Care Redesign
Integrating Mental, Social, and Physical Health

Decreasing the Cost of Care by Avoiding Illness

Article · February 13, 2018

Lengthening Life Expectancy: Improving Health and Decreasing Health Care with the Blue Zones Project

Ben Franklin’s adage that “An ounce of prevention is worth a pound of cure” originally referred to fire safety but now is most applicable to our nation’s health. Keeping people healthy by encouraging wellness and healthy behaviors has many tangible benefits, including improved productivity, lower costs, increased happiness, and longer life expectancy.  Eighty percent of Americans consume very little health care and, according to the World Health Organization,  80% of illnesses are self-induced. As 5% of the population consumes 50% of the nation’s health care resources, successfully decreasing the rate of self-induced illness by making the healthy choice the easy choice will have a profoundly positive effect on health care and the overall economy.

NCH Healthcare System is a nonprofit integrated health care organization based in southwest Florida with the mission of helping our employees and community live longer, happier, healthier lives. As part of our effort to improve health and add life expectancy, NCH, along with 3.3 million people from 45 communities in 9 states, is currently leading a well-being initiative known as the Blue Zones Project. The goal of the Blue Zones Project is to improve health by preventing self-induced illness. Changing the focus of the health care industry from sickness to health (i.e., from a “repair shop mentality” to a “prevention program”) makes perfect sense if we wish to decrease the burden of illness for our nation.

NCH’s Change of Culture

Helping our entire community to become healthier started with ourselves. In 2009, NCH had a typical self-funded health insurance plan that emphasized coverage for sickness and lacked proactive wellness prevention. NCH’s previous mission had been similar to that of most national health care organizations — that is, to treat disease and collect reimbursement. During that time period, we had the sad experience of having three nurses with breast cancer whose commonality was that they were not getting appropriate mammography screening and therefore had bad outcomes.

Thus, we implemented a new plan. Among other changes, we followed the U.S. Preventive Services Task Force’s recommended screening guidelines for primary care practice and found that a surprising number of individuals had undiagnosed conditions, including breast and colon cancer, prediabetes, hypertension, and metabolic syndrome. Early discovery and prompt treatment changed prognoses for the better, with a 2% reduction in high-risk BMI since 2009. Although we initially noticed a spike in cost for the treatment of occult diseases, we subsequently noted a marked decrease in costs as patients were screened and treated earlier.

One of other the changes that we implemented during this period was a tobacco policy update in 2009 that named NCH as a smoke-free campus, followed by another update in 2011 mandating that NCH would no longer hire smokers. NCH continues to see a drop in its employee smoking rate, which fell from 2.8% in 2015 to 1.3% in 2016. In comparison, the smoking rate in Florida during the same time frame was 15.8%.

Ending the Repair Shop and Growing a Community’s Health and Well-Being

Motivated by our experience, we wanted to codify our changes and learn how to encourage these good behaviors within the community that we serve. As community care was not one of our core competencies, we searched for an affordable program that had demonstrated objective success on the basis of valid metrics. After evaluating various programs, we selected the Blue Zones Project in 2013. That same year, NCH became the sponsor of the very successful Blue Zones Project for Southwest Florida, and, in both 2015–2016 and 2016–17, our community was recognized as the healthiest and happiest community in the nation, adding 0.2 year of life expectancy during the latter period. This trend is unique in America: sadly, for the first time since 1963, the nation’s overall life expectancy has decreased for the past 2 years.

Blue Zones Certification

In 2017, NCH Healthcare System became the first Certified Blue Zones Worksite in Florida and the first health care system in the nation to earn such certification. Blue Zones Worksite Certification signifies that an employer has made demonstrable and measurable improvements in the well-being of its employee population. To validate the impact of those improvements, we reviewed several key metrics. These metrics were reviewed before Blue Zones Project work began and again after all standard requirements and best practices had been completed and validated. To reach certification, NCH Healthcare System had to maintain or improve scores in its Gallup-Sharecare Well-Being 5 aggregate score as well as in 17 specific metrics.

Employee Health and Wellness Metrics:

  • Sales of sugar-sweetened beverages
  • Number of workdays lost related to any and all types of injuries from fiscal year 2015 to 2016
  • BMI
  • Blood pressure
  • Blood lipids
  • HbA1c
  • Risk status of plan members
  • Nutrition score
  • Depression score
  • Physical activity score
  • Personal health assessment wellness score
  • Stress
  • Critical value report
  • Per-member per-month costs for inpatient, outpatient, professional, or pharmacy
  • Tobacco use
  • Total spend per member per month
  • Total spend per employee per month
Source: NCH Employee Health and Wellness Director

The rate of voluntary participation in our program in the last 5 years is well over 88%.  Following implementation of the Blue Zones Project, NCH saw a 2.8-point improvement in its Gallup-Sharecare Well-Being 5 employee survey metrics between 2015 and 2016. This scientific survey measures the five interrelated elements that have been shown to have the greatest impact on well-being: purpose, social, financial, community, and physical.

According to the national leaders in the Blue Zones Project, NCH has had among the highest annual gains in the overall Gallup-Sharecare Well-Being 5 index. Having positive energy, being encouraged to be healthy, feeling safe and secure, and using one’s strengths to do what one does best everyday are just some of the positive factors that result in happy, engaged, and satisfied colleagues and families. “In the last 7 days, you have worried about money,” was the only worsening metric, which we will be addressing with educational courses. Other very positive trends from 2015 to 2016 are highlighted below.

2015 and 2016 Gallup Sharecare Well-Being 5 Key Metrics Data for NCH Healthcare System Blue Zones Project Life Expectancy

  Click To Enlarge.

Financial Success

The costs for healthier people are lower, which makes intuitive sense. A 2012 study presented in the scientific journal Population Health Management connected a 1% improvement in population well-being with a 2.2% reduction in the likelihood of hospital admissions, a 1.7% reduction in the likelihood of ER visits, and a 1% reduction in the likelihood of incurring health care costs. Similarly positive findings have been reported by others.

With this in mind, we have instituted economic incentives as a way to encourage our employees to buy down our health plan’s high deductible of $1,500 by participating in various activities such as cooking classes, group exercise classes, walking/cooking teams, financial education programs, parenting classes, and other requested self-help experiences and classes. These incentives have demonstrated successful results: NCH has lowered deductibles by about $1 million per year in the aggregate for employees. An audit of NCH’s financials showed a 54% decrease in health care expenditures over 6 years, most recently resulting in $27 million savings from fiscal year 2013 to 2016. We have not raised health insurance premiums for colleagues for the past 4 years and, in fact, have lowered them for single parents who are already economically stressed.

Spreading an Epidemic of Health and Happiness

Even though our community enjoys the nation’s longest life expectancy or close to the longest life expectancy according to the Institute for Health Metrics and Evaluation, most of the nation is stuck in sickness and sadness as most health care providers continue to perpetuate a repair shop mentality focused on 5% of the population. NCH’s mission is to spread our success with America. For everyone to live longer, happier, and healthier lives, we will need to change our focus from treating sick patients to building healthy people. Moving upstream by preventing obesity, avoiding tobacco, decreasing loneliness, addressing mental illness, and stopping drug addiction early in the development of these noxious forces is much more effective than any later treatment. We are pleased to learn from others, share our best practices, and have others join in success for their communities.

New call for submissions ­to NEJM Catalyst

Now inviting longform articles

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

More From Care Redesign
Cleveland Clinic Time-to-Treatment Cancer Programming Overall Scorecard 2015-2017 Sample

Reducing Time-to-Treatment for Newly Diagnosed Cancer Patients

How Cleveland Clinic initiated a multidisciplinary program to reduce time-to-treatment and accomplish a 33% reduction.

Treatment Authorization Increases and Rapid Boost in New Mexico Medicaid Members Treated for Chronic HCV

A Collaborative Model to Expand Medicaid Treatment Coverage for Chronic Hepatitis C Virus

How managing the benefit coverage expansion for the treatment of HCV in New Mexico was successfully achieved after less than 2 years.

Data Analytics Improves Clinical Care

Care Redesign Survey: How Data and Analytics Improve Clinical Care

Data and analytics are a key means for clinicians, clinical leaders, and executives to transform health care delivery. Yet health care organizations have work to do in getting measures right and much to learn about effective use of data, according to our most recent Insights Council survey.

Nobody Wants a Waiting Room sketch

Nobody Wants a Waiting Room

A study in system change.

Orszag02_pullquote - In Defense of the Hospital Readmissions Reduction Program HRRP

In Defense of the Federal Hospital Readmissions Reduction Program

In the current debate about HRRP, the evidence tilts toward no effect or a beneficial one on mortality, says the former Director of the U.S. Office of Management and Budget.

odel for Complex Gynecologic Care Team at the Women's Health Institute

An Innovative Approach to Treating Complex Gynecologic Conditions

How the Women’s Health Institute at The University of Texas at Austin designed their clinic to provide comprehensive, team-based, and patient-centered care for women.

Massachusetts Community Health Centers Collaborative Teledermatology Process

A Teledermatology Initiative to Increase Access for Community Health Center Patients

A group of seven community health centers in Massachusetts collaborated to implement a teledermatology program that improved access to specialty care for patients with skin conditions and reduced overall dermatology spending.

Chang05_pullquote interpersonal medicine

Beyond Evidence-Based Medicine

Interpersonal medicine is not just about being nice — it’s about being effective.

Summary of Comprehensive Approach to Physician Behavior and Practice Change

Engaging Stakeholders to Produce Sustainable Change in Surgical Practice

How an initiative designed to improve patient outcomes and satisfaction while containing costs led to sustainable change in surgical practice and physician behavior.

Myths and Realities of Opioid Use Disorder Treatment.

Primary Care and the Opioid-Overdose Crisis — Buprenorphine Myths and Realities

There is a realistic, scalable solution for reaching the millions of Americans with opioid use disorder: mobilizing the primary care physician (PCP) workforce to offer office-based addiction treatment with buprenorphine, as other countries have done.

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

Topics

Coordinated Care

131 Articles

Reducing Time-to-Treatment for Newly Diagnosed Cancer…

How Cleveland Clinic initiated a multidisciplinary program to reduce time-to-treatment and accomplish a 33% reduction.

Care Integration

67 Articles

Integrated Care Lessons from Across the…

Just throwing things together doesn’t make for integrated care. If we spent more time looking…

Design Thinking

15 Articles

Nobody Wants a Waiting Room

A study in system change.

Insights Council

Have a voice. Join other health care leaders effecting change, shaping tomorrow.

Apply Now