Healing What Ails America

In the first two blogs of this series, I identified that America's cardiometabolic issues mainly arise from time and money pressures, and then outlined two primary solutions: biomedical technology (devices, procedures, and polypharmacy) or intensive lifestyle interventions. In this third blog, I’ll review the options and start exploring the economics.

Option A: Biomedical Technology

The default approach of physicians throughout my years in medicine. It can be astoundingly effective, but drives health care costs beyond what society can afford.

Option B: Lifestyle Interventions

There are multiple business models, with simplified descriptions below. 

Options A and B are neither mutually exclusive nor dichotomous. In a patient with poorly controlled type 2 diabetes and experiencing severe end-organ damage (retinopathy, renal insufficiency, neuropathy, etc.), the rapidity of benefit from bariatric surgery might be wise. Whereas another patient, younger, more recently diagnosed and not yet experiencing complications might be better off with an intensive lifestyle intervention. Many patients are in the middle, best helped with a bit of each.

When I was in training, I was taught to look at every patient’s medication list and ask “Which of these could I stop”? Either by using a newer medicine that served the purposes of two older ones, or by a lifestyle intervention so that they didn’t need a medication anymore. My experience is that almost all patients would rather not take any medicines, that most patients can reduce doses or get off some of their medications, some can get off all meds. I favor lifestyle interventions over biotech because lifestyle is the only way I've seen to get off all cardiometabolic drugs. 

But in the latter part of the 1990s, medicine gradually switched to a different paradigm, wherein the metric for quality was whether or not the patient was at guideline (usually a biometric like blood pressure, cholesterol level, A1c, etc.). Instead of asking if medicines could be stopped, the question became what medicine to add in order to get to guideline. This is how Option A promotes polypharmacy! 

So what is the best way to deliver Option B?

The choice of business model depends on balancing issues of affordability, accessibility and scalability. In the last 30 years the population with obesity (and subsequent complications) has become over half of all Americans, making scalability a dominant factor. 

Affordability means that the cost to the buyer seems reasonable for the services rendered. But as we’ll see,  physician time has become, quite frankly, too costly for providing one-on-one lifestyle counseling. Allied health professionals have significantly shorter and less expensive educations, so these team members scale much more readily than physicians. 

Here are the major options for delivering Option B services:

Primary Care Physician: has the highest moral imperative but they aren’t accessible and don’t scale well. Which is why primary care visits last only a few minutes! Have you tried to book an appointment with your PCP lately? Team-based care would be ideal, but USA payment models assign “value” almost exclusively to the physician and very little value to allied health workers best suited for this work.

Lifestyle Medicine Specialist: lifestyle medicine referrals in a disease-care mode easily support a specialist niche and this sector is growing. But lifestyle medicine specialists have the same “brain mortgage” cost problem, and there aren’t enough lifestyle medicine physicians to provide accessibility to everyone in need. 

Health Centers: Hospitals can underwrite lifestyle centers and employ a full team in referral mode, particularly when paired with a medical fitness facility. Hospitals charge both professional and facilities fees, which are more costly for employers and payers. 

Medical Fitness Facilities: offer guided and/or supervised services for various clinical populations, but have high overhead due to facility standards for clinical populations.

Spas and Resorts: comprehensive lifestyle education in an immersive environment, but are unaffordable for the average American. 

Concierge Care: annual fees greatly improve the ability to spend time with the doctor, but most concierge practices focus on disease-care and not lifestyle. More affordable than spas, but not affordable for all Americans. 

Internet-based: telehealth digital services offer scalable lifestyle intervention solutions, especially for a younger, digitally-savvy sector. Local telehealth (e.g., from the patient’s local provider) may be better for poorer or older people who have less online access and facility with digital technology and/or who need to use community-based resources.

Payer-based: insurers have been providing telephonic interventions, but are generally non-collegial with PCPs and seem to prioritize profits over patient well-being. 

Employer-based: workforce wellness programs vary in effectiveness and are often outsourced to maintain privacy; they rarely involve the PCP unless the employer hires a practitioner to serve all employees.

Overall, 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 remote contact through telehealth and digital health technology, and
• meet specific population-based needs (e.g., social determinants of health) 

…all for a total cost of a few hundred dollars per patient per year. 

In my next blog, I’ll outline what that system could look like.