Wednesday, August 19, 2015

Making the Sickly System (and me) Well: The Shift from Disease to Health

By Ann Kuglin Jones, RN, MSN, MBA, AOCN, NC-BC, FACHE
PhD Student, University of Utah College of Nursing 

How Did This Happen? 
 I am a female in my early 50s who has always been “healthy as a horse”; and on schedule, I attend my annual wellness visit just to prove it.  Three days ago my primary care provider told me I am thirty pounds overweight, I am pre-diabetic, I failed my cardiac stress test, and I need to start on three new prescriptions for high blood pressure, high cholesterol, and a “little something” for the high stress level I must be experiencing.  Seriously?  What happened in a year and who is going to make me well again?

The Old Existing Model
The disease management model we call healthcare today is inefficient, costly, and lacks in superior outcomes.  Providers are financially rewarded for volumes, mandated by the government to implement new systems at their own expense, and pressed by consumers to prescribe the latest medicine or test as seen on TV.  The consumer (aka patient) experiences higher co-pays and deductibles (if insured at all), multiple care providers because answers and access to treatment cannot be obtained in one place, and the responsibility for connecting their own dots that balance the mind, body, and spiritual aspects that inherently defines their personal wellness.

The New Model
The health model will see a system built on strategies that include the prevention of chronic illness, a holistic approach that addresses an individual’s lifestyle, environment, and genetics, and a person/family-centric (as opposed to provider centric) position that not only engages the individual themselves as the first level of primary care but also supports them in their lifestyle choices.  The new model will require the efforts of the individual, the community, and society. 

Driving Forces for Change
The United States spent 17.2 percent of its GDP ($2.8 trillion) on health care in 2012; up from 16.2 percent ($2.3 trillion) in 2008.  In 2010, eighty-six percent of all health care spending was for people with one or more chronic conditions.  It was estimated in 2012 that the U.S. health care system wastes $750 billion a year – roughly 27 percent of the total spent http://resources.iom.edu/widgets/vsrt/healthcare-waste.html.  In an international study that included eleven countries in Europe, North America, and Australia, the United States ranked dead last on overall performance and health outcomes achieved for ten years straight.  The United States “boasts” the most expensive, least efficient, worst access, highest inequity, and results in the unhealthiest lives http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror

Conflicts Arising from the Shift
The acute care, specialty driven model of healthcare proudly evolved during the 20th century.  Many technological advances, including medication development, have and continue to revolutionize the way acute conditions (including infectious disease and trauma) is diagnosed and treated.  Research and development of new technology must be funded and indeed consumes many of our health care dollars.

The problem in the 21st century is the dominance of chronic illness.  The chronic disease trajectory is related to lifestyle choices, environmental toxin exposure, and genetic make-up.  The compartmentalized way that typifies the disease management model directly conflicts with the holistic approach needed when dealing with chronic conditions.  An individual encounters many complexities that must be considered through the healing process on the return journey to health.

Health care is big business.  Providers are accustomed to fee-for-service and volume driven income.  The paradigm shift toward value based reimbursement means pay for quality.  Reduction in health care services such as medications, imaging, lab tests, surgery, etc. could mean a reduction in suppliers and vendors profits.  The role of professional caregivers and health care providers will dramatically shift as the work of healthcare changes.  Health care is expensive but has been a stable force in the economic landscape.

The role of individual autonomy vs. government intervention in changing health behaviors will be a source of stress.  Despite evidence that clearly outline examples of risk to one’s health (cigarette smoking, failure to wear seat belts, etc), our society does not easily accept being told what they can or cannot do.

Barriers to adoption of a health (versus disease) model
  • Attitude – Our society has a need for immediate gratification. We are conditioned that health can be bought in the form of a pill.
  • Convenience – As a society, we have become lazy. The convenience of purchasing fast food and clicking the remote are symbols for our overweight bodies due to lack of movement and poor nutritional status.
  • Access – If technology exists and it is marketed on TV, then it must be meant for us whether it is indicated or not. 
  • Affordability – If I can’t afford it, then the government will surely pay for it. Somebody’s taxes will pick up the tab. 
  • Void of voice – One day someone turned on the “patient” centered care switch suggesting that the consumer would now be engaged. Unfortunately, the voice of the consumer is mostly heard through the “professional patient” who represents all on the local health care advisory board.
  • Lack of knowledge – The consumer is ill-prepared in navigating the old system. A system that does not prepare and educate the consumer on how to be their own first line of offense in the pursuit of wellness will equally fail in the new health model.
Potential Impact
Shifting the paradigm from disease management to health and wellness means the development of a whole new system of care.  Simply overlaying a health model that will utilize new tools, unconventional means and integrative therapies on top of the current acute care model will further dilute resources, convolute the goals of reform, and fail to turn around an economic situation spiraling out of control.  A whole new approach that incorporates the prevention intent of the Affordable Care Act (ACA) is needed. 

I predict that the following 4 elements will become foundational in the new paradigm focusing on health.
  • The consumer will be an engaged and educated first line of offense in the primary health care system.
  • · By addressing the underlying causes of disease, functional medicine will rise as the preferred methodology in healing and health restoration.
  • Complementary and integrative therapy will become mainstream in the transdisciplinary collaborative approach to the new care delivery system.
  • Health coaching will replace the disease specific nurse navigator role.
Keep Your Eye on the Future
  • Watch the longitudinal study results of the P4 model (predictive, preventive, personalized, and participatory) unfold. 
  •  Contemplate new roles that will emerge for nurses and other healthcare professionals.  Instead of experts who care for patients, providers will be enablers who support the consumer in making decisions.  
  • Imagine the return of “community” supporting better lifestyle choices
  • Envision the care I will receive-by the year 2025 it will no longer be in the bricks and mortar once known as hospitals and clinics. My smart device will alert me to variances in my health status and I will virtually consult my provider as needed. 
 I will take the lead in making change to make me well again.

Key References
Hood, L., Lovejoy, J. C., & Price, N. D. (2015).  Integrating big data and actionable health  coaching to optimize wellness.  BMC Medicine 13(4), 1-4.  doi:  10.1186/s12916-014-0238-7  

Institute of Medicine.  (2011). The future of nursing:  Leading change, advancing health.  Washington, DC:  National Academies Press. (2014)

Jones, D. S. & Quinn, S. (2014).  Introduction to functional medicine.  Institute of Functional Medicine website.  Retrieved from https://www.functionalmedicine.org/files/library/Introduction.pdf.

Schroeder, S. A. (2007).  We can do better – improving the health of the American people.  The New England Journal of Medicine, 357(12), 1221-1228.


Creative Commons License
This work is by Ann Jones licensed under a Creative Commons Attribution 4.0 International License

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