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"The U.S. spends more on healthcare per capita than any other nation in the world -- and gets worse results," says Angelo Falcone. US Acute Care Solutions/Dignity Integrative Health Solutions

For the past thirty years, I have had a front-row seat to the many failings of U.S. healthcare.

After residency training, I helped found and lead a physicians group at one of the state’s busiest emergency departments, in Rockville, Maryland. We treated everyone who came through the door, regardless of their ability to pay, their race, status or gender.

That mission is part of why I became an ER physician. Treating people when they are having one of the worst days of their life is a great responsibility, one that has given me great satisfaction throughout my career.

Yet, as my company grew, I could see that the work we were doing to improve care and be good partners to health systems was like a drop in the bucket when it came to the larger problems of U.S. healthcare. I could see first-hand that these problems are systemic, deeply embedded and not easily fixed.

Many smart people and innovative organizations have tried to address these failings, whether through politics and policy, new technologies, or campaigns to change the way we think about health in the first place. All of these have been worthy efforts, and I have watched many of them.

But after thirty years of practice, it’s clear that at least one fundamental problem remains almost completely unaddressed. The problem is that 99 percent of healthcare happens outside of a doctor’s office.

Most chronic disease is preventable

It’s no secret: The U.S. spends more on healthcare per capita than any other nation in the world -- and gets worse results.

The U.S. has lower life expectancy than many of its peer nations, but we also have far higher rates of chronic disease. According to the Commonwealth Fund, fully 28 percent of U.S. adults have been told by a doctor that they suffer from two or more chronic conditions (diabetes, heart disease, hypertension, etc.).

The frustrating part is that we know there are solutions. “The major causes of chronic diseases are known,” wrote the World Health Organization in a fact sheet about chronic illness. “And if these risk factors were eliminated, at least 80 percent of heart disease, stroke and type 2 diabetes would be prevented; over 40 percent of cancer would be prevented.”

The challenge for efforts at healthcare reform is that many of these risk factors begin 20–30 years before these chronic diseases show visible signs of being a problem. What we need is a significant realignment of our system to health and disease prevention.

How do we make that happen? It all comes down to incentives -- something we’ve tried to shift before, with some positive effects but also unintended consequences.

The Affordable Care Act and its consequences

When the Affordable Care Act passed in 2010, my company had grown to see approximately 500,000 patients each year -- many of them coming into the ER uninsured.

For years, the rate of people in the U.S. without health insurance had been growing steadily, reaching 17.8 percent in 2010, or 46.5 million people.

The ACA aimed to reverse the trend, and by that metric, the law was a great success. The law was good for patients, and it was good for my company since we could now bill the insurance providers for services we had previously been providing for free.

But the ACA also had a big unintended consequence. The law introduced financial incentives for health systems to make improvements in quality and patient satisfaction. To do this required more data, more investment and more scale. Following the ACA, there was a wave of consolidation.

Health systems bought local hospitals and medical practices. They integrated care, but they also became, in effect, local monopolies that were able to raise prices. Commercial insurance companies responded both by consolidating themselves and by shifting more of the cost of care onto patients through higher deductibles and premiums.

A viable plan for fixing healthcare

Meanwhile, many of our system’s most fundamental problems remained. As I said above, much of our health is determined by factors outside the doctor’s office. Much chronic disease can be prevented, but to do so requires the system to address risk factors over decades, as opposed to responding to disease as it appears only after years of neglect.

Fundamentally, we need to focus on three core areas of health and wellness:

  1. Eating better: more whole foods, less processed foods
  2. Movement: reducing sedentary lifestyles and moving for at least 30 minutes every day
  3. Mental health: building mental resiliency through mindfulness and strengthening social connections to address an epidemic of anxiety, depression and stress

But how do we make this happen? How can we use available resources, technology and political will to encourage better health choices at scale? This really is the crux of the challenge.

1. Shift Medicare and Medicaid funding. This is important because where Medicare and Medicaid go, the commercial insurance payers usually follow.

Medicaid is, essentially, a grant program to the states (and Medicare Advantage is a block funding grant to insurance companies and providers), which means a particularly forward-thinking state governor and legislature could have a huge impact in deciding to re-appropriate where that money is spent. Specifically, we need to begin moving this money away from health systems and toward disruptive outsiders.

These outsiders will be focused on getting people to eat healthier, move more and take better care of their mental health.

2. Reorient SNAP. The Supplemental Nutrition Assistance Program (SNAP) is a hugely important tool that individual states can use to incentivize more healthy eating over time. State SNAP programs can and should partner with meal service companies -- the kind that deliver healthful, easy-to-prepare meals to your doorstep -- to ship healthy meals two to three times a week to SNAP recipient homes.

Current SNAP benefits average $175 per person per month, or $1.20 per meal. That is enough money to make a significant difference in improving people’s diet if the money is used properly. The goal should be to maximize whole foods and minimize sugar and refined carbohydrates.

3. Using technology to scale patient incentives. For those with private insurance, technology has provided a huge opportunity to incentivize an individual’s contribution to his or her own health and well-being.

Fitness trackers, for example, could be used to incentivize movement. Those meeting the weekly recommendation of 150 minutes of movement per week would get a reduction in their premium that month. A similar type of program could be applied to sleep with sleep trackers, or to mindfulness with meditation apps. Many activity trackers share information through secure portals with patient consent and are capable of tracking crucial metrics related to chronic disease.

Programs like these won’t just begin to educate more Americans about the importance of movement, sleep and mental health; they will also attach a financial incentive to actually improving their daily, weekly and monthly habits.

4. Use school funding to impact healthful behavior. As the pandemic taught us early on, our public schools serve many functions aside from education, from being refuges from damaging home environments to sources of free lunch for millions of low-income children.

It’s time we acknowledge that schools can have an outsized impact on health and in instilling healthy habits. Much attention has been put on healthier school lunch programs, which is good. We should also experiment: For example, incentivize schools to start the day with 10 minutes of meditation or breathing exercises as part of “homeroom,” and track the impact on learning and misbehavior.

5. A national wellness system. Finally, local leaders can embark on a program to dramatically widen what we mean by healthcare. Call it a national wellness system, rather than a national healthcare system.

This new wellness system would include local farms incentivized to grow vegetables rather than corn, wheat and soy. It would include gyms and yoga studios and increased access to parks, trails and the great outdoors. It would include tools and strategies of all kinds to improve our sleep and our mental health.

When we talk only about healthcare, we think the job is left to doctors, nurses and hospital administrators to fix. But when we talk about wellness, that suggests a much wider effort encompassing much of society.

Change from the outside

In 2020, after three decades of practicing emergency medicine, I decided to retire from an active leadership role in my company, which had merged to become a national leader in acute care. I started a new practice, called Dignity Integrative Health and Wellness, to see if there was a way to help patients address the root causes of disease.

Many health systems and care organizations continue to do extraordinarily important work of caring for the sick and the chronically ill. Unfortunately, I don’t believe the change we need is going to happen as a result of leadership from existing, large health systems. They simply have too much incentive and too many sunk costs to make the kind of pivot we really need.

Much like the large, legacy automobile manufacturers needed an outside upstart (Tesla) to jolt them into action on electric vehicles, dramatic change in healthcare is most likely to come from the outside.

My new practice seeks to address many of the deficiencies with the traditional medical system, but I am far from alone. Many care providers are beginning to experiment with new models of care. Many startups are seeking to leverage technology to improve long-term health and address root causes. And many political leaders, business leaders and even regulators are trying to use the tools they have to leverage innovations to improve the system.

All these efforts are good and worthy of interest and attention. In our current era of national polarization and federal paralysis, starting local and building from the outside isn’t just a viable solution -- it may be our only solution.

(Angelo Falcone, M.D., is the founder of Dignity Integrative and former president of US Acute Care Solutions.)