Choosing Wisely?

Today I was asked why I recommend that PCPs do Wellness Visits, when the Choosing Wisely initiative of the American Board of Internal Medicine (ABIM) has recommended against “health maintenance” visits? This is a great question, so I thought I would answer in my blog.

I’ve been interested in the debate over annual physical exams since I was a med student 30 years ago. I have never been a proponent of them because the preponderance of data has always been that they are not a good use of time and money. I totally agree with ABIM on that.

Prevention-oriented visits still need to be done, though, for vaccinations, certain screenings (Pap smear, colonoscopy, etc.), and perhaps most important for the doctor to have an opportunity to do the 5 A’s (Ask, Advise, Assess, Assist, Arrange) in regard to tobacco, alcohol and physical activity.

Cardiometabolic disease is a major economic threat:
http://bipartisanpolicy.org/events/2012/06/lots-lose-how-americas-health-and-obesity-crisis-threatens-our-economic-future

The American College of Cardiology and American Heart Association recommend performing a cardiovascular risk assessment (the choice of which tool remains controversial):
http://circ.ahajournals.org/content/129/25_suppl_2/S49
http://circ.ahajournals.org/content/129/25_suppl_2/S102
http://circ.ahajournals.org/content/129/25_suppl_2/S76

The New York State Prevention Agenda essentially acknowledges that tobacco, physical inactivity and diet (as well as poor stress coping and abuse of intoxicating substances) are far and away the dominant population attributable risks for morbidity and mortality (the Prevention Agenda focuses more on tobacco, physical activity and diet).

[Fair Disclosure: as the chair of the Medical Society of the State of New York Preventive Medicine and Family Health subcommittee, I served as a co-chair of the subcommittee that drafted the Preventing Chronic Disease component of the New York State Prevention Agenda].

So should doctors be involved?
How about the primary care physician (PCP) - what is his or her role?

I am not a primary care physician, but was trained to be one. If there is no formal venue for having a patient-PCP discussion on those issues, any such discussions get tacked-on to the end of a disease-care visit. If discussed at all. And, following ABIM’s Choosing Wisely guideline, any asymptomatic person with no chronic conditions - but who has lots of risk in these domains - might never have a chance to discuss these issues with the doc until they had an adverse health event. If that event is a heart attack, about half of those people die.

Imagine you were the PCP for this dead patient. Wouldn’t you want to at least have tried? If only just once?

Further, imagine you were the PCP being held “accountable” for this death. Now how do you respond?

My view isn’t based on whether or not PCP visits for health maintenance have proven to save lives and stamp out disease, but more of question of whether a wellness visit could serve the health system in unique ways that are otherwise very hard to do.

That is an implementation / system design question, not an evidence-based medicine question.

Meanwhile, many corporate wellness programs and health insurance companies provide their beneficiaries a health risk assessment (HRA), but such wellness programs rarely make use of the moral imperative of the primary care physician. That's most unfortunate, because unlike the employer or health plan, the PCP has no ulterior motive when advising health promoting activities and speaks only for the best interests of the patient’s health.

Moreover, the HRA database could be used to quantify the social, behavioral, environmental and lifestyle disparities (what Sustainable Health Systems calls health ecology), that are known to determine some 85% of the “actual cause” of chronic disease and death.

If an employer collects data on disparities, it risks accusations of discrimination (besides, it’s not clear that they really need this data). The health system, on the other hand, really needs to know about disparities and barriers to good health, because these same barriers become gaps in care after the employee/patient develops a chronic condition.

Today, very little of the health ecology information is in a quantifiable format for health networks and plans, because these questions are not part of the electronic medical record (EMR) or claims data.

I call this the “Dark Matter / Dark Energy of Health”, because we know that it determines 85% of health outcomes, but - like Dark Matter / Dark Energy - it’s not visible to us. The difference is that Dark Matter / Dark Energy remain a cosmological mystery, but health ecology is only invisible because it’s not in the database. Not that it couldn’t be, because the items of concern are pretty well known. Most of the NIH-recommended items come from the CDC’s BRFSS project, and all have undergone public comment and are well-validated.
https://www.gem-beta.org/public/EHRInitiative.aspx?cat=4

Putting this all together, here are the health ecology implementation problems:

How is your system going to get the data?
Who is going to collect the data?
How will they be paid for their efforts?
Is this just make-work, or does it solve problems?
What is the sustainable business model for managing this data?

Answer: Wellness Visits, with a health ecology risk assessment that is linked to resources

This type of data should be secure, HIPAA-protected, but I think it’s different than EMR data because, well...one sort-of wants to invite the external resources into the system to help patients overcome barriers and gaps in care. That's what corporate wellness and employee assistance programs are for!! But those folks probably shouldn’t be nosing around in the patient's EMR portal! What you really want is a social networking tool, private and secure, focused on health promotion and administered by the PCP.

In sum, we need to break down the silos between disease-care and prevention services, so that we all collaborate better as a seamless health care system. Right now, most doctors aren’t doing much for prevention, and most prevention specialists are struggling to get more involved in disease-care.

So let's get everyone together! One very logical mechanism is to use the Annual Wellness Visit. Better yet, let go of the "annual" thing and make it an interval of the PCPs recommendation (hey, I wasn’t asked about the official name).

• Empower PCPs with a little bit of time to promote primary prevention on behalf of the payer/employer,
• Have the PCPs use an employer’s local prevention resources as “covered benefits”, and
• Most important of all - use this opportunity to provide the PCPs and networks a quantifiable measure of their patient population’s health ecology.

The Institute of Medicine is leaning towards recommending my “Dark Matter of Health” as an element of Meaningful Use 3.0:
http://www.iom.edu/Reports/2014/Capturing-Social-and-Behavioral-Domains-in-Electronic-Health-Records-Phase-1.aspx

But if this stuff determines 85% of health outcomes, that’s critically important! So why are we waiting another 3 years or more, when we know the recommended items, we have the tools and the means to start doing PCP Wellness Visits in order to start overcoming health disparity barriers now?

Finally, having time to connect, to form a human bond with a patient is perhaps the most important element of being a physician, because that bond provides spiritual power that elevates the sanctity of that relationship above the other relationships one has with people. Dr. Francis Peabody famously advised, "For the secret of the care of the patient is in caring for the patient” - the humanistic trait of empathy that the American medical system has been extinguishing. Having the PCP take the time to get to know the LIFE of the patient, not just the disease, goes a long way towards putting the caring back into primary care..