In many countries, when patients see specialists such as surgeons, the physician focuses on the primary health issue and does not screen the patient for chronic conditions or unhealthy behaviors. This is a missed opportunity. Programs that have been launched in Michigan, North Carolina, and England to address this problem can serve as a model for other regions and health systems.
Today, a patient in the United States and other developed countries may see an array of specialists, undergo a variety of procedures, but never speak to a doctor about fundamental health behaviors such as smoking, diet, or exercise or chronic conditions such as diabetes, obesity, and stress.
Consider a hypothetical patient seen in the emergency department for abdominal pain and referred to a surgeon for symptomatic gallstone disease. She is a 54-year-old woman with obesity, poorly controlled diabetes, active smoking, and unbeknownst to the surgeon, difficulty affording her prescription medications. Since none of these conditions is a contraindication to surgery, she undergoes an uncomplicated, outpatient operation to remove her gallbladder. Two weeks later, at a follow-up visit, the surgeon ascertains that her incisions are healed, she feels well, and has no complaints. By every current quality metric, her episode of care was a complete success. She had no complications, did not require hospitalization, and was completely satisfied with her care. However, she emerged from this high-intensity encounter without anyone addressing her chronic conditions, which could significantly shorten her life.
This is a common story. Millions of patients in the United States and other countries have a similar experience. How can we leverage these discrete care episodes with specialists to move the needle on our nation’s most pressing population health needs?
One way is to integrate existing resources that address foundational health issues like health behaviors and chronic conditions — which account for the majority of premature deaths — into specialty care pathways. Hospitals already have the tools to manage chronic diseases, but patients are rarely connected to these resources at the time of an operation. Screening and referral to treatment for chronic health conditions not only improves immediate postoperative outcomes they also allow patients engaging with the health care system in a narrow, specialized manner to establish meaningful, long-term health maintenance. There are innovative models already doing precisely this.
The Michigan Surgical Home and Optimization Program (MSHOP) at Michigan Medicine and the Preoperative Anesthesia and Surgical Screening (PASS) program at Duke Health are interdisciplinary programs that address longitudinal health around the time of surgery. Patients pursuing any type of operation are screened for chronic conditions such as diabetes, obesity, smoking, malnutrition, physical inactivity, frailty, and stress. Patients who are found to have any of these intervenable conditions are then referred to appropriate providers to establish longitudinal care for them.
In the United Kingdom, the National Health Service England is taking a similar approach with its Making Every Contact Count (MECC) effort to help patients make health behavior changes such as quitting smoking and increasing physical activity. Patients undergoing anything from a routine eye examination to a minor operation are screened for chronic health conditions and offered brief interventions and referral to treatment. What’s more, MECC trains caregivers at all levels (e.g., waiting room staff, medical assistants, physicians) to identify and engage patients in these brief interventions around health behavior change.
These programs reduce the cost of care, improve chronic medical conditions, and help patients make crucial lifestyle changes such as quitting smoking. Considering that 50 million surgical procedures are performed annually in the United States, such an approach is a powerful way to improve population health within current care-delivery pathways.
There is long-established evidence that this pragmatic way to tackle foundational health problems within the existing U.S. health care system is effective. Research published over the last 20 years shows that major life events such as undergoing surgery, visiting an emergency department, or receiving a new diagnosis serve as “teachable moments.” These are events that motivate individuals to make changes in their health that they had previously not considered or been unable to make. For example, while fewer than 10% of smokers successfully quit each year, more than 50% of smokers undergoing surgery for smoking-related diseases successfully quit after surgery. Even patients undergoing operations completely unrelated to smoking, such as elective joint replacement, become more likely to quit.
As surgeons, we see this phenomenon repeatedly: patients told they need surgery speak of a newfound motivation to do everything in their power to ensure the best possible outcome. Currently, however, few health systems have processes in place to transform that motivation into lifelong actions.
Leading the Charge
You can’t improve what you don’t measure. A critical way in which clinical leaders can help incorporate population health needs into specialty care pathways is by creating quality measures that explicitly recognize these efforts. In surgical care, the quality of care is traditionally measured by whether a patient has a postoperative complication or gets readmitted to the hospital. Expanding measures of quality to include things like referral for longitudinal health management at the time of surgery — an equally important component of high-quality care — is an essential step in changing clinical practice.
In Michigan, we have begun to do just that for one of the most common surgical operations: hernia repair. Recognizing the especially high prevalence of unmanaged health conditions in patients undergoing hernia repair, hospitals now capture and report the number of patients who are referred for smoking cessation counseling, diabetes management, and weight loss management at the time of surgery. Michigan Medicine has even created a dedicated multidisciplinary clinic to track surgical patients’ progress as they get plugged into treatment for their chronic health conditions. Already, simply measuring these processes has led to an eight-fold increase in referrals for long-term health management around the time of surgery and helped patients achieve remarkable health improvements that last long after they have undergone their operation.
There are other efforts underway in Michigan with similar aims. Two statewide initiatives have recently been launched specifically to help hospitals measure and improve health behaviors and social determinants of health as part of routine specialty care.
Insurers can also help lead this charge through financial incentives. Two programs recently implemented by Blue Cross Blue Shield of Michigan are examples. One, which is part of the initiative for patients undergoing hernia repair, pays hospitals extra for reporting their screenings and referrals for chronic health conditions at the time of surgery. The other offers hospitals an end-of-year bonus for referrals to smoking cessation counseling as part of the surgical episode.
The System We Have vs. the System We Want
It is said that every system is perfectly designed to get the results it gets. If a hospital stands to recoup nearly $1 million in reimbursement for a complex surgical procedure such as an organ transplant but only $25 for smoking cessation counseling, it is easy to see which efforts it will prioritize. While the adoption of value-based, or capitated, health care, which ties payments to outcomes and patient satisfaction could change these priorities, the examples above demonstrate that even within the still-dominant fee-for-service payment structure in the United States, there are ways to align the delivery of specialty care with efforts to address the most salient health needs of the population.
Returning to our patient example above, we could now envision a scenario in which her surgical care involves automatic screening which leads the surgeon to refer her to the hospital’s existing smoking cessation program, an endocrinologist who would evaluate her and help optimize medications and diet to better manage her diabetes, a structured exercise program, and social work services to get financial assistance for her prescriptions. These simple steps could profoundly alter her health trajectory long after her surgical care has ended. Success in even just one of these areas would likely have a far bigger impact on her longevity than her surgical care.
Health care reform in the United States is likely to continue to be a slow process. In the meantime, creatively embedding the kinds of efforts we have described into the health care system that we have — rather than waiting for the health care system that we want — may be our best bet for improving the health of our population.