08 Jan An Integrated Approach To Health: The Ultimate In Patient-Centered Care
Post Written By Adam Perlman, MD, MPH, FACP and Alan Spiro, MD, MBA
Most health systems in the United States aim to promote and deliver “patient-centered care,” although the term, admittedly, has been interpreted in many ways since its inception over twenty years ago. We subscribe to the original definition of patient-centered care as having “deep respect for patients as unique living beings and the obligation to care for them on their terms.” And, we submit that in order to accommodate true, patient-centered care, the very focus of our healthcare system must shift from only treating disease to also creating health and well-being. The following article lays out a new, integrated model for helping people fulfill their own health needs and ultimately achieving the cost and quality outcomes that health managers seek.
For all the wonders of our advanced medical practices and expanding healthcare system, we still are not winning the battle against the incidence and toll of chronic illness in the United States. According to the Centers for Disease Control and Prevention, 70 percent of all deaths in the country are due to chronic disease and treating chronic conditions accounts for 86 percent of the nation’s healthcare costs. The National Center for Chronic Disease Prevention and Health Promotion estimates that productivity loss due to individual and family health issues costs U.S. employers $1,685 per person annually for a collective $225.8 billion a year. Despite an awareness of the issue, the efforts of policymakers, the availability of pharmaceutical therapies, and employers’ investment in wellness programs and behavior modification, the problem persists. Here, we envision a solution that integrates three existing care models and that has been proving effective in increasing consumer satisfaction, improving health outcomes, and reducing costs.
Looking Beyond Disease to Optimal Vitality
Traditionally, the medical community has viewed patients through the lens of disease to the point of categorizing them according to their diagnosis. For instance, Mike, who has been diagnosed with Type 2 diabetes, is designated as a “diabetic” by providers and health system administrators. Yet his diabetes is not central to his own identity. Indeed, he is much more than the pathophysiology that is affecting him. He is also a husband, a father, a runner, a gardener and so on. And, as a unique human being, he has his own point of view, belief structure, set of values, and hopes and dreams.
What’s more, because his condition is well controlled, Mike views himself as healthy rather than chronically ill. He has his sights set on completing a triathlon and fitting into his old Marine Corps Dress Blue uniform. Treating Mike without an appreciation for the whole person or an understanding of his perspective will likely fail to achieve all of his health goals. Yes, drug therapy should keep his glucose levels in check, but that doesn’t mean that he will be able to do what he wants to do on any given day. There is more to Mike and his sense of well-being than a blood sugar metric, and Mike’s healthcare provider should be looking beyond his lab values as an indication of treatment success.
In our view, health and well-being goes beyond the absence of disease. It encompasses all of the factors that affect one’s status as happy and fulfilled in all of life’s realms, covering the full range of physical, mental, emotional, spiritual, relationship, financial, career, and environmental dimensions. And wellness isn’t a “feel good” objective reserved for healthy people, but a desirable state for everyone.
Based on this premise, the medical community and all those interested in managing the health of populations must move away from separating people into two categories: those who are at risk for disease and those who actually have disease. Once we erase that demarcation, we can broaden healthcare’s remit from treating a person’s disease to helping a person achieve his or her own health and wellness goals. Thus, the desired end point is defined by the patient, and invariably, especially in this era of chronic disease, is more about the patient’s well-being than the classic definition of a cure. As we proceed toward this ideal, we should also recognize that the same disease will impact different people in different ways because of a multitude of factors. In this way we can practice personalized health — a parallel to personalized medicine.
Changing the Life-Health Trajectory
All humans have a life-health trajectory that spans the inevitable journey from birth to death, although that’s where the commonality ends. All the points in between are quite individualized, being influenced by an array of factors as seen in the charts below.
If we agree that the goal of healthcare is to transform the trajectory such that people flourish and live with vitality for as long as they can, we must necessarily be prepared to address as many of the influencing factors as possible. Of course, not all the factors can be influenced, although a great many can. Treating illness is a major part of the equation, but it also means addressing self-care and prevention as well as providing support in virtually all aspects of people’s lives. Such a comprehensive and holistic approach considers each individual’s unique situation, belief structure, values, and health goals. The patient’s point of view, regardless of the presence of illness, becomes paramount.
An Integrated Care Model
Today, health optimization and management is supported by three primary care models:
· The Conventional/Biomedical Model is tied to today’s reimbursement models in that providers are rewarded primarily for treating pathophysiology, rather than creating health, per se. This approach, therefore, tends to be physician directed, reactive (treat the disease once it presents in a patient), and fragmented (often, multiple providers treating the same patient are not necessarily communicating with one another). For the most part, individuals are left to their own devices in seeking care and following through on treatment.
· The Integrative Medicine Model is characterized by an openness in considering a broad set of therapeutic modalities as potentially appropriate for an individual. Complementary and alternative medicine (CAM) approaches can include biologically-based practices, mind-body medicine, energy medicine, and manipulative and body-based practices. (See the Wheel of Health at left.) In contrast to the biomedical model, it is more generally health-oriented, proactive, involves lifelong planning and partnerships between patients and their healthcare providers and also offers patients support in implementing their health plans.
· The Assistance Model that the majority of care decisions are made by patients, not physicians, outside of the treatment room. It gives consumers a trusted advisor who provides both clinical and non-clinical resources to aid in the process. By engaging with the person to understand life context — everything from cultural issues and spiritual beliefs to competing priorities and logistical challenges — the health assistant influences behavior to ensure that the person gets the right care at the right time. (See chart at left.) Support can include answering benefits and claims questions, helping with provider selection and access, and navigating and coordinating care.
Although the conventional model clearly dominates the U.S. marketplace, integrative medicine is experiencing a surge of interest. Patients, for their part, are integrating all manner of treatment modalities into their overall care, as seen in the chart below. And, there are now more than 60 members within the Consortium of Academic Health Centers for Integrative Medicine.
The Assistance Model is also gaining traction as large self-insured employers and payer organizations see that it delivers value in the form of more engaged healthcare consumers and significantly lower healthcare costs. It is common for organizations to cut their healthcare costs by 5 to 8 percent in the first year of implementation.
Currently, these three models are often siloed and usually employed in isolation from one another. One is not better than another, and they are not interchangeable; all have their place. No one would suggest, for example, that an herbalist is the provider of choice in the emergency room. In an ideal world, however, all three care models would work together to help people achieve their health goals. A true, patient-centered approach treats the body, mind, and spirit using whatever combination of tools is most appropriate.
For providers and payers to embrace such a comprehensive approach will require a cultural shift and the institutional will to break down the walls that have been erected between wellness, prevention, and therapeutics. We are optimistic that this will happen in time, as the forces needed to bring it about are mounting and many leaders are forging the way. We cannot sustain our current level of expenditure on treating chronic disease indefinitely; the public is demonstrating an interest in, and growing demand for, Integrative Medicine; and health managers are tracking measurable savings and improvement in employee engagement and connection to the company from the Assistance Model as consumers get help in finding the right treatment at the right time. As more economic data on the value of a holistic, patient-centered approach becomes available, the practical argument for blending all three models of care will add fuel to our appeal for healthcare to be driven by humanism.
We maintain that people ought to enjoy optimal vitality as they extend their life-health trajectory, and we contend that this can best be achieved by marshaling resources from across all three care models. Care should be tailored to each person’s unique perspective, goals, and life context for a personalized approach to health. This would do more than treating illness. It would help people optimize their state of well-being in the health equivalent of self-actualization. This in turn would reduce the healthcare bill, especially that portion related to chronic disease, and increase workforce productivity.
Dr. Alan Spiro is a recognized expert in the interface between health care delivery, health benefits and finance. He is the Chief Medical Officer of Accolade. Dr. Adam Perlman is the associate vice president for Health and Wellness for the Duke University Health System and executive director of Duke Integrative Medicine, contributing to the work of healthcare transformation within and beyond the university system. He also is a member of Accolade’s Medical Advisory Board.
 Epstein, Ronald M, MD, Street, Richard L, Jr. PhD, “The Values and Value of Patient-Centered Care,” Ann Fam Med. 2011 Mar; 9(2): 100–103.