Can We Save Wellness from Obscurity and Reinvigorate the Patient-Physician Relationship?
Part III in an exploration of wellness in healthcare
I complained earlier in this exploration of wellness about the missed opportunity for primary care providers (PCPs) to not only engage with, but lead on wellness programming for their patients. It’s not that I’m ignorant of the abundance of wellness programming already live in the market. The problem from my vantage point is that the majority of programming is sponsored and deployed by employers that come with far too many shortcomings, some inherent (i.e., poor uptake and limited accountability) and others that appear to be misguided design (i.e., overly ambitious goals or insufficient scope).
Although I know a PCP-led wellness program won’t be perfect, it could meaningfully address many of these short-comings to handedly outperform the current standard. Additionally, I believe meeting patients’ demonstrable appetite for physician engagement on the topic of wellness holds the potential to renew the sanctity (and, therefore, the effectiveness) of the patient-physician relationship. Let’s evaluate 5 key failures of the status quo and how we might envision the opportunity — posed as questions because, frankly, I don’t have all the answers.
FAILURE #1: Poor uptake / enrollment
Most employer-based approaches fail on this very first step because they depend too heavily on email solicitation. In today’s busy world, less than 1 in 5 emails are opened, and 1 in 33 get clicked, and yet it’s the foundation of most internal communications. Obviously, some companies do a better job than others by adding physical enrollment opportunities and reinforcement mechanisms (i.e., a nagging manager), but most still rely foundationally on a digital announcements. Although odds of email enrollment can improve with simple but infrequently utilized tactics like sending from known names (i.e., employee’s previous PCP) or personalizing the subject line, the ceiling for participation through mass email invites is still pretty low — especially when opening the email is the first of a multistep process that involves downloading a new app, registering your account, linking accounts for benefits coverage and then self-selecting relevant content (as is often the case with 3rd party employer-sponsored wellness programs).
Key questions: What if we looked for opportunities to embed wellness programs in habits that already exist (i.e., annual exam) or in channels that already have traffic (i.e., the patient portal / EMR app)? How much more likely or excited would you be to engage in an annual wellness program if the following were true?
Your doctor asked you to
It was on an app already on your phone and accessible to your doctor inside your medical record
Your doctor would review and discuss your submission with you during your next visit
What would it take to make the above process a reality? What could it mean for the patient-physician relationship?
FAILURE #2: Little or no accountability
Numerous programs create scale or cost-effectiveness by leveraging DIY content or automated chatbots. Unfortunately, in my experience, the more you remove human interaction, the more likely I’m going to ignore the program when I’m not in the mood to be compliant (which is most of the time). Conversely, if I know that another human being is tracking my progress, and is going to hold me accountable, I’m far more likely to be adherent — especially if that human is in a position of authority like my doctor. Although employer-sponsored plans enjoy a major advantage in their ability to achieve high completion rates through payroll incentives (like avoided surcharges or gained bonus payments — over $1,000 annually for some employers), completion rates don’t necessarily equate to success. Often participants only comply with the bare minimum requirements to receive their payments and move on (I’m sad to admit that I’ve personally taken this approach for multiple years, and with multiple employers).
Key questions: How valuable is encouragement and accountability from the patient-physician relationship for behavior change? What conversations are doctors already having that could naturally include more discussion of wellness? Can payroll incentives still play a meaningful role in basic engagement by linking these employer-based programs to a provider-led wellness program?
FAILURE #3: Misguided notions of “evidence-based”
The latest in employer-sponsored wellness programs often tout loudly their “literature-backed” programming or “evidence-based” protocols. In fact, you’d be hard pressed to find a Silicon Valley wellness startup that isn’t based on cutting edge behavioral science or doesn’t have a nationally-renowned economist on its advisory board. However, let’s also be honest about the realities the evidence base in wellness:
Most employer-sponsored programs aim higher than their wax wings can carry them by shooting for either cost/utilization reduction or improved outcomes (each as admirable as it is elusive). As described in part II, the goal for providers should pragmatically be more consumer oriented, like understanding the patients’ personal objectives, appetite for change and desire to engage with their doctor. Put more bluntly, the goal should explicitly be an engaged patient — on their terms. That means “evidence” should really be focusing on programmatic KPIs like engagement levels, customer satisfaction, net promoter scores, loyalty/retention statistics, etc. that receive little to no attention in traditional academic literature.
If/when we do aspire to include some literature-backed interventions and corresponding outcome measures, translating results from small, academically-sponsored research cohorts to large-scale, real-world deployments should not assume — it should be tested with skepticism and refined as will almost assuredly be needed.
Key questions: How do we currently measure patient engagement (if at all)? What information do we currently have about our patients satisfaction with our services / programming? How timely and representative is this information? What would we do if we had more feedback about how, when, how often and through which channels patients wanted to engage us?
FAILURE #4: Limited scope / relevance
Not surprisingly, the vast majority of wellness programming focuses on weight loss and mental health. However, wellness programs rarely ask patients why they can’t eat better, be more active, or manage their stress — the sources of which are likely multifactorial and interrelated. When looking at annual aggregate data from the American Psychological Association, the causes of stress nationally quickly reveal a stark deficit in what traditional wellness programs are equipped to address. In fact, the top 5 stressors now include “the future of our nation”, “current political climate” and “violence and crime”. Admittedly, these are new answers undoubtedly linked to the unorthodox political times we’re living in (none of these three particular answers were in the top 5 a decade earlier), but why does that put them off limits? Other traditional mainstays of the top 10 include “money”, “work”, “family responsibilities” and “relationships” — topics with equally absent from traditional programming that I believe represent a massive opportunity to engage our patients on the most human level.
Key questions: How can we better understand what individuals are wholistically concerned about? What would that do to our scope and definition of wellness? What could it look like if the healthcare industry acknowledged and engaged on any source of suboptimal human performance? Do we really need to have all the answers, or could simply engaging on these topics with our patients lead to mutual vulnerability and better trust? What if goal setting wasn’t just about losing weight, but rather understanding what difficult situations in your life are leading to overeating?
FAILURE #5: Lack of personalization and static programming
The current standard for wellness program assessments (also known as Health Risk Assessments — HRAs) is the National Committee for Quality Assurance (NCQA) certification. Although the certification is an intensive process that takes over a year to complete — including prequalification, gap analysis, multiple audits and more, there’s zero requirement that the assessment be personalized or adaptive to the user. Additionally, despite the fact that maintaining early wins in behavioral change is a known challenge, most wellness programming is 100% static — read or watch content, maybe take a short quiz and then move on. Completely unresponsive to your behavior or actions.
Key questions: Instead, what if the assessment changed depending on your answers, and your individual responses triaged you to programming specific to the issues you identified? How should the program change and adapt to the fatigue and relapse inherent in sustaining behavioral change? What if the programming monitored your engagement level and responded when it dipped? What if the program were staged to your education, motivation and capability level at any given point in time, and reassess those critical factors periodically to maximize your engagement? Essentially, what if the same data and technology that kept you binge-watching Netflix shows could be used to keep you engaged in wellness?
Conclusion
I’m well aware that PCPs hardly have enough time in their day to handle all the sick patients they need to see, let alone adding time and services with each patient for wellness topics. Ideally, PCPs would lead multi-disciplinary teams with expertise and skills in motivation, behavior change, nutrition, fitness, therapy and mental health (just to name a few). Unfortunately, we don’t have an ideal system, nor the time to wait for one. Instead, how could we achieve the above while minimizing the impact on clinical workflow? Can we rethink, append or replace current inefficient or ineffective parts of a new patient onboarding? How could technology be used to monitor the patients’ progress and motivation, address barriers and encourage continued engagement?
