The Whole-Person Integrated-Care (WPIC) Wellness Solution: Part 6

In the first five parts of this series on the Whole-Person Integrated-Care (WPIC) Wellness Solution, I discussed how particular personality characteristics -- i.e., one's cognitions (thoughts), emotions, knowledge, and coping strategies -- determine whether or not people take good care of their health. On one end of the spectrum are the self-motivated "Activists" eager to attain and maintain excellent health. On the other end are the "Ignorer/Deniers," who strongly and consistently resist self-managing their health for many reasons.

I now begin to answer the question: What's necessary for people to change how they think, feel, and act in a way that promotes healthy living?

I assert that AWARENESS is the place to start. People have little incentive to change if they are unaware that they have health problems or risks or are managing chronic conditions poorly. These people first need greater awareness of their health status and probable future, whether due to ignorance or self-deception. Understanding their health problems, risks, and poor self-management tends to give rise to fear. This fear is based on their belief that they will experience pain, become disabled, or die. For some, such fear is a motivator. For others, the fear leads to denial, so it's wise for them to "reframe" the situation in terms of the "joy of life" rather than the "fear of death," as I discussed in an earlier post. Nevertheless, awareness is essential.

Things that can promote self-awareness are other people, media, and information technology. These people may be sick-care professionals (e.g., doctors, nurses, and therapists); well-care coaches and counselors; family and friends; and even "virtual acquaintances" through Internet-based social networking (see Web 2.0). Media include websites, TV, movies, newspapers, books, etc. Finally, information technology includes health information systems, such as personal health records (PHRs) and online health data repositories.

In this post, I will focus on good and bad health information technology for consumers since there is great debate about its usefulness. See, for example, this recent article in Business Week about Google and Microsoft's Internet-based products for electronic healthcare information storage and access and the Robert Woods Johnson blog for their Project HealthDesign PHR development initiative.

We are in the "Stone Age" of health information technology. But, unfortunately, current-day products are not very useful to the typical consumer and could be more helpful to professionals. That's because the most valuable information is not obtained by simply having a place to store personal health data. Instead, value comes from using these data to help consumers, and their healthcare professionals prevent physical and mental health problems, treat acute illnesses, and self-manage chronic conditions.

So, what about search Internet engines such as Google? Well, they're not of great value either since only 16 percent of online consumers find what they were looking for since search engines tend to focus on breadth rather than on content quality, which means they usually provide an overwhelming number of generic "hits" that are often of questionable validity. This is particularly true for searches on health topics such as alternative medicine, herbal and nutritional supplements, prescription drugs, disease cures, and nutrition. In fact, 70 percent of scientific studies show that the quality of online health information is a significant problem.[1]

Things have been improving, however, with websites such as Helia Health, Organized Wisdom, Revolution Health, and WebMD. The problem is that they all focus on providing general rather than personalized information. This means people must scan through pages of information and links, most of which have nothing to do with their needs. And when they finally navigate to where relevant information is located, it tends to be generic, not specific to each individual, which can lead to information overload, knowledge underload, and inaccuracies.

What's needed is an easy, low-cost way for data from healthcare providers and consumers, no matter where they are stored, to be transformed into useful information. This information should increase people's awareness of their current health status and risks through comprehensive, holistic assessments. It should also provide targeted, personalized information that increases their knowledge and understanding of the most cost-effective ways to deal with troubling health-related issues. These issues may include coping with a stressful life situation, changing unhealthy lifestyles, adhering to one's care plan, making valid diagnoses, and deciding wisely about which treatment option and insurance plan to choose. As discussed in a previous post, these capabilities go beyond data storage and access and enter into personalized, holistic (mind-body-spirit) decision-support and self-help assistance. Unfortunately, today's PHRs need to be more mature regarding these capabilities.

I've long been recommending the creation of disruptive (radical, discontinuous) technologies that can achieve the lofty goals I described above. By way of full disclosure, I've been developing such a system, called the Personal Health Profiler™, for over two decades. It is a significant departure from the kinds of PHRs and websites in use today in that it promotes rapid and more complete understanding of a person's:

• Current physiological, psychological, and mind-body functioning and risks
  
• Wellness interventions and self-management plans
  
• Sick-care treatments
  
• Changes in health status (trends over time)
  
• Clinical outcomes and costs of care received.

This information is presented in a personal health profile. It yields a better (more profound and broader) understanding of a person's problems and needs, improving diagnostic and treatment/intervention decisions. It comes from analyses of detailed data about the relationships between one's:

• Internal factors include problematic physical signs and symptoms, illnesses, emotions, cognitions (thoughts, attitudes, perceptions, beliefs, "self-schemas," attributions & appraisals, expectations, memories, etc.), and knowledge & understanding.
  
• Behaviors including diet, exercise, alcohol and substance use, risky activities, sleep, mobility, etc.
  
• External influences/causes including stressful interpersonal relationships, stressful and unhealthy physical (e.g., work, living) environments, economic pressures, etc., on the one hand, and supportive conditions that promote good health on the other hand.
  
• Medications and abnormal lab test results to identify possible interactions (e.g., how certain drugs being taken may be causing one's white blood cell count to drop and interfering with one's sleep).
  
• Mind and body, such as medication side effects and physical illnesses that present as mental health problems and physical symptoms that may be due to (or exacerbated by) stress.

In addition, this next-generation application provides these essential functionalities:

• "Pushes" targeted information to consumers and professionals to fill knowledge gaps and increase understanding instead of requiring that the information be "pulled" by them. This means exceptional "findability;" navigating to and accessing relevant information is a breeze compared to the complex and often convoluted process required to obtain and filter desired information from typical web portals and search engines.
  
• Identifies key stressful/distressing life issues and health risks, which help focus wellness-counseling efforts.
  
• Identifies how a person's underlying beliefs (cognitions) and related emotions foster or hinder healthy behaviors and wellbeing, which also helps focus counseling efforts and helps break through resistance and denial.
  
• Delivers warnings and alerts essential to effective prevention.
  
• Delivers ongoing feedback to the consumers and professionals on their progress, so any necessary adjustments to the wellness plan can be made efficiently, and good continuity of care can be maintained.
  
• Uses a structured, personalized coping & problem-solving methodology that helps a person achieve positive results as quickly as possible by targeting the most problematic situations first and applying a proven method for resolving them.
  
• Supports well-care / sick-care integration.
  
• Continually evolves using flexible software modules, data sets, and algorithms that are all transparent and easily modifiable.
  
• Accommodates any current and future data and technology standards
  
• Continually feeds a knowledge base with de-identified treatment and outcomes data to support research efforts.

These capabilities increase consumer awareness and cut the time the health professionals have to spend trying to understand a person's problems, needs, and cognitive-emotional blocks, speeding the creation and improving the accuracy of their care plans. And the targeted information, self-help tools, warnings & alerts, structured coping & problem-solving methods, and continuous knowledge base feeds offer a cost-effective way to help improve outcomes, including better health, wellbeing, and overall quality of life, increased productivity, and workplace safety.

Note that such a paradigm-busting disruptive technology need not make conventional technologies obsolete since they can work together.

In subsequent posts, I'll explain how the Personal Health Profiler™ works and offer collaboration opportunities in its continued evolution.

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[1] "Health Information Search Engines Emerge; Growing Consumer Demand for Health Information Increases Need for Better Quality, More Personalized Searches, Says Expert at 11th World Congress on Internet in Medicine." Internet Wire (Oct 18, 2006).

The Whole-Person Integrated-Care (WPIC) Wellness Solution: Part 5

In my last post [click here for the first of the series], I discussed the personalities, coping strategies, and health-related needs of the third type of individual, the "Inactives." I now conclude this series by examining the fourth and most resistant group: the "Ignorers/Deniers."

Simply put, Ignorers/Deniers just don't focus on their health. This is for a variety of reasons, which I'll be discussing. First, these people "close their eyes and ears" to information about healthy living. They refuse to acknowledge or accept they have health problems or risk factors, or they refuse to do anything about it. These maladaptive behaviors are a consequence of a mindset they adopt, which includes thoughts such as:

• "I do not accept there's a problem with my health" – despite convincing evidence.
• "I fine the way I am … It doesn't matter what others say" – even though their health is deteriorating, relationships are crumbling, and overall quality of life is suffering.
• "I'm different … I'm special … I'm not like those other people … Nothing's going to happen to me!" – a false sense of security and invincibility.
• "I don't trust doctors" – an attitude based on gross overgeneralization.
• "Getting help is a sign of weakness ... A strong person handles one's own problems" – an irrational belief driven by pride and based on a distorted measure of self-worth.

Ignorers/Deniers, therefore, differ from the other personality types in essential ways; for example:

• The three other types of individuals think about their health, and when confronted with a health problem, many question whether they can make good decisions and help improve things, which may make them anxious due to self-doubt. Nevertheless, despite their anxiety and doubt, they are willing to learn and act wisely. Many Ignorers/Deniers, on the other hand, are so terrified by the notion they may have (or get) a severe illness that they avoid thinking about their physical and emotional health—preferring, instead, to pretend everything is all right. As a result, Ignorers/Deniers may refuse to accept the reality of their situation, even when confronted with the threat that they will probably die from their health problems; to them, the thought of being or being ill is too great to consider. Although this self-deception may keep their fear in check for a while, their inaction and ignorance make them vulnerable to worsening health and personal problems.
• If Ignorers/Deniers did think about their health, many would feel hopeless and helpless, believing they cannot deal with serious illnesses or personal problems. And those who portray an air of invincibility are likely covering up great self-doubt and fear, or they may be delusional.
• While other types of individuals may have valid concerns about finding a competent healthcare practitioner, some Ignorers/Deniers are so distrustful of the healthcare profession that they won't even consider seeing a doctor, even if they are in pain or distress, often until it's too late.
• While health problems may cause other types of people to become sad or even depressed, for a time, they can get themselves motivated and begin to take constructive action because they want to live and be happy. Ignorers/Deniers, on the other hand, may be so lonely and depressed that they believe they have nothing for which to live. For them, living longer in chronic emotional pain isn't motivating. And when confronted with the knowledge that their health risks can kill them, many Ignorers/Deniers deny the facts because the idea of dying is also too emotionally painful for them to acknowledge; the threat of death, therefore, isn't a motivator. In fact, the odds are great that such a person will fail to make substantial lifestyle changes, even if facing probable death. This prevents them from having the drive and focus needed for constructive action.
• While other individuals are willing to get help when needed, Ignorers/Deniers may have been so influenced by their cultures that they believe seeking assistance for personal problems is a sign of weakness.
• Unlike the other personality types, Ignorers/Deniers may have physical addictions or powerful psychological compulsions that prevent them from focusing on healthy living until they reach "rock bottom," which, unfortunately, may be too late.

What this means is that Ignorers/Deniers rely on some of the same "avoidance" coping strategies as the Wannabes and Inactives; that is, they may:

• Try to feel better by doing enjoyable or interesting things rather than gaining knowledge and developing a plan of action
• Act as if nothing has happened or trying not to think about their problems
• Resign themselves that nothing can be done to improve the situation, even though they lack adequate understanding and fail to exert sufficient effort.

As I discussed in my previous posts, these coping strategies are maladaptive in the long term since the inertia (inaction) they promote allows their health risks to emerging as serious problems and their existing health problems to worsen.

Because these thoughts, feelings, and reactions are so deeply ingrained in their personalities, getting through to Ignorers/Deniers is very difficult. However, all is not lost! Consider the following:

• There are compelling discoveries in cognitive science, linguistics, and neuroscience about how "reframing" serious health-related issues can help motivate resistant people to change. For example, instead of trying to break through the denial of Ignorers/Deniers through threats they will die, it may be much more helpful to reframe the issue in a way that focuses them on a vision of "joyful living" rather than a "fear of dying," since joy is a more powerful motivator than fear [reference]. This kind of reframing changes the mental structures that shape one's view of the world; it typically requires months of psychological counseling to break through the thoughts and feelings that block Ignorers/Deniers' awareness and motivation to change.
• When cultural influences create a "machismo" attitude, in which Ignorers/Deniers perceive getting help as a sign of personal weakness or failure, cognitive-behavioral counseling can combat that belief. In addition, innovative self-help software that guides the person toward healthier behavior and thinking can be helpful. One focus would be reframing the situation from (a) getting help revealing weakness to (b) receiving help when needed and using it to improve one's life is a sign of wisdom and personal strength, whereas refusing help is childish and self-destructive.
• Dealing with a person's lack of trust may require the intervention of a wellness coach who takes the time to establish a close, positive relationship with the Ignorer/Denier and has the knowledge and experience to gain the person's confidence.
• As for Ignorers/Deniers with addictions or compulsions, lengthy counseling (and possible medications) may be needed before they acknowledge their problems and have the will to confront them.

Regarding wellness programs, the Ignorers/Deniers are the least likely to participate. Engaging them is critical, such as offering meaningful incentives to take a self-assessment and speak with a wellness coach. The initial goal of such wellness counseling should focus on understanding and helping reframe their beliefs and perceptions. This will enable them to be more open to gaining awareness about their health situation. Innovative technologies that help focus and entice people to break through their negative mindsets and resistance would be helpful. Once Ignorers/Deniers stop deceiving themselves, have a stronger desire to live and enjoy life, gain trust, are more aware and open to receiving help, and are no longer controlled by their addictions/compulsions, they can be treated as Inactives or Wannabes as appropriate.

The Whole-Person Integrated-Care (WPIC) Wellness Solution: Part 4

In my last post, I discussed the personalities, coping strategies, and need of the "Wannabes." This time I examine the "Inactives."

Inactives think about their health on occasion but do not believe they should or can do anything to improve their health and wellbeing. This is because they tend to have thoughts such as:

• "I doubt I'll be able to do what's required to improve my health, so why even bother."
• "I don't deserve to be sick…it's not my fault…so why should I have to be the one to do anything about it"—or—"I do deserve to be sick…Illness is my punishment…I'm just getting what I deserve."

Inactives doubt that they can deal effectively with their health risks and problems, which causes them great stress. Some also believe they don't deserve what happened to them, making them resentful and angry. This stress and resentful anger not only distract them from focusing on constructive health improvement activities; it is also likely to worsen their physical health since illnesses such as coronary heart disease and cancer may be exacerbated by a negative psychological state (for examples of how this mind-body connection affects one's health, see: this link, this link, and this link). Other Inactives may have different views, such as believing they deserve to be sick and there's no hope because they are doomed.

The result is that the Inactives, like the Wannabes, lack the self-confidence and motivation to improve their health and wellbeing. But what makes Inactives less likely to change their unhealthy lifestyles is that:

• Their self-doubt is stronger because it comes from the belief that they are not able (rather than may not be able) to (a) make the correct decision about treatment for an existing problem or (b) make the attitude and behavior changes required for better health and wellbeing.
• Their inertia (inaction) may be exacerbated by (a) fear that they will be shamed if they try to improve their health and failure causes them to resist taking constructive action, (b) the belief that there is no good way to solve their health problems or prevent their health risks from becoming problems, and (c) despair related to the belief they deserve to be ill.
• Their stress and resentful anger likely worsen their health through distraction and the adverse effect of negative emotions on physiology.

Furthermore, they will likely look for reasons for not adhering to the wellness care plan, such as:

• Money problems that prevent them from carrying out their wellness plan of care (e.g., buying more healthy foods, a gym membership, prescribed medications, diagnostic tests, etc.)
• Family and other demands consume their time and thus make lifestyle change difficult.
• Physical handicaps or cognitive impairments.

The result is that Inactives fail to deal with their health risk and problems promptly and effectively while simultaneously worsening their health and wellbeing through inertia and emotional distress.

The way Inactives attempt to cope with their pessimism, fear, anger, resentment, and despair is similar to the negative avoidance strategies the Wannabes use. That is, they may

• Try to feel better by doing enjoyable or interesting things rather than focusing on the problem.
• Act as if nothing has happened or try not to think about their problems.
• Express negative emotions by yelling or crying, taking it out on others, or avoiding certain people rather than doing something constructive.
• Hope a miracle will make things better or that one's wishes or prayers will be answered, rather than gaining knowledge and developing a plan of action.
• Resign themselves that nothing can be done to improve the situation, even though they lack adequate understanding and fail to exert sufficient effort.

While these coping strategies may alleviate their emotional distress temporarily, they are maladaptive in the long term since their inaction allows their health risks to emerging as serious problems and their existing health problems to worsen.

Nevertheless, since Inactives think about their health & wellbeing on occasion, it is possible for them to become more focused and motivated with the help of wellness coaches/counselors and helpful health information technologies. They may be willing, for example, to take health risk assessments that evaluate their health status, especially if they have concerns about their physical or emotional health. They may also be willing to gain greater knowledge about their problems, risks, and constructive strategies for dealing with them, although they will likely have to be convinced (through counseling and maybe incentives) to use these tools and professionals. And they may be willing to get help to:

• Use the knowledge they gain to make a treatment decision for dealing with an acute physical or mental health problem.
• Implement a wellness care plan designed to self-manage a chronic condition.
• Make positive lifestyle changes to avoid a risk factor from becoming a health problem.

All this means they will need wellness counseling, which should focus on the following:

• Overcoming their inertia, changing their self-defeating cognitive and emotional blocks (including self-doubt, fear, anger, and shame)
• Replacing their negative avoidance-based coping strategies with the positive approaches of the Activists.

This counseling should include powerful forms of persuasion in which well-care professionals--using next-generation health information technologies, which I will describe in a future post--help increase their willingness to take responsible action that improves their health and wellbeing. This is likely to involve significant effort focused on changing beliefs/thoughts. I have previously posted about the relationship between beliefs and physical health, starting at this link.

In my next post, I examine the fourth most challenging personality type: the "Ignorers/Deniers."

The Whole-Person Integrated-Care (WPIC) Wellness Solution: Part 3

In my last post, I explained why "Activists" — the first of four types of people affected by influential psychological characteristics — tend to be healthiest and why they are most likely to take advantage of wellness programs. In addition, I discussed how they have the kind of personality traits that enable them to cope with health-related issues through positive action and rational acceptance. In this post, I discuss a second group of individuals with different personalities and coping strategies: the "Wannabes."

Wannabes talk about improving their health & well-being and are willing to learn about healthy living, but they never seem to act on it or do so half-heartedly. This is because they tend to have thoughts such as:

• "I may be able to do what's required to improve my health, but I'd rather not deal with it right now."
• "I'm not sure what to do."
• "I'm just not ready."

As a result, Wannabes tend to be aware--or are willing to be aware--of their physical and mental health problems & risks, but they lack the self-confidence and motivation they need when it comes to doing something about it. Their self-doubt and lack of drive may come from the belief that they may not make correct decisions about preventing or treating their problems. This uncertainty, in turn, may cause them to avoid making decisions and changing their attitudes & behaviors for fear of failure; i.e., they don't want to be ashamed or embarrassed if they try but fail. Or if they believe there's no acceptable way to solve their health problems or prevent their health risks from becoming problems, they will likely take no action.

Wannabes, in other words, tend to cope with their doubts and fears through avoidance. What they do, for example, is:

• Try to feel better by doing enjoyable or interesting things rather than focusing on the problem.
• Act as if nothing has happened or try not to think about their problems.
• Express negative emotions by yelling or crying, taking it out on others, or avoiding certain people rather than doing something constructive.
• Hope a miracle will make things better or that one's wishes or prayers will be answered, rather than gaining knowledge and developing a plan of action.
• Resign themselves that nothing can be done to improve the situation, even though they lack adequate understanding and fail to exert adequate effort.

While some of these coping strategies may temporarily alleviate their emotional distress, they are maladaptive in the long term since they foster procrastination, which allows their health risks to become severe and worsen their existing health problems. Nevertheless, there are several positive and negative aspects of the Wannabe personality.

On the positive side, since Wannabes think and talk about improving their health & well-being, they will likely want to participate (to some degree) in health promotion programs that:

• Evaluate their health status, especially if they have concerns about their physical and/or emotional states.
• Help them learn about their problems or risk factors, including understanding the pros & cons of different treatment and prevention options.

On the negative side, Wannabes are likely to procrastinate when it comes to:

• Using their knowledge to make decisions about dealing with (treating) acute physical or mental health problems
• Acting on wellness plans designed to self-manage chronic conditions and avoid complications
• Making positive lifestyle changes to prevent risk factors from becoming health problems.

If they 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 may use it as an excuse for not making a firm decision or adhering to the wellness care plan.

If they have family and other demands that consume their time and thus make lifestyle change difficult, they will likely use it as an excuse for non-action. And if they have physical handicaps or cognitive impairments, they will likely use these limitations as excuses for inaction.

All this means they will need wellness counseling focused on modifying their self-defeating cognitive and emotional blocks (including self-doubt, fear, and shame) and changing their avoidance-based coping strategies. The goal is to help them become more like Activists. Only then will they be willing to take responsible action that improves their health and well-being.

In my next post, I'll examine the third personality type: the "Inactive."

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

Last week, in part 1 of 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 and its goals and methods. I also mentioned that (at least) four types of people with different character traits require different approaches to wellness due to their other 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 processes (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 essential 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 judge/evaluate things rationally and sensibly
  • Creating and imagining
  • Focusing attention on what's important (i.e., having 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 dealing 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 issues 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 asks 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 be solved and what has to be done to solve it. Then, a specific action plan is 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 fosters 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 cope with it through positive reappraisal and rational acceptance. While it may help reduce one's upset temporarily, this strategy is maladaptive 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 issue. As with behavioral distraction, the strategy may help reduce one's upset temporarily. Still, 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, push them away, and waste precise time.
9. Wishful Thinking is another negative avoidance strategy in which a person simply hopes a miracle will make things better or that his/her wishes or prayers will 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 helplessness), 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 (at least) four types of people: Activists, Wannabes, Inactives, and Ignorers/Deniers. In this post, I present the Activists. They are 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 views reflect a joy of living and a willingness to take constructive action to reduce fear, uncertainty, and doubt through problem-solving (if their health problems can be resolved) or rational acceptance (if the problems can't be fixed). Activists tend to be confident, motivated, aware, rational, and assertive regarding their character traits. From a whole-person integrated-care perspective, they seek knowledge about their physical and mental health status and risks to help them make wise decisions. And they try to understand how to avoid health problems, self-manage chronic conditions, treat existing problems most safely and cost-effectively, 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 by thinking of different ways to handle it
• Talking to someone about what they are going through and asking certain people for advice or help.
• Determining what must be done to solve a problem and then using a specific action plan.
• 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, 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 varying 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. Finally, 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.

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

In this post, I discuss how to bring high value to the healthcare consumer through a new wellness program we're developing, offering 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 well-being 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 cost-effectively treating health problems because it helps lower overall healthcare expenditures, improve care outcomes, and enhance well-being since many physical disorders and psychological issues 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
• Severe 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 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 are 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 noticeable 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 essential, 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 the 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 physically and psychologically healthy 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.

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, achieving a sense of emotional well-being and peace of mind through healthy living, wise decision-making, and responsible action to deal with distressing life situations, and using effective coping strategies.
• Sick-care treats 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 on 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 vital to solving the current crisis and bringing greater value to the consumer.

Altogether 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 employees are healthier, happier, and more focused. These benefits include increased employee productivity and employee retention, lowered healthcare expenditures, reduced sick time, and fewer workplace accidents and errors.

It is crucial to solving the healthcare crisis by reducing overall expenditures.

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

• Performs a comprehensive health and well-being assessment and generates a whole-person health profile that includes a full mind-body work-up.
• Uses the health profile to create an individualized wellness plan focused on improving one's health, happiness, and achievement through lifestyle changes, wise decision-making, and 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 well-being 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 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 & well-being issues actively
• Wannabes talk about improving their health & well-being 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 & well-being.
• Ignorers/Deniers are not health conscious because they don't accept that they have health problems or risk factors or 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.

---

[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 suffering 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, 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 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 providing 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 demonstrates an undeniable interplay between biomedical, psychological, and social factors and points specifically to a causal link between mental/emotional problems and many physical illnesses. The field of psychoneuroimmunology demonstrates that stressful life events can adversely affect the immune system. Other researchers are identifying "coronary-prone behaviors" such as insecurity and a perceived lack of self-efficacy. Still, others find 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 the mind and physical health by being linked to increased blood pressure, abnormal heart rhythms, and 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 and heart disease often go hand in hand. Reuters Health. Available at http://go.reuters.com/newsArticle.jhtml?type=healthNews&storyID=11380752&src=rss/healthNews

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 propose a healthcare system that focuses 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. 

Workplace Wellness Programs: Motivating Employees to Live Healthy

A recent Wall Street Journal article--Wellness Programs May Face Legal Tests: Plans That Penalize Unhealthy Workers Could Get Tighter Rules--discusses the US Department of Labor’s decision to curtail the ability of employers to motivate workers to kick unhealthy habits by making health insurance more expensive for unhealthy workers than for their colleagues.

Workplace wellness programs--which focus on illness prevention and chronic disease management through self-maintenance--are one key ingredient for healthcare cost control. Healthier employees tend to be happier, more motivated and more focused, which benefit their employers through reduced healthcare-related expenditures, improved productivity, lowered absenteeism and fewer on-the-job accidents. While “sticks and carrots” can help convince some employees to adhere to their wellness plan and lead healthier lifestyles, it will be ineffective or even harmful for some due to powerful psychological, physiological and situational factors. These strong internal and external influences will affect the wellness market by giving credence to the legal issues in article and by stressing the judicious use of incentives and disincentives.

Even most presidential candidates agree that wellness programs are essential for controlling healthcare costs. Employer-based wellness programs have been shown to have substantial return on investment through increased productivity and reduced absenteeism, by promoting employee health & safety and organizational effectiveness, and by reducing expenses through lowered sick-care utilization. For example:

• The Leapfrog Group reported that many of the largest U.S. employers, with 54% of them now offering some version of health coaching to employees.
• The US Dept. of Health and Human Services reported that: (a) a Johnson and Johnson’s wellness program yielded an estimated savings of at least $1.9 million through decreased medical costs, reduced sick leave, and increased productivity; (b) city employees insured by the City of Mesa, Arizona revealed a significantly greater decrease in health care costs of employees who participated in a mobile worksite health promotion program, as opposed to employees not participating. Health care costs decreased 16%, resulting in a $3.6 savings for every dollar spent on health promotion services; and (c) the return on investment enjoyed by five large companies, as a result of their health promotion and disease prevention activities, ranged from $2.05 to $6.15 per employee.
• The Small Business Wellness Initiative found that businesses that invest $1 in workplace wellness can often reap $3 to $5 in savings through lowered healthcare costs, decreased absenteeism and decreased workers’ compensation claims.
• The Texas Coalition for Worksite Wellness reported that the average cost of adding prevention and wellness services to a private health insurance program is typically $50 to $85 per person. Yet, every dollar invested in worksite health promotion yields $3.50 to nearly $6 in savings through reduced absenteeism, increased productivity and decreased health care costs.
• And a wellness program at IBM returned $3 in healthcare savings for every $1 spent on wellness.

Despite these convincing numbers, workplace wellness programs ought to be cautious in their use of rewards and punishments for motivating employees to lead healthier lifestyles. There is good reason for the Department of Labor’s recently issued regulatory guidelines rejecting the use of incentives and disincentives that make health insurance more expensive for unhealthy workers than for their colleagues. I’ve identified the following three reasons why such tactics are unrealistic and won’t work for many employees.

1. Addiction (and compulsion). As mentioned in the article, smoking (as well as drug and alcohol) addiction is due to the influence of a powerful complex of biological and psychological factors. For many people, counseling (and medications) is required, and numerous relapses are common. Instead of simply punishing smoking, those addicted ought to be rewarded initially for participating in counseling to deal with the physical and psychological causes of their addictions. For employees whose health would improve if the curtailed their use of alcoholic beverages and recreational drugs, the same strategy should be offered, assuming they are not breaking company policies.

Similarly, certain compulsions, such as the drive to persistently overeat, are driven by powerful physiological, mental and emotional influences. As with addictions, weight loss typically requires counseling, family/peer support, and even medications or other medical procedures (e.g., gastric bypass or band). Our culture makes matters worse by promoting unhealthy diets through commercials and fast-food companies selling high-carb and high-fat foods and beverages. If we’re serious about reducing obesity, our society also should focus on changing these maladaptive cultural influences.

2. Hopelessness/Helplessness, Depression, and Denial. Some people lack the optimism and confidence to change their unhealthy lifestyles. Feelings and perceptions of hopelessness and helplessness are part of their personalities, which have been created by their personal experiences, attitudes and emotions. People who don’t believe they can succeed are not motivated to change, of course. Likewise, lonely or depressed people aren’t going to change their lifestyles in order to extend their lives because the prospect of living longer in chronic emotional pain isn’t very motivating. And when confronted with the knowledge that their health risks can kill them, many people tend to deny it because the idea is just too emotionally painful to acknowledge. So, threat of death isn’t a powerful motivator for many. In fact, the odds are nine to one that a person will fail to make substantial lifestyle changes, even if facing probable death!

Compelling discoveries in the fields of cognitive science, linguistics and neuroscience, however, are helping us understand how “reframing” the issue is essential. For example, people are more motivated to change if they can have a vision of “joy of living” rather than a “fear of dying,” since joy is a more powerful motivator than fear. This kind of reframing changes the mental structures that shape one’s view of the world, and it typically requires psychological counseling (individual and/or group). It may take months of counseling to the break through the thoughts and feelings that block one’s motivation to change. [Reference]

Sticks and carrots alone will not motivate these people to change; and some sticks may even lead to denial. Instead, they must first believe they can succeed in making the necessary changes in their lives and they must have a mental framework in which the prospect of a longer life brings them joy. Their initial incentives, therefore, ought to be focused on getting them involved in the counseling they need.

3. Time and Money (Resource) Constraints. Many employees have work, family and other demands that consume their time and make lifestyle change difficult. What they need is help with time management and developing wellness plans that take their busy schedules into account. Some have serious money problems, which prevent them from buying more healthy foods, a gym membership, prescribed medications, diagnostic tests, etc. s Sticks and carrots will be useless until these time and financial issues are resolved.

In conclusion, using incentives and disincentives fails to motivate many employees to live healthier lives. Wellness programs, therefore, ought to focus on providing the risk assessment, feedback and counseling necessary to deal with the emotional, attitudinal and resource blocks that prevent employees from making positive changes. Rewarding these people for participating in such counseling make sense, but punishing them for failing to improve their health is foolish and worthy of criticism by the Labor Dept. Not until these employees have attained a more positive psychological/emotional state will they be motivated to change. Only then does is make sense to reward them for achieving biologic benchmarks (e.g., weight, cholesterol levels, blood pressure, etc.) and behavioral goals (e.g., diet, exercise, non-smoking, reduced alcohol consumption, medication compliance, etc.).

In my next post, I discuss how a "whole-person integrated care" model addresses the particular needs of people with different personalities and levels of motivation.

Can our government be trusted to run a universal healthcare system?

I've been involved in several discussions about the Analysis of the Candidates’ Healthcare Proposals web site I published last week (and have updated since then). Much of the debate centers on mandates and trust of our government to run a nation-wide universal healthcare system.

One reader had this to say:

Within the current system, the mandated "Medicare drug plan" appears to be heavily weighted to benefit the pharmaceutical manufacturing & distribution industry. Please give me your thoughts or analysis on the recognition of the candidates in what certainly appears to be an industry with very powerful influence in government. My personal assessment/feeling leans toward a more competitive market with as few government controls as possible. However I do feel government has a needed and viable role in the healthcare of our citizens.

I responded as follows:

I haven't analyzed who benefits most from the Medicare drug plan, but based on my understanding of our current healthcare system, I have little doubt that powerful lobbies influence policy. For example, a 2004 study on healthcare lobbyists [here’s the link] found that, of the of 1192 organizations were involved in healthcare lobbying, pharmaceutical companies spend more money lobbying Congress than other health care organization. Other top lobbyists are medical device manufacturers, insurance companies and healthcare provider organizations. In 2000, healthcare lobbying expenditures totaled $237 million, which was more than the lobbying expenditures of every other industry, including agriculture, communications and defense.

This supports your implication that our government can’t be trusted to do the right thing for the masses due to the influence of special interests.

At the same time, these data imply that these special interest groups--i.e., those making money from the current system--will not likely start delivering high-value to the consumer/patient on their own since greater cost-effectiveness for the consumer/patient eats into their profits under our current broken healthcare system (see this link for more about the need for a greater value).

So, I agree that more sensible competition is one part of the solution, and I agree there must be government mandates if we are to have quality improvement, cost control and good care for all. But it’s debatable as to the kind of government influence is needed (e.g., what types of mandates) and what can be done to hold politicians accountable to the people/consumers/citizens?

Personally, I’d like to see our government provide funding and management for all the reasonable quality improvement and cost control strategies presented in the candidate comparison web site. I’d like this to be done in the most effective and efficient way possible, with all government agencies involved being closely watched and scrutinized by an independent oversight organization whose allegiance is to the consumer.

One question is whether a single-payer system, which is run completely by the government as in other countries, would be better than a system in which private insurers compete with a government run universal healthcare program. As discussed in the candidate comparison web site, the main arguments against a single-payer system can be disputed. CMS does run Medicare and Medicaid after all, which is a single-payer system.

The issue of trust in our government, however, remains unresolved. I suggest that these be the healthcare-related issue we focus on.

Analysis of the Candidates’ Healthcare Proposals

After analyzing the details of each Presidential candidate’s healthcare proposal, it appears that a person is likely to select a proposal based on one’s:

• Current health insurance plan
• Level of wealth
• Priority for assuring good healthcare for all.

Combining these three factors results in eighteen groups of voters--each with particular wants and needs--who would prefer different candidates' proposals based on these factors.

Here is a link to the Analysis of the Candidates’ healthcare Proposals web site. It presents a systematic detailed comparative analysis of each candidate's healthcare proposal based on the wants and needs of the 18 voter groups. The analysis resulted in the following conclusions:

• The candidates most concerned with improving the quality and controlling the costs (i.e., increasing the value) of healthcare are: Clinton, Edwards, Kucinich, Obama, Richardson and McCain.
• Voters who want good care for all are willing to do what it takes—including paying increased taxes, etc.—to support a publically-funded UHS. Candidates who want a Federal Employees Health Benefits Program UHS (FEHBP-UHS) and want to keep private insurance as an option are: Biden, Clinton, Dodd, Edwards, Obama and Richardson. Only Kucinich proposes a government-run Single Payer UHS (SP-UHS). Choosing between these two options is discussed on the web site.


• If an FEHBP-UHS is desired, then Clinton and Edwards are the best choices because they also more focused on increasing care value, with Obama and Richardson coming in second.
• If an SP-UHS is desired, then Kucinich is the only choice. Note that his plan (HR 676) is also the most detailed (has the greatest specificity), which means it may be the most credible.

 

On the other hand, any Republican is a suitable choice for voters who (a) are not concerned about the care others receive (they aren’t interested in good care for all) and (b) are confident they will always have excellent insurance, or can afford to pay for the care they need out-of-pocket if they lack adequate insurance. Choosing between Republican candidates would likely be based on their strategies for:

• Minimizing taxes and reducing personal health-related expenses
• Increasing healthcare value (cost-effectiveness), in which case McCain is probably the best choice since he proposes the most strategies of all Republicans for improving quality and controlling costs (as well as being the only Republican addressing the health need of veterans through the VA).

Note, however, that there are significant gaps in every candidate’s proposal. It would be useful to know how what it would require to (a) evaluate all the quality improvement and cost control strategies described in this document and to (b) implement the effective ones efficiently.
All these and other related issues are examined on the web site, including issues concerning healthcare quality improvement, cost control, financing new publicly funded universal healthcare systems, subsidies, mandates, tax changes, and more.

I welcome your comments.

Presidential Candidates’ Healthcare Proposals: Public Insurance & Single Payer Plan

In my last post, I discussed whether the U.S. needs universal coverage. In this post, I examine the candidate's proposals concerning how universal coverage can be achieved. A key strategy involves the deployment of new and expanded public insurance programs, which includes a heated debate about a government run single-payer system.

All the Democrats propose universal healthcare (coverage for all Americans). Only Kucinich supports HR 676, which is a single-payer, "Medicare for All" plan that gives everyone comprehensive coverage. Gravel also proposes a single-payer solution, but through use of federally funded vouchers. All the other Democrats propose a public Federal Employees Health Benefits Program (FEHBP) type program and/or Medicare, Medicaid, SCHIP, which are supported by subsidies (e.g., through tax credits or vouchers) to low income persons.

Republicans, on the other hand, do not propose new public programs, the expansion of existing public programs, nor universal coverage. Instead, they all propose market-based private insurance solutions through tax deduction/credit subsidies to lower insurance premiums and deduct medical expenses from the taxes of lower income persons. Other strategies include increasing competition, tort reform, and payment changes to providers.

New and Expanded Public Programs

All Democrats (and no Republicans) propose new public programs.

v Comments about Public Insurance in General

Consider the following:

Public insurance programs offer the greatest potential for automatic and continuous enrollment and the ability to cover everyone. Enrollment could be facilitated through local Medicare or Social Security offices. Those failing to enroll could be signed up when they seek health care services or coverage could be verified as part of income tax filing. With everyone eventually enrolled at birth in an expanded Medicare, people would automatically be enrolled and stay enrolled across their lifespans. Most proposals would establish a minimum standard benefit package modeled on the typical plan offered to members of Congress or to employees of large firms. For those proposals requiring enrollees to pay cost-sharing or a portion of premiums, a ceiling on out-of-pocket costs and premiums as a percentage of income would be established to ensure affordability. Some proposals modeled on the Canadian health system, for example, would not include patient cost-sharing for basic services and would be financed by federal and state taxes.
Given Medicare's low administrative costs and broad risk pooling, substantial savings could accrue in an expanded Medicare approach through a reduction in administrative costs. Other sources of savings would likely arise from paying providers Medicare rates that are lower, on average, than private rates.

The proposals modeled on the current Medicare program would provide choice of plans, including the private plan options currently available to Medicare beneficiaries and the program's self-insured plan.

The public insurance approaches to health insurance reform would create dislocation, with people moving from their current coverage to coverage through Medicare or another public plan. However, people would still likely keep their same set of providers. Proposals that would allow employers to continue offering coverage would be less disruptive initially, although it is anticipated that most employers would ultimately prefer to pay a part of the Medicare premium rather than private coverage premiums, which would probably be higher.

These proposals would allow the nation to develop and utilize common quality metrics, gather data on the health care outcomes of the full population, and evaluate and improve the performance of providers based on a large pool of patients not fragmented by insurance type. They also would allow for the creation of uniform provider payment systems that reward high-quality care, standardization in health information technology, and the creation of universal processes to improve safety systematically across health care institutions.

Financing is likely to come largely from federal income and payroll taxes or new taxes, such as a value-added tax or consumption tax. This would be less administratively complex than providing premium subsidies based on income. The distribution of financing is most likely to be more progressively related to income than either individual insurance market or mixed private–public group insurance proposals. [Reference]

Single-Payer Government-Run System

Kucinich is the only candidate proposing a single-payer government run system (HR 676), which gives each person their own healthcare card.

v Comments about Single-Payer Government Run System

The case for universal healthcare was discussed above. But should it be a government run single-payer system?
The primary arguments in favor of a single-payer system center on cost control issues.
Here are views about how it would reduce administrative costs:

The most obvious difference between [European] health care systems and ours — that their governments provide universal insurance — certainly plays a big role in the cost differences. Look behind the receptionist at your doctor's office, and you will very likely see a staff of people filing claims to different insurance companies. The insurance companies, meanwhile, employ a small army charged with figuring out how to avoid covering the unhealthy. The administrative costs of our patchwork bureaucracy eat up about 25 percent of health spending… Even in Europe's single-payer systems, administrative costs account for about 15 percent of health spending [italics added], once everything is included, according to the Lewin Group, a consulting firm…. Medicare, which has administrative costs roughly as low as those of other countries' universal plans. Younger Americans, by contrast, have private insurance, with all its inefficiencies. Yet elderly Americans' share of national health spending is similar to that of the elderly in other countries, as Arnold Kling, an economist, has noted [source].
Private insurers spend large sums fighting adverse selection, trying to identify and screen out high-cost customers. Systems such as Medicare, which covers every American sixty-five or older, or the Canadian single-payer system, which covers everyone, avoid these costs. In 2003 Medicare spent less than 2 percent of its resources on administration, while private insurance companies spent more than 13 percent … Although it's rarely described this way, Medicare is a single-payer system covering many of the health costs of older Americans. (Canada's universal single-payer system is, in fact, also called Medicare.) And it has some though not all the advantages of broader single-payer systems, notably low administrative costs. [source].

Here's a discussion of how a single-payer system would control healthcare delivery costs:

…the evidence clearly shows that the key problem with the US health care system is its fragmentation. A history of failed attempts to introduce universal health insurance has left us with a system in which the government pays directly or indirectly for more than half of the nation's health care, but the actual delivery both of insurance and of care is undertaken by a crazy quilt of private insurers, for-profit hospitals, and other players who add cost without adding value. A Canadian-style single-payer system, in which the government directly provides insurance, would almost surely be both cheaper and more effective than what we now have. And we could do even better if we learned from "integrated" systems, like the Veterans Administration, that directly provide some health care as well as medical insurance. … 

[Another] source of savings in a system of public health insurance is the ability to bargain with suppliers, especially drug companies, for lower prices. Residents of the United States notoriously pay much higher prices for prescription drugs than residents of other advanced countries, including Canada. What is less known is that both Medicaid and, to an even greater extent, the Veterans' Administration, get discounts similar to or greater than those received by the Canadian health system. 

We're talking about large cost savings. Indeed, the available evidence suggests that if the United States were to replace its current complex mix of health insurance systems with standardized, universal coverage, the savings would be so large that we could cover all those currently uninsured, yet end up spending less overall. That's what happened in Taiwan, which adopted a single-payer system in 1995: the percentage of the population with health insurance soared from 57 percent to 97 percent, yet health care costs actually grew more slowly than one would have predicted from trends before the change in system [source].

And the following argues that a single-payer system is the only way sensible solution:

A mere shift of power from Republicans to Democrats would not, in itself, be enough to give us sensible health care reform. While Democrats would have written a less perverse drug bill, it's not clear that they are ready to embrace a single-payer system. Even liberal economists and scholars at progressive think tanks tend to shy away from proposing a straightforward system of national health insurance. Instead, they propose fairly complex compromise plans. Typically, such plans try to achieve universal coverage by requiring everyone to buy health insurance, the way everyone is forced to buy car insurance, and deal with those who can't afford to purchase insurance through a system of subsidies. Proponents of such plans make a few arguments for their superiority to a single-payer system, mainly the (dubious) claim that single-payer would reduce medical innovation. But the main reason for not proposing single-payer is political fear: reformers believe that private insurers are too powerful to cut out of the loop, and that a single-payer plan would be too easily demonized by business and political propagandists as "big government." 

These are the same political calculations that led Bill Clinton to reject a single-payer system in 1993, even though his advisers believed that a single-payer system would be the least expensive way to provide universal coverage. Instead, he proposed a complex plan designed to preserve a role for private health insurers. But the plan backfired. The insurers opposed it anyway, most famously with their "Harry and Louise" ads. And the plan's complexity left the public baffled. 

We believe that the compromise plans being proposed by the cautious reformers would run into the same political problems, and that it would be politically smarter as well as economically superior to go for broke: to propose a straightforward single-payer system, and try to sell voters on the huge advantages such a sys-tem would bring. But this would mean taking on the drug and insurance companies rather than trying to co-opt them, and even progressive policy wonks, let alone Democratic politicians, still seem too timid to do that [source]. 

Two important lessons can be learned [from the Massachusetts Health Reform Law]. First, we need to sever the connection between healthcare and employment. People need continuous, portable coverage that is affordable, comprehensive, and equitable. Second, we cannot depend on the private insurance industry to provide this for us.
Piece-meal reform such as the new law will not work. Both employers and the public support the concept of single-payer healthcare. Big business is starting to realize that a single payer system will be the only affordable way to cover everyone. When will our politicians understand that their political futures will depend on supporting this kind of comprehensive reform? [source] 

The reason we spend more and get less than the rest of the world is because we have a patchwork system of for-profit payers. Private insurers necessarily waste health dollars on things that have nothing to do with care: overhead, underwriting, billing, sales and marketing departments as well as huge profits and exorbitant executive pay. Doctors and hospitals must maintain costly administrative staffs to deal with the bureaucracy. Combined, this needless administration consumes one-third (31 percent) of Americans' health dollars. 

Single-payer financing is the only way to recapture this wasted money. The potential savings on paperwork, more than $350 billion per year, are enough to provide comprehensive coverage to everyone without paying any more than we already do.
Under a single-payer system, all Americans would be covered for all medically necessary services, including: doctor, hospital, long-term care, mental health, dental, vision, prescription drug and medical supply costs. Patients would regain free choice of doctor and hospital, and doctors would regain autonomy over patient care.
Physicians would be paid fee-for-service according to a negotiated formulary or receive salary from a hospital or nonprofit HMO / group practice. Hospitals would receive a global budget for operating expenses. Health facilities and expensive equipment purchases would be managed by regional health planning boards. 

A single-payer system would be financed by eliminating private insurers and recapturing their administrative waste. Modest new taxes would replace premiums and out-of-pocket payments currently paid by individuals and business. Costs would be controlled through negotiated fees, global budgeting and bulk purchasing [source]. 

Single payer, universal health care administered by a state public health system would be much more democratic and much less intrusive than our current system. Consumers and providers would have a voice in determining benefits, rates and taxes. Problems with free choice, confidentiality and medical decision making would be resolved [source].

The primary arguments against a single-payer system center on concerns about:

• Loss of options or increased expense to those who currently have employer-paid plans
• Rationing of care
• Stifling of innovation
• Long wait for care.

Regarding the first two bullets, consider the following:

Most lucky Americans with good insurance are doubly isolated from financial reality. They don't pay for their health care and they don't even pay for most of their insurance—their employers or the government pays. …[With a single-payer system, the government would have to start] saving money by simply not providing effective treatments that cost too much. …Should people be allowed to opt out of [such] rationing if they can afford it? That is, if the system (private or single-payer) won't pay for the $100,000 pill, should you be able to pay for it yourself? …There are the makings of a deal here. Better-off or better-insured people could be told, individually or as a group: Give up your health-care subsidy [i.e., buy insurance or healthcare with your own money] and you may opt out of any rationing-type restrictions that the system imposes [source]. 

In a Single-Payer system, everyone has an EQUAL access to insurance coverage. But it doesn't mean that everyone is able to access all the care that they want or even believe they need. …Since users of the system don't pay for care directly, the only way to control costs is to limit utilization & access to medical technology. A single-payer system's economic success is …to limit access to services, as well as access to the most sophisticated and expensive types of medical treatment and services. …Significant savings in single-payer systems come from limiting the supply of medical services to curb demand (rationing of treatment and technology)… 

Residents in countries with single-payer systems pay significantly higher taxes…Canadians are currently paying 40 percent more taxes than Americans, and Europeans are paying 60 percent more than we are! [source]

A counter argument is that our system needs to increase value to the consumer, so that everyone gets the safest, most cost-effective care possible. That will only happen when (a) we know what care gets the best results for the least cost for each person (which is a problem in its own right) and (b) there are mandated rewards for delivering such high-value care and punishments for not. Single-payer system countries are working diligently to identify the most cost-effective tests, treatments and prevention methods, and to minimize over-testing, over-treating and use of expensive drugs and procedures when more cost-effective options exist. The U.S. healthcare system, on the other hand, does just the opposite: More profits go to providers, pharmaceutical companies and medical device manufacturers when patients get sick, receive more tests and treatments, especially when they're expensive; this does not bring high value to the consumer [see this link]. This means that we've got to transition from "pay-for-volume" to "pay-for-value"—instead of arguing that waste is "a benefit" private insurance allows—and a single-payer system can help drive such value.

Nevertheless, what if certain consumers want to throw their money away for expensive care with little evidence of efficacy? Or what if they want to pay more than is necessary for care when there are less costly options that are just as good? If they are willing to pay for it out of their own pocket for it—through costly private insurance or cash—then shouldn't they have that option? Should our government refuse them access to overly expensive or ineffective care? Well, this depends on whether allowing people to opt out of the single-payer system drains so much money from the system that it cannot survive. This issue is discussed later in the mandates section.
Anyway, here's a discussion of why rationing makes sense:

Americans seem to be less willing [than Europeans] to take no for an answer and more willing to try almost anything, no matter how expensive or how slim the odds, to prolong life. … It has made us obsessed with medical advances and turned this country into the world's research laboratory. …But much of it is simply wasteful. Expensive procedures…are often no more effective than basic ones, according to research. Yet doctors can keep on getting reimbursed for the expensive ones. "Basically, anything that doesn't kill patients is paid for by Medicare and insurance companies," said Jonathan Skinner, a health care researcher at Dartmouth College. …We Americans tend to treat any rejection of a health claim as some conspiracy by insurance companies, the government, doctors and the pharmaceutical industry. In other countries, people have arrived at a better understanding that health care necessarily involves economic triage [reference].

The argument that switching to a single-payer system would stifle innovation is based on the fact that since the U.S. spends so much more on healthcare than other nations, it enables researchers to obtain superior financial compensation, which leads to more medical discoveries in our innovation-rich environment. The counter-argument states that there isn't any proof:

…that it is the difference in health care systems that has caused the agglomeration of research facilities in the U. S. Even if the U.S. were a single-payer system, drug companies, etc. would still do research and it is likely that much of it would be carried out in the U.S. just as it is now. In addition…much of the research that is done here is funded directly or indirectly by the government. [And,] given that European countries can free ride on this research, comparing the amount spent in the two countries may not accurately reflect European willingness to fund health care research since the two figures may not be independent. If the U.S. spent less, European countries might be induced to spend more [source].

When it comes to waiting for care--while people in the US go without needed healthcare because of cost more often than people do in the other countries--waiting time for specialized healthcare services (e.g., elective surgery) is typically shorter in America than in other countries, at least for insured Americans. However, the US ranks low when it comes to the prompt accessibility of appointments with primary care physicians, often waiting six or more days for an appointment, and having trouble making an appointment on weekends and evenings [ reference ]. So, waiting time for non-emergency care is an issue in countries with universal healthcare. Nevertheless, things are improving in many of them [ reference ]. In other words, there are problems with both systems and the question is whether access to excellent primary and specialist care, even if there's a longer wait for elective surgery, is a better option than not being able to afford excellent care.

Federal Employees Health Benefits Program (FEHBP)

Biden, Clinton, Dodd, Obama and Richardson want the new program to be based on the Federal Employees Health Benefits Program (FEHBP).

v Comments about FEHBP Model

Biden, Clinton, Dodd, Obama and Richardson want insurance coverage to be modeled after the FEHBP, but this may not be realistic. The least expensive FEHBP coverage for a family appears to cost at least $10,000 per year, and most plans cost $12,000 or more. The government (taxpayers) pay only 75% of that amount on behalf of employees leaving the employee to cover 25% of the premium plus copays and deductibles out of his or her own resources. It is highly unlikely that low income people would be able to afford that much. At the same time, to provide an adequate subsidy or limit the individual's out of pocket exposure for premiums, deductibles and copays to some acceptable percentage of income (6.5% has been suggested) would likely be a tough sell when the staff and Congressional Budget Office try to estimate the overall cost to taxpayers. While less than perfect, defining minimum creditable coverage as a high deductible insurance plan would be considerably less costly and more feasible. If we can develop ways to save money by safely driving down utilization of healthcare services, we could always expand coverage later.

Vouchers

Gravel proposes the federal government issue annual vouchers to individuals based on projected health care needs, which they would use to pay for their care.

In the next blog post, I will discuss the thorny issues of allowing private insurance, mandating that everyone has access to coverage through individual and/or employer based requirements, and the use of insurance pools.