Improving Health by Taking It Personally

To resolve the nation's health care dilemma and tackle exploding costs, the current sporadic and reactive focus on treating episodes of disease must be transformed into one that is coordinated to improve health and minimize the consequences of chronic diseases.

Because care is more effective when services are coordinated,¹ there are mounting efforts to spur greater integration of delivery systems. What is missing is an approach that aligns the patient's individual needs with health services tailored to meet those needs. Coordination of services will be insufficient unless they are driven by plans designed to anticipate the health needs of the patient over time. A proposal to do this is “prospective care,” a strategic approach that combines personalized health planning with integrated care services to focus on individualized health promotion, disease prevention, monitoring, and early intervention.² Personalized health planning has the potential to effectively engage individuals with any aligned delivery system and serve as a foundation for payment models for valued outcomes.³ To deliver prospective care, 3 interrelated elements are essential: (1) a care model that uses personalized and predictive health planning, patient engagement, and processes to track health status, anticipate events, and personalize care when disease occurs; (2) care delivery systems to support the patient's strategic health plan and medical needs in a coordinated, integrated fashion; and (3) a reimbursement system that supports prospective approaches and provides incentives for effective interventions.

A problem with the current approach to care is that it is reactive, as exemplified by the medical work-up that starts with the “chief complaint and history of the present illness” and attempts to find the root cause of the disease and treat it. This model is well designed to treat disease events but not to promote health, prevent disease, or effectively treat chronic disease. Currently, many patients take little responsibility for their health, resulting in adherence barriers to effective prevention and treatment of long-term conditions. Existing reimbursement rewards interventions for disease events rather than prevention and continuity of care. Moreover, the current approach does not align with scientific concepts of disease development that indicate that an individual inherits a range of susceptibilities to chronic diseases and that, depending on exposures, health may improve or deteriorate into recognizable illnesses.

Based on these concepts and emerging research enabling clinical prediction, the idea of prospective care, a strategic approach to personalized medicine, was developed.^{2 ,4} Personalized medicine refers to all factors that distinguish an individual's health characteristics and risks, including family history, clinical data, behavioral factors, and genomics when applicable. Prospective care uses personalized health planning as its underlying approach to effectively link the patient and the delivery system. Personalized health planning is based on the understanding that an individual's genetic inheritance creates baseline risk for diseases that are modified by environmental factors, resulting in development of or resistance to disease. Given the time dependency of the disease process, an individual's health risks and status can be quantified and tracked over time, with strategies developed to engage patients and caregivers to minimize diseases and treat them appropriately when they occur.

The personalized health plan consists of a health risk assessment, a process to track risk factors, and a wellness-therapeutic plan that involves patients and maximizes their commitment. Thus, the plan serves as a point of coordination between the patient and the delivery system over time, ensuring maximum engagement on the part of both toward the goals of enhancing the patient's well-being and minimizing disease.

Inherited and acquired risks continue to be identified for many common diseases. The fields of genomics, proteomics, metabolomics, and bioinformatics will improve individual risk prediction accuracy,^{5 - 6} but they are not required to get started. A key element in the proposed medical workup is the identification of the patient's specific susceptibilities to chronic diseases and the risk factors that allow tracking of disease development. Physicians are trained to anticipate disease risks based on numerous clinical factors including family history, physical findings, and results of laboratory tests. It will be important to adopt a more formal approach using the latest evidence-based standards and health risk assessment tools to develop personalized plans to track risk factors associated with disease progression.⁷ Collaborating with the patient, plans are made to enhance health and avoid progression, thus enhancing the likelihood of adherence.

The medical workup and medical record will need to be adapted to create the personalized health plan, but this will merely shift much of what has already been done to a more coherent strategic process.⁷ The plan's creation, monitoring, and intervention can link the patient to any delivery system, thereby creating seamless portability. Relating to prevention and acute care, personalized health planning is largely a primary care function, but it integrates with specialty or trauma care when needed. Personalized health planning provides the operational framework on which delivery system models and reimbursement methodologies can be built.

Coordinated approaches for preventing and minimizing disease have been associated with favorable clinical outcomes, improved preventive care, decreased health disparities, and reduced costs.⁸ Progress has been made toward developing coordinated models of care, eg, the medical home, which seeks to transform primary care practices to provide patient-centered continuity of care. Large, self-insured health maintenance organizations such as Kaiser have mounted substantial efforts to coordinate care, but these efforts have been limited by the lack of strategic approaches to patient care.

The value of linking coordinated care with a personalized health plan and applying it to tertiary prevention was explored by the Duke University Health System in 1998. A patient-focused, physician-directed, disease management program was created, engaging 117 patients in health planning to minimize congestive heart failure.⁹ Through intense patient education and development of a personal plan, including strict attention to medication, diet, exercise, and access to a health coach, the process was highly effective clinically and economically. Pre-enrollment costs ($16 025 per patient per year) were reduced substantially (by a median of $8571 per patient per year) resulting from a major decrease in hospitalizations, which far offset a slight increase in outpatient costs. Ironically, because reimbursement compensates in-hospital patient care at a higher level than outpatient services, the health system realized a financial disadvantage, and the program proved economically unsustainable.

To overcome the reimbursement barrier, Duke Prospective Health was developed for Duke's self-insured employees, thereby aligning financial incentives with clinical outcomes. The major components included a health risk assessment and personal health goals and involved primary care physicians, health coaches, and, when appropriate, disease management. During the first 2 years, medical costs for high-risk individuals decreased 3.5%; emergency department visits and hospital stays also decreased.¹⁰ After 2 years, Duke's health care costs averaged $5298 per employee, below the national average of $7498. Duke more than recovered its initial investment to launch the program and sees greater potential as the program evolves.¹⁰

Personalized, prospective approaches to health will not be attainable without reimbursement reform to support them. Suggestions have included global and value-based payments that reward good performance and outcomes.³ It is also critical that the medical profession and payors embrace the concepts of strategic health planning. Federal funding for pilot projects to validate and improve such delivery models will speed the creation of even more effective care. With ongoing experience and research refining clinical predictions and providing better means for encouraging patient engagement, prospective care with personalized health planning will be the impetus for continuously improving cost-effective health promotion and personalized care and thus create meaningful health care reform.