Mary is admitted to the hospital with symptoms caused by high blood sugar. She has type 2 diabetes and is overweight. The hospital staff restores her fluids and insulin to proper levels. Did her health conditions cause her hospital stay?
Are health conditions the symptoms or cause?
We treat health conditions with counseling, education, medications, therapy and other medical treatments such as surgery. The health conditions include physical (high blood pressure, high cholesterol, coronary artery disease), mental (depression, anxiety) and functional conditions (walking, hearing, dementia). While some of these health conditions are a result of natural causes, many may be attributed to individual behavior.
If Mary doesn’t change her behaviors such as diet, physician activity and managing her insulin, she will negate the good work of the providers in the hospital. Did her behaviors cause her health conditions and thus her hospital stay?
Are behaviors the symptoms or cause?
To improve Mary’s health conditions, she receives obesity counseling, diabetes self-management education and nutrition therapy to address these behaviors:
- Physical Activity
- Medication adherence
- Treatment compliance
- Adverse behaviors (including tobacco, alcohol, substance abuse)
We may believe Mary’s behaviors were the cause and if she doesn’t improve, it is not the results of her clinical care.
We are all familiar with the numerous studies that describe how behaviors cause poor health conditions. The correlation is so strong that the Center For Disease Control (CDC) developed a Health Risk Assessments (HRA) for physicians to capture patient behavior information to improve the treatment of patients. The CDC HRA has 33 questions with 18 related to health conditions and 15 related to patient behaviors. Medicare recommends this CDC HRA (or similar) be used by physicians as part of patient’s Annual Wellness Visits.
A study by the University of Wisconsin funded by the Robert Wood Johnson Foundation shows that the CDC HRA may be ignoring 50% of the determinants of health outcomes. A Health Affairs review of several studies shows that clinical care and behaviors represents only 50-60% of health outcomes. The three determinants of health missing are social, economic and environment. Did these determinants of health drive Mary’s behaviors, resulting in her health conditions causing her hospital stay?
Are social, economic & environment determinants the cause?
Mary may need to care for her homebound spouse or lacks support if she needs help (social), or she can’t afford medicine or nutritional food (economic) or she lacks transportation and lives in an unsafe neighborhood (environment).
Mary’s clinical care to treat health conditions can be negated by her behaviors. Yet in some cases, the nutrition therapy, diabetes self-management education and weight loss counseling will be ineffective until the underlying social, economic and environment determinants are addressed. Mary’s low-income and food insecurity makes her vulnerable to being overweight and obese with:
- Limited resources and lack of access to healthy, affordable foods
- Fewer opportunities for physical activity
- Cycles of food deprivation and overeating
- High levels of stress
- Greater exposure to marketing of obesity-promoting products
- Limited access to health care
The good news is that new Accountable Care (see Will Accountable Care Be A Game Changer?) incentives for providers have resulted in them trying to understand more than Mary’s health conditions and behaviors. For Accountable Care providers to be successful, they need to find and address the cause. Innovative Accountable Care providers have improved patient outcomes and generated significant savings by addressing each of the determinants of health. They offer Respite Care to home-bound spouses like Mary’s husband so that Mary can take care of her health conditions and take a break. They help patients like Mary address the cost of managing multiple chronic conditions. They shift them to generic medicines, get them Medicaid coverage and connect them to prescription assistance programs offered by pharmaceutical companies. They connect patients (and follow-up) with community social services such as Meals on Wheels, transportation services and help finding jobs and housing. They assign care managers to people like Mary to help her navigate the clinical care and social services.
Are still looking for the answer? Are We Treating Symptoms While Ignoring The Cause? The answer is likely sometimes. To begin to understand how often this happens, we’ll have to get to know patients better. Providers in these new Accountable Care reimbursement models will begin doing more comprehensive patient assessments and will connect patients to the services they need. Then we will begin to get a better understanding whether we are treating the cause or the symptom.