Is Whole Health A Fad — Or an Inflection Point?

One of the traps that companies fall into is taking the solution that worked last time and then applying to the problem of the opportunities of today. Many times, what we have to do is break out of our own design traps.” — Albert Segars

Introduction

Is the success of Whole Health in the VA a “fad” or an inflection point? I argue it is an inflection point.

The Veteran’s Health Administration (VHA) is the U.S. government agency of the Veterans Administration responsible for providing healthcare to 6.3 million qualifying Veterans of the US Armed Forces. With the introduction of a new healthcare paradigm called Whole Health, the VA is changing care delivery with the hope of helping Veterans, their caregivers and VA employees seek better health and a more fulfilling life. They would also like to attract more of our nation’s heroes to seek care within the system. Another 3.9 million Veterans are eligible for care and don’t use the VA. In particular, Veterans aged 35–55 are the least likely to utilize the system. The question to answer is: Why? Why do almost four million Veterans choose to not seek health care at the VA? And, where do 35–55 years old receive their care?

Whole Health

Whole Health is an innovative and transformative patient- centered system of healthcare that complements the traditional find-it-fix-it model of allopathic medicine. Through the assistance of health coaches, trained peers, and educated medical professionals, the Whole Health Service engages each individual patient from a personal perspective.

We encourage Veterans to develop their own Mission, Aspiration, and Purpose (MAP), which ultimately influences conversations around and decisions about their healthcare and self-care. The model of Whole Health is depicted in (Figure 1). Besides health coaching, Whole Health provides a number of unique services including shared medical appointments, educational opportunities to embellish self-care practices, and complementary and integrative health modalities such as yoga, tai chi, massage therapy, mindfulness, reiki, energy therapy, and hypnosis that are covered U.S. Veterans benefits.

A three-globe diagram of the V.A. Whole Health System including the Pathway; Well-being Programs; Clinical Care
Figure 1: The Whole Health System of Care

Whole Health was introduced into the VA to help tackle three major dilemmas:

1. Opioid misuse and addiction: 115 people in the US die every day after overdosing on opioids; 416,000 Americans have died from opioid overdose between 1999 and 2016. The economic burden of prescription opioid misuse alone in the US is $78.5 billion a year. 21 to 29 percent of patients in the general public prescribed opioids for chronic pain misuse them.1 Veterans are part of these statistics. One in 15 Veterans struggle with substance use disorder. From 2001 to 2009 prescription opioids increased 24% in the Veteran population to treat chronic pain. As prescribing of opioids increases in the Veteran population, so does suicide. (2)

2. Persistent unacceptable levels of Veteran suicide: 20 Veterans die by suicide every day. Increased risk of mental health and substance use disorders, especially opioid addiction put Veterans at risk for suicide. Other risk factors include social isolation, limited access to healthcare and gun ownership. (3) Veterans with problems abusing drugs or alcohol are twice as likely to die from suicide compared to civilians. (4) Women Veterans who misused opioid drugs were very high-risk (98.4 out of every 100,000 taking opioids died from suicide).

3. Escalating healthcare costs: In 2016 the United States spent approximately $3.3 trillion on healthcare, which accounts for 17.9% of our gross domestic product (GDP)5. Of the $3.3 trillion, 32.4% was spent on hospital care, 19.9% on physician and clinical services, 9.8% on prescription drugs, and 4.9% on nursing care facilities. The VA has experienced similar increasing healthcare costs.

At the end of the day, the VA is also very interested in increasing the number of unique Veterans we see as patients, just like our counterparts out in town. There is concern over the threat of privatization of VA Healthcare if we cannot up our game and attract more consumers. What will bring them to seek care with us? Can Whole Health provide unique services that draw eligible Veterans aged 35–55 (the largest demographic that does not use our services) into the VA at least for well-being care?

VA Healthcare

The Veterans Health Administration operates the largest integrated health care system in the U.S. caring for approximately 6.3 million Veterans, operating 1,240 medical facilities, and employing 385,233 personnel with an annual budget of $188.65 billion. Not all Veterans are eligible for service within the VHA. Of the 10.2 million eligible Veterans, only 6.3 million actually engage the VA for at least some of their healthcare. (Exhibit 1) The question to answer: Why are there 3.9 million eligible Veterans not choosing to receive their care at the VA.?

Quality of VA Care: Although public perception may not be in alignment, a recent comparison of quality of care in the VA vs. non-Veterans Affairs settings demonstrated the quality of care in VA facilities met or exceeded that of similar health care outlets within the same community. This is no different than a similar study that was completed 20 years ago.

VA Priorities and VHA Strategic Plans to Retain and Attract Veterans

The VA is undergoing a major reorganization to transform the way it provides services for its Veterans nationally.6 7 This effort is led by five priorities: (1) World class customer service, (2) The MISSION Act (Maintaining Internal Systems and Strengthening Integrated Networks) that mandates implementation of a cohesive community care program including coordination of VA and non-VA programming, virtual care; (3) Updating the electronic health record; (4) Business systems transformation and (5) Suicide prevention — the top clinical priority. (Exhibit 3)

Given the aforementioned priorities, four strategic goals have been outlined: (1) Provide better access to care; (2) Deliver reliable and integrated care; (3) Regain Veteran trust; (4) Transform business operations. “Elaborating upon goal #2, Delivery of highly reliable and integrated care that emphasizes their well-being and independence throughout their life journey.” All this to say, that Whole Health — the VAs name for care the emphasizes life-long “well-being and independence”- is now listed on the priority list. Is this a component that will attract more Veterans?

An Analysis of Potentials: Where are eligible Veterans seeking care?

Scenario analysis otherwise known as Narrative Building is an analysis of potentials…of what is possible. For the sake of this paper, I will apply Scenario Analysis to assess the potentials to explain where eligible Veterans who do not seek care within our facility — especially those between the ages of 35-to-55 — where are they getting their healthcare? And, once we know, how can we shift our resource allocation to encourage them to try the VA?

When people select their health care provider, there are many variables they will consider such as location, reputation, accessibility, cost, health education instruction and facility appearance. But, ultimately Veterans — just like the general public — are making their healthcare choices based usually upon their state of health (are they seeking care for a disease state or well-being support) and their predilection for the type of care (traditional vs. nontraditional) services they prefer.

Scenario Analysis

Figure 1 depicts the scenario analysis that defines four competitive futures.8 The horizontal Axis details the spectrum of services offered to manage disease states. They range from systems of care to individual modalities of care. The vertical axis represents Well-being services and range from traditional to nontraditional options.

1. Traditional Systems of Care include all allopathic general and specialty care including Internal Medicine, Surgery, Endocrinology

2. Alternative Systems of Care include all non-Western complete systems of care including Osteopathy, Chiropractic Medicine, Integrative Medicine, Traditional Chinese Medicine and Ayurveda. In general, care delivered in alternative care systems are not covered by medical insurance.

3. Traditional Well-being Services are modalities either prescribed or self-selected by patients but necessitate proactive patient behavior. These modalities are generally covered by traditional insurance.

4. Complementary and Integrative Services are self-care proactive modalities that are usually accessed through self-referral; they take significant consumer engagement. They are not generally covered by standard insurance.

Figure 1: Systems of Care vs. Services

Figure 2 depicts the four possible futures and their recent migrations that are closely correlated with the locations where specific demographics seek their preferred healthcare services whether disease-based systems of care or self-care modalities; whether traditional or nontraditional forms of well-being services.

1. Homestead Care individuals who prefer Traditional Systems of Care are generally older, have an average health level, trust the traditional medical system, are infrequent users of technology, prefer face-to-face visits, prefer to be cared for by the medical team, take and follow treatment recommendations and are likely to adhere to the plan as outlined. Relationships with the medical team members are very important; they are unlikely to change providers if they are dissatisfied with the level of communication.

2. Trailblazers are healthcare consumers who prefer Alternative Systems of care. They are very active in their own care, prefer complete care by alternative providers, most likely to follow a healthy diet and traditional exercise regularly, are tech savvy, prefer virtual visits, and rely upon ratings to assess whether or not they will pursue care within the system/practice. They are most likely to change providers if they are unsatisfied with the level of communication. They are part of the youngest demographic of independent health consumers.

3. Naturalists seek Complementary and Integrative Services. They prefer self-care modalities as opposed to systems of care but may migrate to become a Trailblazer if they experience a prolonged illness. In general, they do not trust the conventional healthcare systems. They are similar to Trailblazers in that they belong to a younger demographic, they are very invested in their health. Sound nutrition is a priority for them; they prefer to pursue self-care modalities; prefer to utilize nontraditional wellbeing services for the majority of the interaction with healthcare professionals.

4. Bystanders are healthcare consumers who use peripheral traditional well-being services such as social work therapy sessions, work with a dietitian, seek support groups and attend well-being lectures in the community. In general, Bystanders do not trust medical professionals and participate infrequently in self-care. They are likely to be older, least likely to use technology for health care and the least likely to consider virtual care visits. However, they are also the least likely to change healthcare providers if they are dissatisfied with communication levels.

Migration Patterns

Figure 2: User Characteristics & Migration Patterns

1.) Homesteaders are migrating to the Bystander wellbeing practice quadrant due to a perceived breach of trust by the traditional healthcare systems. They prefer to continue to utilize ancillary, self-referral services for well-being.

2.) Homesteaders are migrating to the Trailblazer quadrant relying more upon nonconventional healers and systems to treat their disease processes.

3.) Trailblazers are now adopting more Naturalists behaviors; now that the science is proving the efficacy of these modalities or personal experience indicates the nontraditional well-being services fulfill the majority of their healthcare needs.

4.) Bystanders are migrating to the Naturalist quadrant undertaking more self-care nontraditional modalities including yoga, tai chi and mindfulness.

5.) And, finally, Homesteaders, regardless of their predilection for conventional systems of care are starting to participate in more nontraditional self-care modalities.

Resources

Resources differ for each of the quadrants from space requirements to technology capacity.

1.) Homesteaders: Resources needed for this demographic include traditional health care spaces, traditional health care teams, excellent communication skills. Providers in this arena should involve the patients’ caregivers if pertinent, leverage community resources, tailor solutions for barrier to care adherence and treat them with respect.

2.) Trailblazers: Vital resources include alternative office spaces that provide patients the opportunity to purchase recommended vitamins, herbal therapies, or additional supplies to assist with nonconventional care. Trailblazers expect access to tech savvy interactions and virtual visits. They require excellent communication from their providers.

3.) Naturalists: This group requires ample community resources. Service delivery spaces should exude tranquility, contain individual spaces for one-on-one care and large group spaces to practice group complementary and integrative health modalities. They, too, are tech savvy and prefer virtual visits when appropriate.

4.) Bystanders: Traditional medical office spaces provide appropriate accommodations from the segment. They would benefit from having multiple disciplines available in one office space to avoid the need to travel between appointments. Recommend having a social worker on staff to assist those in need of community resources and assistance with daily functioning.

Recommendations

This analysis would be valuable to healthcare systems and manufacturers/distributors who understand the importance and value the well-being trend underway right now in society. My assessment provides evidence that Homesteaders who seek traditional wellbeing services that are engulfed within a traditional system of care are migrating to other groups — therefore, the number of patients who desire only traditional systems of care are dwindling.

In addition, all groups are currently migrating to the naturalist’s quadrant. Therefore, it is prudent for any healthcare system who wishes to attract additional patients, including the VA, to offer Complementary and Integrative services as part of their normal day-to-day patient care. The VA already offers Whole Health as the answer to this charge. Therefore, my assertion that Whole Health is not a fad, but a point of inflection, is well-founded.

Another reason to offer these services is to assist patients to acquire self-effective behaviors thereby reducing the cost of healthcare in the United States. Although this is counterintuitive to the current business model of conventional Western medicine who relies upon specialty care and procedures for the bulk of its revenue, we all have a responsibility to be better stewards of healthcare dollar utilization in the US.

In addition, preliminary research indicates that Whole Health (i.e. Complementary and Integrative Health) modalities reduce the cost of healthcare and reduce the utilization of opioids. For this reason, it is important to offer CIH modalities within every community especially those particularly hit with the impact of opioid misuse, abuse and addiction.

Resources:

[1] https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis

[2] https://www.recoveryfirst.org/veterans/opioid-abuse/

[3] https://www.recoveryfirst.org/veterans/suicide/

[4] University of Michigan, Michigan Medicine. (2017). Drug and alcohol problems linked to increased Veteran suicide risk, especially in women.

[5] Peterson-Kaiser. Health System Tracker: How does health spending in the U.S. compare to other countries? February 13, 2018. Accessed 11/15/18. https://www.healthsystemtracker.org/chart- collection/health-spending-u-s-compare-countries/#item-relative-size-wealth-u-s-spends- disproportionate-amount-health

[6] https://www.hsrd.research.va.gov/about/strategic_plan.cfm

[7] https://www.va.gov/oei/docs/FA2018-2024strategicPlan.pdf

[8] Adapted from The US Health Care Market: A Strategic View of Consumer Segmentation Deloitte Center for Health Solutions. 2018; PATH. The Nine PATH “Valuegraphic” Profiles of Health Care Consumers.

Exhibit 1: VA Strategic Goals, Objectives and Priorities

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Jacquelyn Paykel

Dr. Jacquelyn Paykel is Chief of the Whole Health Service at the Tampa, Florida VA Hospital. She is an author & accomplished speaker on novel medical paradigms.