Two middle-age professionals both suffered from the same symptoms: frequent urination, fatigue, and thirst. They both were intelligent, well-educated and had diabetes.
John Henry “kept his appointments, took his medications, changed his diet, started exercising and saw a diabetes educator.” He is thriving, enjoying his healthy new lifestyle according to Dr. Aldo Ciccotelli.
The second patient ignored the doctor’s advice. “She soon lost feeling in her legs, had one amputated, and went blind. Last year, she died” says Dr. Ciccotelli.
In the traditional fee-for-service payment models, physicians could write “non-compliant” in a patient’s medical record and hope they change. With the emergence of new alternative payment models, providers are being held accountable for overall patient costs and outcomes. They will need to improve addressing the leading cause of chronic conditions: behavior.
Chronic conditions such as heart disease, COPD, high blood pressure, diabetes, kidney failure and arthritis are typically caused by an accumulation of lifelong behaviors. Physical activity, nutrition, smoking, alcohol, substance abuse, stress, medication adherence, dental hygiene are some of the contributing behaviors. This has led to 31.5% of the people in the United States with multiple chronic conditions and 20% taking 5 or more medications. Many of these patients are so complex that 5% of American’s are consuming 50% of all of the healthcare costs.
While chronic conditions are sometimes attributed to genetics, toxic exposures or aging, most are the cumulative effect of our behaviors. Advising patients not to order the supersized value meal via the drive thru has clearly not been enough. A recent study in JAMA Internal Medicine found that 75 percent of men and 67 percent of women ages 25 and older are now overweight or obese.
The CDC reported 52% of adults over 18 years old did not meet recommendations for aerobic exercise or physical activity. 76% did not meet recommendations for muscle-strengthening physical activity. More than 42 million adults said they currently smoked cigarettes in 2012. The result is 47% of US adults have now developed at least one of the following major risk factors for heart disease or stroke: uncontrolled high blood pressure, or uncontrolled high LDL cholesterol.
If the United States achieves the announced goal of 50% of Medicare spending in 2018 through alternative payment models, behavior will need to be addressed. It is unlikely behavior can be addressed in a 15 minute physician visit. It will require a team approach with physicians, mental health professionals, nurses, social workers, health coaches, pharmacists, dietitians, health educators, caregivers, other family members and the patient. For the top 5% of patients in United States spending $40,876 per year, properly managed chronic conditions could save billions of dollars by keeping them out of hospitals.
Human behavior is so complicated, which may explain why patient treatments and education have not been enough. Behavior could be impacted by physical health (pain), mental health (depression) or functional conditions (shortness of breadth during activity). It could be influenced by social determinants such as the lack of a family care giver or children responsibilities. It could be driven by socioeconomic determinants from the lack of money for medicines or good nutrition or from a high deductible health insurance plan. It could be from environmental determinants such as lack of transportation or a safe home. It could be as a result of a care plan that is not coordinated, inappropriate or lacks care after business hours.
It the direct effect of patient behavior impacts the financial bottom line for providers in alternative payment models, we need new science and technology to help our physician develop new approaches. Healthcare professionals may need to be trained in motivational interviewing and more mental health professionals may need training in cognitive behavior therapy. They each will need to engage, listen to and understand patients to identify patient goals and what may change their behaviors. We must address behavior related to managing current conditions as well as future health risks:
- Current: Behavior in managing multiple chronic conditions
- Future: Behavior that will (in 1 to 30 years) lead to chronic conditions
It may be unfair to expect a healthcare provider to be accountable for the middle-age professional with diabetes that ignored her physician’s advice. Yet this new accountability may help improve physical activity, nutrition, reduction of adverse behaviors (alcohol, substance abuse), medication adherence and resilience with stress resulting in a greater impact on cost and quality of life than any potential innovative medical advancement. It could lead to behavior that enables more people to thrive and enjoy a better lifestyle like John Henry.