Fashion and makeup retailers tell women they are too old and ugly. Beer sellers and truck sellers tell men they aren’t manly enough.
Why? Because it works
We have an obesity crisis, yet doctors are telling patients they are too big to absolutely no effect. Why? Because the biggest issue with low rates of behavior change in patients isn’t non-compliance by patients. It’s the unwillingness of providers to commit to innovating how they engage with patients.
Right now, most hospitals that do “innovation” make a big fuss about how digital health is the future, and maybe throw money at an innovation center or get grants for research. And make big press around the products that come out of these efforts. The problem is that they aren’t prepared to operationalize their successful pilots because their organization has no channels for integrating these innovations into regular practice beyond a one-off basis.
This is because innovation isn’t building workplaces that looks like Twitter headquarters – it isn’t disruption, it isn’t necessarily upheaval and displacement. It’s very simply taking principles and practices that are commonplace in one context, and applying them in a new context. That might result in disruption, or it might result in a smooth transition. Or better yet improve the lives of patients.
One big problem is that the bureaucracy in the hospital world is what insulates the day to day business of care practice from innovations introduced by startups, industry outsiders, individual contributors or c-level forward thinkers. Bureaucracies built to handle regulatory compliance, reduce liability risk, and negotiate billing rates with payers are not built for constantly changing business practices.
Another other big problem is elitism – the thinking that medical practice is somehow different as a business than retail or every other industry. That top down interaction between doctors and patients is the only right way to engage, and that patients themselves are not qualified to have a say in how they are diagnosed or treated. But obviously if “doctor knows best” were true, obesity wouldn’t be so bad that it is considered a national security threat.
The fact is, many of the communities who need the most support in addressing chronic disease also have a historical distrust of the healthcare system due to years of marginalization, experimentation, and downright lack of basic respect. The doctor-patient relationship is badly broken and needs to be repaired first before anything else. Bureaucracy and elitism together prevent us from rapidly incorporating lessons from other industries into how this relationship can be more effectively managed.
So how do we change?
1. Two way communication and information sharing
We need to move away from one way communication between doctor and patient. Simply ignoring input from the patient if you as a doctor don’t trust the info you are getting from patients can be problematic, if understandable at times. Ignoring it as a health system means you are systematically excluding your patients from their own care, treating them as objects rather than people. If as a system, you are getting bad data from your patients, you need to innovate in information gathering so that you can improve the quality of the patient-doctor dialogue.
Additionally, providing patients with the means of getting more involved has been shown to reduce passivity in self-management. It can be as simple as open access scheduling, or establishing channels where patients can within minutes get a human response to questions that they have.
2. Create space for experimenting
Don’t just talk about change. Put skin in the game and fund a pilot. If you don’t have the money, find partners, apply for grants. Nearly 40% of hospitals operated in the red last year, and fee-for-service is dying. Waiting for the healthcare market at large to figure out processes for you to follow is a dangerous game to play if you are just treading water and are short on ideas. Invest whatever you able to in trying out new things, and exploring alternative care delivery and business models. It doesn’t have to be organizational culture change – even just iterating on solving simple problems that create financial pain or impact patient outcomes can lead to positive progress.
It’s looking very likely that the memo for the next four years at least from the Capitol and White House is to accelerate value-based care. Financial risk will be pushed more aggressively onto providers and patients than with the ACA, which means that providers and patients will need to find more effective ways of working together to manage chronic disease.
At ProjectVision, we talk a lot about two elements that are essential to building condition management programs and interventions that not only retain patients, but keep them actively engaged in behavior change:
- Quantifying environmental barriers to behavior change
Because of the difficulty in gathering complete behavioral data, many chronic condition management programs focus “personalization” based on clinical risk – A1C level, BMI, blood pressure, etc. Using historic demographic data, they can predict with reasonable accuracy when a patient will shift from Pre-Diabetes to full Type 2 Diabetes.
However, clinical risk doesn’t tell us the “why” in the same way that behavior risk does. Focusing on clinical risk also pushes providers into a mental trap of treating patients with the same clinical risk and demographic characteristics as monolithic. Studies have shown that not more than 20% of patients who successfully lose weight in a structured program are able to maintain that weight loss in the long term.
The unsatisfactory long term outcomes of current condition management programs points to three key issues with the current models of chronic condition management:
- The program is disconnected from the social, cultural, and environmental reality for most of the patients
- Behavior risk stratification is not used to further tailor the program to each patient’s unique psychological needs
- The environmental barriers faced by patients are beyond the scope of clinicians and care providers
So let’s dive deeper into each of these three issues:
Programs Disconnected From Patient Reality
In early November, I presented a webinar centered on more effectively engaging low-income and minority patients in health behavior change. I started that presentation by analyzing the rapidly growing amount of money retailers were spending on digital ads, making the point that in an industry where failing to understand your customers deeply means going out of business, companies make a big investment in tools to help them understand and speak directly to their customers.
A big problem in healthcare is that biases about certain patient groups – the overweight, the poor, the non-white – are allowed to drive program development without being acknowledged and confronted. Failures to recruit patients in adequate numbers or keeping patients engaged in programs often comes down to incongruent messaging on the part of providers. For example, using pictures of thin, white women doing yoga when advertising a condition management program to mothers of color in lower-income communities with high obesity prevalence will not create the necessary connection with those we are trying to reach.
Programs that don’t acknowledge and build behavior change around existing deep structures within a community can expect to continue to get unimpressive results. Making this change requires letting go of assumptions about how people in certain communities think and feel, and instead, relying on observations from actual data gathering.
Simply put, a good program is responsive to psychological variance within the participating patient population. In an inpatient setting, the frequency and intensity of care is based on the clinical risk faced by the patient. Good chronic condition programs should be able to similarly moderate the level of care provided based on the behavioral risk faced by each patient. We need to move away from one-size-fits-all models of intervention. There are many different paths a person can take from being healthy to becoming diabetic.
Effective Interventions Are More Than Just Clinical
We are shaped by our environment, and we generally take the path of least resistance when making day to day decisions. If a patient lives in a healthy environment – where they have walkable access to healthy food options that they can afford, with clean air, low crime, and easy access to recreation – they are more likely to be healthy. Obesity rate has a very strong negative correlation with income.
By the same token, it’s not within a hospital’s scope to provide adequate healthy food options in a food desert, or job resources for unemployed males in high crime neighborhoods, or for addressing a myriad of other social determinants of health that are not strictly clinical.
In order to be more effective, chronic condition programs run by clinicians need to engage with non-clinical resources in direct partnership. They need to work in concert with food banks, legal services, community health programs like the YMCA, and others to properly address the environmental issues that are causing their patients to fail in more traditional programs.
This more networked approach helps address the two key issues above around being disconnected from the patients’ reality and lacking true behavior stratification. If we understand what each patient’s personal goals are as well as their unique barriers, we can better understand the norms that shape their life and the specific type of support they need to get the most out of a clinical behavior change program. By partnering with non-clinical resources, we can now start actually tailoring the services around those unique needs in a scalable fashion.
By building networks of resources to support patients, we can start leveraging network effects to exponentially increase the value of condition management programs to patients as more resources and more patients become part of the network. You start to have opportunities to leverage past participants as peer advocates as well as your non-clinical partners to bring in billable, reimbursable patient cases.
Bringing Things Together
Current condition management programs have long-term success rates that are anything but impressive. Given the cost concerns of CMS, it is imperative that we aggressively identify new models that can more reliably support behavior change.
Successful new models will address implicit bias and involving high-risk patients more directly in care planning, focus data collection on behavioral risk stratification, and build close partnerships with non-clinical resources.