Healthcare is very complex but very much interconnected. In my last column, I discussed why it is imperative that pharmaceutical companies overhaul their research and development (R&D) approach, and how failure to do so will lead to serious, unintended consequences for cancer patients in desperate search of and need for life-saving drugs. While tightening legislative and regulatory pressures are major contributors to this serious predicament, there is also trouble brewing upstream.
For those living with chronic conditions, a fractured U.S. healthcare delivery system that prioritizes profits over patient outcomes has left them in the lurch. Given that many chronic illnesses can lead to cancer and untimely death, consumers need to understand the risks of chronic disease and what they can do to manage them. However, they shouldn’t be expected to do it on their own. Healthcare professionals and providers have to step up to provide support for those already struggling with chronic disease and provide the resources and tools to curb a rising epidemic.
Today, almost half of the U.S. population, or 133 million Americans, are living with at least one chronic condition and 40% of adults suffer from two or more. Heart disease and diabetes are two leading causes of death, with diabetes affecting about 1 in 10 Americans. In adults ages 65 and older, hypertension and high cholesterol are the most prevalent maladies. We have known about chronic diseases and their causes for decades.
During my tenure in the 1980’s as an assistant professor at Washington University in Saint Louis, I was part of a clinical research team at the medical school focused on helping individuals with diabetes understand how to better manage their personal health. For the better part of the last half century, researchers and the federal government have been trying to address the underlying causes and risk factors contributing to chronic diseases — diet, lack of exercise and sleep, elevated stress levels, high blood pressure, smoking and the list goes on.
Thankfully, we have made some positive strides in identifying underlying causes of chronic illness and changing some behaviors, like reducing smoking rates among adults and younger Americans. Additionally, some of the most historic developments in treating chronic conditions have emerged over the last 35 years, thanks to investments from major pharmaceutical companies. Pfizer’s Lipitor, developed in 1985 to treat high cholesterol, has now become “the best-selling drug in the world, and the second-most potent statin medicine.” Other popular drugs on the market today include Lisinopril (Prinivil, Zestril), used to treat high blood pressure and Metformin (Glucophage), which is commonly used to manage type 2 diabetes. Metformin has been around for more than 60 years.
As a result of these wonder drugs, research shows how pharmaceutical innovation has significantly increased life expectancy and improved mortality rates. This has also greatly reduced the need for expensive and lengthy hospital stays, which means more people can go about their daily lives and stay gainfully employed — a win for the economy, too. But, with more awareness of chronic diseases and their contributing factors, and more drugs for managing them on the market than ever before, the question still remains: why does the incidence of chronic disease continue to increase? In fact, Americans may be getting worse in some respects.
One study finds that more than 170 million Americans could be living with one or more chronic conditions by 2030. Another statistic puts this figure close to 230 million. By the year 2060, cases of diabetes mellitus, hypertension, dyslipidemia and obesity are all expected to increase. Managing chronic disease is and remains a costly business: according to the Centers for Disease Control (CDC), 90% of the roughly $4.1 trillion spent on healthcare goes to chronic and mental health conditions.
Clearly, we have a healthcare epidemic on our hands. So, what’s the problem? First, it is instructive to understand one dynamic element, namely underlying behavioral factors that lead to chronic conditions.
Chronic conditions can be the result of bad health choices and other factors within a person’s control. However, many conditions, such as pre-diabetes and high blood pressure, don’t always manifest themselves with early, visible symptoms, meaning patients continue their unhealthy lifestyle, unaware of how it affects their body. This is especially true if they don’t get regular checkups. The other factor is that genetics also play an important role in terms of having a predisposition to a disease.
While patients are ultimately responsible for their behavior and lifestyle choices, it’s hard going it alone, especially if an addiction or other environmental, social or economic obstacles are involved-what we call social determinants of health (SDOH). They need help along the way from various stakeholders in the healthcare delivery system. Unfortunately, that support, today, is also largely missing.
For years, both in this column and in my books, I’ve been warning about the negative impact a siloed, inefficient, confusing and expensive healthcare delivery system is having on patient care.
First and foremost, we have a broken fee-for-service model that has prioritized revenue capture and lowering operating expenses to increase margins over improved health outcomes. It’s been happening for years and shows no signs of a course correct. With little incentive or time to devote to achieving outcomes that matter, patients are often given referrals and to see more specialists, get more diagnostic tests and unnecessary procedures. In my latest book, I recount what one hospital CFO told me bluntly: “I’m not investing one dime in wellness; it doesn’t pay the bills. And I don’t think it ever will.” On top of this, treatment costs are often opaque.
Today, many patients have no idea what is the true cost of the care they are receiving — or even why they are receiving it. The obfuscation is quite intentional. When profits and volume are driving decision-making, doctors often take a “trust us” mentality, which discourages patients from asking hard questions about the standard of care they are or should be getting. Compounding matters, employer-based health plans that advertise zero copays or lower out-of-pocket costs in the name of savings can also disincentivize cost management. Feeling entitled to care, patients demand more drugs and services, and physicians are often too happy to oblige. For patients taking drugs to manage chronic conditions, this system can give them a false sense that as long as they are taking their medications, life can go on as usual.
Thankfully, the malfeasance is not going unnoticed. Surveys show a majority of Americans are dissatisfied with the current system. Industry disruptors and pharmaceutical companies also smell trouble, which is why they are now playing more of a role in filling the gaping holes. But, as we know, a band-aid approach has limits.
Today, we are seeing all kinds of players stepping in to fill the void left by our nation’s healthcare system. Disruptors like Amazon and Walmart are now making it easier for consumers to access care where they live and shop. Also, to their credit, Big pharma has been transitioning from just being drug manufacturers to more of a partner by showing how their products deliver value “beyond the pill” to key stakeholders. All you need to do is go to the websites of major manufacturers to see how they are now re-branding themselves.
The lead banner on Roche’s website reads: “Doing now what patients need next.” Eli Lilly’s website leads with: “Broadening Our Impact. Our team develops life-changing medicines. But we don’t stop there. We’re continually in pursuit of something larger — the idea that we can, and should, do all we can to help make life better for everyone.” And, Novartis’ website has a section dedicated to patients and caregivers. Many more companies are taking similar approaches. But is it enough?
At the end of the day, consumers are responsible for the choices they make given their genetic constraints. But there is also a practical human constraint that is often lost: changing one’s behavior can be challenging. Sure, social programs, personal fitness devices and gym discounts can tell you what you should be doing and offer incentives to get you to do it. But old habits die hard, and often, the membership goes unused, and the behavior doesn’t change. If people don’t understand what got them to this point and what’s standing in the way of moving forward, these incentives are of little help.
As one primary care physician succinctly put it “…clinical care only accounts for about 10 to 20% of patient outcomes. So, the other 80% is influenced by things like behavior, social determinants in the environment, [and] where [the patient] lives. So pretty much the majority of health care outcomes are actually driven by factors that are outside of the clinical care and the health care delivery environment.”
While there are a plethora of community-based programs and resources to promote health and wellness, it is the responsibility of our nation’s healthcare system to take the lead. Unfortunately, today, the system fails to engage patients at their point of need and throughout the continuum of care-prevention, early diagnosis, intervention and rehabilitation. Yes, there are many physicians committed to their patients’ well-being, but they are increasingly in the minority as cost pressures from payers and system consolidation have created a “test more, treat more, consume more health services,” mentality. In fact, an American Academy of Family Physicians (AAFP) survey found that while 83% of family physicians agree that they should help their patients address SDOH, 80% of respondents said they don’t have the time and 64% said they aren’t properly staffed to address risk factors with patients.
These same disincentives that we have had in place for decades still permeate the healthcare landscape today. Hospitals are now required by law to post prices of common procedures, but many have failed to do so. Every three years, tax-exempt hospitals must conduct a Community Health Needs Assessment (CHNA) to address the “significant health needs” of the communities they serve. Figures show many have not. And, a great many do nothing with the surveys they conduct.
Like individual habits, institutional ones are hard to break. But for a system that has failed to do its job —and at tax-payer expense — it’s time they answer to the people they claim to serve. To see the changes that we desperately need, we must hold health care delivery organizations financially accountable for care across the continuum, with payment tied to outcomes that matter. If not, we will continue to be left trying to pick up the system’s broken pieces.