In this series of blogs, I’ve identified that America's cardiometabolic issues stem from time and money pressures, outlined medicine's two basic types of solutions – biomedical technology or lifestyle interventions. In this blog, we’ll take a first dive into the business viability of lifestyle interventions.
The business model we’re looking for must:
• Leverage the physician’s moral imperative but use little physician time,
• Be delivered mainly by allied health professionals for accessibility and scalability,
• Maintain contact between visits through telehealth and digital health technology, and
• Meet specific population-based needs (e.g., social determinants of health).
Most important, our model needs to be affordable, accessible, and scalable to every community, nationwide. America needs a $500 solution, not a $5000 one.
Tech enthusiasts and financiers see web-based models as the way to go because they believe in technology, but I don’t get the impression that they know how hard it is to change lifestyle behaviors. Since we know knowledge doesn’t change behavior, the logical inference would be that the mechanism of delivery of knowledge won't make a difference. This is likely why wearables without adequate support systems often end up in a dresser drawer.[Patel; Smuck]
What changes behavior is a person investing their time and emotional energy in helping another person make changes. In the timeless wisdom of Francis Peabody, M.D.,
“The secret in the care of the patient is in caring for the patient”.
Caring is what drives behavior change. The late psychiatrist M. Scott Peck, M.D., defined love as “the will to extend one’s self for the purpose of nurturing one’s own or another’s spiritual growth”.[Peck] But doing so is really difficult to do. Extending one’s self beyond one’s comfort zone is scary, everyone knows that it’s easy to fail if they try to reach too far.
Fear of failure is a really big deal. The research of Carol Dweck, Ph.D., has shown that setting goals intimidates roughly three out of four people, because we all come to any growth challenge with the experience of failing at many things – for some, even most things – that we've previously tried to learn.[Dweck]
Indeed, many weight loss patients have told me that I was their last hope, that they’d “tried everything else” (usually not, but it felt that way to them). Those patients had not just a record of failure, but specifically failing at the reason that they were coming to see me. Much of the allure of GLP-1 agonists is that they reduce the risk of failure. After learning of Dweck’s research, I never ever again had patients set goals and only focused on mastering the process of living a healthier life.
Caring for the patient requires seeing the world through their eyes and not our own. This is especially difficult for doctors, even lifestyle medicine specialists, because our health care system preens doctors to see ourselves as the ones with the answers, allergic to the phase "I don't know".
It takes a lot of time to find out how someone sees their world, with a view to helping them extend themselves and nurture their own growth. Caring is beyond empathy. If lifestyle change were a “medicine”, the half-life would be weeks and the time to a stable “drug level” would be months. For the physical activity piece alone, my experience and advice to patients is that it takes beginners 9 to 18 months (usually closer to 18) to get to an emotional place they can’t imagine a life wherein they do not exercise. For some, exercise never stops feeling like a chore.
With these notions in mind, let’s take a critical look at business entities that can deliver caring, as described, in a health and well-being service line.
Primary Care: Best location for health and well-being services, by far, but PCPs are time-constrained and need to use team-based care that isn’t adequately compensated. The best strategy is for nurses, dietitians, health educators and health coaches do Annual Wellness Visits (AWVs) as a triage to health and well-being services, using provider-led group visits in a disease-reversal model.[PL 111-148]
Lifestyle Medicine Specialist: Fits the consultant model dominant in the USA, and requires PCP collaboration for referrals. One could set up a 1099 contractor arrangement to do the above primary care model on behalf of a network of primary care providers.
Health Centers: Hospital backing helps cover startup costs and generates more revenue due to technical fees in addition to professional fees (but the added cost won’t thrill employers and payers). Also, a center-based strategy makes it much easier to hire personnel from different areas to form a diverse and highly skilled team. Centers offer the possibility of including a variety of rehab programs (cardiac, vascular, pulmonary, neurological, musculoskeletal, others), particularly if the center is based in a medical fitness facility. Centers are probably the best way to serve the urban and rural poor.
Concierge Care: Great place for a PCP-style strategy, as above, and with better access for patients who can afford to pay cash. Concierge fee can underwrite a number of the team-based services, allowing the PCP to focus on general medical services while providing some lifestyle medicine services. Unlikely way to serve urban and rural poor, so not a population health solution.
Telephonic and Internet-Based: From payers, such programs tend to focus more on disease management, aiming to reduce heterogeneity in care quality. Patients are likely to be skeptical of the payer’s motives, making the “caring” aspect difficult to do. Challenging to connect with those who struggle with technology (e.g., many elderly). Tech enthusiasts and workforce wellness vendors are pushing this model.
Telehealth solutions are scalable and are early adopters of AI tools, but they aren’t likely to be local. If delivered by payers, again, patients are likely to be skeptical of the motives, making the “caring” aspect difficult to do.
In my next blog, I’ll dive deeper into these proposed solutions.
Citations
MS Patel, et al. Wearable devices as facilitators, not drivers, of health behavior change. JAMA 2015; 313(5): 459-460. https://doi.org/10.1001/jama.2014.14781
M Smuck, et al. The emerging clinical role of wearables: factors for successful implementation in healthcare. npj Digital Med, 2021; 4:45. https://doi.org/10.1038/s41746-021-00418-3
FW Peabody. The care of the patient. JAMA, 1927; 88(12):877-882. doi:10.1001/jama.1927.02680380001001
MS Peck. The Road Less Traveled. Simon & Schuster, New York, 1978; p. 81.
CS Dweck. Self-Theories: their role in motivation, personality and development. Psychology Press, New York, 2000.
Public Law 111-148, 111th Congress: The Patient Protection and Affordable Care Act. U.S. Government Publishing Office. 2010, Sec. 4103(b)(hhh)(3)(C) https://www.hhs.gov/healthcare/about-the-aca/index.html
- GE Moore MD's blog
- Log in to post comments
- Follow our Blog