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2023 Prediction 4: The Quest for Optimal Individual Health Will Begin To Drive a Proactive Approach to Population Health

Prediction 1  |  Prediction 2  |  Prediction 3

By Carolyn Senger, MD, MPH

Optimal health. Everyone wants it. Some claim to know how to achieve it. Few actually do. Why the disconnect? First, we need to broaden our view from the individual to the population. By placing the onus on individuals and not taking a broader, evidence-based view, both the focus and the approach miss the mark. Second, all too often, critical barriers to optimal health get missed such as social determinants of health (SDOH), disparities and inequities, and access challenges. Further, clinicians are incentivized for volume over value, sustaining a climate whereby a reactive, transactional care approach is rewarded, while outcomes continue to lag. 

As a board-certified preventive medicine physician, I know that it’s critical to understand the factors that support or inhibit health and health behaviors, which represent up to 50-80% of the modifiable contributors to health outcomes and include the conditions in the environments where people live, work, and play. When we look at this with a view of the population – be it geographical, community, or workplace where members share common risk and resilience factors – the need for continuity vs. transactional care is even greater. 

My team and I view optimal health through a wide lens that allows us to take that broader, evidence-based view, partnering with individual members to understand the factors that impact their health and health behaviors, and share tailored tools and resources to help them succeed. To achieve this, continuity of care must be supported at the primary care level to increase equity and improve health outcomes. We believe this approach will unlock the healthcare system’s potential to play a bigger role in fostering optimal health of populations in 2023 and beyond; and below is how we see it unfolding.

A PCP-driven, proactive approach to optimal health and wellbeing will shift the paradigm

Research shows that robust primary care delivery, focused on preventive services and whole-person wellbeing, remains the foundation of optimal health and leads to more equitable outcomes, lower costs, and better quality care for populations overall. Still, we are undervaluing primary care’s role: while it accounts for 35% of healthcare visits, it receives just five cents of every health care dollar spent. Data also shows that every $1 increase in primary care spending produces $13 in savings. A paradigm shift that fosters a broader understanding of patient wellbeing and barriers is imminent, and will begin in primary care where proactive, personalized interactions engage members and address their most pressing health and lifestyle challenges. 

Primary care clinicians (including physicians, nurse practitioners, and physician assistants, collectively known as PCPs) hold great power as “the first contact with health services, [who] facilitate entry to the rest of the health system….[with the] ability to recognize individual risk factors of patients and intervene, paralleled with their growing awareness of the social, environmental, and community determinants of health.” Not only are PCPs the front door to the health system, they are also entrusted with building relationships with patients, connecting the dots of their various medical and non-medical needs, and serving as advocates and coaches for attaining full health potential at every life stage.

Considering community, workplace health

Indeed, the evolving responsibilities of PCPs, the foundation and heart of our health system, are substantial. They are working to close care gaps, mitigate care barriers, prevent disease, reduce the burden of chronic illness, and promote the value of health. That said, to have the best impact, we need to think much more broadly about health and wellbeing in the context of population health versus a transactional, volume-driven approach.

This year, let’s commit to empowering our communities to be promoters – and not  barriers – of good health. While some neighborhoods may be rich with walking paths and grocery stores, others may experience crime, lack healthy food options, or have limited means of public transportation, making basic tasks such as exercising regularly, accessing nutritious food, or visiting the doctor challenging. Similarly, workplaces may foster a sense of community and purpose, promote healthy choices, and have policies that support workers to get the healthcare they need. On the flip side, some workplace communities are fueled by a relentless “do more” mentality that leaves employees stressed, isolated, and depleted. When employees are unable to spend time with their families or even go to the doctor, maintaining health and wellbeing becomes unattainable.We all have a role to play in empowering healthy communities. 

Managing the whole patient

That’s where a team-based approach to care, focused on the population, will continue to be the game changer. When patients have the opportunity to discuss community challenges with trusted clinicians, they foster tighter connections that ultimately lead to optimal health. Longer appointment times, like we have at Crossover Health foster this. Our standard appointment time is 30 minutes with first appointments at 60 minutes, compared to the national average of 18 minutes. The duration supports discussing a patient’s whole health, including emotional, social, physical, mental, and environmental risk factors, as well as lifestyle and health behaviors. By screening every member for SDOH factors, we open the door for important conversations to gain a deeper understanding of the whole patient. Further, clinicians engage with members in various ways to support an ongoing dialogue about what matters most for their health in the context of their larger community. 

For example, when the pandemic changed the way our populations lived and worked, Crossover anticipated shifts in key risk factors and health conditions in our community like physical inactivity, loneliness, and chronic disease. We focused on conducting proactive member outreach to our members and leveraging hybrid care options such as on-site and virtual appointments and asynchronous secure messaging to ensure members and their health didn’t fall through the cracks. From there, an integrated care team managed individuals and the population at large via this proactive approach to wellness.

The power of dedicated teams and supportive tools in action

This focus on proactive outreach made all the difference for one of our members, a relatively young man who had been fairly healthy. In response to my message, he responded that he had been struggling with fatigue and weight gain. He subsequently screened positive for loneliness, obesity, and elevated blood pressure, with labs that indicated pre-diabetes. Stressed and working around the clock, he had stopped  exercising and felt isolated from loved ones. What could have been an overwhelming set of diagnoses or a situation where we relied solely on medications and referring out to specialists, became an opportunity to empower him to take charge of his health. 

Under our care model, I was able to connect him with health coaches, who provided  strategies for weight loss, stress management, hypertension reduction, and lifestyle modifications to prevent or delay his risk of progressing to diabetes. Self-care resources through our Be Well platform offered patient-friendly advice and tools so he could understand loneliness and take steps that felt right for him. The member also started taking on-demand fitness classes through Be Well that fit his schedule, and I continued to connect with him and with our integrated care team to support his health goals. Within a year, he attained a healthy weight, normal blood pressure, and reversed his prediabetes without medication or treatment by outside specialists. He reported feeling more connected and less stressed. In his own words, he said that he never would have made the time for that initial health visit, let alone the subsequent work on his health, without that proactive outreach message and its connection to a physician who cared deeply about his health. 

That’s the power of team-based prevention, which can drive change for individuals and entire populations. In 2023 and beyond, to achieve optimal health, we must rethink transactional care episodes in favor of a broader, evidence-based approach. Using technology and data-driven solutions to connect and engage, patients will have the support of an integrated care team built on a strong primary care foundation. Ultimately, shifting to team-based prevention, supported by population health, will unlock the healthcare system’s potential to play a bigger role in fostering the optimal health of populations. “Not being sick” is simply not good enough.

Frequently Asked Questions

What are the key factors that contribute to the disconnect between the desire for optimal health and the ability to achieve it?

The key factors include a focus on the individual rather than a broader, population-based approach, as well as missing critical barriers like social determinants of health, disparities, and access challenges. The incentive structure that rewards volume over value also sustains a reactive, transactional care approach.

How does the role of primary care providers (PCPs) in preventive services and whole-person wellbeing support optimal health and population health outcomes?

Research shows that robust primary care delivery focused on preventive services and whole-person wellbeing remains the foundation for optimal health and leads to more equitable outcomes, lower costs, and better quality care for populations.

How can patients be more proactive in achieving optimal health?

Patients can be proactive by communicating openly with their primary care provider about all aspects of their health and wellbeing, including social and environmental factors. They can also actively participate in preventive care and lifestyle changes.

How can employers promote a culture of health and wellbeing among their workforce?

Employers can offer wellness programs, healthy food options, opportunities for physical activity, and flexible policies that support work-life balance.

What should patients look for when choosing a primary care provider who focuses on whole-person health?

Patients should look for providers who allocate sufficient time for appointments, have a team-based approach, and demonstrate a commitment to preventive care and addressing social needs.

How can patients leverage digital health tools to support their ongoing health management between provider visits?

Patients can use apps, patient portals, and remote monitoring devices to track their progress, access educational resources, and stay engaged in their care.

What should patients do if they feel their provider is not adequately addressing their social and environmental health needs?

Patients can have an open discussion with their provider about their concerns, and if needed, seek a new provider who demonstrates a stronger focus on the whole-person approach.