Outlier Wellness

Outlier Wellness

“Only a handful of outlier health problems are preventable in any real sense,” writes Dave Chase in his book The Opioid Crisis Wake-Up Call, “about seven percent, according to my colleague, Al Lewis.”

 

My last post was about the cost of outliers, how just a small percentage of patients account for a huge percentage of overall healthcare spending in the United States. We know that there are a few unlucky individuals whose healthcare is incredbily costly, yet they are not the first people we think of when we think about excessive healthcare spending in the United States. As a result, we fail to truly understand the weaknesses of our healthcare system and how our healthcare dollars are actually being spent. We introduce programs that don’t actually address the real problems in escalating healthcare costs.

 

This is where the ideas about and problems with wellness programs begin. Chase continues, “While the notion of workplace wellness and prevention was a noble idea, we now know that company after company is spending a huge amount of plan dollars and resources trying to do something that can’t be done.”

 

The idea of workplace wellness programs is to encourage healthy living habits and lifestyles of employees. Since our employers are usually paying a lot for our healthcare coverage and sometimes directly for our healthcare, anything employers can do that makes employees more healthy, outside of the healthcare space, will reduce the healthcare costs and needs of employees, generating a return on investment in the long run.

 

Unfortunately, the people who cost the most, who really drive incredibly high healthcare spending in the United States, don’t suffer from conditions that can be addressed through workplace wellness programs. Your plan to encourage workers to walk more, to buy foam rollers for the office, and to reward employees who count calories is not going to prevent an employee from being diagnosed with a congenital heart arrhythmia, won’t stop a rare blood disorder, and isn’t going to prevent any other unpredictable obscure disease from costing thousands or millions of dollars for your health plan.

 

What is worse, wellness programs usually just encourage those who are already living healthy lifestyles to flaunt how healthy their lifestyle already is. You likely won’t reach or encourage the employee who has a second job someplace else, the single mom with two kids who is just  trying to get dinner on the plate each night, or the employee who has been discouraged and dejected their whole life. An Apple Watch or an iPad isn’t going to solve the problem of a long commute, an unsafe neighborhood, or past trauma. We spend a lot of money on wellness plans that don’t address the real upstream social determinants of health for many employees, and can’t possibly address the health problems of the most expensive outliers in our healthcare system. The idea of workplace wellness programs has the right spirit, but the truth is these interventions need to happen at a much larger level than what the employer can really address.
Businesses and Healthcare Solutions

Businesses and Solving Healthcare Problems

We often overlook businesses when we think about the problems in American healthcare and how we can fix the issues that plague our system. But about half of all American’s receive their health insurance as a benefit provided by their employer. Businesses purchase and provide health insurance for millions of Americans, and must think about employers and the plans they offer when we think about the problems in the American healthcare system.

 

Everyone will tell you that healthcare is complicated. We know that insurance is hard, getting to a doctor can be hard, understanding what you have to pay is hard, and trying to guess what kind of plan you need for the next year is hard. All of this makes the solutions to our healthcare problems hard, but for a majority of Americans, the person who is shaping the structure in which they will make these decisions and figure out what is available to them is someone at their job. And for a lot of those Americans, the person at their job is probably in HR, and their main goal is not to find a great healthcare solution for the employees, but to just not get yelled at by the CEO for raising health insurance coverage costs and to avoid being yelled at by unhappy employees. Nevertheless, businesses can step up and play a role in making changes for the positive in the American healthcare system.

 

Dave Chase in his book The Opioid Crisis Wake-UP Call writes, “The opioid crisis is a complicated issue over 30 years in the making. But companies have played a major role in creating and sustaining the crisis. And a vanguard of employers are realizing that they have a major role to play in solving it, and that the solutions fall well beyond what the government alone can do.”

 

Companies, since they control the healthcare of half of Americans, can start making real changes to the care available to people. Employers who set up their own plans can make primary care access, physical therapy, and nutrition services virtually free to their employees. By providing a greater selection of preventative services, they can improve employee well-being and reduce the likelihood that an employee will deal with chronic pain and develop an opioid addiction. This is an over-simplified example of what companies can do, but it is important that we realize that the employer is a major player in the fight to improve the American healthcare system, and if we don’t step up to demand better from our employers, we won’t see the changes we want.
Constructive Thoughts on Wellness

Constructive Thoughts on Wellness

There is an argument in the world of public health that the American medical system is too focused on solving problems rather than preventing problems. This argument that is presented in Sam Quinones’ book Dreamland, expressed by Dr. Alex Cahana, “The U.S. medical system is good at fighting disease, … and awful at leading people to wellness.”

 

The difference between fighting disease and leading people to wellness has to do with where you step in to help with people’s health. Our country generally focuses on providing medical care and attention after someone has gotten sick. We ask doctors, nurses, and medical professionals to correct a huge range of problems, many of which stem from bad habits, unhealthy environmental factors, and conditions that are generally beyond the control of an individual, and not open to medical interventions. Attacking the problem once it has already developed, once a set of factors have set in that promote the health problem, makes any real changes expensive and difficult.

 

Wellness requires that we think about medical care, costs, and health further upstream, before anyone ever gets sick. Consider the idea of wellness in the context of car maintenance (I know, I know, I just wrote about the problems with comparing ourselves to cars, but this will be helpful).

 

If you regularly change your oil, rotate your tires, and drive as if your grandma was in the car with you, then your vehicle is going to operate more smoothly with fewer major costs (in general) throughout its entire life. You are making small interventions along the way to make sure your car is operating optimally. The costs of changing your oil and putting in the necessary effort to keep it working well are not trivial, but we know that those costs are less than what we might face otherwise.

 

Failing to maintain our vehicle could lead to a catastrophic engine failure. Driving our car like a teenager that just downed two Redbulls is going to put a lot of strain on the vehicle, wearing out our tires and breaks much faster. When things wear our quicker, when unexpected failures occur, we suddenly have to pay a lot more money to keep the car going.

 

Our bodies are similar, and whether it is our national Medicaid or Medicare systems, or our private health insurance systems, the cost we pay for healthcare is interconnected with where we step in to try to make people healthy. Paying for interventions downstream, once we already have health problems is expensive. It is equivalent waiting until our human check engine lights turn on before we consider doing anything to help our health. The solution that many medical professionals and many public health researchers encourage is moving upstream from the actual health problems that develop to focus on interventions before anyone develops terrible disease. The idea is to focus on wellness first, and hope we don’t have to pay for as much medical care for the prohibitively expensive diseases down the road. Rather than focusing all our effort on solving disease, we can redirect some of the money and effort into improving our environments, finding new ways to help people adopt healthy lifestyles, and finding more ways to connect and help us share in wellness as a community.
A Different Take on Chronic Pain

A Different Take on Chronic Pain

In his book Dreamland Sam Quinones includes a quote by Dr. John Loeser, Professor Emeritus of Neurological Surgery at the University of Washington in Seattle. Quinones spoke with him to better understand chronic pain and how chronic pain can be approached without the use of opioids. Loeser has an approach to treating chronic pain that doesn’t rely purely on drugs and is more centered around the patient, their environment, and their social supports. Loeser describes his approach as a bio-psycho-social approach and Quinones provides the following quote:

 

“Chronic pain is more than something going wrong inside the person’s body. It always has social and psychological factors playing a role.”

 

What I think is interesting with this quote is how far it is from the experience that many of us have with doctors and medicine today. Much of our medical care comes in tiny ten minute packets, where we go back and forth with a doctor for a few minutes before they write us a prescription for something and send us on our way. The providers often don’t end up doing much to help us through our current issue, and we rely on a pill to suddenly make our lives better. The approach completely misses many other factors of health.

 

Where we live matters. Who we have in our lives matters. What our diet is like, what stress factors exist around us, how easily we can get outside or to a gym for physical activity matters. A ten minute conversation and a pill cannot address these issues and certainly cannot change them.

 

I’m not introducing this all to suggest that chronic pain isn’t real, or that it is all in a person’s head. I’m also not introducing it to suggest that people suffering from chronic pain simply are not trying hard enough, need to take more personal responsibility, or just need to move to fix their pain. Often these social determinants of health are beyond the control of any one person. Before criticizing another person, and if we want to help them, we must also consider their environment, and whether we ourselves are a factor that helps or hinders the health of another.  Our world is too connected to say that someone’s health is purely a matter of their own choices and behaviors, even if personal responsibility does have a role to play in managing health. Approaching health from this angle helps us understand that an opioid is never going to be sufficient in truly alleviating chronic pain. There have to be more efforts to understand the bio-psycho-social realities of the person’s life and the chronic pain they experience.

The Benefits of Joining a Choir?

I have never been much of a singer, and the last memory I have of singing in a group (besides a happy birthday here or there) is from elementary school, when I got in trouble and had a parent teacher conference with my mother and the music teacher because I was inserting inappropriate lyrics into the song You Are My Sunshine (I’ll let you guess what kind of lyrics a fourth grade boy came up with for that one on your own).

 

Public singing, however, might be something that is really good for human beings, especially when done in a group. Dan Pink highlights the benefits of choral singing in his book When, “The research on the benefits of singing in groups is stunning. Choral singing calms heart rates and boosts endorphin levels. It improves lung function. It increases pain thresholds and reduces the need for pain medication. It even alleviates symptoms of irritable bowel syndrome. Group singing – not just performances but also practices – increases the production of immunoglobulin, making it easier to fight infections. In fact, cancer patients who sing in choirs show and improved immune response after just one rehearsal.”

 

That is a huge range of benefits from something as simple as just singing in tune and rhythm with other people. Pink presents the study in his book when talking about synchronicity with other people. He also highlights rowing competitions and the benefits that individuals receive when working in concert with other people. Being part of a group engaged in a singular activity and actively synchronizing your physical body in time with others seems to be something that brings humans a lot of benefits.

 

When specifically looks at choirs and row teams, but I would not be surprised if you saw similar benefits from people who run together in groups, play Hungry Hungry Hippos together, or engage in flash mob dances. I would expect that anything involving social interactions and coordination among people will begin to build the types of health benefits that researchers have found with choral singing. Physical activities probably boost our health more than board games, but I would not be surprised if studies of social board games would show reduced stress and improved physical health markers as well.

 

I think this is an under-explored area, especially in the United States. We really like our individual super heroes, who carry the weight of the world on their shoulders. We subscribe to the Great Man of History view and if you look at this year’s presidential election you will see arguments from the Democrats about which candidate is the one who can deliver and unseat the current president, but you won’t hear arguments about who can bring together the best team of thinkers and policy makers. Our country, with a foundation of Protestant work-ethic and a capitalistic culture that tells you that you can purchase everything to make your life fulfilling, is stuck on individual interventions and choices to health and happiness.

 

Choral singing and rowing and Hungry Hungry Hippos (ok no research on that last one) shows us that we need groups and benefit from social interactions and synchronicity. Despite the way we think about ourselves and our role in society in the United States, we depend on others and when we coordinate with social groups, we feel better. My suspicion is that any research into the health benefits of activities done socially will yield positive health results. This is an area we should explore more broadly, and in our individual lives, I believe we all need to take more steps to join choirs, do our exercising with other people when we can, and set up our own Hungry Hungry Hippo board game groups. It is not just our individual selves who will benefit and who need these groups, but all of society.

On Naps

Quoting Nicholas Bakalar from an article in the New York Times, in which Balakar cites research from a 2007 journal article by Androniki Naska et al., Dan Pink writes the following in his book When: “Naps also improve our overall health. A large study in Greece, which followed more than 23,000 people over six years, found that, controlling for other risk factors, people who napped were as much as 37 percent less likely as others to die from heart disease.” Quoting Bakalar directly, “an effect of the same order of magnitude as taking an aspirin or exercising every day.”

 

In the United States, we are really missing out by not having a siesta culture. Pink was skeptical of naps going into his book, but I’ve listened to him in a couple of podcasts describe how the surprising benefits he uncovered have changed his views toward napping. Relatively short naps, say 20 minutes or so, can provide us with a lot of benefits: reduced blood pressure, better cognitive functioning, and increased vigor to name a few. Naps can have a big impact on overall health and well being, but in the United States they are not appreciated and are in many ways looked down upon.

 

Pink writes, “In general, concludes one analysis of about twenty years of napping research, health adults should ideally nap for approximately 10 to 20 minutes.”

 

For some reason, we believe that all one needs to do to be an effective and efficient employee is get a full night of sleep and then have the willpower to work hard and churn out good work throughout the day. Our ability to not be distracted, to think clearly, and to produce innovative insights are all seen as within our control if we simply work hard enough and apply ourselves with dedication.

 

The research into naps, however, suggests that we are thinking of our personal strength in focusing and producing meaningful work incorrectly. Rather than just focusing on our effort and intention with our work, we should consider our environment and small tools and techniques that can help us perform better. Yes, we should make sure we sleep well at night and find ways to motivate ourselves to do our best deep focus work, but we should recognize that it can’t all be 100% on our conscious brain. Yesterday’s post talked about the restorative power of walks, and today’s post is about the restorative power of naps. Both of these activities can seem like foo-foo time wasters, but they can actually be quite powerful in giving our brain a chance to reset and perform better in the time after we step away from our work. Rather than valuing people as automatons who should be chained to a desk of productivity, we should remember that we are creative, thinking, problem solvers, and need a little TLC to help our brains perform the best on work that matters.