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.
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.

Personal Medical Decisions?

A couple weeks back my grandma sent me a message on Facebook that was a picture of two very obese individuals eating a giant pizza and drinking soda. A caption on the photo read, “This is why I don’t want to pay for your healthcare.” As a person who is interested in and taken classes about public health and health policy, I actually think about these things all the time. I recognize the importance of making smart health choices, but I also understand that health outcomes can be a result of a complex web of social determinants of health. There are factors that are beyond our control in regard to living healthy, and there are some factors that seem like easy decisions to some people, that are monumental challenges to others. Despite the amount of time I spend thinking about these things, I don’t have a clear answer in my head for when people need a tough love kick in the pants versus compassion, and when a given outcome is generally more the result of poor individual decisions and habits or more the result of uncontrollable social determinants of health. There likely is no clear answer to this question, and I think it is reasonable to say, “I have thought about this a lot and I don’t know.”

 

This leads me to another factor that compounds the complexity of healthcare decisions: What choices, decisions, and behaviors are personal, and which ones should be considered public? If I chose to smoke, is that a personal decision even though there may be public consequences if I die early, have poor health overall, and require more emergency medical care which ultimately drives everyone’s healthcare premiums up? Do I have to exercise every day to stay healthy as a public good and not just as a private good? If I go get an x-ray on the ankle I sprained to make sure it isn’t broken, is that going to take time away from medical professionals who could help someone that really needs it when all I likely need to do is ice it a little bit?

 

In the book The Elephant in the Brain, Kevin Simler and Robin Hanson write about Steve Jobs and his decision to forgo cancer treatment as recommended by the American Medical Association’s best practices. Jobs is an interesting case because the fortunes of a company that many people love rested on his medical decisions. Beyond just his own health and the considerations of his family, people felt that they had their own money on the line if they owned apple stocks. If Jobs lived and survived his illness, it would be good for Apple, but if he denied standard treatment and died, what did that mean for the public?

 

“The point here,” write Simler and Hanson, “is that whenever we fail to uphold the (perceived) highest standards for medical treatment, we risk becoming the subject of unwanted gossip and even open condemnation. Our seemingly personal medical decisions are, in fact, quite public and even political.”

 

The kind of medicine we pursue and the lifestyle we live are never going to be restricted to just ourselves. We will at the very least be judged by others for our health and medical decisions. Our choices may or may not have major financial implications for other people, but that doesn’t mean that we can make our choices in a vacuum.

 

What is important to remember here is how complex the line is between personal and societal responsibility. Our individual decisions can have bigger impacts than we realize, and it is hard to keep something just within our own bubble. Added to that are questions about liberty and the authority of the state. It is not an easy question to ask if your diet should be controlled by anyone other than yourself, or if you should be forced to exercise and sleep a certain amount. Approach questions about healthcare understanding that these questions don’t have clear answers, and whichever choice we make is going to have strange consequences as a result of these complex inter-dependencies.