updated June 22, 2017
As I described in my mission statement, Affordable Health Care and Beyond for ALL Americans, my definition for health care has two components–before sickness and after sickness. We are all familiar with after sickness care because it is our traditional understanding of health care; namely, there is a breakdown in bodily function (mental and physical) and it is called upon to repair us or manage it, if possible. After sickness care almost always requires the assistance of paid healthcare professional(s) while before sickness health care does not. Before sickness health care is centered and controlled by the individual person and after sickness “health” care is centered and controlled by medical doctors. After sickness “health” care should really be called “sick care”.
What Exactly is Before Sickness Health Care?
Before sickness health care is EVERYTHING we do to minimize the future probability of sickness. In before sickness health care, the individual is asymptomatic (i.e., has nothing that needs obvious fixing). The goal of before sickness health care is to stop the occurrence, misery, and severity of sickness. Its application is initiated by individuals and often encouraged by health insurance payers (government, employers) through before sickness health benefits.
Examples of before sickness health care include:
- When an individual eats a healthy diet and keeps physically fit, he/she is practicing before sickness healthcare.
- When an insurance plan incentivizes beneficiaries through programs like free gym memberships, free preventive screenings and immunizations, and wellness programs, it is practicing before sickness health care
- When a doctor is incentivized to explain how to prevent future health problems, he/she is practicing before sickness health care
- When our government funds community-based lifestyle education and support programs or funds social programs that ensure basic needs (i.e., adequate nutrition and safe housing) are met, it is practicing before sickness health care.
These before sickness healthcare measures have the potential to help people live longer, minimize disability from disease, and be more productive. Some measures are even cost-effective (e.g., most immunizations and taking a daily aspirin to avoid a heart attack or stroke for people with heart disease).
Types of Before Sickness Healthcare Initiatives
Evidence-Based Preventive Services
Evidence-based preventive services either stop disease from occurring (immunizations) or they catch diseases at an early stage when it is easier to treat (screenings for various diseases like breast cancer). While preventive screenings are typically done through a medical doctor, immunizations can be administered by a variety of healthcare professionals. If a disease is found during a preventive screening, it is treated as soon as possible. Preventive services are shown in the figure below.
Under Obamacare (PPACA), the Essential Health Benefits covered by health insurance plans included many preventive services at no cost to the patient (i.e., $0 cost-sharing) to incentivize beneficiaries to take advantage of them. Many Americans were shocked to learn that if a preventive service finds something wrong then the concept of $0 cost-share goes out the window (e.g., if polyps are found during a colonoscopy). For this and many other reasons, a large number of Americans still fail to get preventive services today. The report found that adults without insurance or without a regular source of health care generally had the lowest preventive services use.
Are these immunizations and preventive services cost-effective? In the United States, only immunization recommendations are evaluated for cost-effectiveness. The total price tag for preventive services is controlled by limiting the eligibility rules for the services—a total cost rather than a cost-effectiveness management tool. Zero cost-share, adult preventive screenings are usually aimed at people who are at highest risk for specific diseases (like people over the age of 50 and smokers).
As with all no-cost-share preventive services, make sure you are eligible and the medical coding for the service is correct BEFORE getting the no-cost-share care.These preventive services are available to everyone, but will only be free of charge to those Americans who are defined as higher risk candidates. If you are not in one of the higher risk groups but still want a preventive service, you will have to pay for it yourself.
Government-sponsored health plans have their own lists of no cost-share preventive services. For people with Medicare coverage, the list of no-cost-share preventive services, who is eligible, and how often they are covered is provided online.
Wellness programs are typically designed to identify health risks among employees, manage unhealthy lifestyles, and chronic conditions for improved productivity (and of course, reduced healthcare costs). They are offered (and controlled) by individual employer-sponsored health insurance plans. Wellness programs were initially authorized by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and further defined under Obamacare (PPACA) to make sure that health insurance plans that incorporate them do not discriminate against people based on their health condition (e.g., an asthmatic cannot be required to exercise). The primary aim of a wellness program is to reduce the employer’s health insurance costs and improve worker productivity. There is no requirement that wellness programs be evidence-based or accredited. Participation in wellness programs is voluntary and employers cannot legally discriminate against workers who chose not to participate in them.
Wellness programs vary in design, services, and activities offered but can be subdivided into two categories:
1. Participatory Programs—employees simply participate in health offerings and do not have to show health improvement (e.g., employer pays for a gym membership or smoking cessation program, offers a reward for undergoing a diagnostic test or attending an educational seminar)
2. Health-Contingent Programs—employees must meet defined health results to gain rewards or suffer surcharges
a. Activity-based programs—rewards employees for completing an activity (e.g., walking 3000 steps per day)
b. Outcome-based programs—employees submit to a health exam (called a biometric screening) that measures the employee’s risk factors for certain health issues and rewards them for meeting defined health results (e.g., keeping body mass index, blood cholesterol, and blood glucose levels below certain levels)
Participation in both categories above is typically low (less than 40% of eligible employees participate in any given year) and therefore employers must provide financial incentives to encourage employees to participate. Wellness programs also may require employees to complete a health risk assessment (HRA) questionnaire that identifies health risk areas. This involves sharing health information with the employer and the employer directing the employee to needed health services. According to the Kaiser Family Foundation, 71% (2016) of large firms have wellness programs that collect personal health information on their employees.
Disease management services for employees with chronic conditions (e.g., diabetes and high blood pressure management) can be participatory or health-contingent programs. For a more in depth analysis of employer wellness programs, see the 159 page research report Workplace Wellness Programs: Services Offered, Participation, and Incentives by the Rand Corporation for the United States Department of Labor in 2014.
Unlike the employer-sponsored wellness program (whose primary goal is for the financial benefit of the employer and only reaches a subset of individuals), community-based initiatives are centered on improving the health of ALL Americans within a given community. Community-based initiatives include such broad areas as education, community support, lifestyle management, and the use of professionals outside the traditional doctor’s office. Examples of these initiatives include providing access to affordable, nutritious foods, providing places where physical activity can be practiced safely (e.g., making more sidewalks and parks), and or unhealthy habits discouraged (e.g., increasing tobacco taxes). These initiatives can be uniquely designed to meet the needs of the local populations and identify the highest risk individuals.
Support for these community-based initiatives needs to start at the top with federal government funding, guidance, and flexibility. Local governments, public health agencies, schools, and community organizations need to work collaboratively to identify, develop, and promote initiatives unique to their community needs. In addition, successful implementation of these community-based before sickness health care initiatives requires health insurance plans to be more flexible in whom they’ll reimburse. According to the Trust for America’s Health, some of the most common chronic, preventable diseases might be best addressed outside the doctor’s office at places like community YMCAs and houses of worship.
Educational and promotional efforts are also crucial for community-based health initiatives to succeed. My adult son told me that he never took up smoking because of a tobacco-blackened cow’s lung he saw at a local children’s fair when he was eight years old. It scared him away from ever taking a single puff.
Summary of Before Sickness Health Care
Before sickness health care IS health care! It consists of everything we do to stay healthy for as long as possible like eating healthy foods, living in healthy environments to nurture good health, keeping physically active, staying away from unhealthy habits, and availing ourselves of evidence-based preventive services that help us keep sickness at bay.
While after sickness health care (i.e., sick care) consumes the vast majority of our national health spending, our government needs to make before sickness health care a national priority! Funding before sickness health care demands a policy shift from putting the financial interests of for-profit healthcare businesses first to putting the health (and financial interest) of the individual American first. Remember my affordability message: “Health care affordability can only be accomplished by decreasing the TOTAL cost of sick care and/or by INCREASING patient wellness so that fewer medical services are needed!”
Many lifestyle choices contributing to long-term health require many years of practice, behavioral support, and continuing education before healthy habits are learned or any unhealthy habits unlearned. Employer-sponsored wellness programs are typically short term “fixes” at best and unlikely to be effective over the long run. If you have ever dieted and lost weight, you understand the long term commitment healthy eating requires. Poorly designed wellness programs can decrease employer health premiums (through employee penalties) without making employees healthier. Because before sickness health care is largely initiated (and controlled) by the individual, flexible and community-based efforts have the potential to reach the greatest numbers of Americans for better health care.