MedCity Influencers, Consumer / Employer

The status quo is a death sentence for the US health system

Of all systematic changes to healthcare, these four adjustments would be easy enough to roll out quickly and would have a massive impact on the country’s health outcomes

According to a recent study published in the Journal of the American College of Cardiology, only 6.8% of adults in the US have optimal cardiometabolic health. This study wasn’t just another paper saying Americans are overweight; it goes far beyond that, looking at blood pressure, cholesterol, blood sugar, and the presence of cardiovascular disease among other things. How did we get to a place where 9 in 10 adults are considered unhealthy? What can we do to get out of this?

Besides being a literal death sentence for millions of Americans, our current health crisis is an economic death sentence too. Each year, the US spends a staggering $4 trillion+ on healthcare, and, while only 50% of people in the US have a chronic disease, nearly 90% of that $4T is spent treating the downstream effects of chronic physical and mental health conditions. Why don’t we invest in proactively preventing and managing these diseases before they become so serious that only costly treatments can help?

Instead, our healthcare system embraces reactive approaches to some of our most costly conditions like diabetes, hypertension, COPD, CHF, etc. This reactive approach results in higher physician costs, more ER visits and longer hospitalization times, all of which drive healthcare spend to be the largest chunk of U.S. federal spending — more than 20%, higher than defense, education, and transportation combined. It’s undeniable, we need a new, bold, multi-faceted approach to address the healthcare crisis in our country.

Here are four things the government should implement now to get us on track for a healthier future:

1. Continuous care from coaches, dietitians, and other non-physician providers

As a society, we look to the primary care physician (PCP) to be primarily responsible for helping people with their cardiometabolic health and yet when was the last time you remember spending more than just a few minutes with your actual doctor during your annual visit? Those few minutes with the PCP happen once, maybe twice, per year for the average American. That’s hardly enough time to choose what to order for dinner, let alone provide a personalized treatment plan for an individual. On top of their lack of time, PCPs are some of the most expensive providers and should be practicing at the top of their license diagnosing acute illnesses

If we can measure real healthcare outcomes like A1C and hypertension reduction and drive real medical cost savings through continuous care, why not reimburse it? Right now it’s easier to bill for a one-time acute care visit for something like a heart attack than it is to bill for continuous care with an RD, coach, or trainer that could help avoid that heart attack in the first place. Continuous care, outside of remote patient monitoring (RPM) codes, isn’t valued relative to the health outcomes and economic value it drives in our system. Continuous day-to-day measures of blood sugar levels, nutrition changes, stress, sleep and many other lifestyle variables with a trained RD can drive meaningful results that avoid ER visits and hospitalizations. The future of health is continuous virtual care.

2. Bundle value-based primary and chronic care

Value-based care is all the talk these days, but unfortunately it’s been just that, lots of talk with little action. Only a third of national reimbursement contracts are value-based. Why is it moving so slowly? Our current fee-for-service reimbursement model pays providers for their services whether the treatment works or not. Why wouldn’t we shift as much as possible to a reimbursement model that puts fees-at-risk, reimbursing based on the outcomes the treatments achieve? We need value-based care codes and plans for people living with chronic disease to be embraced by PCPs and insurance companies at large. For example, why not have a code for a person living with diabetes, hypertension, hyperlipidemia, depression, and anxiety that could be bundled in any value-based contract or used by any PCP or insurance company as part of a bundle to treat these conditions? After all, nearly a third of Americans have multiple chronic conditions and people with diabetes are 2 to 3 times more likely to suffer from depression. Better yet, why not include continuous chronic care as a requirement for value-based care contracts since that’s the most effective way to address those conditions?

3. Rethinking reimbursement from insurance companies

Insurance companies should reimburse for more continuous care and create codes for registered dietitians (RDs), coaches, social workers, digital therapeutics, etc. that are equally credible and repeatable as a PCP visit. Frankly, we should want people to work with lower cost RDs, coaches, etc. on a regular basis in conjunction with their annual PCP visits. Reimbursed remote patient monitoring (RPM) codes aren’t sufficient and only cover device connectivity and very light touch from a nurse practitioner instead of ongoing care that drives more significant medical cost savings. RPM codes don’t include the behavior change or day-to-day care provided by coaches, nurses, and RDs that’s required to manage complex conditions like diabetes. Medicare should immediately increase the reimbursable RPM codes to include a wide range of continuous care treatments.

Employers and insurance companies understand the need for continuous care, so they’re buying supplemental services for chronic conditions including diabetes and mental health. However, we need stronger economic incentives that would likely come in the form of reimbursement codes and higher RPM rates. Those could then be bundled in the medical loss ratio and expensed the way other medical services like PCP visits are billed, so employers can bill claims and offer broader coverage.

4. Embrace the body + mind, whole health approach

For years we’ve known that treating the body and mind together results in better outcomes. The mental health parity act passed more than 25 years ago and yet mental health is still siloed as a carve out for many insurance companies. People living with diabetes and depression are significantly more expensive than those with diabetes alone; with a mean cost of more than $20k per year. But if we treat them with a continuous care model, we would see substantial medical cost savings.

We all know you can’t really treat T2 diabetes without addressing the underlying mental health issues and vice versa. Why, then, is the US so slow to embrace whole health? Can we increase the number of providers for mental health by turbocharging reimbursement for a whole health bundle? ? Unfortunately, mental healthcare is largely an out-of-pocket cash expense. But if we increased the reimbursement rates for therapy, we’d likely see a lot more people go into the much-needed profession. Moreover, we should be reimbursing for health coaches in addition to therapists as they can help with lower to middle acuity mental health. We need holistic support from insurance companies for reasonable mental health rates for both adults and adolescents which will lead to a much more robust network of providers.

In most cases, our healthcare system is a big ship trying to make a sharp turn — change doesn’t typically happen fast. But, as evidenced by some changes made during the pandemic, it can happen. Of all systematic changes to healthcare, these four adjustments would be easy enough to roll out quickly and would have a massive impact on the country’s health outcomes. Just as importantly, they’d bring substantial medical cost savings down the road. It’s well past time for us to admit that our healthcare system is largely broken, and time for our leaders to make the adjustments needed to get it back on track.

Photo: sweetandsour, Getty Images

Stephanie Tilenius is Founder & CEO of Vida Health, a virtual care platform that treats a whole person – and a whole population – by addressing a full range of chronic conditions and the behavioral conditions that accompany them. Vida is deployed in Fortune 500 companies and large insurance carriers and health plans. Before starting Vida, Stephanie led large consumer and enterprise platforms and P&Ls at Google, eBay and PayPal. She sits on the Board of Seagate Technology.

This post appears through the MedCity Influencers program. Anyone can publish their perspective on business and innovation in healthcare on MedCity News through MedCity Influencers. Click here to find out how.