Making Wellness Work
Elyas Bakhtiari, for HealthLeaders Magazine, August 28, 2009
Wellness and weight loss programs aren't major revenue generators, but healthcare reformers know they cannot effectively control costs without focusing more on prevention.
Let's face it, although the healthcare system has grown progressively better at detecting and treating diseases over the years, it remains lousy at preventing them.
It's as if providers are 20 feet away from an open fire hydrant, mopping up streams of water running down the street in divergent directions. Giving them better tools and incentives to sop up more water is effective to a certain extent, but it is an exercise in futility unless the torrent coming from the open hydrant is addressed and eventually slowed.
As lawmakers toy with potentially massive healthcare reform this year, it is becoming increasingly clear that changing financial incentives, digitizing records, and tracking outcomes can only go so far in reducing healthcare costs and improving quality. Fixing the healthcare crisis will only be effective if everyone—patients, providers, payers, and politicians—start paying more attention to the health crisis.
That means preventing diseases that can be prevented. Estimates attribute nearly 80% of chronic diseases to lifestyle factors, says Kathryn Menard-Rothe, wellness manager for Froedtert & Community Health, a regional hospital system in Wisconsin.
Obesity is the primary culprit, and some of the statistics are alarming: Two-thirds of American adults are now overweight, and nearly one-third are obese. The numbers are reaching epidemic proportions, and the excess weight is leading to more cases of some of the most deadly and debilitating diseases—diabetes, kidney failure, cancer, depression, and heart disease. These conditions are even hitting earlier in life now, in part because one-in-five children under 11 is overweight.
For all the complex cost-savings plans and campaigns to save lives, it can't be overstated how much collective weight loss, and overall wellness improvement, would help in saving money and improving the healthcare system. "The three main things we can do to make a big impact on [people's] lives are to convince them to quit smoking or not start, eat a healthier diet, and be more active. That's really the magic," says Menard-Rothe. "It sounds so simple."
But, in many ways, preventing chronic disease is more difficult than curing them. Bad habits have solidified into cultural norms; change requires new levels of patient responsibility; and perhaps the biggest obstacle is a payment system that provides almost no incentive for wellness and weight loss services that can prevent these problems.
That may change—it has to change. The Obama Administration has acknowledged that healthcare must be more preventive and has promised a greater focus on wellness as part of its healthcare reform efforts. While that might not mean wellness and weight loss as top priorities, it does suggest a changing wind.
Some hospitals have already figured out how to make wellness and weight loss programs work in the current system. Those that are successful will be well-positioned if, in the not-too-distant future, prevention gets the attention (and incentives) it deserves.
Service Line Success Key No. 1: Evaluate how services are organized
The financial case for wellness and weight loss is different from most service lines, but that doesn't mean the services aren't worthwhile. They may not ever be a leading revenue generator for a hospital or health system, but the financial model is often at least break-even, or in many cases a loss-leader that can boost revenue in other sectors.
Insurance companies don't reimburse for most of the preventive services that would be listed on a pamphlet for a typical wellness or weight loss program. Working with that reality, the trick is to target the right types of patients who can pay out of pocket while at the same time building a foundation on the few services that are reimbursable.
For Northwestern Memorial Physician Group's wellness program, that means starting with a base in internal medicine, says JoEllyn Tiesi Trad, RN, MPH, director of health promotion and corporate services for the 92-physician primary care group that is owned by Northwestern Memorial Hospital.
New patients have a choice to either meet with a physician or to enter directly into services—nutrition consults, smoking cessation programs, exercise physiology—in the group's Center for Integrative Medicine and Wellness. "Without the internal medicine foundation, it's hard to pay rent and make it on alternative money that you get," says Trad. "The ability to ground ourselves with internal medicine that is insurance based gives us that cash."
It doesn't have to be primary care that grounds a program. For the Johns Hopkins Weight Management Center, a small portion of reimbursable income comes from bariatric surgery, which is increasingly covered by insurance plans, and other medical and surgical options available to a patient with a weight problem. There are limits to that strategy, however. About 90% of patients receive nonsurgical treatments, so the program has to target patients who are willing to pay for services out-of-pocket, says Lawrence Cheskin, MD, director of the center, which is part of Johns Hopkins Bloomberg School of Public Health in Baltimore.
"It distorts the kinds of patients you tend to see in a treatment program ... It's a process of self-selection to some extent," says Cheskin. "When you're asking people to pay out of pocket, there's only so much you can charge. We generally charge less than you'd bill insurance for the amount of time and services that are provided."
Other physicians can sometimes help with finding that niche patient, as primary care providers often refer patients with serious weight problems to the center, says Cheskin. Reaching out to those doctors to educate them about the weight loss offerings helps build those referrals, but even with referral help, the market is constrained by the reimbursement system.
Key No. 2: Reach out to employers
There is another financial source, however. While federal and private payers don't want to pay for preventive services, and patients often can't, employers increasingly recognize the benefits of improving their employees' health.
Most of Northwestern's marketing for wellness services is directed toward corporations, not individual patients. Savvy corporate executives see the value in reducing health-related absenteeism and lowering the risk for heart disease and other chronic conditions that can add to overall healthcare costs, says Trad.
Northwestern has several "corporate wellness" targeted programs designed to capitalize on this market. It sends physicians and nurses to workplaces to perform physical exams and biometric screenings; it offers a "learn at lunch" series in which speakers visit a workplace and educate employees about wellness and weight loss topics, as well. In each case, the company, not the patient, foots the bill.
"I'm getting more and more requests for nutritionists, registered dieticians, going and doing short consultations with employees, or exercise physiologists who can come and teach employees how to exercise," says Trad. "Companies, as their healthcare costs are going up, are looking for ways to decrease expenses and finding it's cheaper to bring someone in to keep their employees healthy than pay their healthcare bills."
The most eager employers to focus on employee wellness are often hospitals themselves. Froedtert & Community Health's wellness plan, for instance, covers about 5,000 employees in three hospitals and a large clinic. Employees are eligible for a discount of $30 off their medical plan premium if they undergo a health risk appraisal, and the system partners with a disease management company to help high-risk staff.
The goal is to ultimately save money by reducing employees' health risks, says Menard-Rothe, who oversees the plan. "Participants who have multiple risk factors cost about three times as much as a staff member who has zero risk factors. If you're healthy, your average medical claims per year are about $1,350. If you're in that higher risk group, if you have multiple risk factors, your average medical claims are over $3,000. Our goal is to move people away from those risk factors."
This is where the managed care approach to wellness and wellness as a hospital service line converge. One priority of the program is to educate employees about primary care services, particularly if they don't currently have a primary care physician or haven't seen one in a long time. The wellness program refers patients who are interested to primary care doctors who practice at the hospital, creating a cycle that benefits the organization more than once.
Key No. 3: Prioritize the patient experience
Whether a patient is self-pay or part of a corporate or managed care wellness initiative, the real benefit of the service line is often seen in indirect or longer-term financial contributions.
"One of the reasons the hospital is so willing to support the service and keep it kind of upfront is because even though it doesn't make money per se, it's a huge feeder and a huge satisfier to patients," says Trad. "It makes the whole brand look better, plus any referrals we do are done within the system."
But that potential for loyalty is only realized if patients feel they've gotten their money's worth, particularly if they're paying out of pocket. In most of the healthcare system, reimbursement cuts are forcing physicians to spend less time with each patient to increase volume. The financial dynamics of wellness or weight loss require an almost opposite approach.
"It's a very labor-intensive effort," says Cheskin. "I spend an hour with each patient who starts, and that's virtually unheard of in other forms of treatment. This is a means of having perhaps one of the closest relationships with patients that we as care providers and institutions have."
Before starting the weight loss program 20 years ago, Cheskin practiced as a gastroenterologist. While patients are grateful when a doctor can cure an ailment like an ulcer, successful weight loss programs can be more life changing and ultimately earn more patient appreciation, he says.
"If you help someone face the demons that make them susceptible to weight gain and all the health consequences of that, and it also makes them feel better and how they're viewed in society … you've really done something that has a major impact on their lives, and I think you get a lot of devotion and appreciation that you seldom see in other types of healthcare."
Key No. 4: Make it multidisciplinary
The gift of time is one way to up the value patients get from a wellness or weight loss program, but that isn't the only factor that affects satisfaction. Patients often want, and pay for, a fairly wide range of options. Although wellness or weight loss programs benefit from a foundation in a reimbursable field of medicine, the fields and providers involved often run the gamut.
At the Johns Hopkins Weight Management Center, behavioral therapists counsel patients to address underlying behavioral issues that contribute to weight gain. Dietitians and nutritionists explain the details of nutritional health, an area that physicians are often undertrained in, says Cheskin. Exercise specialists, often with a degree in physiology or fitness, teach classes and help patients develop workout routines. Then there are bariatric and primary care physicians to take care of other patient needs.
"I think it's important to individualize care. That's another thing an institution-based program that is multidisciplinary can do better. It's not one-size-fits-all, and you need to be able to step back and see what is working and what is not and change plans midstream if that is what's needed," says Cheskin.
Northwestern goes beyond wellness, even, with the diversity of its offerings. Its program was recently combined with the integrative medicine department. In addition to smoking cessation, exercise programs, and health psychology, a nurse practitioner addresses sexual health, a naturopathic physician offers homeopathic treatments, and acupuncturists, massage therapists, and other nonphysicians round out the care team.
While some of the services may seem ancillary or even unnecessary now, there is a lot of patient interest and pent-up demand. If the reimbursement model changes, hospitals with already-built wellness programs could be well positioned to tap into a new revenue stream.
If insurers begin paying for wellness services, both patient and physician interest in the programs will explode, says Trad.
Elyas Bakhtiari is senior editor for physicians and service lines for HealthLeaders Media. He may be contacted at .
Legislating Wellness
President Barack Obama has hinted at shifting healthcare's focus toward wellness. When he began building momentum for healthcare reform this spring, the president held roundtable discussions with a variety of stakeholders, including business executives from around the country who have demonstrated cost savings through corporate wellness programs.
While praising the results of the programs, Obama suggested that wellness initiatives—such as smoking cessation, healthier eating, and exercise—could be adopted at a federal level.
"You have companies like Safeway that have been able to hold their costs flat for their employees at a time when other companies have been seeing double-digit inflation in their healthcare," Obama said. "Now, if we can do that in individual companies, there's no reason why we can't do that for a country as a whole."
But how important will wellness and weight loss be in the context of broader healthcare reform?
There are a couple of possible approaches. Congress could simply focus on strengthening the employer-driven wellness movement. Sen. Tom Harkin's (D-IA) Healthy Workforce Act of 2009, which would offer tax breaks to employers that implement wellness programs, already seeks to do that. Alternatively, Congress may look to integrate wellness more fundamentally into the healthcare system.
Sens. Ted Kennedy (D-MA) and Max Baucus (D-MT) seem to favor the latter approach and have suggested strategies such as eliminating copays for recommended preventive services provided by Medicare and Medicaid and providing grants for communities to develop wellness programs. Both approaches may receive more support. But ultimately, it will be difficult to consider healthcare reform legislation successful if it doesn't include payment for physicians and hospitals to prevent, rather than just treat, chronic diseases.