Wednesday, November 26, 2014

The HICCup Manifesto

NEW YORK – It is hard to find anyone in health care who does not believe that spending $100 now on healthy behavior – exercise and proper nutrition, counseling for pre-diabetics, risk monitoring, and so on – could yield more than $200 in reduced costs and improved outcomes later. The numbers are fuzzy, of course, and there are plenty of methodological caveats, but there is little dispute about the desirability of such an approach.

And yet neither individuals nor communities seem to act on the basis of this knowledge. Individuals often lack willpower or access to healthy food or convenient exercise facilities, and are surrounded by poor examples that encourage instant gratification rather than effort and restraint. And, on a broader, institutional scale, the money spent and the money to be gained do not belong to the same pocket.

Instead of just complaining, I recently decided to create HICCup, the Health Intervention Coordinating Council, a self-appointed counseling service aimed at persuading local institutions to embrace a long-term perspective and launch a full-scale intervention in their communities. For practical reasons, there are a few guidelines – but anyone who wants to do this without following our rules is welcome to do so.

For starters, HICCup will focus on communities of 100,000 people or fewer. The majority of the community and its institutions must be enthusiastic. If most community members work for just a few employers and obtain health care from just a few providers, the effort of corralling the players will be easier. And, of course, community leaders – the mayor, city council members, and others – must work together rather than undermine one another.

So, how will this be funded? Not by HICCup. The trick is to capture some of what is being spent on health care already. As a rough calculation, assume $10,000 in annual per capita health-care costs, or $1 billion per year in a community of 100,000. (There are also all the separate costs of bad health, which are much harder to count or capture.) That money ultimately comes from individuals and employers who pay it in taxes, insurance premiums, or direct payments, and should be intercepted somewhere between the payers and the health-care delivery system.

Instead of spending $1 billion a year, imagine spending $1.2 billion the first year, but, say, only $750 million in the fifth year. That sounds like an attractive proposition – but someone must make the initial investment in exchange for a claim to the later savings. (And, one way or another, the investor will need to repurpose the health-care facilities and workers to some other role, including prevention, serving outsiders, or conversion to another use entirely.)

This is where the first miracle is needed – a benevolent but ultimately profit-driven billionaire or hedge fund, or a philanthropy that sees a way to do good while earning money for future goodness. There are a lot of billionaires out there, some with vision. There are health-care companies that might bite, hedge funds looking for large-scale projects, and so-called social-impact bonds. There also are large employers that might decide to work with other employers in certain communities.

All of these entities would be taking a substantial leap of faith. But I think it is doable – especially if they work together to figure out the numbers, study the effects of small-scale healthy-living/preventive health-care efforts, and encourage one another to move forward. Regardless, each investor must work with existing institutions – if only to access revenue streams initially and benefit from the lowered costs later on.

Although grants are a nice source of funding for demonstration projects and research, only a for-profit approach that attracts broader investment will ensure that this scheme catches on. The funder makes a deal with whoever is responsible for the health-care costs: upfront investment in exchange for continued payment of the $1 billion yearly baseline, with the funder to keep the future savings against originally predicted costs. The money may be paid by employers, private insurers, or government health-care funds (the trickiest source).

Community officials and voluntary organizations also need to sign on – or, indeed, they could drive the process and find the investors themselves. They could also contribute with complementary changes in school meals and gym classes; zoning and other planning measures to encourage cycling, walking, and the like; provision of health counseling; and perhaps by working with local restaurants and food stores to subsidize healthy choices and discourage unhealthy ones.

The X Prize Foundation once promoted this idea, but dropped it when a funder lost interest. But there are many smaller-scale examples, such as Oklahoma City, which lost one million pounds of collective weight in a population of about 600,000; we hope the people involved will join with HICCup to share their experiences, good and bad.

Indeed, HICCup will not choose which communities participate. They will choose themselves. HICCup’s role will be to advise them and help them to communicate and learn from other communities going through the same process. We also want to be a clearinghouse for vendors of health-oriented tools, services, and programs. There are many bargains to be struck between communities and vendors offering discounts in exchange for wholesale adoption of their tools or programs.

There is, however, one unbreakable rule: To work with HICCup, communities must collect and publish a lot of independently vetted data (without personal information, of course). For starters, they will need benchmarks of current conditions and projected costs, and then detailed statistics on the adoption of the measures, their impact and costs, and what happens over time. HICCup will spend a lot of time with lawyers and actuaries!

Indicators to be measured include not just rates of obesity, high blood pressure, and incidence of disease and related costs, but also absenteeism, school grades and graduation rates, employment statistics, accidents, and the like. Although the funder keeps the reduction in health-care costs, the community gets all of the many payoffs from a healthier population – including an enhanced reputation.

It is now time to try this on a broad scale. Five years from now, we will wonder what took us so long to get started. So, again, who will those investors be?

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    1. CommentedMichael Rossi

      There maybe some valuable insights to human health decisions in a lecture by Dr. Volpp.

    2. CommentedZsolt Hermann

      The idea of prevention instead of treatment is very good, actually this is the only right approach and not only in terms of healthcare but at all avenues of life, in all areas where humanity is facing crisis today.
      But this problem cannot be solved by initial cash injections, with benevolent benefactors lending money in order to save, or even gain profit from it.
      As with the medical example until we identify the root cause, the true disease we will not be able to prevent or treat it.
      The reason we act as we do today, even if logically we understand and accept that prevention is better than treatment is that our inherent human nature drives us to achieve immediate, short term benefit and profit, as we try to grab for ourselves whatever we can immediately.
      Although decades ago it seemed humanity is capable of making long term plans, making 5 or even 10 year plans and act accordingly, by now as if we regressed, back to a child-like behavior "I want it, and I want it now".
      Today no politician, expert or simple human being is able to act in a long term, calculating manner. Decisions, actions are changed weekly, daily according to polls, market reactions, etc.
      As our evolution is the evolution of our self driven ego, today this ego has become so strong that it does not allow us to make any calculations, any plans that does not bring ourselves immediate satisfaction, fulfillment.
      This is the reason of the global crisis and this behavior is true to each and every human being.
      Thus there are no quick, immediate, miracle solutions as our politicians or expert would like, as first of all we have to adjust, even change our inherent human nature.
      Somehow we have to entice each and every human being out of his/her protected, self centered boxes, corners and invite them to participate in the building of a completely new, mutually responsible and cooperating human network in order to build new systems, societies where the priority is on sustaining, maintaining the health, optimal function of the whole and only care for the self after.
      In our new, global, integral, interdependent world system this makes sense even selfishly, since in this system the health, prosperity of an individual is directly related and dependent on the health and property of the whole.
      Thus first we need to initiate a global education program helping people of all nations, social layers, education and ages understand the system we exist in, and how a human being needs to adjust in order to adapt to the system.
      We have a huge opportunity to not only solve all the increasing and deepening problems we are facing today at all levels of human life, but to rise onto a very different, and much higher quality of existence since instead of the present, ruthlessly competitive and thus destructive humanity we would have a mutually complementing one that is capable of solving any problem it encounters as a single organism.

        CommentedJeff Burd

        I totally agree with Zsolt Hermann. Humanity should learn to cooperate with each other at every level, instead of antagonistic competitive behavior we learn from early childhood and continue through all of our life.

    3. CommentedNathan Coppedge

      There is a strong argument going for the idea that people simply do what they want. If they have very particular tastes---however 'atrocious'---they are not likely to benefit by a program which could only benefit them in another aspect of their lives. So it seems that secretly, what HICCup offers is benefits in extraneous areas. These may not be extraneous from a healthy point of view, but they are extraneous from the position of expense and supplementation for the existing program that individuals have implemented.

      So you must take it for granted that you're asking people to exercise or eat vegetables. I don't resent that these factors may be good influences. Aside from buying vegetables or commercializing exercise, I don't see what could really be done. Unless the program is overtly an ethical one. Ethics is very tricky. People want existentialism or literature before they want genuine ethics.

      Not that my insight into the negatives should dissuade the program. It's a genius idea, as far as basic economics goes. But if there is no way to re-allocate budget, I'm not sure that an investment is the thing that is necessary.

      A lot of people should eat more vegetables. Some people would benefit by a fresher, healthier looking medical system. But the medical system is thousands of times more expensive than the vegetables.

      So what you need is an 'exceptional' system (in a 'patented' sense). A system that knows exactly what to do to get results. If it is not a conservative system, is it an 'advanced' system? Am I stuck on ancient issues? Does it introduce ideas, or instead, a new emotional approach? Do the clients learn these approaches from specialized medical staff? Are these medical staff at all in the first place? Perhaps what is needed is a more basic approach than the fully trained doctor system. Preventative care might not require much training, if there are a few experts who have contributed the best available ideas. Ideas can be perfected without education. And good intentions and TLC might not be overrated in assessing what people need, when disasters are preventable.

      One thing to consider is that information is perfectible in an organized way, and that 'just the right influence' is more valuable than expert advice misinterpreted as a patriarch figure or something like that.

      But 'going the distance' (or some similar concept) on informational organization may be difficult without taking the risk to re-conceive the very nature and perception of value and benefit, something that is conventionally thought to be dangerous, and misguided.

      So the project faces a lot of hurdles: 1. How to affect genuine choices, such as diet, in the client's life, without offending them, 2. How to make ethics appealing without getting under their skin, maybe like a metaphorical video game scenario, 3. How to use an empathic, loving influence and other exceptional methods that conversely may not require much training, and 4. How to be original without being a quirky misconception.

      Maybe that's a good outline to consider on the side. Even if these are general concerns, it seems possible that they may influence long-term planning in a profound way. Assuming the program is under control.