By STEPHANIE TILENIUS / Sep 28, 2020 at 5:29 PM
The way we manage chronic disease in the United States is fundamentally flawed, and even counterintuitive.
There are different paths an individual can take when treating, managing, or preventing chronic illness. The first is one with which we’re most familiar, where health visits end in prescriptions and pamphlets outlining what to do next. It takes place in a traditional brick-and-mortar setting, and attempts by a primary care provider to influence better health are limited to the charge to go home, eat better, and lose weight. Follow-up is difficult, not because PCPs don’t care, but because they can’t also be dietitians, certified diabetes educators, personal trainers, and therapists.
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The alternative model is one where an individual who exhibits risk factors or early signs of chronic conditions experiences integrated care from a team of professionals dedicated to this person’s whole health. Their team provides guidance on healthy eating behaviors, suggestions for daily exercise, and help managing everyday stressors, depression, and anxiety. Weekly — even daily — check-ins are enabled by virtual visits, augmenting the in-person care they receive. Through messages, video, and audio chats, their providers proactively lead this person to a better lifestyle. And through remote monitoring with connected devices like a Fitbit or connected scale, early risk indicators are caught in real time. Instead of assigning medications and surgeries, the team can prevent disease onset.
The only way to adequately manage chronic disease is by fundamentally shifting everything we believe to be true about disease management, by moving from our current retrospective, reactionary model of care. Virtual continuous care with remote monitoring and ongoing human accountability drives better outcomes, eliminates unnecessary healthcare spend, and empowers whole health to the populations who need our help.
According to the CDC, 90% of the $3.5 trillion annual expenditure in U.S. healthcare is spent on people with chronic and mental health conditions. We’ve known for years that our approach is incorrect. We don’t need to continue to see astronomical dollars spent on medications and surgeries to know that we need to change.
So, what will it take to make the necessary changes?
In the U.S., we’re currently in a moment of what some might call unrest, but what I recognize as a moment of reformation. Between the inequities represented through Covid-19 and through continued systemic racism, we see that life, liberty, and happiness are more easily achieved for those predisposed to better health.
Now is our moment to change, and I call on my fellow founders and executives — in and out of healthcare — to do the hard things, and to make the tough choices that will change the way we manage and care for the majority of our population.=
To do this will require a proactive approach to medical care.
We do this by:
Improving access to care
According to a 2018 National Health Interview Survey, 11.1% of the U.S. population under the age of 65 is uninsured. And rural Americans — an estimated 15-20% of the U.S. population — are especially at risk of facing not just gaps in insurance, but also of poor access to the healthcare they need. Rural clinics are often limited in the number of doctors available, longer wait times for care, and few specialists available. While access to virtual care has improved significantly due to Covid-19 — the term has become ubiquitous — but the execution of virtual care is still not available to most Americans. The discussion of improving chronic condition care in rural areas could be a tome in itself, but the basics of the issue are clear: there are millions of Americans receiving limited to no care for their chronic conditions, contributing significantly to the prevalence and cost in the U.S. Lack of access to mental healthcare is particularly concerning — 96 million Americans have had to wait more than one week to receive mental healthcare, and 74% of Americans do not believe mental healthcare is easily accessible. We have to do better in increasing access to care, particularly care from specialists such as dietitians, certified diabetes educators, and therapists.
Empowering providers with technology
One of the enduring legacies of the Covid-19 pandemic will be the accelerated adoption of telehealth and virtual care. This will, without question, help us solve the gaps in access to care. Analysts originally projected general virtual medical visits would hit 36 million in 2020; they’ve now blown that projection out with a new expectation of 200 million virtual visits. It took a literal shutdown of all activity to force provider and patient alike to conform to the future of healthcare, and in so doing, have found themselves successfully meeting with their providers in fields from mental healthcare to routine check-ups and numerous visits in between.
With tech like wearable devices serving as remote patient monitoring and cell phones serving as face-to-face discussion, the barriers to access to care begin to come down. RPM and virtual visits are fundamentally changing the way we treat chronic conditions. Through technology, we can more efficiently — and more regularly — survey patients, provide content and lessons personalized specifically to their experience level and needs, and make real time adjustments. This enables us to measure outcomes better than ever while also unlocking the ability to scale personalized care plans. These combined technologies will help us build a world where a person’s location, work commitments, and transportation limitations will never get in the way of needed care and follow-up.
Implementing an integrated care model
Nearly half of those U.S. adults who have a chronic condition, actually have two or more conditions. At Vida, we see an average of 3.3 conditions by chronic members — they need to simultaneously manage conditions like diabetes and depression, or anxiety and sleep problems, or obesity and back pain. When we enable physicians to refer to lower-cost professionals like coaches, nurses, or certified diabetes educators, we begin to see not only improved day-to-day care for chronic patients, but also lower costs. In order for this to be effective, we must focus on outcomes for the entire integrated care team, including mental healthcare. This model is more scalable and more comprehensive for the patient, with lower healthcare costs and better outcomes than the fragmented experience chronic patients currently experience.
Destigmatizing mental illness and measuring outcomes.
One out of every five 5 working-age Americans have a mental health condition and fewer than 40% of these people seek treatment. Sixty-eight percent of adults with mental health conditions have at least one other medical condition; 43% of depressed adults are obese, and people with depression have a 60% higher risk of developing diabetes. We cannot ignore the connection between mental health and chronic health, we should be treating every chronic condition as a mental health condition. We must begin talking about mental healthcare — talk therapy, Cognitive Behavioral Therapy, and more — in the same breath we talk about reducing A1c levels and lowering blood pressure. Further, we need to measure a person’s mental health outcomes and progress just as we measure physical outcomes. Whether a condition causes or exacerbates the other, the link between mental health and chronic health has the potential to revolutionize the way we treat chronic conditions.
Passing reforms to eliminate food deserts
Access to healthy food is a complex problem that will require bipartisan support to solve, but that my fellow executives can influence in the philanthropy they perform and the representatives they support. It’s estimated that nearly one-fifth of the U.S. population is both low income with low access to healthy food, and research has found individuals who live in food deserts have an elevated risk of obesity. We simply cannot expect to solve the detrimental impact poor nutrition has on chronic disease throughout the U.S. if we do not ensure that every American — particularly children — has adequate access to a market that stocks affordably price fresh foods like fruits and vegetables.
Addressing systemic racism within healthcare
This moment of perceived unrest is a powerful moment for African Americans, and we are writing history with our actions. What we do now will be considered for generations to come. Right now the statistics are sobering. African Americans are more likely to die at an early age of all causes when compared to white Americans. They develop severe chronic conditions like diabetes and high blood pressure at younger ages than whites do. And African Americans are at the greatest risk of contracting, being hospitalized, and dying from Covid-19. The most important question we need to ask ourselves right now is, “why.” The most common answer we’ve looked to is social determinants of health, but I recently was on a panel where that was referred to as a fancy descriptor for racism, and when we see the breakdown of social factors, it’s hard not to agree. From poverty, lack of homeownership, limited access to care, and obesity, black Americans are overwhelmingly more at risk than whites. I’ve already committed to making important changes at Vida, and I hope the industry will do the hard work necessary, and make the tough introspective reflections to eliminate racism not just in healthcare, but in all industries and communities.
The expense of chronic illness isn’t just financial. According to this study, patients with chronic illnesses may spend two hours a day or more in managing their disease. But we can prevent this from ever needing to become a reality. By revolutionizing our approach to medicine, and by proactively caring for a person’s health as opposed to reactively treating symptoms we can change the quality of life for millions of Americans.
This will not be easy. We need to rearchitect the system, train every care provider in every specialty, and enable lower-cost providers and communities. But in so doing, we will provide a new model of care where a physician isn’t the person who helps us when we’re sick — they help us be healthy.