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Making Wellness Work

Elyas Bakhtiari, for HealthLeaders Magazine, August 12, 2009
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Wellness and weight loss programs aren't major revenue generators, but healthcare reformers know they cannot effectively control costs without focusing more on prevention.

Let's face it, although the healthcare system has grown progressively better at detecting and treating diseases over the years, it remains lousy at preventing them.

It's as if providers are 20 feet away from an open fire hydrant, mopping up streams of water running down the street in divergent directions. Giving them better tools and incentives to sop up more water is effective to a certain extent, but it is an exercise in futility unless the torrent coming from the open hydrant is addressed and eventually slowed.

As lawmakers toy with potentially massive healthcare reform this year, it is becoming increasingly clear that changing financial incentives, digitizing records, and tracking outcomes can only go so far in reducing healthcare costs and improving quality. Fixing the healthcare crisis will only be effective if everyone—patients, providers, payers, and politicians—start paying more attention to the health crisis.

That means preventing diseases that can be prevented. Estimates attribute nearly 80% of chronic diseases to lifestyle factors, says Kathryn Menard-Rothe, wellness manager for Froedtert & Community Health, a regional hospital system in Wisconsin.

Obesity is the primary culprit, and some of the statistics are alarming: Two-thirds of American adults are now overweight, and nearly one-third are obese. The numbers are reaching epidemic proportions, and the excess weight is leading to more cases of some of the most deadly and debilitating diseases—diabetes, kidney failure, cancer, depression, and heart disease. These conditions are even hitting earlier in life now, in part because one-in-five children under 11 is overweight.

For all the complex cost-savings plans and campaigns to save lives, it can't be overstated how much collective weight loss, and overall wellness improvement, would help in saving money and improving the healthcare system. "The three main things we can do to make a big impact on [people's] lives are to convince them to quit smoking or not start, eat a healthier diet, and be more active. That's really the magic," says Menard-Rothe. "It sounds so simple."

But, in many ways, preventing chronic disease is more difficult than curing them. Bad habits have solidified into cultural norms; change requires new levels of patient responsibility; and perhaps the biggest obstacle is a payment system that provides almost no incentive for wellness and weight loss services that can prevent these problems.

That may change—it has to change. The Obama Administration has acknowledged that healthcare must be more preventive and has promised a greater focus on wellness as part of its healthcare reform efforts. While that might not mean wellness and weight loss as top priorities, it does suggest a changing wind.

Some hospitals have already figured out how to make wellness and weight loss programs work in the current system. Those that are successful will be well-positioned if, in the not-too-distant future, prevention gets the attention (and incentives) it deserves.

Service Line Success Key No. 1: Evaluate how services are organized
The financial case for wellness and weight loss is different from most service lines, but that doesn't mean the services aren't worthwhile. They may not ever be a leading revenue generator for a hospital or health system, but the financial model is often at least break-even, or in many cases a loss-leader that can boost revenue in other sectors.

Insurance companies don't reimburse for most of the preventive services that would be listed on a pamphlet for a typical wellness or weight loss program. Working with that reality, the trick is to target the right types of patients who can pay out of pocket while at the same time building a foundation on the few services that are reimbursable.

For Northwestern Memorial Physician Group's wellness program, that means starting with a base in internal medicine, says JoEllyn Tiesi Trad, RN, MPH, director of health promotion and corporate services for the 92-physician primary care group that is owned by Northwestern Memorial Hospital.

New patients have a choice to either meet with a physician or to enter directly into services—nutrition consults, smoking cessation programs, exercise physiology—in the group's Center for Integrative Medicine and Wellness. "Without the internal medicine foundation, it's hard to pay rent and make it on alternative money that you get," says Trad. "The ability to ground ourselves with internal medicine that is insurance based gives us that cash."

It doesn't have to be primary care that grounds a program. For the Johns Hopkins Weight Management Center, a small portion of reimbursable income comes from bariatric surgery, which is increasingly covered by insurance plans, and other medical and surgical options available to a patient with a weight problem. There are limits to that strategy, however. About 90% of patients receive nonsurgical treatments, so the program has to target patients who are willing to pay for services out-of-pocket, says Lawrence Cheskin, MD, director of the center, which is part of Johns Hopkins Bloomberg School of Public Health in Baltimore.

"It distorts the kinds of patients you tend to see in a treatment program ... It's a process of self-selection to some extent," says Cheskin. "When you're asking people to pay out of pocket, there's only so much you can charge. We generally charge less than you'd bill insurance for the amount of time and services that are provided."

Other physicians can sometimes help with finding that niche patient, as primary care providers often refer patients with serious weight problems to the center, says Cheskin. Reaching out to those doctors to educate them about the weight loss offerings helps build those referrals, but even with referral help, the market is constrained by the reimbursement system.

Key No. 2: Reach out to employers
There is another financial source, however. While federal and private payers don't want to pay for preventive services, and patients often can't, employers increasingly recognize the benefits of improving their employees' health.

Most of Northwestern's marketing for wellness services is directed toward corporations, not individual patients. Savvy corporate executives see the value in reducing health-related absenteeism and lowering the risk for heart disease and other chronic conditions that can add to overall healthcare costs, says Trad.

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