Next, let’s recognize the importance of what most influences health. We know from our own research that 10 percent of your life expectancy is associated with clinical care, 20 percent is related to where you live, 40 percent is influenced by your lifestyle and 30 percent is related to your genetics. That means that 90 percent of the factors affecting premature death occur outside the doctor’s office, hospital or pharmacy, where we spend most of our healthcare dollars. What we don’t invest in are social determinants, a failure that only commands our attention during a crisis—such as the unsafe drinking water in Flint, Michigan, that, starting in 2014, exposed more than 100,00 residents to high levels of lead and where residents today still refuse to drink the cloudy tap water.
We see the practical effects of this failure in other ways. A 2014 study by the Robert Wood Johnson Foundation found that babies born in Montgomery County, Maryland, and neighboring counties in Virginia (Arlington and Fairfax) have a life expectancy six to seven years longer than those of babies born in Washington, D.C., just one zip code away.
Washington, of course, is a much poorer community. Those kinds of jarring socioeconomic disparities between adjacent communities can be found in cities and suburbs across America. In 2018, the Aetna Foundation worked with U.S. News & World Report to assess 3,000 communities in America and to rank the 500 healthiest. My home community in Michigan, Wayne County, didn’t even make the list of 500, while the adjacent counties of Oakland and Washtenaw were in the top 300.
It’s why I believe that as far as morbidity and mortality rates go, your zip code matters more than your genetic code. Or as David Nash, the dean of the Jefferson College of Population Health, said, “Where you are on the map predicts your lifespan.”
We should be investing in those parts of the map that need the most help, but our overall spending is too low to make a difference. In the U.S., our expenditures on social determinants, as a percentage of GDP, are ranked 12th out of the top 13 OECD countries, according to 2013 data compiled by the Peterson-Kaiser Health System Tracker. We underinvest in the very things that can have a big impact for the same reason that companies underinvest in their employees or customers—their costs are immediate, their benefits long term.
Focusing on social determinants lies at the core of prevention, whose benefits should be self-evident. Fifty percent of the American population has a chronic disease, and they drive 86 percent of all healthcare costs. For that cohort, healthcare is not episodic; it’s continuous. The goal is to intervene early to deter bad outcomes down the road. Even delayed interventions can be valuable. At Aetna, we had a 78-year-old female client with asthma who made 405 visits to the emergency room in one year (yes, more than once a day) at a cost of $2.7 million. We sent a nurse to see her, and it turned out that she kept her thermostat at 60 degrees, so she often wore sweaters. Her friends made her angora sweaters, which she liked very much, except that she was allergic to angora!
It’s a perfect demonstration of how preventive measures—in this case, a simple home visit—can improve people’s health while reducing overall costs. Once you visit the person and make a health assessment, you can invest to improve outcomes. But as a country, we don’t get close enough to the community or the home to generate better results.
Making it Personal
Personal engagement also needs to be a top priority: how do we motivate individuals to care about their well-being, and how do we make that engagement meaningful? This is the Holy Grail of healthcare. Progress will not happen at annual checkups (too infrequent, too perfunctory) or at the hospital (too expensive, too late). Progress also won’t occur through some “wellness program.” Many organizations have wellness programs, and frankly they don’t do much. The real question is, what motivates someone to act differently than they ordinarily would?
The answer, in my opinion, is to become more local. We need to meet people in their homes and communities, and find out what matters to them. In putting the individual first, we need to integrate the power of community and technology to engage that person in ways the current system does not.
The federal government is gradually beginning to accept some of these principles. In 2018, Congress, with support of Republicans, Democrats and the Trump administration, passed a law that provides additional social and medical services to Medicare beneficiaries with multiple chronic illnesses. These services include home improvements such as wheelchair ramps and bathtub railings, transportation, home visits by nurses and home delivery of meals. David Sayen, a longtime administrator for CMS, told The New York Times that this new federal policy will give health plans “a whole new toolbox to address social determinants of health.”
We want to move the conversation about your health from the exam table to the kitchen table. When you visit your doctor, you might get 10 or 15 minutes, and if the doctor asks you how much you’re eating, exercising or drinking, you’ll probably offer misleading statements on at least some of those questions—assuming, of course, you even have a doctor. Surveys indicate that between 20 and 25 percent of people don’t.
That’s why I want to bring the conversation to the kitchen table, where you’re with people who know you and where people find out what’s really going on: who’s got a new job, who’s selling their car, who’s getting married or divorced.
That was the idea behind our partnership with Meals on Wheels, whose volunteers notify us of changes in health status. Those kinds of jobs require transferring data or other communications among payers or providers, and all of that is now possible with smartphones and other communication devices. Just as the digital age has changed the workplace, it is now allowing for new kinds of home engagement.
Aetna, for example, has a program with our congestive heart failure patients, who are our most expensive. When they leave the hospital, we give them a scale and install it with Bluetooth technology. We ask that they weigh themselves each day, and when their weight rises to “out of tolerance,” we see that and call their doctor, who can then intervene so that care is provided before the next episode.