Thursday, Jun. 11, 2009

This Doctor Does Not Want To See You

Renee Turner sees sick people every day. Some get well; others do not. As a member of the security staff at the Cleveland Clinic, she knows there is more than luck involved in who stays healthy and who doesn't. Having survived cancer twice, Turner is very aware that there are things you can do to take control. That's something she is learning every day from the physicians, patients and staff at the clinic, a 1,100-bed hospital that is testing ideas on its own staff and now might just be the future of American medicine.

Take weight loss. Turner is considered morbidly obese — you don't have to work in a hospital to know that's bad. That's why she's on a diet; in fact, her entire department is on a diet. Turner and a few of her co-workers are enrolled in the hospital's Lifestyle 180 program, an innovative approach to good health that uses cooking classes, exercise sessions and yoga to educate patients who are obese or who have high cholesterol, high blood pressure, diabetes or multiple sclerosis about how to eat better, become more physically active, manage stress and, ultimately, prevent what doctors call a major health event.

"It's what we talk about all day: changing what we eat," Turner says. Halfway into the 48 hours of sessions, spanning six weeks, she has lost 9 lb., and the good-health philosophy is changing her everyday behavior. She parks farther away when she goes to work or visits a mall. She looks at food labels and thinks before she eats. As an employee of the Cleveland Clinic, Turner is luckier than most: the hospital is covering the cost of her participation in the program. She even gets a "tool kit," complete with yoga mat, recipe book and tips for navigating the food aisles. All Turner and the others have to do is show up. (See pictures of the Cleveland Clinic.)

And that, argues the Cleveland Clinic's CEO, Dr. Delos Cosgrove, is how a health-care system should work. Patients like Turner who want to live healthier lives should be encouraged — and supported, both financially and emotionally — to do so. In fact, we soon may have no other choice.

As the cost of health care continues to climb (60% of U.S. bankruptcies in 2007 were due to medical costs), the health of our nation is not getting any better. Heart disease remains the No. 1 killer of Americans (as it has been for all but a few years since 1900), our collective waistline continues to bulge, diabetes rates march ever higher, and after steadily declining in recent decades, the smoking rate among high schoolers is leveling off. The U.S. boasts the best cutting-edge medicine in the world, yet 75% of our health-care costs are attributable to chronic, preventable diseases. In all, about 40% of premature deaths in the U.S. are caused by lifestyle choices — smoking, poor eating and inactivity.

But while prevention — intervening in patients' lives before they get sick — has long been part of the medical lexicon, programs to educate and encourage patients to adopt healthy behaviors have never truly been embraced. Ours is a system that rewards pills and procedures and nurtures a clinical culture in which the goal is primarily to fix what goes wrong. "I never saw a well patient in my life," says Cosgrove of the years he spent as a heart surgeon. "They were all sick. We are in the sickness business. We need to get into the health business." This idea is at the heart of how President Obama wants to reform health care in America; he argued that the U.S. medical system is designed to provide disease care rather than health care. In a letter to Senators drafting health-care-reform legislation, Obama cited the clinic as a model: "We should ask why places like the Mayo Clinic in Minnesota, the Cleveland Clinic in Ohio, and other institutions can offer the highest quality care at costs well below the national norm. We need to learn from their successes and replicate those best practices across our country," he wrote.

Exactly what are those model behaviors? The Cleveland Clinic and its 10 sister hospitals employ 40,000 people in Ohio, Florida, Canada and the United Arab Emirates. Cosgrove's idea is to turn those campuses into living laboratories, where healthy behavior is rewarded (with cash incentives if necessary) and people start thinking about health as an investment and a responsibility. In a demonstration of this commitment, Cosgrove even created new executive positions, including chief wellness officer, chief empathy officer (now changed to chief experience officer) and arts-program curator. These are not titles you're likely to find in any other organization.

The wellness philosophy that begins in the hospital, Cosgrove hopes, can then seed the community, then the state and the nation. Such an ambitious idea could not have found a better place to start than Cleveland, where smoking rates are above the national average, nearly 28% of the population is obese, and exercise and good nutrition are luxuries. If it can work in Cleveland, it can work anywhere.

Clearing the Air
Health consciousness doesn't come naturally to the average CEO — nor should it be expected to. Paying for smoking-cessation programs or gym memberships makes sense only if a company is reaping some return on its investment. The Cleveland Clinic, as the city's largest employer, has to be more mindful of that fact than most are. Improve employee health and you cut sick days and boost productivity. Most important, you keep insurance premiums under control. And the up-front costs can be minimal.

"There are things organizations can do that send a real message but cost very little," says Cosgrove. "It doesn't cost anything to have a walking program. It doesn't cost anything to tell people to take the stairs instead of the elevator. And it costs nothing to say that you can't smoke here."

Well, almost nothing. In 2007, Cosgrove took the controversial step of deciding not to hire any more smokers. As a high-tech hospital rooted in one of Cleveland's more wanting neighborhoods, the clinic was already viewed as an élitist institution with little compassion for the community from which it draws its workforce. The no-smokers policy would cement this perception. "I had to fight everybody, including human resources," says Cosgrove. "But this sends a message. It's perfectly legal. It's as much symbolic for the community as for the organization."

Since the rule went into effect, smoking rates in Cuyahoga County, which includes the city of Cleveland, have dropped from 21% to 18%. Rates have been declining since 2003, but it didn't hurt that the clinic also spent $30,000 to support antismoking efforts throughout Ohio, culminating in a 2006 statewide ban on smoking at work and in public places.

That's just the sort of scaling up Cosgrove hopes for. But while the clinic was successfully sending a message about tobacco, it was failing miserably as a model of nutritious eating. Dr. Michael Roizen, an anesthesiologist and now the clinic's chief wellness officer, knew something had to change when he heard about a patient's recent dining experience in the hospital's emergency room. The patient arrived with chest pains and was put into a holding area with his family while doctors ran tests. They ended up waiting for several hours, so well-intentioned staff members offered to bring everyone some food. An orderly went out — and came back with Kentucky Fried Chicken. "Can you believe it?" asks Roizen. "That was quickly corrected."

The cafeteria's new, varied menu — particularly with its ban on trans fats — was one response. Roizen is now working with chefs to inject more flavor and excitement into patient meals while keeping the food low in fat, salt and sugar. So far, they have redesigned 36 of the 55 meal offerings, substituting thickeners for fat, citrus flavors for salt, and peppery, spicy ingredients for sugar.

But as innovative as these efforts are, what happens when patients walk out the door and leave the bubble of the clinic? Keeping them motivated and committed to staying healthy, eating right and getting physically active is another issue Cosgrove is addressing — this time with the help of technology.

Nearly all of the 5.5 million patients who have passed through the clinic's doors since it opened in 1921 now have a digital health record, and this electronic paper trail is an ideal partner to prevention. The hospital's patient-record system, MyChart, is synched with Google Health and Microsoft's HealthVault to give patients the ability to upload important health information directly from devices such as scales, home blood-pressure monitors and glucometers, which measure blood sugar. That allows patients to track their progress and also helps doctors see whether treatments are working. Doctors and patients can also communicate better digitally, without the need for appointments.

Lifestyle Turnaround
All this, of course, makes good sense, and studies have already documented the positive impact preventive measures can have on health. What is less established is the financial case — that prevention saves a company money. That's the question that keeps accountants and insurers from investing in these programs, and that's why Roizen is working to answer it.

A compact, intensely energetic man, Roizen has assumed the responsibility of evangelizing beyond the clinic's doors. His message is directed less at consumers than at the health-care industry. "The only way to justify doing wellness in a commercially viable way," he says, "is to demonstrate that you can lower the cost of care."

Roizen is attempting to do that with Lifestyle 180, designed for patients with chronic conditions that generate the bulk of our health-care costs. The program is run out of a facility that seems less a medical institution than a New Age retreat: a bucolic campus in nearby Lyndhurst that was once the corporate headquarters of manufacturing giant TRW. Patients who enroll in Lifestyle 180 get broken in gently. For four hours, twice a week, over six weeks, they are coached through cooking classes in which a chef passes along such tips as healthier panfrying (use thinner pieces of fish or chicken and finer bread crumbs to reduce the amount of oil that gets absorbed), a dietitian teaches smart label-reading, and yoga and stress-management coaches teach meditation and how to build muscle tone.

Throughout the process, members of Roizen's team, led by Dr. Elizabeth Ricanati, take measurements, run blood tests and monitor what is happening in the patients' bodies. The hope is that participants can eventually reduce or eliminate their dependence on insulin or blood-pressure medications or pain pills and actually stop illness in its tracks. Since the program began in October, its 114 patients have, on average, reduced their LDL cholesterol by 10 points and shaved more than 3 in. off their waistline.

What's more, the coaching doesn't stop when the Lifestyle 180 sessions end. The patients come in for five follow-up sessions over the next year, and Ricanati keeps in touch with weekly e-mails of tips to keep them committed to their newfound health habits. So far, a quarter of the patients have either avoided getting on medication, reduced their dose or stopped needing drugs altogether.

Whether Lifestyle 180 can actually reduce health-care costs in the long run remains to be seen. Clinic employees can join the program for free, but anyone else who wants to enroll must pay $1,500. Some local companies have started to pick up the tab, hoping to reap the financial return that Roizen promises.

The Cleveland Clinic's own experience suggests that Roizen's confidence in prevention's payoff is well founded. The hospital's chief human-resources officer anticipates that after growing between 4% and 8% each year over the past six years, employee premiums will not increase in 2010. That's in part due to savings from employees with chronic illnesses who are making lifestyle changes to keep themselves from getting sicker. This saves the clinic between $5,000 and $10,000 a year per patient on claims they would have otherwise filed for treatments such as dialysis, angioplasty or bypass.

The next step, says Roizen, will be to see if lifestyle changes can not only hold off disease but actually reverse it, transforming the strategy into a fully developed treatment option on a par with prescriptions and surgical procedures. Dr. Dean Ornish, a longtime prevention proponent who created the Preventive Medicine Research Institute in California, thinks this is possible. In 2008 he showed for the first time that even the course of a disease like prostate cancer can be altered by diet. Men at low risk of prostate cancer were asked to choose either Ornish's lifestyle program — which involves eating healthier, exercising and reducing stress — or continuing with their current habits. After three months, Ornish studied the activity of the men's genes and found that the healthier behaviors turned on cancer-suppressing genes and turned off cancer-promoting ones.

It's just this kind of data that prevention champions hope will be enough to finally change our reimbursement system as a whole to cover programs like Lifestyle 180. And those advocates now include a majority of consumers as well: in a recent survey by Trust for America's Health and the Robert Wood Johnson Foundation, 76% of Americans said they support an increase in funding for prevention programs.

But even with such widespread support, it won't be easy. It took Ornish 14 years to persuade Medicare to cover his lifestyle program for avoiding heart disease. Employers have been slow to invest up front for health savings that may never accrue to them if their employees leave for other jobs. Yet as the cost of claims rises, even that tide may finally be turning. In Minnesota's Twin Cities region, for instance, major companies such as Target, US Bank and Best Buy are coming together to discuss ways that investments in prevention and long-term cost savings can be shared by all the employers in the area, even if workers are moving between companies.

Will prevention work? And will our health system finally embrace the strategy over prescriptions and procedures? We don't have many other options. Prevention is a timeless idea, one our species has always practiced: pioneers preserved food to prevent starvation in the winter; modern workers invest in 401(k)s to prevent destitution when they're older. Applying the same ethos to medical care ought not be that hard — especially since the country's health, economic and otherwise, may depend on it.

Five Things U.S. Health Care Can Learn From the Cleveland Clinic

1. Make prevention programs free...
The clinic pays for employee memberships to Weight Watchers and Curves

2. ...really free
More people signed up once the clinic began paying club fees up front instead of reimbursing employees

3. Use cash to motivate
Employees in the health plan earn $100 for reaching their fitness goals

4. Share the wellness
The clinic provides free wellness programs at community centers

5. Pass it on
Savings from lower medical-claims payouts help keep employee health premiums from climbing

See pictures of the Cleveland Clinic.