For decades, the cost of health care has been rising much faster than the rate of inflation – now, nearly one dollar in every five dollars that we spend in the United States goes toward delivering that care. Arizona State University researchers, like many others in the medical field, have seen that this rate of growth is neither desirable nor sustainable. Unlike many others, ASU’s scientists have a conceptual framework that holds the potential to reverse this trend.
What if, they ask, we could keep people from needing to go to the doctor in the first place?
ASU is at the forefront of efforts to shift health care from its current focus of treating people primarily at the point when they get sick enough to need a doctor’s care to a system that works to maintain wellness by concentrating on how best to support healthy behavior and how to most effectively treat the biggest consumers of health care, the chronically ill. Such a change would require tools and analysis from many quarters, from policy and law to behavioral psychology and cross- cultural studies, but the university’s strong transdisciplinary orientation is particularly well-suited to address this challenge.
“It’s a fundamental shift,”says Denis Cortese, director of the Healthcare Delivery and Policy Program at ASU and emeritus CEO/president of the Mayo Clinic.“I’m not convinced it’s gained a lot of speed yet from a national perspective, but in certain places, like ASU, things have been shifting already.”
Breathing easier about chronic health conditions
The biggest opportunities and rewards from this change in focus come through addressing chronic health conditions, which account for about 75 percent of health care spending.“The fundamental difference is in how we keep healthier the people who are living with chronic conditions,”Cortese says. “The traditional way would be to treat them when they are sick, but the new way is to keep them out of the hospital in the first place.”
An example, says Cortese, is childhood asthma. When their asthma is not well controlled, kids spend more time in the emergency room and less time in school. The new model of care might involve nurses who can work with the kids to teach them to monitor their own air-flow rates and medications, as well as assistance from a distance using cell phones or text messages, he notes.
Keeping people healthier and preventing health crises are complex tasks, that require a hard look at everything in people’s lives that might contribute to them becoming sick or remaining well, and tracking outcomes to prove which interventions work.
“We are very interested in finding behavioral health solutions that are empirically grounded,” says Jonathan Koppell, dean of the College of Public Programs (COPP). “Many times people know what they are doing is not good for them. So the problem isn’t purely informational. It is about figuring out how people are able to transform their lives.”This is a core part of the mission of COPP, Koppell says, as is advancing policies that promote that sort of analysis.
Because people in various life stages and circumstances can be so different, researchers often have to delve deep into those lives.“A lot of our work is looking into people’s behavior and how that contributes to their efforts to maintain their own wellness,” says Colleen Keller, a Regents’ Professor and a Foundation Professor in Women’s Health, as well as the director of the Center for Healthy Outcomes in Aging at ASU. Keller and her colleagues look at various components of behavior, nutritional activities and weight management, focusing on women of color in general and Latinas in particular.
Keller focuses on certain phases of life where changes in a woman’s health status are the greatest – phases where interventions can have the greatest effect. “We look at things like menarche, or having a second or third child, which might affect them because they have gained so much weight,”Keller says. “Menopause is also a critical time because women undergo hormonal and social changes that may lead them to comfort eating or taking on a sedentary lifestyle.”
The other thing that Keller’s group looks at, she says, are the people who tend to have factors that keep them from wellness behaviors. “Poor nutrition, poor access to health care, family or cultural factors that don’t place high value on physical activity, a lack of access to team sports in high school, or simply a need to have multiple jobs to survive—all of these things can preclude physical activity and lead to poor dietary decisions such as grabbing fast food,”Keller says.
The cost to take care of the chronically ill is currently unsustainable, but even shifting to a more prevention-oriented model will take an investment.
“The future of our nation’s health care delivery will require us to stand up and address the issues of the people who need it the most and (who) will cost us the most, so that we can survive economically,”Keller says.
All for one, one for all
For Gabriel Shaibi, the shift to wellness maintenance also will require a shift to a more community-based model of care. “In order for programs to be effective, we have to look beyond individuals,” says Shaibi, who is an associate professor in the College of Nursing and Health Innovation.“The context where individuals live and work is just as important.”
Shaibi’s work involves preventing obesity-related disease in high-risk kids, especially in minority communities. He and his colleagues have implemented a culturally grounded program that is developed in collaboration with the community to be delivered in the community.
“Community members can deliver information in ways that are more digestible and meaningful for kids and families,”he says. When health behaviors don’t resonate, kids will often drop them soon after a study is over, he says.“Our goal is to deliver information that empowers kids to change their behaviors and reduce disease risk, not tomorrow and not ten days from now, but for the rest of their lives.”
Community-level interventions are also more economical and practical, Shaibi adds.“Providers are trained to identify signs and symptoms and deliver treatment for a certain condition, but they may not necessarily be trained to deliver prevention programs. Communities may be better able to encourage healthy behavior changes.”
Groups that may be in a better position to create change might be county health departments, recreation departments, schools or nonprofits like the YMCA, he says. “These agencies have the potential to reach tens of thousands of individuals a year at a much lower cost than could be done through current medical models.”
Striding over the hurdles to health
While ASU researchers are excited by the possibilities for change in the health care system, they also recognize there are a number of challenges. For one thing, changing the current health system may require certain changes in the law, says Gary Marchant, a Regents’ Professor and the Lincoln Professor of Emerging Technologies, Law and Ethics at the Sandra Day O’Connor College of Law.
Moving health care toward a greater focus on prevention is good for society, but there are important legal implications to those changes, Marchant says.
“The trouble with the legal system is that it has a hindsight bias. There is increased legal liability for doctors because someone can go back after they get a disease and say ‘you should have seen this sign, you should have prevented it.’”
Whether people are considered sick also could change if having a certain biomarker is considered a sign of illness even before symptoms show up. Or people could sue for exposure to hazardous chemicals even if they weren’t sick, simply because it increased their risk for disease.
“The net effect of changes in the health care system will be healthier people, but they are going to produce a lot more work for lawyers,”he says. Money is also a big challenge. Right now, health care providers are paid for treating sick people. There are few mechanisms to pay doctors to treat someone who is currently healthy in order to keep them healthy. One model, says Denis Cortese, is to give providers a set lump of money to take care of a particular group of people with a chronic condition.“If they don’t do a good job keeping the patients healthy they will actually lose money, and if they keep them health they make money,”Cortese says.
Although the challenges to changing the system are wide and deep, Cortese and others think that ASU’s multidisciplinary approach will ultimately be successful. “It’s an all-hands-on-deck effort by ASU,”Cortese says. “Other academic institutions are thinking similarly, but they have not been quite as broad-based in their approach. In the long term, as our country gets serious about better health care at lower cost, the program at ASU will be important to have in place.”