Monday, February 25, 2008

The Whole-Person Integrated-Care (WPIC) Wellness Solution: Part 2


Last week, in part 1 if the WPIC solution, I began defining a new type of wellness program based on a whole-person integrated-care (WPIC) model, which takes a whole person (mind, body, spirit and environment) view of health, and which coordinates sick-care with well-care across the entire healthcare continuum. I included an introductory discussion of the value proposition of such a wellness program, as well as its goals and methods. I also mentioned that there are (at least) four types of people, with different character traits, who require different approaches to wellness due their different thoughts, emotions, behaviors, knowledge & understanding, and coping strategies. In this post and future ones, I examine these differences.

Definitions

Since I'm presenting additional terms, let me take a moment to define them:
  • Thoughts refer to a person's attitudes, beliefs, perceptions, assumptions, reasoning, expectations, memories, "self-talk," and other mental process (i.e., one's cognitions).
  • Emotions refer to a person's feelings and moods (i.e., one's affect).
  • Behaviors are what a person does (i.e., one's actions).
  • Knowledge & Understanding are related terms, which I discuss in some detail at this link. Briefly, knowledge refers to information someone knows about important things, such as relevant people, things, places, times, reasons, rules, and methods. Understanding, on the other hand, is being able to apply that knowledge when doing such things as:
    • Explaining, interpreting, discovering, and gaining insights into the nature of things
    • Noticing contradictions/inconsistencies
    • Using logic and evidence to support decisions, make accurate predictions, and judging/evaluating things rationally and sensibly
    • Creating and imagining
    • Focusing one's attention on what's important (i.e., have good situational awareness), being prepared to act, and justifying one's beliefs/hypotheses.
  • Coping strategies are adaptive or maladaptive ways of thinking, feeling, and acting when trying to deal with problematic situations. Following are ten common coping strategies people tend to use. The first five are positive strategies because they help a person solve a problem or learn to accept it with minimal distress. The latter five are negative strategies because they fail to resolve one's problems or enable healthy acceptance.
    1. Logical Analysis is a positive approach strategy in which a person tries to understand what caused the problem and think of different ways to handle it.
    2. Social Support is another positive approach strategy in which a person explains the problem to someone or asking others for advice or help. This can help determine what, if anything, can be done to solve it.
    3. Problem Solving is another positive approach strategy in which, after logical analysis, a person determines that a problem can probably be solved and what has to be done to solve it. A specific plan of action is then created and implemented, and the person learns from the results and modifies the plan accordingly.
    4. Positive Reappraisal is another positive approach strategy in which a person views a problem as helping him/her change or grow in a good way, find new faith, or learn valuable lessons. This strategy can be used whether or not a problem can be solved.
    5. Rational Acceptance is a positive non-action strategy in which a person accepts—without undue emotional distress and self-defeating behaviors—that nothing can be done to solve a problem, so s/he does nothing except adopt a rational way of thinking about it, which foster psychologically healthy acceptance.
    6. Behavioral Distraction is a negative
      avoidance strategy in which a person tries to feel better emotionally by doing enjoyable or interesting things, rather than trying to solve the problem or to cope with it through positive reappraisal and rational acceptance. While it may help reduce one's upset temporarily, this strategy is negative because it will never solve the problem and does nothing to help one cope with it long-term. This strategy wastes precise time that could be better spent trying to understand and deal constructively with the problem, rather than letting things get worse.
    7. Cognitive Avoidance is another negative
      avoidance strategy in which a person simply acts as if there is no problem, or tries not to think about the problem. As with behavioral distraction, the strategy may help reduce one's upset temporarily, but it will never solve the problem and does nothing to help one cope with it long-term, as well as wasting precise time.
    8. Emotional Discharge is another negative
      avoidance strategy in which a person expresses negative emotions by yelling or crying, taking it out on others, or avoiding certain people or situations. As with the previous two strategies, this one may help reduce one's upset temporarily, but it will never solve the problem and does nothing to help one cope with it long-term. In addition, this strategy may annoy other people and push them away, as well as wasting precise time.
    9. Wishful Thinking is another negative
      avoidance strategy in which a person simply hopes a miracle will somehow make things better, or that his/her wishes or prayers would somehow be answered. As with the other avoidance strategies, this one may help reduce one's upset temporarily, but it will never solve the problem and does nothing to help one cope with it long-term, as well as wasting precise time.
    10. Resignation is a negative non-action strategy in which a person determines that nothing can be done, so s/he does nothing, while remaining in an emotionally distressed state of anxiety, depression (hopelessness and helpless), and/or anger.

Describing the Characteristics of Four Types of Individuals

As I discussed in my previous post, wellness programs should address the particular needs of are (at least) four types of people: Activists, Wannabes, Inactives and Ignorers/Deniers. In this post, I present the Activists. They are the ones most motivated to deal actively and eagerly with health & wellbeing issues, and are most likely to take advantage of wellness programs.

Activists

Activists' attitudes about managing their physical and mental health can be summed up in thoughts such as: "I believe I can do whatever must be done, and I'm willing to do it!" Such thought reflect a joy of living and a willingness to take constructive action to reduce any fear, uncertainty and doubt through problem-solving (if their health problems can be resolved) or rational acceptance (if the problems can't be fixed). In terms of their character traits, Activists tend to be confident, motivated, aware, rational, and assertive. They seek knowledge about their physical and mental health status and risks, from a whole-person integrated-care perspective, to help them make wise decisions. And they try to understand how to avoid health problems, self-manage chronic conditions, and treat existing problems in the safest and most cost-effective way, and use their knowledge to live healthy lifestyles. Activists, in other words, are rational people who deal with their physical and mental health problems (existing conditions and risks) by using positive, proactive coping strategies, such as:
  • Trying to understand what caused the problems and thinking of different ways to handle it
  • Talking to someone about what they're are going through and asking certain people for advice or help.
  • Determining what has to be done to solve a problem and then using a specific plan of action
  • Viewing a problem as something that helps them change or grow in a good way, find new faith, or learn valuable lessons
  • Rationally accepting when a problem cannot be solved to minimize their emotional distress.
When dealing with an existing health problem, therefore, Activists actively seek knowledge and guidance to understand the pros & cons of different treatment options. And when dealing with their health risks, they seek to understand the pros & cons of different prevention options. If Activists have money problems—which prevent them from carrying out their wellness plan of care (e.g., buying more healthy foods, a gym membership, prescribed medications, diagnostic tests, etc.)—they strive to find a way to afford what they need, including political action. If they have family and other demands that consume their time and thus make lifestyle change difficult, they find ways to make time available. And if they have physical handicaps or cognitive impairments that interfere, they will explore alternative approaches to health improvement that accommodates these limitations. The more a person's character traits resemble an Activist, the more likely s/he is to gain from a wellness program and improve his/her health and wellbeing. In my next post, I examine the Wannabes and Inactives.

Monday, February 18, 2008

The Whole-Person Integrated-Care (WPIC) Wellness Solution: Part 1

In the next few posts, I'm going to re-focus on the Patient-Centered Life-Cycle Value Chain series [click here for the first post in the series]. Specifically, I'll discuss how to bring high value to the healthcare consumer through a new type of wellness program we're developing, which offers a whole-person integrated-care solution. I welcome your questions and comments.


What is Whole-Person Integrated Care?

As the name implies, whole-person integrated-care has two related parts: Whole-Person care and Integrated care.

Whole-Person Perspective

Whole-person perspective focuses on improving a person's health and wellbeing by addressing one's physical health (body), mental/psychological health (mind), and the mind-body connection ("holistic" health). In other words, it views an individual as a whole entity, whose body and mind are interconnected.




The whole-person perspective is critical for preventing and treating health problems in a cost-effective manner because it helps lower overall healthcare expenditures, improve care outcomes, and enhance wellbeing since many physical disorders and psychological problems are related; for example:

  • Disturbances of physiology that are related in some way to situational/psychological conditions, but without actual permanent end-organ damage, such as migraines, functional bowel disease and types of chronic pain

  • Disturbances where actual physiological and psychological pathologies are evident, such as hypertension, peptic-ulcer disease, hyperthyroidism, asthma and chronic skin disorders

  • Serious physiological disorders that tend to appear or flare up with significant life changes and stress, such as disturbances in autoimmunity

  • Mental health problems caused by biomedical factors such as delirium, dementia, organic hallucinosis, and organic delusional, mood, personality and anxiety syndromes

  • Illnesses such as coronary heart disease and cancer that may be helped with adjunctive treatments which promote changes in patients' behaviors (e.g., improve eating, sleeping, and exercise habits) and psychological states (e.g., reducing resentful anger and stress-proneness)

  • Emotional difficulties often associated with medical illnesses and procedures such as AIDS, bone marrow transplants, severe burns, heart or liver transplants, end-stage kidney disease entailing dialysis, hip fracture, open-heart surgery, and plastic surgery

  • Maladaptive behaviors and attitudes that have obvious deleterious health effects on oneself and/or others, such as substance and alcohol abuse, anorexia, bulimia, obesity, smoking, unsafe sex, recklessness, suicidal tendencies, and abusive behavior toward others.

A whole-person approach is important, therefore, because:

  • Up to half of all primary care physicians' cases are either accompanied by, or constitute, psychological (emotional and behavioral) problems.[1]

  • Psychological problems cause, exacerbate, or impede healing of many physical illnesses.[2]

  • Psychological treatment (of emotional and behavioral problems) helps remedy many physical ailments and thus reduces overall medical costs.

  • People who are healthy both physically and psychologically have greater peace of mind, are more focused and energized, are more productive, make fewer mistakes, have fewer accidents, and are more satisfied with their lives and work.

See this link for more about whole-person (biopsychosocial) care.

Integrated-Care Model

Integrated care brings together well-care and sick-care:

  • Well-care focuses on preventing physical, mental and mind-body health problems from occurring or worsening—as well as achieving a sense of emotional well-being and peace-of-mind—through healthy living, wise decision-making, responsible action to deal with distressing life situations, and using effectively coping strategies.

  • Sick-care focuses on treating acute, sub-acute and chronic health problems (physical, mental and mind-body) through traditional allopathic procedures and/or complementary and alternative methods.


Thus, Instead of viewing sick-care and well-care as two separate avenues in the road to health, this integrated approach involves a new kind of coordination and collaboration between (a) medical and related sick-care practitioners focused on the diagnosis and treatment of health problems and (b) well-care practitioners focused on prevention, recovery and well-being, as well as peak performance.

By integrating sick-care & well-care in this way, overall healthcare costs would be reduced, health outcomes would be improved, and people's quality of life and productivity would be increased. These desirable results would be achieved by coordinating efforts to prevent and treat illness and dysfunction. This integrated approach is a vital to solving the current crisis and bringing greater value to the consumer.

See this link for more about well-care/sick-care integration.

All Together Now: Whole-Person Integrated Care

This whole-person integrated care strategy offers a sensible way to help people:

  • Remain healthier longer through better self-care/self-maintenance

  • Recover from illness and dysfunction more quickly and avoid complications of chronic disease through greater compliance with plans of care

  • Gain greater peace of mind by removing or coping with stress more effectively

  • Save money through reduced sick-care expenditures

  • Be more productive and focused through reduced stress and emotional distraction.

Employers also benefit when their employees are healthier, happier and more focused. These benefits include increased employee productivity and employment retention, as well as lowered healthcare expenditures, reduced sick time, and fewer workplace accidents and errors.

It is therefore a crucial component for solving the healthcare crisis by reducing overall expenditures.

Implementing this strategy requires a new kind of wellness program that:

  • Performs a comprehensive health and wellbeing assessment and generates a whole-person health profile that includes a full mind-body work-up.

  • Uses the health profile to create individualized wellness plan of care focused on improving one's health, happiness and achievement through lifestyle changes, wise decision making, and development of effective coping skills.

  • Provides ongoing guidance and support from networks of wellness coaches/counselors who use the health profiles and collaborative communication tools to increase the person's knowledge, understanding and motivation.

  • Supplies essential information that enables sick-care practitioners to understand more fully:

    • How to handle the interplay between a person's physical problems, mind-body health needs, emotional drivers & obstacles, and psychological boosts & blocks
    • Complementary & alternative intervention options to traditional medical treatments.

What is the Goal of Whole-Person Integrated Care?

The goal of such a program is to improve people's health and wellbeing by helping them reduce their stress & distress levels (i.e., increasing peace of mind) and change their maladaptive behaviors (i.e., making lifestyle/ compliance changes) via a counseling & education process that deals with the interactions between one's:

  • Cognitions (beliefs, attitudes, perceptions, thoughts)
  • Emotions
  • Behaviors
  • Level of Knowledge & Understanding
  • Coping strategies.

How is it Done?

The Whole-Person Integrated Care process is also personalized; it is tailored to the needs of different types of individuals with drastically different characteristics:

  • Activists are motivated to deal with health & wellbeing issues actively

  • Wannabes talk about improving their health & wellbeing, but never seem to act on it, or do so half-heartedly

  • Inactives think about their health on occasion, but do not believe they should or can do anything to improve their health & wellbeing

  • Ignorers/Deniers are not health conscious because they don't accept that they have health problems or risk factors, or they just don't care.

In the next post in this series [at this link], I examine the character qualities of these four groups, i.e., the cognitions, emotions, behaviors, knowledge & understanding, and coping strategies that promote or impede one's willingness and ability to adhere to healthy living strategies.

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[1] Research shows that a significant percentage of all primary care billing is for stress-induced or behaviorally-related disorders, with a minimum of about 20 percent of patients in a primary-care practice suffer specifically from anxiety or depression. And if one assumes undiagnosed complaints are related to underlying anxiety disorders or depression, the proportion of patients seeking treatment for psychological reasons jumps to 40 to 50 percent. Depression alone, which is the fourth most disabling illness worldwide, has been estimated to cost the United States $83 billion in 2000. Of this amount, $57 billion is attributed to such things as depression-related absenteeism, reduced productivity at work, and the value of lifetime earnings lost due to suicide-related deaths, leaving $26 billion in direct out-of-pocket expenses for healthcare treatment costs.

References:
Goleman, D. (December 14, 1994). Push is on for Family Doctors to Spot Psychiatric Problems. New York Times. Available here
AAFP white paper on the provision of mental health care services by family physicians - American Academy of Family Physicians Commission on Health Care Services. American Family Physician. (May 1, 1995). Available at http://www.findarticles.com/p/articles/mi_m3225/is_n6_v51/ai_16874729
NIMH
Sequenced Treatment Alternatives to Relieve Depression (STAR*D) Study at http://www.nimh.nih.gov/healthinformation/stard_qa_general.cfm

[2] A growing body of research in mind-body medicine not only demonstrates an undeniable interplay between biomedical, psychological, and social factors, but points specifically to a causal link between mental/emotional problems and many physical illnesses. The field of psychoneuroimmunology is demonstrating that stressful life events can adversely affect the immune system. Other researchers are identifying “coronary-prone behaviors” such as feelings of insecurity and a perceived lack of self-efficacy. Still others are finding a connection between optimism, coping skills, and physical health. Potentially high-cost, medically dangerous behaviors — such as excessive consumption of alcohol, use of illicit drugs, violence, and unsafe sex — also find their roots in behavioral disorders. For example, researchers found that depression is a precursor to heart disease, with certain depressed patients being 50 percent more likely to develop or die from heart disease than those without such symptoms, even though they had no prior history of heart disease. Depression, therefore, likely affects not only the mind but also physical health by being linked to increased blood pressure and abnormal heart rhythms, as well as chronically elevated stress hormone levels, which can increase the heart's workload.

References:
Borysenko, J. (1988). Minding the Body, Mending the Mind. New York: Bantam
Cousins, N. (1990). Head First: The Biology of Hope and the Healing Power of the Human Spirit. New York: Viking Penguin
Dienstfrey, H. (1991). Where the Mind Meets the Body. New York: Harper Collins
Gordon, J. S. & Bresler, D. (Eds.). (1984). Mind, Body and Health: Toward an Integral Medicine. New York: Human Sciences Press
Gordon, J. S. (1990). Stress Management. New York: Chelsa House
Ornstein, R., & Sobel, D. (1988). The Healing Brain. New York: Simon & Schuster
Ornstein, R., & Sobel, D. (1990). Healthy Pleasures. Reading, Mass: Addison-Wesley
Kroenke, K. (2002). Psychological medicine: Integrating psychological care into general medical practice. BMJ;324:1536-1537. Available at http://bmj.bmjjournals.com/cgi/content/full/324/7353/1536
Huggins, C.E. (March 1, 2006). Depression, heart disease often go hand in hand. Reuters Health. Available at http://go.reuters.com/newsArticle.jhtml?type=healthNews&storyID=11380752&src=rss/healthNews

Sunday, February 10, 2008

U.S. Healthcare’s Perverse Commercial Incentives

An interesting article recently published by Robert Kuttner in the New England Journal of Medicine explains how our relentlessly increasing healthcare costs are due to more than these usual culprits: Our aging population, expensive new technologies, poor diet and lack of exercise, the tendency for the supply of supply providers, medical devices, and new treatments to generate its own demand, excessive litigation and defensive medicine, and tax-favored insurance coverage.
The other culprit, he explains, is America's "pervasive commercialization," which is dominated by:

... for-profit insurance and pharmaceutical companies, a new wave of investor-owned specialty hospitals, and profit-maximizing behavior even by nonprofit players raise costs and distort resource allocation ... [as] private bureaucracies siphon off $400 billion to $500 billion of the $2.1 trillion spent [due to] perverse incentives produced by commercial dominance of the system.
Mr. Kuttner isn't the only one blaming our economic system for many of healthcare's problems. His explanation of pervasive commercialization driven by perverse incentives is consistent with John Bogle's description of the "pathological mutation of capitalism" that is destroying the American economy. Mr. Bogle is an authority who has been named by FORTUNE magazine as one of the four giants of the 20th century in the investment industry, and by TIME magazine as one of the world's 100 most powerful and influential people. As I wrote at this link, the pathologically mutated form of capitalism he describes has infiltrated and broken our healthcare system by pressuring healthcare providers to treat more patients in same amount of time to maintain their profits, which mean greater likelihood of errors and omissions due to overload. Furthermore, providers who keep their patients healthy longer through prevention, and who treat ill patients in the most cost-effective manner, are at serious risk of financial ruin. Not to mention the lack of good evidence-based guidelines defining what cost-effective care actually is. The end result is that the consumer receives less value, i.e., higher costs and lower quality.
So, our healthcare system is based on a pathologically mutated model of capitalism that encourages a form of commercialization in which perverse incentives maximize profits for some by delivering low value to the consumer … What a mess!

Mr. Kuttner gives examples of the kinds of problems these perverse commercial incentives are causing in the healthcare industry. He begins by explaining how many private insurance companies control costs by:
...practicing risk selection, limiting the services covered, constraining payments to providers, and shifting costs to patients…[thus] resources are increasingly allocated in response to profit opportunities rather than medical need, many attainable efficiencies are not achieved, unnecessary medical care is provided for profit, administrative expenses are high, and enormous sums are squandered in efforts to game the system. The result is a blend of overtreatment and undertreatment — and escalating costs. Researchers calculate that between one fifth and one third of medical outlays do nothing to improve health.
He then claims that:
Great health improvements can be achieved through basic public health measures and a population-based approach to wellness and medical care. But entrepreneurs do not prosper by providing these services, and those who need them most are the least likely to have insurance… Comprehensive, government-organized, universal health insurance systems are far better equipped to realize these efficiencies because everyone is covered and there are no incentives to pursue the most profitable treatments rather than those dictated by medical need… Commercial incentives are not fixing what's broken.
He also explains how primary care physicians are suffering the brunt of our broken healthcare system due to perverse cost-containment strategies, such as income targeting, which cause their caseloads increase and net earnings stagnate or decline:
The idea is that physicians have a mental picture of expected earnings — an income target. If the insurance plan squeezes their income by reducing payments per visit, doctors compensate by increasing their caseload and spending less time with each patient … [which] has multiple self-defeating effects. A doctor's most precious commodity is time — adequate time to review a chart, take a history, truly listen to a patient. You can't do all that in 10 minutes. Harried primary care doctors are more likely to miss cues, make mistakes, and — ironically enough — order more tests to compensate for lack of hands-on assessment. They are also more likely to make more referrals to specialists for procedures they could perform more cost-effectively themselves, given adequate time and compensation. And the gap between generalist and specialist pay is widening.
Another cost-containment tactic is to increase deductibles and copayments in order to:
…dissuade people from going to the doctor. But sometimes seeing the doctor is medically indicated, and waiting until conditions are dire costs the system far more money than it saves. Moreover, at some point during each year, more than 80 million Americans go without coverage, which makes them even less likely to seek preventive care.
Furthermore, a strategy used by hospitals to maximize their revenue involves fierce defense of their profit centers, investing heavily in facilities for lucrative procedures that will attract physicians and patients (such as cardiology). It would be better for our healthcare system as a whole, however:
…to shift resources from subspecialists to primary care [where many things can be done for much lower cost]. But in an uncoordinated, commercialized system, specialists might take their business elsewhere, so they have the leverage to maintain their incomes and privileges — and thereby distort cost-effective resource allocation.
And physician entrepreneurs are increasingly moving toward "boutique medicine:"
...in which well-to-do patients pay a premium, physicians maintain good incomes, and both get leisurely consultation time. It's a convenient solution, but only for the very affluent and their doctors, and it increases overall medical outlays. Other doctors opt out by becoming proprietors of specialty hospitals, usually day surgeries. In principle, it is cost-effective to shift many procedures to outpatient settings that are less expensive but still offer high-quality care. In a government-organized universal system, the cost savings can be usefully redirected elsewhere. But in our system, the savings go into the surgeons' pockets, and their day hospitals often have a parasitic relationship with community hospitals, which retain the hardest cases and give up the remunerative procedures needed to subsidize those which lose money.
I applaud Mr. Kuttner's insight and analysis, but I believe the solution he proposes--a national health insurance program that doesn't rely on private insurance--is not practical for the U.S. today. I examine the pros and cons of such a "single-payer" plan at this link and come to the conclusion that a hybrid strategy is probably best: A national health insurance program offering good coverage for everyone (thereby eliminating the problem of the uninsured), which:
  • Ties a consumer's out of pocket expenses to family income and
  • Coexists with some form of private insurance for those who want it.
This proposed system would focus on bringing value to the consumer by fostering high quality care delivered efficiently (i.e., cost-effective care) through better use of clinical research, evidence-based guidelines, and health information technology. It would also have incentives for:
  • Delivering high value care to consumers
  • Making quality and cost transparent to enable consumers to make better healthcare decisions
  • Offering consumers wellness tools, counseling and guidance to enable them to take better care of themselves.
For this wise solution to succeed, there would be mandates requiring everyone to obtain insurance, as well as probable tax increases for those with higher incomes to help pay for subsidies for low income persons.