Care Redesign
Talk
Patients as Pro-sumers, Not Consumers (11:57)

It’s been about 30 years since the birth of the Healthy Cities and Healthy Communities movement, which is predicated on the belief that health and well-being are what drive vital communities and strong economies. And to improve community health for all, we need to invest in more than just access to high-quality medical care. “If we’re going to have a significant population-level health impact, it’s not just going to be better health care policy, nor better public health policy, but healthier public policies and private policies,” explains Tyler Norris, Chief Executive Officer for Well Being Trust.

What creates health? Living-wage jobs, education, stable housing, access to affordable, healthy food, and mobility to travel to work, school, and worship. Tied to these are the factors of well-being, as identified by the Greater Good Science Center: meaning and purpose, a sense of belonging, awe and wonder, and generosity. When things go awry, people with these factors turn out better. “Health is a byproduct of lives and communities working, not a medical care intervention, as important as that is.”

“What is novel in all this isn’t this information; it’s that the medical and health care sector has known this for decades and yet we have done incredibly little as a sector despite a $3 trillion spend within our control, the fifth-leading economy by itself in the world, to actually change population-level health outcomes,” says Norris. A growing body of research continues to point at the morbidity and mortality gap of Americans compared to other countries. We know this has to do, in part, with the lack of health equity, but even highly advantaged Americans are worse off than their counterparts in other countries. “We are not delivering a return on our health care dollar.”

Norris describes Step 13, a program for homeless substance abusers in Denver, Colorado, which he helped found 35 years ago and which is still in operation today. “We provided something very simple: stable housing. A home, a place to be, that you could save, get a good night’s rest, park your stuff, and wake up.” The second part of the program is readiness for work, making sure everyone is sober the night before and able to keep a job. “The conversation wasn’t, ‘What’s the matter with you?’ It’s, ‘What matters to you?’ And a recognition that behavior change and environmental change are key.”

Across the country, thousands of initiatives have begun to embrace a whole-person, whole-system approach to health. But these initiatives take time. When Norris joined Kaiser Permanente a few years ago, they thought that applying the right incentives of that integrated care delivery system to billion-dollar 1, 2, and 3-year behavior change initiatives in schools and workplaces would make a big impact. The result? It didn’t.

“We have not delivered sustained behavior change in general because we have had inadequate dose. In other words, [the] reach, intensity, and duration of our interventions, of our efforts to be able to create a population-level health impact, have not been adding up. Not long enough, not strong enough,” says Norris.

“It becomes an ethical matter before us as a health care sector when we know that care and coverage for everyone is essential, and clinical-community integration between high-quality care and the community assets that we know are important to health is essential, and we know that we need to meet people’s social and economic needs — they’re basic human needs — we know that our health care organizations need to behave like anchor institutions and buy local and hire local and use their investment portfolios locally to drive the local economy,” argues Norris.

Well Being Trust released a report in November 2017 called Pain in the Nation, which calculates that last decade, about one million Americans, or 100,000 a year, died of deaths of despair — alcohol abuse, substance abuse, and suicide. At current rates, the Centers for Disease Control and Prevention estimates that the next decade will move us from 1 million a year to 1.6 million deaths of despair. In some communities, particularly rural, Well Being Trust expects those rates to almost double.

We need better integration of mental and behavioral health into primary, emergency, and acute care, but that’s just “table stakes,” according to Norris. We also need to address adverse child and adverse community experiences and create healthier public policies that invest in the social determinants of health.

With the health care sector commanding 20% of the U.S. economy, we need to take on a leadership role, Norris argues, working with communities on organizational practice changes, public policy changes, and private-sector impact investments that will ensure intergenerational well-being.

We have two systems: the system of care, and the system of health. One way to help us think about them differently is to stop talking about people as consumers. Consuming medical services is not the goal. “People are pro-sumers,” says Norris. “People drive their health by what they do themselves and how they show up for each other. Health care needs to be buying health from communities that are the producers of health. It creates a very different notion about what the marketplace needs to be.”

From the NEJM Catalyst event Expanding the Bounds of Care Delivery: Integrating Mental, Social, and Physical Health, held at Vanderbilt University Medical Center, January 25, 2018.

More From Care Redesign
Charlotte Yeh head shot - hearing aids hearing loss

“You’re Old Without Hearing Aids”— Addressing the Silent Epidemic of Hearing Loss

Hearing loss isn’t a normal consequence of aging. But it is associated with a higher risk of dementia, depression, and falls. The Chief Medical Officer for AARP Services talks about combating this huge but silent epidemic that impacts all ages.

Dentzer01_pullquote - Stone-Age Policies Stifle Modern Virtual Care Solutions

Stone-Age Policies Stifle Modern Solutions

Health care leaders must advocate for regulatory and reimbursement changes to unlock the potential of innovative technology and care team approaches to Parkinson’s and other suitable conditions.

Idiopathic Pulmonary Fibrosis IPF Multidisciplinary Collaborative Care Model

From Consulting to Caring: Care Redesign in Idiopathic Pulmonary Fibrosis

A multidisciplinary collaborative model to address the palliative care needs of patients with idiopathic pulmonary fibrosis resulted in improved end-of-life care and decreased hospital deaths.

Impact of PCSP on Patient Satisfaction at Providence Heart Clinic

Transforming Specialty Practice in Pursuit of Value-Based Care: Results from an Integrated Cardiology Practice

Despite significant primary care reform around patient-centered medical home models, specialty care remains fragmented, with poor communication between primary care and specialists. How should specialty practices be reformed to deliver more coordinated, patient-centered care?

Michael Bennick Yale New Haven Hospital Medical Director of the Patient Experience - Yale Living History Project

The Living History Project: Open-Ended Patient Interviews Create a Therapeutic Bridge

A program at Yale has students conduct open-ended interviews with patients about their lives, their hopes, their values, and what they most want their medical team to know — creating the opportunity for human connection and a better care experience.

Fisher02_pullquote hypertension guidelines

Hypertension Guidelines: Achieving 90% Success

Focused and innovative health systems are managing to control blood pressure for 9 in 10 patients, which is well above the national average of 50% to 60%.

Health Care Organizations Are Moderately Effective in Using Data

Survey Snapshot: Using Data for Change

NEJM Catalyst Insights Council members discuss how data and analytics are being used at their organizations, both now and with the future in mind.

Percentage of U.S. Adult Hemodialysis Patients Achieving Dialysis Adequacy, 2013-2016. Data will be released in early 2019.

Innovation in Dialysis: Continuous Improvement and Implementation

The U.S. dialysis sector has been criticized for its lack of innovation, but this criticism disregards the kidney community’s success in creating — and continuously improving on — dialysis as a safe, globally scaled, quality-oriented outpatient therapy.

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.

Connect

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

Learn More »

Topics

Mental Health

29 Articles

Stay in Your Lane? Clinicians vs.…

Should physicians stay in their clinical lanes when it comes to behavior change and social…

Opioids Epidemic

25 Articles

New Evidence on Stemming Low-Value Prescribing

New research suggests that deploying strong and surprising messages could help to address overprescribing of…

Coordinated Care

134 Articles

Disrupting the Payment Model

We should modernize our payment mechanisms to reflect the reality of our digitally enabled lives.

Insights Council

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

Apply Now