Wellness Measurement and Guidance is Essential to Health Insurance.

How to have four times the positive effect of traditional clinical medicine.

Introduction

As we discussed previously in our Substack article and YouTube video, a study commissioned by County Health Rankings asserted that clinical care only affects modifiable outcomes by about 20%.  We spent 4.4 trillion dollars, 17.3% of the gross domestic product and barely moved the needle.  What can we do to positively affect the other 80%?  What are the other factors that comprise the other 80%?  Today we will discuss these and take a look at possible remedies for these other factors.

The Problem

Medicine in the US is reactive.  When you are young, there is almost nothing to do but set broken bones and generally repair injuries.  As we age the problems become more insidious, creeping up on us over decades.  Your doctor will say “lose weight”, “exercise more,” “drink less,” or “quit smoking,” but these are such nebulous little nuggets of advice that they almost have no meaning.  “Do this or what?  I’ve always been as healthy as a horse” you say.  Or, “yes, doctor,” and then forget all about it.  Even worse, I have never heard a practitioner say “do it and measure it or you are going to die.”  The only thing worse than hearing bad news is delivering bad news.

Social and Economic Factors

The largest determinant of health outcomes is social and economic and contribute to about 40% of outcomes

Economic Factors  

Affording healthcare can be a big problem, but it is more nuanced than that.  Economy has been defined as a ‘social domain that emphasizes the practices, discourses, and material expressions associated with the production, use and management of resources.’ It is simply more expensive to eat fresh and healthy.  It is a time and fiduciary burden to even just get out and walk.  A patient may have to prioritize exercise in a way that jeopardizes his or her livelihood.  Additionally, gym memberships, workout equipment and clothing are all expensive.  A larger problem is systemic hurdles (courtesy of the NIH):  

Table 1 - Matrix of economic factors at local, national and international levels

These all boil down to one thing: The people with more money have better health outcomes.

Societal Factors

Societal determinants of health can be defined as conditions in the social, physical, and economic environment in which people are born, live, work, and age. They consist of policies, programs, and institutions and other aspects of the social structure, including the government and private sectors, as well as community factors. Societal determinants include, but are not limited to, factors commonly referred to as “social determinants”.

Social Environments

The social environment includes interactions with family, friends, coworkers and others in the community, as well as cultural attitudes, norms, and expectations.  It encompasses social relationships and policies in settings such as schools, neighborhoods, workplaces, businesses, places of worship, health care settings, recreation facilities, and other public places.  It includes the social aspects of health-related behaviors (e.g., tobacco use, substance use, physical activity) in the community. It also encompasses social institutions like law enforcement (e.g., the presence or lack of community policing), and governmental as well as non-governmental organizations. At a societal level, policies made in governmental, corporate, and non-governmental sectors can impact health and health behaviors in whole populations both positively and negatively.

Physical Environment

The physical environment consists of the natural environment (i.e., plants, atmosphere, weather, and topography) and the built environment (i.e., buildings, spaces, transportation systems, and products that are created or modified by people). Physical environments can consist of particular individual or institutional settings, such as homes, worksites, schools, health care settings, or recreational settings. Surrounding neighborhoods and related community areas where individuals live, work, travel, play, and conduct their other daily activities are elements of the physical environment.

Societal Factors Conclusions

A close examination of the underlying causes of specific diseases reveals many of the same factors are at play and, over time, can result in physiologic changes that exacerbate chronic disease. Therefore, focusing on these common underlying societal determinants has the potential to impact many different health and disease outcomes. Because the effects of societal determinants begin to take hold well before disease processes appear on the clinical horizons, addressing societal determinants often offers an opportunity to prevent or delay the development of disease.

Put bluntly, educating patients about the outcomes of their decisions addresses this problem.

Social and Economic Factors Conclusions

40% of health outcomes, then, could be affected by making more money, or conversely spending less money on healthcare and educating patients on the consequences of their choices and behaviors.

Health Behaviors

Health behaviors are calculated to affect overall health outcomes by about 30%.  Thes are broken down into two categories

Positive Health Behaviors

Positive health behaviors, including getting regular physical activity and quitting smoking, have been tied to decreased risks of disease. For example, when a person stops smoking, their stroke risk is reduced within two to five years to that of a person who has never smoked.

Negative Health Behaviors

Negative health behaviors, such as overeating, smoking, consuming excessive alcohol, getting insufficient sleep, having a diet high in saturated fat, or being sedentary or physically inactive – are associated with myriad adverse health outcomes, including obesity, heart disease and dementia. More than 12% of American adults – or 25 million – engage in three or more unhealthy behaviors.

Health Behaviors Conclusions

Informing patients of the consequences of their negative health behaviors and encouraging positive ones could increase positive health outcomes by about 30%

Physical and Environmental Factors

Several modifiable environmental factors—such as outdoor air pollution, household air pollution, drinking water contamination, occupational exposure to hazardous materials, lead exposure, and built environments that discourage physical activity—influence the risk and experience of chronic disease by about 10%.

While many of these are only tenuously linked to the individual patient, educating the patient on environment and physical factors and explaining the risks and consequences could very well cause a change in venue or the activism to clean up their particular environment.  

Knowledge is power.

Clinical Care

Clinical care affects health outcomes by about 20%.  Let’s assume that the US has the best clinical care in the world and we need to do nothing to change it.  Let’s focus on the other 80% and see how to increase positive outcomes there.

Problems Conclusions

These four modifiable determinants of health (Social and Economic, Health Behaviors, Clinical, and Environmental) all boil down to two things: Money and Knowledge.

The Solution

It appears that the entirety of health and wellness that medicine doesn’t take care of can be addressed with patient education and by lowering the barriers to health insurance, that is making it less expensive.

Science Based Health and Wellness

The patient education part has traditionally been addressed by advice, in person, from your practitioner.  This advice has been don’t eat so much, eat better stuff, get more exercise, and don’t get angry.  Those are all great points and easy to understand but difficult to execute.  How much is ‘less?’  What is ‘better?’  How much is ‘more?’  How in the world do you just not get angry in this tumultuous world?  So that advice generally falls on deaf ears and if taken and followed, only lasts a short time.

Educating Patients

The method we use to educate patients is to automatically prescribe short articles for them to read based on their lab work and procedures performed. We chose Krames and WebMD as part of this education.  They have thousands of articles on almost any medical topic.  To this we add a ‘temperature gauge’ that shows the patient what allowable values for any particular measurement are, where they fall in (or outside of) that range, how this situation developed, and what to do about it in an easy to read and understand Problem/Solution format.  This gives the patient specific steps to follow and sets goals to correct behavioral deficiencies like diet and exercise.  Below is a sample page illustrating the temperature gauge and the Problem/Solution format.

Figure 1 - Sample Patient Education

Putting Teeth into Patient Education

Since the education comes from us and is available only on our portal, we know when it has been accessed.  This means that not only do we automatically generate this education based on the patient’s test results, but we can gently remind them to go look at it as appropriate.
We can also offer discounts to patients that read and follow our education; we ARE the insurance company.  Since this is all science based and recorded as structured data in a database, not just text like our competitors, we can compare test results assessment over assessment.  (We don’t say year over year, some patients require more monitoring than that).  That allows us to monitor the patient’s progress in their health and wellness journey and offer additional discounts to people who follow the advice dispensed and actually get better, or at least not worse.  The amount of the discount will be commensurate with the performance of the patient.
This gives us the ‘teeth’ we need to motivate patients and bring down the cost of healthcare for everyone.  Let’s take a look at those costs in detail.

Controlling Healthcare Costs

If it hasn’t become obvious, the health and wellness application is part of a larger suite of applications that include a fully functional, easy to use electronic medical records system (EMR).  This EMR also contains the insurance payments and pulls patient deductibles, co-insurance and co-pays from our insurance clearinghouse, so the patient and the practitioner know EXACTLY what a procedure will cost before deciding to do it.  These costs are also published so the patient can shop for doctors.  There are half a dozen other applications inherent in the suite of applications, but those have been documented elsewhere on this site.  However, with the procedures, the patient, the practitioner and the procedure information all in one place, we have managed to automate the entirety of the health insurance industry.  The practitioner documents the patient encounter and we electronically transfer the agreed up on funds to the practice account.
Your legacy insurance company only returns 53% of your premiums as benefits.  That means they keep 47% of everything you pay them.  With this new, automated process, we return all of that to you as the patient.  We only ask a $10 per month data management fee like a Netflix or Amazon.

Further, with this new system, we have eliminated the need for medical coding, a separate EMR for the practice and compliance reporting.  All that is inherent in the system and will save the average practitioner over $70,000 per year, each.

Finally, with this new system incentivizing staying healthy the overall cost of healthcare will go down.

Conclusions

County Health Rankings indicated that 80% of health outcomes are beyond the control of medicine. Of that 80% they determined three things (healthy behaviors, physical environment, and socioeconomic conditions) comprise the lion’s share of those outcomes.  We boiled those factors down into education and cost.  The patient can’t solve a problem they don’t know about.  We then detailed the solution to both educate the patient and reduce costs by half.  We do this by incentivizing healthy living and by automating and streamlining the insurance process.

We have built a comprehensive health information system to keep the patient healthy and on the right track with the ability to incentivize healthy living.  Implementing this system should be fairly simple and will completely revolutionize the way healthcare is paid for, saving countless lives.  We have shown a way to use this system to make the best healthcare system in the world also the most efficacious and the most affordable.