Two Truths and Lie: Why Physicians Should Care About Wellness
Part II in an exploration of wellness in healthcare
If you haven’t heard of the game “two truths and a lie”, it’s a fun ice breaker where people introduce themselves with three statements and others have to guess which two are true and which one is the lie. Think of it like a 5th grade pop quiz: Which of the following statements is NOT true? I think people who love the game (like I do) appreciate the mischief of a) being able to tell outrageous truths to strangers and b) challenging stereotypes and dispelling ‘conventional wisdom’. Today, let’s play the game about 3 reasons why primary care physicians (PCPs) should care about wellness:
In the impending value-based future, PCPs will get paid for addressing wellness
Patients receiving wellness programming have better outcomes
Consumers want wellness, and if they can’t find it from their doctor, then the market will evolve new competitors to provide it
Do you know which one is a lie? Do you feel confident? Let’s build the suspense by examining them one-by-one:
#1: In the impending value-based future, PCPs will get paid for addressing wellness
I often hear doctors, especially PCPs, lamenting about how they’re not able to spend the appropriate time with their patients or focus on holistic care that includes promoting wellness. More often than not, the leading culprit they point to is a payment paradigm that almost singularly rewards doctors for the reactive treatment of acute problems that, not surprisingly, comprises the vast majority of services delivered by healthcare professionals in the US. These complaints aren’t just vague feelings of discontent, they reflect a systematic deprioritization and devaluation of wellness services in the fee-for-service (FFS) world. If you think I’m exaggerating, try looking for a single ICD-10 code (out of 68,000) that is obviously designated or regularly used for wellness services. I’m by no means an expert in medical coding (fortunately my wife is), but the closest I could find, Z00.00, is a non-reimbursable code that reflects a medical exam with no abnormal findings.
Unfortunately, even in more progressive “value-based care” (VBC) payment models where PCPs are incentivized to help reduce the total cost of care (i.e., capitation or shared savings), the focus of physician time notably turns to ‘quality metrics’ that typically fall into one of two categories:
How well patients with chronic disease are being managed (e.g., HbA1C, a blood test that serves as a measure for long-term diabetic control)
Broad completion of preventive screenings like colonoscopy or mammography
Although some VBC contracts might have provisions for annual exams where PCPs could arguably cover wellness, there’s no specific requirement for a holistic or comprehensive view of wellness that would extend to topics like nutrition, fitness, or emotional, social or financial health. So despite the innumerable opportunities that VBC offers to reshape our health care system, I would argue that there’s no guarantee that we’ll see wellness as an integral part of those opportunities in the near future.
Verdict: LIE
#2: Patients receiving wellness programming have better outcomes
Given the heartburn that physicians describe when talking about the unfulfilled need for wellness in their practice, an unfamiliar observer could reasonably assume it represents a grand oversight of effective policy, or at minimum an example where short-sighted FFS reimbursement models have prevented us from making the requisite investment in good long-term policy. After all, despite the fact that most PCPs are keenly aware that they are never going to get paid for providing wellness programming or services to their patients, many I’ve talked to still report feeling that they’re doing their patients a disservice. Some have even told me that they secretly wish they could teach their patients yoga or offer cooking classes instead of putting them on medications. So, wellness must be an overlooked albeit effective tool in a holistic care toolbelt, right? We’ve already identified the lie, so this statement must be true, right?
In fact, there’s very little research backing any claim about the efficacy of large scale wellness programming to date. Most practitioners anchored in evidence-based medicine would likely call the fact-base on the effectiveness of historic wellness programs inconclusive at best (damning at worst). Although I’d argue that there’s a lot of opportunity to improve the scope and focus of wellness programming to challenge these judgements going forward, the reality is that we shouldn’t (and personally, I wouldn’t) be making arguments for wellness programming based on historic performance. If we stretch our scope of literature to adjacent fields like psychology and behavioral science, however, the future looks much brighter with the promise of concepts like Nudge Theory popularized by Richard Thaler or Pascal Sheeran’s Intention-Behavior Gap research. However, we’ll have to wait until there’s scalable implementations with large structured cohort analysis before we can call this statement a truth.
Verdict: LIE (Yes, I tricked you. Mischief, remember?)
#3: Consumers want wellness, and if they can’t find it from their doctor, then the market will evolve new competitors to provide it
So if doctors literally have no way to get paid for offering wellness programming, and there’s unclear evidence to support their efficacy, why should doctors even bother? Well, the answer likely depends heavily on whether you believe that consumerism is one of the fundamental forces reshaping healthcare in America. Hint — it IS, and along with digitization, big data and a perpetual need for abating cost growth, it will result in a dramatically different healthcare system in 5–10 years time than we know today. You don’t have to take my word for it. Just consider that on Google, the medical term searched the most across the US — and typically by a wide margin — is “urgent care”, a concept specifically designed to exploit a niche for people who didn’t want to wait to see their doctor (Source: Google Ads Keyword Planner).
It’s pretty clear to any practicing physician not planning to retire within the next 5 years (perhaps even more clear to those who are) that consumerism has already drastically changed the expectations for healthcare services. Not only is there a race to create high quality, better access and lower prices, but patients are now demanding service with a smile (the gall of them!). But does wellness represent a significant enough opportunity or threat to warrant PCPs’ attention in the face of numerous other demands that come with consumerism? Historically an afterthought, I’d argue that wellness now has the opportunity to move to the forefront of the modern primary care practice.
Once again, you don’t have to take my word for it. In March 2019, a research firm Ipsos (sponsored by Welltok) conducted an online survey of more than 1,600 adults age 21 and over across the U.S. who had visited their provider twice or more over the past year. You can download the report here, but some key findings that speak to the opportunity that wellness presents for providers:
Patients want wellness programming — over 9 out of 10 of those surveyed said they were looking to their providers for programs on healthy eating habits, appropriate physical activity, emotional / mental health support, getting better sleep and managing stress
Patients turn to providers as authority figures — around half of those surveyed still recognize providers as the first place they would turn for holistic health and wellbeing support (ahead of health plans, employers, pharmacies, health departments or pharma companies)
Patients want to be loyal — over 4 out of 5 of those surveyed said they would feel a greater sense of loyalty to their provider organization if their overall wellbeing was being supported outside of a clinical setting
Patients don’t feel like providers currently care about wellness — almost half of respondents under 55 felt their providers only focus on diagnosis/treatment, and don’t care about their overall health and wellbeing
Finally, like urgent care emerged a few decades ago, new models of services are starting to fill the gap that the Ipsos survey identifies. I could easily point to One Medical and other concierge practices as the first evolution of primary care, specifically trying to appeal to “urgent care” consumers with guaranteed same day appointments and messaging with your doctor. However, I don’t believe they’ve meaningfully captured the opportunity related to wellness. Instead, I’d point to models like Forward or Parsley Health that make holistic wellness an essential part of their value proposition.
Let’s dive a little deeper into Parsley Health, a model born in 2016 out of its first location in SF, but already expanded to NYC and LA (a common path for innovative service models that blend physical spaces and technology). Parsley’s public value proposition details a very non-traditional set of services like soliciting diet, exercise and lifestyle choices and having designated ‘health coach’ positions. For those unfamiliar with this new category, some important highlights:
Holistic practices come at a premium (base membership for both Parsley and Forward start at $150/mo vs around $200/yr for typical concierge practices)
Holistic practice providers (including Parsley’s MD founder) are often trained in functional medicine, which likely plays a big role in their approach to patient care
The integration and reliance on technology, testing and diagnostics can vary in holistic practices (appears to be a far less integral part of Parsley than Forward, which highlights “genetic testing, real-time blood testing and 3D body scans” as part of the membership)
Verdict: TRUTH (at least in my opinion)
So there you have it, two lies and a truth about why PCPs should care about wellness. Now, I can already feel my doctor friends sharpening their knives, ready to tear me apart for suggesting that they ‘do more’ when they’re already churning through 30+ patients per day. Simply adding dedicated time to evaluate, endorse and track wellness programming for all their patients is not a realistic option, nor what I’m suggesting. Instead, I’m imagining a scenario where wellness programming isn’t a zero-sum game that requires any time spent on wellness is time not spent on the dozens of other requirements for high quality primary care. Next time, we’ll explore how PCPs can leverage technology to reclaim wellness and reinforce the sanctity and effectiveness of the patient-physician relationship. Please sheath the knives until then…
