Chronic diseases pose a huge problem to the US healthcare system. 90% of Americans over 65 have at least one chronic disease; nearly 80% have more than one; and chronic diseases account for more than 75% of direct healthcare spending.
High deductibles aren’t helping here. While ideally they incentivize patients to choose lower-cost treatment, in the absence of low-cost options they generally lead patients to spread out or forego treatment. This in turn contributes to another cost driver: acute episodic care that arises out of preexisting conditions. We’re emptying the coffers, but patients still aren’t getting adequate treatment.
Take diabetes for example – a chronic disease for which we have no definitive cure and spent $176 billion in 2014. When diagnosed with type II diabetes, patients are given a protocol of interventions meant to slow disease progression, including blood sugar monitoring, medications, diet, and exercise. In theory, if patients all followed this protocol, they would a) on average, improve their quality of life, and b) reduce systemic health costs.
But these assumptions don’t hold up under closer inspection. Blanketed in that calculation are hefty social, emotional, and financial costs to the patient. Today’s type II diabetes “solutions” do not integrate seamlessly into patients’ lives.
Adherence numbers back that up. World Health Organization (WHO) metadata suggest that daily self-glucose monitoring sits very low – as little as 20% in many populations – and by the end of the first year, only 15% of adherents take their prescribed oral medication daily. Diet at below 50%, and exercise at 25%, are marginally better. This suggests that protocols are hard to follow.
Why don’t patients with type II diabetes follow their regimens more consistently? Well, they (we) think the exact same way that everyone does – they weigh pros and cons and make a decision based on which is greater. But this is a dynamic equation, meaning it changes as a patient experiences different circumstances during a given day, week or month.
When asked to follow protocol in the existing treatment model, the perceived benefits are often too small, and the time and energy cost too big. Within the context of everyday life, this model helps us understand why patients adhere to therapy – and why they don’t.
For chronic disease patients, the physician’s practice model tips this equation positively in only a fraction of circumstances (see WHO data). The overall problem lies not with provider or patient errors, but that we’ve selected the wrong business model. Instead of redesigning our businesses to fit humans, we’re trying to get humans to conform to the business. This is at the root of adherence issues.
As Clayton Christensen points out in The Innovator’s Prescription, the two main determinants of adherence are:
- Degree of motivation to adhere to therapy (i.e., are the consequences of not adhering immediate or distant?)
- Degree of behavioral change required (a lot or a little)
This framework provides a healthy dose of reality to dealing with chronic disease. Providers’ current focus is on the mythology of what the patient should do as opposed to the reality what the human will do. But we can turn this around. For instance, consumers readily create certain types of data about themselves when using social media. Tapping into these same motivations to create health data is a lot easier than asking patients to interrupt their lives for 10 minutes every day and enter in data about their chronic condition. That’s likely the cause behind Google’s EHR failure (and many others).
New business models that harness, rather than fight, human behavior can address our systematic failure to adequately treat chronic diseases and reduce costs.