care. That will help stem the rising tide of chronic disease.
The emergence of big data creates opportunities for value-based care. Health plans can sort hundreds of millions of claims to identify opportunities for physicians to find a moment of influence in the life of a person living with multiple chronic conditions. The ability to prioritize patients based on immediate need or risk for future event will be crucial in controlling health care expenditures and improving quality of life.
For example, look at people participating in Medicare Advantage who are aged 65 or older with prediabetes. If these members increase physical activity and lose weight, they can avoid diabetes and the associated medications and complications. The primary benefit of value-based care is that it’s focused on improving health outcomes, as opposed to just providing episodic engagement, and it reimburses for results, not services. The successful health companies of the future will identify and bring resources to the physician, integrating data analytics and compensation for outcomes, so they can holistically treat people over 65 living with chronic conditions.
Health Is Sustained Outside the Doctor’s Office
Fundamentally, the value-based care model can improve a person’s health because it supports a holistic approach that addresses the individual’s lifestyle. That’s essential for the hundreds of days a year that a person over the age of 65 is not in a doctor’s office.
We’ve proven that arming people with prescriptions and referrals doesn’t necessarily create better health. The U.S. spends more on health care, including pharmaceuticals, than 35 countries in the Organization for Economic Cooperation and Development, yet we’re the most obese country, and our life expectancy ranks 27th.
Successful value-based care goes beyond the physician’s office to address the social determinants that can negatively impact an individual’s life. For example, more than 5.4 million seniors are food insecure, and more than 33% of Americans over the age of 65 live alone, which can lead to social isolation and feelings of loneliness.
Addressing these social determinants recognizes that health is local, it happens outside the doctor’s purview, and no single entity can do this alone. Grocery stores, local government agencies, food banks, and other local community organizations must band together to impact not just physical health, but mental health, where health happens. For example, as part of Humana’s Bold Goal effort to improve the health of the communities we serve, we joined the San Antonio Health Advisory Board. In conjunction with H-E-B Grocery, local physicians, and the YMCA, we’re focused on helping San Antonians who are living with diabetes improve their understanding of nutrition.
The path to value must move beyond the transaction-driven, fee-for-service approach that has been the foundation of the U.S. health care system for decades. Health care professionals must spend time educating and engaging their patients, and must be incentivized to do so in a value-based agreement. A value-based approach that builds a strong relationship between the physician and the patient and recognizes that health is local and happens outside the doctor’s office is the best approach to solving the chronic-condition epidemic of the 21st century. By embracing the fact that no one entity can do this alone, we can help build a model of care that creates a healthier country by moving away, once and for all, from the episodic “one-and-done” treatment.