Evolving from Sick Care to Well Care

MOST AMERICANS have always regarded the U.S. healthcare system as the best in the world. And, while that is largely true, what the U.S. has is a great sick care system. Also known as the acute care model, the sick care system was designed to treat illness and disease rather than promote good health.¹ In essence, it is reactive to illness rather than proactive to prevent it. For obvious reasons, this model doesn’t make sense in the long run, but change is never easy. The acute care model and its cultural basis has been in place since the Stone Age, when man first treated a wound, set a bone or identified which plants helped relieve pain or soothe a fever.

Basically, the current healthcare model is unsustainable for many societal and economic reasons. For one, because it is tailored to treat illness rather than prevent it, many modifiable risk factors for chronic diseases are not addressed adequately by medical providers. Therefore, evolution to a preventive model focused on forestalling the development of diseases before symptoms or life-threatening events occur is long overdue.

Secondly, according to the Centers for Disease Control and Prevention (CDC), the U.S. spent $10,739 per person for healthcare in 2017, for a total spending of $3.5 trillion, or 17.9 percent of the total gross domestic product.2 This puts the U.S. No. 1 in spending in the world for medical expenses, which might be acceptable if the U.S. were No. 1 in health outcomes, but it’s not. The U.S. ranks number 37th in health outcomes among world health systems. The question is: How did we get into this position, and how do we cure it?

Changing the current model means changing its political, social and economic underpinnings. And, the biggest roadblocks are how patients, providers and payers in the U.S. view the current system. In response, the Institute for Healthcare Improvement introduced the Triple Aim initiative (Figure) that implements programs designed to improve the patient care experience and the health of patient populations and to reduce the per capita cost of healthcare. Yet, while these sound like simple concepts, they will require a significant change in the healthcare culture and investment in technology.

Embracing a Holistic Approach

Currently, Western medicine uses the reductionism method to diagnose, treat and prevent diseases. According to KevinMD.com, “The basic premise of reductionism is that by breaking down (or reducing) complex biological or medical phenomena into their many parts, one is much more likely to understand a single cause and devise a cure.” Yet, while this method has been responsible for tremendous successes in modern medicine, it has its limits. These traditional medical care interventions contribute only about 10 percent to reducing premature deaths compared to interventions such as genetic predisposition, social factors and individual health behaviors.³ Chronic diseases, for instance, have multiple causes that must be considered. Therefore, future medical providers must be taught to address the whole patient from a psychological, social and economic standpoint. This means medical schools must teach prevention strategies alongside treatment approaches with a focus on lifestyle modification.2 The whole-body approach is particularly important when treating chronic disease patients.

Reimbursing for Well Care vs. Sick Care

Payers must also shift their way of thinking by reimbursing for well care rather than just for treatment. Reimbursing only for treatment incentivizes providers to conduct numerous tests, procedures and medications when the patient is ill, instead of incentivizing providers to educate patients about how to stay healthy. The result is the overuse of medical procedures rather than behavior change education and counseling.

Payers can reduce costs and improve quality of life by offering insurance plans that cover chronic care and whole-person disease management programs, wellness education, smoking cessation and other preventive healthcare programs. Tying reimbursement to improved outcomes can also help.

Some payers are recognizing the benefits of changing the current healthcare model. In 2018, Stephen Cassell, Cigna’s vice president of global branding, announced the company wanted to change its dialogue regarding healthcare to recognize the multiple factors that challenge people’s health, including not only the physical factors but also the emotional, financial, social and spiritual components.⁴ According to Cassell, the company realized it had an opportunity to save the lives of thousands of people every year who were not getting the preventive care they needed.

To encourage a change in the sick care mindset, Cigna introduced the “Say Ahhh” and “Job Swap” campaigns, which used social influencers to motivate people to take better care of their health by getting annual checkups. The shift from the sick care to the well care model at Cigna increased the number of adult preventive care checkups by 18 percent,⁵ or literally millions of people. The company’s approach was met with support from both customers and healthcare professionals.

Taking Responsibility for Health

If well care is going to succeed, it’s not just providers and payers who need to rethink what healthcare means. It’s also everyone else, too. Under the sick care system, people go to the doctor only when they are sick. This needs to change. They need to seek out medical care prior to becoming ill or developing a chronic disease. Further, people need to reduce their risk factors for disease by maintaining a healthier lifestyle. This includes managing risk factors such as obesity, lack of exercise, stress, alcohol consumption, use of tobacco products and substance abuse.

According to CDC, chronic diseases that are avoidable through preventive care services account for 75 percent of the nation’s healthcare spending, and they lower economic output in the U.S. by $260 billion a year. If everyone in the country received the recommended clinical care, the healthcare system could save more than 100,000 lives a year.⁵

Diabetes is one example of the cost savings and improvement in a population’s health that a preventive approach can achieve. The cost of treating a diabetic patient each year is roughly $6,000. However, many cases of diabetes can be prevented by modest behavioral changes such as increased exercise and a healthier diet. In one study, a group that was able to implement lifestyle changes developed diabetes at a 58 percent lower rate than a group with no interventions.¹

With an aging population, the shift in the burden of disease toward chronic conditions has accelerated. The most prevalent preventable causes of death today are obesity and smoking, which result in delayed but progressive disease. Currently, about half of all Americans have at least one chronic condition. Patients with a chronic illness need to take an active role in their own treatment by educating themselves about their illness. The more knowledge patients gain, the better able they are to interact with their healthcare providers during medical visits. Active participation by patients allows healthcare providers to spend more time during medical visits educating patients about appropriate actions to take at home to control or even cure diseases.⁶

For people with chronic diseases, well care equals disease management. A large component of disease management is patient education, behavior modifications and involving patients’ families in assisting them at home to follow through on necessary changes. For this to work, patients must be engaged and active in their healthcare. Patient empowerment is an essential component in changing any part of the healthcare system.

Applying Technology

A big part of the transition to well care can be aided by developments in technology aimed at improving individual patient outcomes and quality of life, while reducing costs. Tech companies are currently developing programs to help medical providers streamline services such as urgent care, behavioral health, radiology and chronic care verticals.⁷

Some examples of how technology can help reduce costs and improve outcomes are the use of patient portals that allow quicker access to care providers, the development of medical devices and apps that allow patients to be monitored remotely, and the use of portable medical records aimed at reducing overlapping medical procedures and testing.

But, the medical community isn’t the only sector where changes in technology need to occur. To reduce costs and improve patient outcomes, payers also need to adopt new technology such as the rapidly growing role of telemedicine (the use of telecommunication technologies to deliver health services over a distance) to provide care for the underserved, those at a distance or for whom care is inaccessible. Telemedicine applications have demonstrated dramatic growth during the past decade, particularly in rural areas for clinical specialty applications, the most common being radiology, cardiology, orthopedics and mental health services. Reimbursement for teleservices by payers has emerged as a crucial issue to the development of these services. For projects to evolve from the demonstration stage to a mainstream component of health delivery,⁸ payers must adapt how reimbursement is viewed.

Preventive Care Is Key

Healthcare in the U.S. has reached a critical tipping point where it must evolve from sick care to well care. The long-established model of treating disease rather than preventing it is not sustainable. For change to occur, there needs to be a shift in the established culture of sick care to more time and effort spent on preventive care that results in less time and money spent on patients. Moving toward a well-care model focused on prevention is the best solution!