What Counts in Care?
By Ray McBeth, Ph.D.
Health inequity is a pervasive fact in American life, but does it have to be? Today, there is a constant flow of health information targeted to consumers. All this information can be confusing and often conflicts with what we have heard from our physicians, neighbors, and family members. As a consumer, we are told that we need to manage our weight, control our blood pressure and cholesterol, eat healthy and exercise. If most chronic conditions such as hypertension, diabetes, and obesity are preventable, then why are they so prevalent? There are at least two contributing factors: how health care is delivered and individual behavior.
Changing the way health care is delivered is key to changing outcomes. During an annual wellness visit, a physician notices that his patient’s blood sugar is elevated and consistent with prediabetes, or his blood pressure is higher than previous visits, or his weight has increased since the last office visit. There is little the physician can do except suggest lifestyle changes to daily habits and monitor for change. On the other hand, if the patient is diagnosed with diabetes, hypertension, or high cholesterol, then the physician can treat the patient with medications, follow-up visits, and other interventions. In our current fee for service reimbursement model, a patient’s physician is reimbursed to treat disease, but typically is not reimbursed to prevent disease. As healthcare moves to a value-based reimbursement system, this will change. Physicians will be reimbursed on outcomes—preventing and managing chronic conditions—and not just for services delivered.
Addressing behavior as it relates to chronic conditions is more complex. Research suggests that about 40 percent of patients do not adhere to their treatment regimens. There are many factors that contribute to this issue. Patients may not take their medications as prescribed because they cannot afford the medication, have unreliable transportation, there is low literacy, low health literacy, or lack of caregiver involvement. These same factors also impact a patient’s ability to make multiple physician follow-up visits, complete treatment regimens, and make recommended changes to lifestyle such as diet and exercise. The reasons can be directly linked to an individual’s zip code: the local pharmacy may be miles away from their home, their physician may be located in a neighboring town or multiple bus transfers away, and their specialty physician may be located in another county. The frequency of follow-up visits is impacted by a patient’s ability to have access to reliable transportation, afford copays for medications and office visits, and what they perceive is the value of the healthcare service.
Zip Code? Many consider zip code to be the single best predictor of health. In fact, the actual health care that we receive in a clinic or hospital only constitutes 10-15 percent of our total health, but zip code can work to quickly summarize many factors that determine an individual’s health, because our zip code is where we live, learn, work and play.
Zip codes tend to be made up of people with similar incomes, education levels, racial and ethnic characteristics, social and cultural norms, and lifestyles, all of which affect health. Some of our most vulnerable neighbors are clustered within the same or nearby zip codes. These individuals tend to have more social determinants of health, such as food insecurity, lower-quality housing, and limited transportation options.
But there’s more to health than just where you live. While it is true that there is a direct correlation between an individual’s income, their access to care, and their overall health, it is not just the most vulnerable populations of people who suffer from chronic conditions and poor health. The Centers for Disease Control says that of the factors contributing to premature death, 40 percent are behavioral, or the choices a patient makes.
How can we help more people make healthier choices and begin to address the behavioral issues that factor into an individual’s health outcomes? Just like addressing the way we deliver care, we need to expand the care team beyond the physician to include staff who are trained in behavior change techniques, such as motivational interviewing, cultural competencies, vast knowledge community resources. The key comes down to investing in care management services. A culturally competent care manager can identify why the patient is not following the recommendations of the health care providers. She can find the patient’s motivation to change and support the patient’s movement towards that needed change in a way that is consistent with the patient’s values, beliefs, and preferences. For example, in practice, she can find a pharmacy that will deliver medications to a patient’s home and identify available financial support for the medications. She can also provide the patient with education on how and when to administer the medications, locate transportation to treatment facilities, or find appropriate alternatives like telemedicine. She can educate the patient on the reasons for the various recommendations and how best to meet them so the patient can live the healthy life that he wants to live in a way that’s consistent with his values and cultural norms. What’s significant about the care management model is it addresses gaps in health outcomes for patients of all income levels and from all zip codes.
So what counts? It all counts. We must work to ensure that those without access to jobs, stable housing, healthy food, transportation, and health care receive the services that will allow them to live healthy productive lives. We must work to change the way health care is delivered, as well as more fully addressing the behavioral issues that contribute to chronic conditions and negative outcomes. We must develop a health care delivery system that focuses on wellness not disease. Our healthcare system must provide patients with insights into how their behavior affects their health and how their choices can lead to unhealthy consequences. It must also provide patients with the tools to make the choices that are consistent with their healthcare goals in a way that works for them—no matter what zip code they may live.