Three Market-Based Strategies to Prevent Chronic Illness

In prior posts, I’ve asserted that both the individual and society share responsibilities for the prevention of chronic illness (see Individual v Community Responsibility for Health, KP 101: our philanthropy, and A Tour of Trees, among others).  I’ve also described the gap that often exists between what an individual knows he/she should do and what is actually done (The Knowing Doing Gap).

the vitality institute logo

In this post, I’ll combine those themes in the context of the Vitality Institute, a non-profit NGO launched last year seeking the creation of public-private partnerships that promote health (rather than healthcare) and prevent illness (rather than measures to treat it). Instead of arguing my point using the traditional science of public health, however, I’ll use the science of market-based economics, believing the latter more useful when understanding and influencing human behavior. Each example I provide is scalable, from a small to large company or community.

First, Create Supply… of healthy food choices, fitness opportunities, and preventive services. I know, I know. Traditional econ says demand precedes supply. But I believe the opposite is true when creating healthy human behavior, because 2 million years of evolution has hard-wired us to prefer simple sugars, dietary fat and animal protein, and the conservation of calories.

atlanta beltline

Public Supply – provide multiple points of entry to multiple green spaces (see Atlanta Beltline); set aside land for future public parks (see Trust for Public Land or Georgia Conservancy); provide subsidies for communities to nurture Green Markets and Buy Local campaigns; correct the imbalance of supply of unprocessed ingredients (i.e., grocery stores) and processed food (i.e., fast food restaurants) in low socioeconomic communities; create bike and pedestrian space (see TED Talk of Janet Sadik-Kahn, NYC DOT under Mayor Bloomberg, Atlanta Beltline); spread Power Up for 30 in our public schools (see GA Shape); and embrace certain provisions of the 2010 ACA (preventive care has no co-pay).

nyc bike and pedestrian lanes

Private Supply – corporate subsidies of gym memberships or Zumba classes; provision of showers and locker-rooms in the building; change the contents of vending machines; create non-smoking campuses; arrange for healthy food trucks during lunch; build on-site health clinics;  sponsor nutrition classes and flu-vaccine fairs.

Second, Create Demand… for those good choices. Wouldn’t it be cool if we changed our worship of beautiful appearance to worship of healthy behavior?  I’m told some women do indeed prefer salad-eating, gym-going men.

Public Demand – insist grocery stores provide the provenance of produce; create compelling advertising and marketing campaigns that express the benefits to individuals of buying local (think of the successful Made in the USA campaign); revise the school lunch program to provide healthier choices, then make those choices more appetizing to kids (yes, it’s been done successfully);

buy local

Private Demand – sponsor participation in fitness or philanthropic programs like the annual KP Corporate Run Walk, AHA Heart Walk and Komen for the Cure; sponsor corporate “challenges” like the TSPMG 21-day Vegan Challenge, or one of the biggest loser competitions;

Lastly, Facilitate Consumption … of those good choices.  Seldom do we behave in healthy ways merely because those choices are available, coupled with the knowledge those choices are “good for us”. Our belief systems, borne from our past experiences, dictate our behavior much more than “perceived choice” or “possession of knowledge about the potential benefits of the better choice”. Those better choices must align with our individual, immediate feelings and benefit our individual, long-term interests, whatever they are.

weight of the nation

Public Consumption – make the public green-space safe at all hours of the day; make city-bike programs easy to use and affordable; ensure the safety of pedestrians and cyclists on city streets; halt the subsidization of high-fructose corn syrup (watch Weight of the Nation), and perhaps begin a modest subsidization of fresh produce; create funding for infrastructure that reduces commuting time (such as the 2012 Georgia Transportation Referendum), thus increasing discretionary time for fitness or food preparation.

Private Consumption – employers can provide podometers and incentives to employees to “consume” fitness or proven preventive screenings; healthcare providers (physicians, hospitals and delivery systems) should prove that a specific level of in-year employee consumption of their employee’s good choices will guarantee for the company an equally specific decrease in healthcare costs or increase in profitability.

jawbone

In my market-based approach, I’ve deliberately ignored the important area of Reducing Risky Behavior. Institutions such as the CDC, States Department of Public Health, National Transportation Safety Board, NIOSH and OSHA (among many others), have that covered.  But one could summarize all as “abstain from tobacco, avoid excessive alcohol, use condoms, and wear seatbelts”, roughly in that order).

Kaiser Permanente has been a national and local leader in creating and enhancing such public-private partnerships for the betterment of America’s health. Just here in Atlanta, we’ve sponsored the Green Market at Piedmont Park, the Annual Corporate Run-Walk, the Eastside Trail of the Atlanta Beltline, the HBO documentary Weight of the Nation, the 21-day Vegan Challenge, gym memberships for employees, and so on.  More such partnerships and infrastructure are needed in Atlanta and across the US to create the supply, demand and consumption of healthy behavior, if we are to reverse America’s raging epidemic of chronic diseases.

Farewell, KP

At the end of this month, following 20 years of service, I will leave Kaiser Permanente.  For each of those years, I’ve given all I had to the organizations – particularly during the last ten years.  It’s simply time I do something else.

I’m proud of what we have built together:

We’re #1 in Quality in the state every year, now nine years running, and one of only three Medicare Advantage plans east of the Mississippi that has earned the coveted 5 STARS.

We are a medical group with a wide range of specialties, broad capabilities in analytics and the science of improvement; led by physicians, professionally managed.

And a medical group that works hard to get better every day. 

My decision to leave has nothing to do with our business in the Georgia Region.  Our care model and quality results are the envy of the Georgia market. 

Rather, it’s time I use my experience and skills to make a difference “out there” – beyond KP and beyond the Georgia market.  I’ve accepted a role with Huron Consulting, headquartered in Chicago.  Huron has a well-earned reputation for providing sustainable operational, financial and work-flow solutions to healthcare providers, intently listening to and serving its clients.   Huron also is a cultural fit for me – a collaborative team of hard-working consultants that enjoy helping clients.  I hope to help the industry transform from “fee for service” to “fee for value” and create safer, more effective, and patient-centric care.  That’s been my mission since my days in training.  It’s why I made KP my home these 20 years. 

I’d like to think I’m leaving our Medical Group in better shape than I received it.  And, as proud as I am of this organization, the next EMD will make it even better.  Please show him or her the same support, the same enthusiasm, the same high commitment to excellence and continuous improvement that you’ve given me. 

In these final days, I’m thinking of my happiest moments here… the time spent at the bedside with you, my trusted colleagues, together figuring out our patient’s illness and what you and I were going to do about it… documenting incisive medical reasoning… using evidence-based medicine… putting the interests of the patient and family above all others. 

I wish you all well. Thank you for 20 great years.

Kids Must Move

 kid bored

Allow me to ask three questions, each having the same answer, I believe. 

1.       “What is the most important tactic in our fight against childhood obesity?”

2.       “How can we improve childhood learning in the classroom without cramming any more fact-memorization into an already bulging curriculum?”

3.       “What will cause kids to ‘behave’ better during classroom instruction, having nothing to do with teacher-enforced discipline?”

 Exercise. Before and during school.   

kid zumba Nov 2013

Largely as a result of budget constraints and the pursuit of higher Standardized Test Scores, most schools have eliminated exercise (“PE”) from the student’s day.  Bad idea.

 Sope Creek Elementary School in Cobb County has reintroduced exercise into the school day, mostly before school, but yes, even at the expense of some classroom time during the day, improving test scores and classroom behavior along the way.  Any good parent knows that kids must move … to behave, to grow, to be happy.  Furthermore, as a community it’s time we attack the greatest threat to current and future generations of Georgians … childhood obesity (for more information, see the state-wide initiative known as GA Shape – we are making a difference). 

 GA Shape logo, Nov 2013

Here’s what Sope Creek Elementary did, organized by Principal Martha Whalen, Coach James Hunt and Coordinator Shawn Maloney:  (1) began a 20 minute Zumba class before school, (2) ensured that all kids, every school day, had at least 30 minutes of exercise while at school, typically in a low-cost activity like running, shooting hoops, or playing hand-ball with a dodge ball, and (3) made it fun (!) for the kids.  All kids that I saw and spoke to, of all ages and backgrounds and body types were thrilled to be moving.  It was way more about the moving than the specific exercise, although everyone loves Zumba.   

 exercise & test results Nov 2013

Here’s what happened: kids now race off the bus to the Zumba room; kids compete with self to improve their running time or distance; absenteeism declined; 5th graders teach the Zumba moves to 4th graders, who teach the 3rd graders; the song/dance repertoire was 5 songs, now 20; the kids are more calm and attentive in class; standardized test scores were already high in the school, and got measurably higher. 

 cardio and scholastics

In fact, as fitness improved for a child (as measured by a simple schoolyard aerobic-capacity test) scholastic aptitude improved (as measured by CRCT tests).    That finding is not new … read “Spark” for more information.

Spark book cover

All ages should heed Sope Creek Elementary’s insight.  We humans must move … to behave, to grow, to be happy … regardless of age, but especially when young.

einstein rides a bike  

The Face of Future Health Care

Journalist Reed Abelson begins his New York Times article today with “When people talk about the future of health care, Kaiser Permanente is often the model they have in mind.” Let’s examine the ‘why’ and the ‘how’.

We believe better-coordinated patient care leads to more rapid diagnosis, more rapid and effective treatment, through a more humanistic and holistic approach, individually tailored to the person before us. We achieve those superior outcomes first and foremost through (1) a culture of collaboration (highly-reliable team-care, Patient-Centered-Medical-Homes [PCMH]), (2) a culture of safety (best care, best time, best place, no errors), (3) a culture of continuous improvement, powered by (a) sophisticated technology (our exceptional electronic medical record – embedded with the latest best practices; analytics; and performance management systems), as well as (b) physicians and staff who confidently place the interests of the patient before all else.

We believe that physician pay should compensate for long hours of very intense work, devoted to the patient and family, simultaneously devoid of financial incentives of self-enrichment. That’s why our physicians are salaried, rewarded for individual or collective quality achievement, patient satisfaction, and keeping members optimally healthy. Traditional models of healthcare, particularly “fee-for-service” (FFS) models, lead to self-enrichment by maximizing testing, treatment, surgeries and hospitals, often without benefit to the patient (see Atul Gawande’s 2009 New Yorker article, or Steven Brill’s 2013 Time article, among many others).

We believe that physician leadership is a critical component of “re-engineering care” to make it more affordable, more highly satisfying, and more effective, as Mr. Halvorson states in the interview. To do so requires the sensibilities, experience and expertise of physicians. We provide the care in the exam-room, at the bedside, in the OR, after all. Our medical groups are self-governed, making ALL medical decisions with patient and family through a shared-decision-making process. What the Permanente physician establishes as medically necessary for that particular patient gets done, without ANY interference from the insurance end of the business. See my recent editorial in the Atlanta Business Chronicle for more information about the role of physician leadership in redesigning medical care in our country.

We are indeed the face of future health care, AND we have even more re-engineering work to do before we sleep.

It’s Good To Be Home

It’s an iconic scene in a classic genre.  One of the show’s many protagonists walks through the door, and everyone exclaims “Norm!!”.  It’s good to be home.

Home and House mean different things.  Home is warm, welcoming, and safe.  Home comforts you, and if needed, fixes what ails you, through a community of people who care deeply for you.

The National Committee for Quality Assurance (NCQA) recently recognized five Kaiser Permanente of Georgia (KPGA) Medical Offices as Patient Centered Medical Homes (PCMH). The five medical centers – East Cobb, Lawrenceville, Holly Springs, Sugar-Hill Buford and Cumberland – all earned Level 3 recognition, the highest possible recognition.

PCMHs use systematic, patient-centered and coordinated care processes, which leads to more rapid, effective and personalized healthcare.  Kaiser Permanente is the first organization in Atlanta with multiple locations to receive the recognition.

Our primary care physicians lead a healthcare team that takes collective responsibility for patient care, preventing illness, diagnosing and treating illness, and when needed or desired, arranging for care with other clinicians, often colleagues within our Permanente Medical Group.

Organizations that use the PCMH model of care typically have better patient outcomes, increased patient satisfaction, and deeper staff fulfillment.  Those outcomes reduce waste in healthcare as well.

All adult medicine and pediatric offices should receive PCMH recognition by the end of 2013.  Our members deserve nothing less.

Must Innovation Always Involve Electrons, Steel and New Molecules?

Like many Americans, I eagerly await the release of the next-gen iPhone, Ford Focus and new uses of carbon-fiber in manufacturing.

Like all physicians, I celebrate the enhanced precision and clinical efficacy made possible with the use of electronic medical records (EMR), robotic surgery and immune-modulating biologicals.

But what if I told you that “workflow” (the precise sequences nurses, doctors, and pharmacists use to get their work done) creates MORE health benefit for Americans than the more-celebrated new electrons, steel and molecules?

Three decades ago, air travel transformed itself – it is safer to fly (commercial airlines) than drive your car. That improvement in safety was NOT due to new electrons (our air-traffic control systems are archaic, bound together with duct-tape); NOT new steel (with rare exception, airlines fly airplanes designed in the 1970’s, built in the 1980’s, and updated in the 1990’s); NOT new molecules (except for the troubled carbon-fiber Boeing 787).

Instead, the airline industry created exemplary safety (and efficiency – airlines ‘turn-around’ a plane within 45 minutes) using efficient and reliable workflow, checklists and culture-change. We’ve used those same tools in healthcare to reduce infection / sepsis, more quickly liberate patients from the mechanical ventilator, and reduce medication errors.

Sometimes the most useful innovations in healthcare come from redesigning HOW we care for patients. That’s why at Kaiser Permanente we’ve invested not only in new electrons, steel and molecules, but also process improvement, continuous quality improvement and the creation of highly-reliable teams. All for the benefit of you, our 9 million members.