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Michael Battle and Leon Kilpatrick, right, pick up bags of apples at The Martha O'Bryan center in Nashville.(Photo: Josh F. Anderson for USA TODAY)
As the Affordable Care Act pushes doctors and hospitals to join forces to slash health care costs, those with the least-expensive solutions say they're still largely being ignored.
Community health groups and companies that specialize in healthy eating and fitness are arguing for more recognition of non-medical ways to prevent and treat chronic conditions such as diabetes, hypertension and heart disease. Physicians and hospitals are rapidly forming what's known as accountable care organizations (ACOs) to reduce the duplication of services and keep large groups of patients well. But community groups, which could be far less expensive partners, have to fight for a "seat at the table" on the doctor-dominated boards of ACOs, according to a 2014 report by a North Carolina physicians' coalition.
"We're seeing the beginning of the health care system reaching out to these community and health-based partners in a big way now," says Bo Bobbitt, a Raleigh, N.C., health care lawyer who was lead author of the report. "The bad news is that the gap between the medical system treating illness and disease and the community health system was larger than we had feared."
The health care industry still focuses almost all of its attention on costly medical interventions instead of helping patients make more effective lifestyle changes, public health experts say. While more than 75% of the $2.6 trillion spent each year on
medical care is for preventable chronic conditions, only about 3% of U.S. health spending goes to public health and prevention, such as diet and exercise, according to a 2012 Institute of Medicine report.
"Compared to even the best medical therapy, we can decrease heart attacks, strokes and deaths by between 35% and 45% by changing lifestyle," says Paul Rogers, a Louisville, Ky., cardiologist at one of the KentuckyOne Health System's three healthy lifestyle centers, which provide medically supervised exercise, nutrition counseling, stress management, and classes in yoga and other disciplines.
Dropping about 10% of weight reduces cardiac risks significantly, says Rogers. And if weight drops by 15% to 20%, he says, diabetes starts to reverse, blood pressure goes down, cholesterol levels improve and sleep issues improve.
LITTLE MONEY FOR ROBUST RESEARCH
There are plenty of pharmaceutical industry-funded studies into prescription drug solutions, but those promoting wellness in other ways say they don't have the money to invest in robust research. And without studies, few will invest in their programs.
The success of a lot of community health programs is proved in small academic studies that aren't as useful when programs are being implemented on large scales, says Jeffrey Levi, executive director of the non-profit Trust for America's Health.
"The source of funding for research is at the NIH (National Institutes of Health), and this kind of research has never been a priority there," he says.
Besides, when it comes to nutrition, physical fitness or stop-smoking campaigns, some in Congress "don't see that as health funding," says Georges Benjamin, a physician who is executive director of the American Public Health Association.
"There are arguments that it's the 'nanny factor,'" he says.
The fallout:
• Annual funding authorized by the ACA for the Prevention and Public Health Fund was supposed to hit $2 billion starting in 2015 but won't reach that level until at least 2022. Scheduled increases in the money, used to fund public health programs around the U.S., have been delayed and the money has been siphoned off for other things. It isn't slated to start growing again until 2018.
• The Centers for Disease Control's Community Preventative Services Task Force, which researches and recommends community programs that are effective, is "woefully underfunded" and has "a huge backlog in terms of looking at the data," says Levi.
• There's little financial risk to ACOs are part of one of the Centers for Medicare and Medicaid Services' programs that allow them to share in any savings to Medicare. But teaming up with community health groups is still "disruptive innovation" that is hard for hospitals and doctors to adapt to, says Bobbitt, who represents many ACOs.
"It's hard to change the culture in a transformative way," he says. "Doctors say, 'We just never thought that way.'"
There are administration efforts to turn the tide, however.
Department of Health and Human Services announced a new payment and health care delivery plan last week for ACOs that further rewards doctors and hospitals for keeping people healthy. During a press call with reporters , Centers for Medicaid and Medicare Services acting principal deputy administrator Patrick Conway highlighted a project involving Maryland hospitals that are being paid to keep people to keep out of the hospitals, which they are achieving in part through partnerships with community groups.
Clyde Edwin Jr. carries boxes of food for his family as he leaves the Martha O'Bryan center in Nashville.<span style="color: Red;">*</span>(Photo: Josh F. Anderson for USA TODAY)
AN 'EPIDEMIC OF CHRONIC DISEASES'
Nearly 29,000 people have participated in the YMCA of the USA's year-long Diabetes Prevention Program over the past four years, and they've lost an average of 5.6% of body weight by the end of the program, says Matt Longjohn, a physician who is the Y's national health officer.
Medicare is paying for a federal demonstration project involving the program and seniors in 17 cities. Longjohn says they are working to get it covered by Medicare even after the demonstration concludes in June.
Conway also discussed the Y program last week and noted that Congress would need to authorize a national expansion of the project, which would be true for any of what CMS calls "innovation" projects like that in Maryland.
The Y's program is classroom-based and helps adults at risk of developing Type 2 diabetes focus on eating better and increasing physical activity.
"We are faced with just a ubiquitous epidemic of chronic diseases," says Longjohn. "The root causes of these chronic diseases are preventable, and community-based organizations can be a part of expanding care."
Rogers says lifestyle changes are not only more effective than relying on pills; they are also much less expensive and much safer. Rogers cites a Department of Veterans Affairs study showing someone taking eight drugs – which is not unusual for those in their 60s or 70s – has a 100% risk of potentially harmful drug interaction.
And there is a growing body of evidence showing lifestyle changes can turn heart problems around, he says.
Kevin French, 57, a construction contractor in Louisville, says he was raising two young children with his wife in 1993 when he began having chest pain and had to have two stents implanted in his heart. In cardiac rehab, he learned that his previous eating habits, lack of exercise and smoking played a big part in his heart problems.
Heart attack survivor Kevin French, under the supervision of a trained medical staff, works out at the KentuckyOne Health Healthy Lifestyle Center.<span style="color: Red;">*</span>(Photo: Marty Pearl for The Courier-Journal)
"Before, I guess I was like everyone else in the population – a constant visitor to McDonald's, if it's fast food, I ate it, ate on the go, always rushing, smoking, a lot of stress, didn't know how to relieve stress," he says. "I didn't know how to work out, I didn't know how to exercise, I didn't know how to eat. I basically didn't know how to live."
He says with the help of the healthy lifestyle center, he's learned how to eat well, handle stress, exercise, "basically change everything" – and that's improved not only his health but his family's as well.
The Nashville-based Martha O'Bryan Center promotes healthy lifestyles in the community by working with a local group that delivers up to 1,000 pounds of fruit and vegetable donations a week from local farms. The donations not only improve the healthy choices for their clients but also teach them about new foods such as persimmon and kiwi, which most of the children had never seen or heard of. Older clients of the center teach the younger ones how to cook foods, like purple tomatoes, that they may not be familiar with, says Marsha Edwards, CEO of the center.
Funding for fitness is another story, however.
Jose Pagan, Director of the Center for Health Innovation at the New York Academy of Medicine.<span style="color: Red;">*</span>(Photo: handout)
"In neighborhoods like ours, where we are in a food desert and there are safety issues, efforts to draw funding to our facility as a safe and positive place to have recreation has been extraordinarily difficult," she says.
Jose Pagan, a health economist who directs the New York Academy of Medicine's Center for Health Innovation, says a key challenge is that doctors and hospitals are going to keep working to keep the money flowing their way.
"If you go to a surgeon for a solution, they're not going to give you massage therapy," he says.
"There's going to be progress, but it's going to be very slow."
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