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Promotion of a Healthy Workforce – Part 5

By: David P. Lind

As mentioned in earlier blogs within this series, the cost of obesity among employees is immense, and employers need to understand that workplace and employment conditions can actually contribute to employee health. Efforts by employers to encourage physical activity and healthy eating among all employees should be implemented to slow this growing non-COVID epidemic.

Comprehensive Obesity Treatment

Comprehensive obesity treatment coverage offered by employers serves as a complement to the promotion of physical activity and healthy eating. This treatment will typically include three types of coverage benefits: 1) Behavioral/Nutritional Counseling, 2) Weight-Loss Surgery, and 3) Pharmacological Treatment. It is critical, therefore, that employer’s partner with their health plans (insurance companies) and other vendor partners to promote seamless coverage to ensure sustainable success.

  • Behavioral/Nutritional Counseling

Improving access to healthy foods and physical activity is a key component to success. But this is just the beginning. Offering evidence-based health promotion programs with proven success may help nudge behaviors in new, healthy directions. One example of this is the National Diabetes Prevention Program (National DPP), which is part of the Centers for Disease Control and Prevention (CDC).

National DPP offers a lifestyle-change program designed to prevent Type 2 Diabetes. This initiative is a year-long intervention that is delivered in person, online, through distance learning, or through other approaches in group settings. This 16-segment curriculum is spread over 12 months and is designed to meet stringent CDC requirements. Research demonstrates that this program is highly successful. People with prediabetes who have taken part in this program, and have lost 5-7 percent of their body weight, can reduce their risk of developing type 2 diabetes by 58 percent. Results a decade after initiation of the program are impressive: “Program participants were one-third less likely to develop type 2 diabetes than individuals who did not join a program.”

  • Weight-loss Surgery

Weight loss surgery is also known as bariatric and metabolic surgery. According to the American Society for Metabolic and Bariatric Surgery, there are five different weight loss surgeries, each having advantages and drawbacks depending on the medical history of the patient and unique medical circumstances based on risks. The goal of these surgeries is to modify the size of the stomach and intestines to treat obesity and other related diseases. By making the stomach smaller and bypassing a portion of the intestine, less food will be consumed and changes will occur in how the body absorbs food for energy. This results in decreased hunger and increased fullness. The surgery improves the body’s ability to achieve a healthy weight.

Weight loss surgery also requires an overall treatment plan that includes lifestyle modifications, such as nutrition guidelines, exercise and behavioral counseling. To qualify for one of these surgeries, general medical guidelines use body mass index (BMI). An adult with a BMI of 40 or higher may qualify. But surgery may also be an option for an adult who meets other conditions if they have a BMI of 35 or higher – such as having at least one obesity-related medical condition and at least six months of supervised weight-loss attempts. Mayo Clinic provides these guidelines here.

Because safety of any procedure is paramount, using an Accredited Center for obesity surgery is usually stipulated by insurance companies. Based on a 2019 Bariatric Surgery Source article, most insurance companies cover weight-loss surgery. In Iowa, Wellmark, the state’s largest health insurance company, covers weight-loss surgery, subject to the provisions of the various policies they offer.

  • Pharmacological Treatment

According to a 2016 study, only one percent of individuals with obesity who are eligible for medication treatment actually receive the medication. One explanation is that there is a tremendous variability in provider prescribing rates and restricted coverage by health plans. Medications used to treat overweight and obesity work in different ways. Some medications, for example, help the patient feel less hungry or full sooner. Other medications make it harder for the body to absorb fat from the foods being consumed.

Similar to weight-loss surgery, qualification for medications to treat obesity typically begin with the individual’s BMI number. If an adult has a BMI of 30 or greater, a physician may prescribe medication for treatment. If the adult has a BMI of 27 or greater, but has a weight-related health problem, such as high blood pressure or type 2 diabetes, medication may be prescribed. Such medications are not a replacement for physical activity or healthy eating habits – all three work together to provide optimum weight loss. The National Institute of Diabetes and Digestive and Kidney Diseases provides an overview on medications to lose weight.

A New Game Changer in Obesity Medication?

In June 2021, the Food and Drug Administration (FDA) granted the approval to Novo Nordisk for semaglutide 2.4 mg (Wegovy™) for chronic weight management in adults with overweight or obesity. 

The safety and efficacy of semaglutide 2.4 (Wegovy) were studied in four, 68-week randomized controlled trials. More than 2,600 patients received semaglutide 2.4 for up to 68 weeks and more than 1,500 patients received placebos. From this, individuals who received Wegovy lost an average of 12.4 percent of their initial body weight compared to individuals who received placebo. The most common side effects of semaglutide 2.4 included nausea, vomiting, and diarrhea that were most common during the first several weeks of treatment. These symptoms reportedly abated thereafter. Of course, with about any new medication that reaches the market after FDA approval, little is known about the long-term safety of the drug for those who require ongoing use.

From a local physician perspective, Dr. Kara Thompson, who specializes in weight loss/bariatric surgery and nutrition at MercyOne Des Moines Bariatric Surgery in West Des Moines, confirmed, “The medications for weight loss are safe and effective if given to the correct patient and in conjunction with lifestyle changes. Studies have shown the most effective medications for weight loss is the GLP-1 class that includes Saxenda and Wegovy – but they are extremely expensive. 

I inquired with Wellmark about whether this new medication was approved as a ‘covered’ benefit under my health plan. A Wellmark customer service representative responded “this drug is excluded from your pharmacy benefit…prescription drugs for weight reduction are excluded.” Representatives from Novo Nordisk indicated that Wegovy is priced “around $1,340” monthly. For health plans that do cover this medicine, this price may be ‘negotiated’ downward by insurance companies and their selected pharmacy benefit managers.

Prior to Wegovy’s approval, many insurance companies have not covered weight-loss medications. It is unknown how many insurance companies will approve coverage for Wegovy. Novo Nordisk does offer a Wegovy Savings Card that can provide some financial relief, but cost will generally determine just how accessible semaglutide will be for patients. Large, self-insured employers can decide whether or not to include this medication as a ‘covered’ benefit under their health plan, but it will vary by employer. Dr. Thompson states that employers requiring their insurance companies to cover weight loss medications under their health plans would be very helpful in the treatment of persons living with obesity.

Summary

This five-part series on obesity touches on the basics of why employers may desire to implement workplace health programs for employees. There are plenty of financial and health reasons for employers to help mitigate obesity in the workplace. Although the body mass index (BMI) is considered to be a fundamental tool in these programs, there are important limitations that must be recognized. Obesity is now widely considered to be a disease, rather than a ‘lifestyle choice,’ and wellness programs that merely address nutrition and physical activity may miss other important approaches that can guide successful opportunities for each individual. Counseling and nutrition programs that address the needs and desires of each individual is a good first step.

Finally, surgery and medication are only meant to serve as a complement to diet, exercise and behavioral mindfulness. Learning as much as possible about the efficacy and safety of these treatments will be key for employers when considering the best ways to support and encourage the health of their employee population. Requesting coverage of weight related treatments, such as doctor visits, nutrition and behavioral counseling as well as weight loss medications and bariatric surgery by health insurance providers is a good first step. If insurance companies have enough fully-insured employers requesting this coverage, perhaps they will provide it as an option. Of course, self-insured employers can elect to include this coverage under their own health plan. No doubt, there are no ‘silver bullets’. However, the core of any program needs to ensure that stigma, prejudice and discrimination are removed from the workplace.

This post is the fifth in a five-part series. Click here to read “Obesity Requires Employer Attention and Focus – (Part 1),” “Is the Body Mass Index (BMI) Useful? (Part 2),” “Obesity – a Disease or a Choice? (Part 3),” and “Employers: Establishing A Culture of Healthfulness – Part 4.”

To stay abreast of healthcare-related issues, we invite you to subscribe to this blog.

Employers: Establishing A Culture of Healthfulness – Part 4

By: David P. Lind

According to a 2020 report, adults spend one-third of their lives (about 90,000 hours), at work. No doubt, since the outbreak of COVID-19, the workplace has changed. However, because employees often move about less while working from home, the urgency to address obesity in the workplace has arguably increased. 

It is extremely important for employers to understand that obesity must be treated as a disease because it has become: 1) much too common, 2) a serious threat for developing other comorbidities, and 3) very costly both in lost productivity and increased healthcare costs. (NOTE: It is equally important to understand that being underweight – having a BMI below 18.5 – is also a risk factor for serious complications of COVID-19 and other health issues.)

Addressing obesity solely to reduce healthcare costs and boost productivity will send the wrong message to employees. A successful obesity program must project a culture of acceptance and inclusivity, rather than stigmatize and dehumanize persons with obesity. Therefore, the more effective way to help employees living with obesity is to establish a culture that encourages healthfulness for all employees.

Dr. Kara Thompson, who specializes in weight loss/bariatric surgery and nutrition care at MercyOne Des Moines Bariatric Surgery in West Des Moines, provided her viewpoint for this blog about how employers can make their wellness programs more effective. She said employers having conversations with employees about their weight would not be well received. Instead, Dr. Thompson feels employers should focus on the general health of their workforce, as a much better approach to get employees engaged. “Successful programs are those backed by a culture that supports health.” 

Standard Lifestyle Modification Intervention Programs

Standard worksite wellness programs that address obesity interventions include financial incentives to employees for keeping their cholesterol and lipids within healthy range, attending health education classes, lunchtime walks, activity trackers and step counters and other opt-in health programs that primarily focus on behavior change. However, employers must be aware of the HIPAA nondiscrimination rules and the U.S. Equal Employment Opportunity Commission (EEOC) final rules when offering incentive plans for wellness programs. 

Science and research on physical activity continues to evolve. In fact, according to a New York Times article published in September 2021, there are two new large-scale studies of physical activity and longevity that suggest a ‘sweet spot’ of 7,000-8000 daily steps that will provide optimum benefits for those in middle adulthood.

Lifestyle modification workplace interventions have proven to produce modest weight loss and improvements to weight-related health problems. According to a 2018 review of workplace obesity programs by the American College of Occupational and Environmental Medicine (ACOEM), these modest improvements do not result in sustained employee engagement and long-term results. The authors suggest that lifestyle behavioral modification must be coupled with other approaches, including medical intervention. 

Other research on wellness programs, such as one from Harvard Medical School, suggests limited success in realizing large investment returns – at least in the short term. The authors concluded that wellness programs did not have, after 18 months, better clinical measures of health such as BMI, blood pressure or cholesterol. These programs did not exhibit lower absenteeism, better job performance or lower health care use or spending.

Unfortunately, studies have shown that yo-yo dieting can actually cause weight gain in the long run.  One theory, known as “set point,” says our bodies have a natural weight and will always fight to stay within a certain weight range (the patient’s “set point”) and that dieting will not change that weight permanently.  When asked about this, Dr. Thompson said this is a complicated question.

“We truly don’t have all of the answers to why some people lose more than others, or why weight loss can stall out. We do know that if someone drops calories really low, the body can fight that decrease by increasing hunger, decreasing calories used and even pulling more calories out of the food that was eaten, and that happens even if the body has lots of fat stores. My experience has shown that if one’s body thinks it is not getting adequate nutrition, fat or protein to support all of its demands, it does the same thing. I am frequently telling patients to eat more protein or more healthy fats, and that can often stimulate weight loss.

Dr. Thompson summarizes with this:

“It’s the types and quality of food eaten along with the individual’s genetics, age, activity, hormones, sleep, stress, muscle mass and even medications taken influencing all of this and you can see why it is so complicated.”

A 2020 Milken Institute report, “Obesity in the Workplace: What Employers Can Do Differently,” succinctly wrote the following about existing mainstream wellness programs:

To date, obesity programs in the workplace have failed to meet people where they are. They promote impersonal behavior change rather than provide employees with tailored support. The consensus among experts is clear: Interventions commonly characterized as targeting worksite wellness” have not adequately demonstrated improved health outcomes.

What Can Employers Do About Obesity?

First of all, there is no silver bullet for employers to eliminate employee obesity. There are, however, a number of strategies that employers can take that will hopefully result in a healthier workforce. 

To begin, employers must understand that obesity is a disease and address the stigmatization of obesity.

Dr. Thompson agrees that obesity is a disease. “Some people are genetically set up to carry more weight and some are in the situation where making better choices is difficult…like most diseases, outcomes for obesity can often be influenced by lifestyle and medical management.”

Coming from various resources, some recommended action steps employers can pursue include the following:

  • Understand the Science

It is important to understand the science of obesity that impacts both appetite and energy, and why losing weight and keeping it off is so difficult. 

  • Reduce/Eliminate Stigma 

Stigma begins with how obesity is perceived and communicated in the workplace. One primary example of this stems from the words we use when addressing obesity. Instead of inappropriately labeling people as “an obese person” or “an obese employee,” employers should approach obesity as a disease that affects individuals. People-first language, such as “a person with obesity” or “an employee living with obesity” may appear to be a subtle difference, but it more appropriately refers to the person first and their condition second. When carefully used, words can avert harmful stigma and stereotypes.

  • Prevention

Having a culture of healthy eating at work, both in-person or remotely, is one important aspect of obesity prevention. Employers can help influence the choices of healthy food options in the workplace cafeteria and at the vending machines. Employers can pursue initiatives and education that encourage nutritious and healthier eating habits at home. The promotion of active lifestyles – both at the workplace and at home – are also critical components to any program promoting good health. Of course, monitoring employee uptake of these programs will help the employer understand patterns of employee engagement.  An improved culture of healthfulness will positively impact all employees.

  • Treatment and Health Plan Coverage

Does your health plan view obesity as a lifestyle ‘choice’ or as a disease? The answer to this question reveals a big difference in treatment and whether coverage is included in the health plan. Obesity treatment covers a full range of healthcare options, including behavioral counseling, medical visits for obesity, dietician visits, anti-obesity medications, and bariatric surgery. Dr. Thompson states that it is very frustrating, from a physician’s perspective, to not be able to prescribe the medication best suited for a patient’s condition because the medication is not covered by insurance and is, therefore, cost prohibitive. Employers making this coverage a priority would go a long way in supporting their employees who seek obesity treatment.

Summary

Obesity is not a lifestyle choice, but rather, a disease. Employers should mindfully establish a company culture that encourages healthfulness.  This will benefit all employees, including those employees living with obesity. A culture that encourages healthfulness might include access to individual counseling, as well as dietary education and accessibility to healthy food in the workplace.  Also, education about other obesity risk factors such as physical activity vs sedentary time, stress and poor sleep can encourage changes that result in better health, especially when coupled with other employer sponsored work-life balance initiatives. Committed employers should also investigate coverage options available through their health plan that affect pharmacological and surgical treatments. When considering how to develop a comprehensive benefits package for outcomes-based obesity treatment, George Washington University provides a guide that identifies core components of a successful strategy – STOP Obesity Alliance.

The fifth and final installment of this series will address the treatment of obesity through healthcare interventions.

This post is the fourth in a five-part series. Click here to read “Obesity Requires Employer Attention and Focus – (Part 1),” “Is the Body Mass Index (BMI) Useful? (Part 2),” and “Obesity – a Disease or a Choice? (Part 3).”

To stay abreast of healthcare-related issues, we invite you to subscribe to this blog.

Obesity – a Disease or a Choice? (Part 3)

By: David P. Lind

The public often views obesity as a failed lifestyle stemming from poor diet and little physical activity. Yet, research ties obesity to a variety of genetic, metabolic, hormonal and systemic factors that predispose individuals to obesity.

According to a 2016 report from NORC at the University of Chicago, almost half of Americans (48 percent) tend to believe that obesity is not a disease – it is caused and perpetuated by a person’s lifestyle choices (eating and exercise habits). In fact, the biggest barrier to weight loss, they believe, is largely due to lack of willpower, laziness, lack of self-control – all untrue stereotypes.

During the past 18 months, COVID-19 has increased awareness of obesity. This is because obesity has been identified as a risk factor for severe COVID-19 symptoms. People are increasingly expressing concern about gaining weight during the pandemic, the so called “quarantine-15.”

Genetics, Environment, Behavioral and Emotional

Researchers, however, have found that obesity, which affects at least one-third of Americans, is not caused by sloth and gluttony. According to The Centers for Disease Control and Prevention (CDC), hundreds of human genes give the body instructions for responding to changes in its environment. Individuals are attracted to inexpensive food with abundant portions. ‘Food deserts‘ are a prime example. People in a given geographical area have restricted access to affordable, healthy food options – especially fresh fruits and vegetables.  Absence of grocery stores within convenient traveling distance creates barriers to healthier eating. The CDC terms this as part of the social determinants of health, which “are conditions in the places where people live, learn, work, and play that affect a wide range of health risks and outcomes.”

In 2013, the medical community – including the American Medical Association (AMA) and other influential medical groups* – has generally reached a consensus that obesity is a disease. Part of the motivation for making this decision can be tied to pharmacotherapy and surgical intervention – both of which go beyond the standard lifestyle prescription of “improving diet and exercise more.”

Although experts have divergent views on the science of losing weight, it is the consensus of medical experts that obesity is caused by a combination of genetic, environmental, behavioral, and emotional factors. Some illnesses, such as Cushing syndrome and polycystic ovary syndrome, may lead to weight gain and obesity. Using steroids and specific antidepressants can also cause weight gain.

The Stigma of Obesity Must End

‘Lack of willpower’ is not a valid cause of obesity. It is a form of shaming based on uneducated philosophies and beliefs. Labeling obesity as simply being an individual lifestyle ‘choice’ has no scientific basis. Such stigmatization threatens the health of obese individuals, generates health disparities, and just as importantly, interferes with effective intervention efforts.

Obesity can effect individuals regardless of gender, job title, education, age, location, or political preference. However, there are known disparities in obesity rates based on race/ethnicity, gender, and socioeconomic status. The stigma, prejudice and discrimination that is pervasive in the workplace, healthcare facilities, educational institutions, mass media and other places perpetuates a narrative that it is socially acceptable to negatively stereotype obese individuals. Some argue that this stigma will help serve as a useful tool to motivate obese people to adopt healthier lifestyles…this thought process is grossly misguided.

A June 2010 paper, “Obesity Stigma: Important Considerations for Public Health,” published in the American Journal of Public Health, takes a deep dive into this issue. Obesity is a public health priority. The resultant suffering and comorbidities require local and national discourse addressing this epidemic. In short, the stigmatization of obesity is not an effective way of addressing this disease.

Summary

As mentioned in “Obesity Requires Employer Attention and Focus – (Part 1)” in this blog series, a new employer mindset must evolve to alter the alarming trajectory of the obesity epidemic. Employers have a fundamental interest in addressing this persistent health crisis. The final two segments of this obesity series will focus on approaches employers might consider when addressing obesity.

* World Health Organization; National Institutes of Health; Centers for Medicare and Medicaid Services; Obesity Society; Institute of Medicine; and American Association for Clinical Endocrinology.

This post is the third in a five-part series. Click here to read “Obesity Requires Employer Attention and Focus – (Part 1)” and “Is the Body Mass Index (BMI) Useful? (Part 2)“.

To stay abreast of healthcare-related issues, we invite you to subscribe to this blog.

Is the Body Mass Index (BMI) Useful? (Part 2)

By: David P. Lind

This series on obesity continues with the discussion of body mass index (BMI), and whether BMI is over-valued when assessing the health of individuals.

BMI is a medical calculation that is almost 200 years old. Developed in 1832 by a Belgian mathematician, Lambert Adolphe Jacques Quetelet, the BMI was designed to quickly estimate the degree of overweight and obesity in a defined population that would help governments decide the allocation of health and financial resources. Quetelet believed the BMI was useful only in providing a snapshot of a population’s overall health – his intent was not to measure the health of single individuals.

BMI is derived from your height and weight, calculated by dividing weight (in pounds) by height (in inches squared) and multiplying by 703.  If you’re curious, you can quickly learn your own BMI here. Once calculated, the BMI is compared to the BMI scale, which is broken down into five categories:

  • Underweight: BMI below 18.5
  • Normal: BMI ranging between 18.5 and 24.9
  • Overweight: BMI between 25 and 29.9
  • Obese: BMI of 30 or higher
  • Severe Obesity: BMI of 40 or higher

Is BMI Outdated?

Critics believe BMI is being overused and not very useful when analyzing the health of individuals. In fact, BMI is considered too simplistic, if not misleading. The critics make a number of points, including the following factors:

  1. Fat versus Muscle – Some people have high BMIs, but not much body fat. One prime example is an athlete, such as a football player. This athlete can have high muscle tissue (and low body fat) which pushes up his weight – and his BMI number.
  2. Activity Level – An individual who is very inactive, has lots of body fat and low levels of muscle and bone, may have a BMI in the normal range. But this individual is often elderly, in poor shape and sometimes sick. However, this individual with a ‘normal’ BMI has risks similar to people who carry a high amount of body fat and have a high BMI. These underlying risks are not reflected in the BMI score.
  3. Body Type – The location of your fat can make a big difference to your health. The belly fat (apple shape) type is generally at higher health risk, and the chance of heart disease and type 2 diabetes increases. This fat settles around the waist instead of the hips. Likewise, fat that appears on the hips and thighs (pear shape) is not considered to be as harmful. BMI does not indicate the location of fat and, therefore, does not reflect those risks.
  4. Age – As one ages, they may carry a little more weight, which may actually be beneficial. One possible reason is that as we age, a little extra weight can serve as reserves to draw on when fighting an illness. Because of this, an ideal BMI score may change as one ages.
  5. Ethnicity – The BMI can be different based on ethnic groups. For example, people from India face higher health risks at relatively lower BMIs. As mentioned earlier, the standard definition of overweight is a BMI of 25 – 29.9. However, people of Indian descent may begin to develop a risk of diabetes when the BMI is 21 or 22. Asian-Americans tend to develop health risks, such as diabetes, at lower BMIs than whites. In other words, a healthy BMI for Asians ranges from 18.5 to 23.9, which is one point lower than the standard range. Asians are considered obese at 27 or higher. Compared to whites with the same weight and BMI, African-Americans may have less fat around their organs and more muscle mass. This means that African-Americans, despite having a high BMI, may have fewer health risks than whites.

These five factors give credence to the argument that BMI is both outdated and inaccurate when assessing the health of individuals. 

So why continue to use BMI?

The counter-argument to continue using BMI can be equally persuasive.

Despite the concern of accurately identifying whether a person is healthy, most studies do link low and high BMI scores with a person’s risk of chronic disease and premature death. As an example, a 2017 study of 103,218 deaths found that people who had a BMI of 30 or greater (“obese”) had 1.5 to 2.7 times greater risk of death after a 30-year follow-up.

A 2014 study that included 16,868 people showed that “obese” BMI individuals had a 20 percent increased risk of death from all causes and heart disease when compared to those in the “normal” BMI range.  From this same study, researchers found that people in the “underweight” category and the “severely obese” or “extremely obese” categories, died an average of 6.7 years and 3.7 years earlier, respectively, than those in the “normal” BMI category.  Adults with a BMI greater than or equal to 40 are considered severely obese.

The data on BMI greater than 30 is quite substantial as it relates to the increased risk of chronic health issues such as heart disease, type 2 diabetes, breathing difficulties, kidney disease, non-alcoholic fatty liver disease, and mobility issues. (See references below)

In short, having a 5-10 percent reduction in an individual’s weight has been linked to decreased rates of metabolic syndrome, heart disease, and type 2 diabetes.

Summary

Despite the criticism of BMI, one can safely assume that BMI may be more useful at predicting future health – rather than diagnosing the current health. 

Standard BMI definitions of overweight and obesity were based on white populations, which differs from other races and ethnic groups. Because of this, BMI should not be the only diagnostic tool when estimating a person’s risk of developing various chronic diseases. Many alternative measurement assessment tools exist to determine obesity and related health issues. The Harvard T.H. Chan School of Public Health has listed such measurements here.

Though BMI oversimplifies the health of individuals, research suggests it can serve as an important barometer to estimate a person’s risk of chronic disease, risk of early death and metabolic syndrome.

It’s important to know your BMI, but it is equally important to recognize its limitations.

This post is the second in a five-part series. You can read “Obesity Requires Employer Attention and Focus – (Part 1)” here.

To stay abreast of healthcare-related issues, we invite you to subscribe to this blog.

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References:

‘Health’ Care vs. ‘Medical’ Care
It’s About Improving Population Health

By: David P. Lind

Controlling health costs and improving population health – we cannot have one without the other.

Healthcare costs continue to outpace general inflation. PricewaterhouseCoopers recently projected a 6.5 percent medical cost trend in 2022. By comparison, the annual inflation rate for the United States was 5.0% for the 12 months ending May 2021 – the largest increase since 2008. For those of us who have health insurance coverage through our employment or have purchased coverage through a market-based exchange, we live in constant anxiety about paying more for our insurance.

Aside from having a high-cost, inefficient healthcare ‘system,’ the major source of this problem is our unhealthy population. “Upstream” environmental factors greatly impact our “downstream” health – for all of us. Upstream factors are many – primarily poor nutrition, inadequate housing and education, and low incomes – all considered to be social determinants of our health (SDOH). For discussion sake, healthy behaviors, social & economic factors and physical environment are all considered to be somewhat manageable by taking proactive (or preventable) measures – and these are lumped together as Upstream factors.

A great video about addressing SDOH from Broadlawns Medical Center can be found here.

UPSTREAM: 80 Percent is ‘Health’ Related

According to the County Health Rankings Model, as much as 80 percent of the factors that influence our health and well-being – physical environment, social and economic factors, and health behaviors – operate outside the services for which we pay hospitals and clinics. These factors are considered to be upstream, and to a large extent, can be modified and proactively managed. Conversely, only about 20 percent of our actual health outcomes is impacted by the clinical care that we pay to our healthcare providers (see diagram below).

Again, proactively staying healthy comes from determinants such as the social and economic environment, the physical environment, and each person’s individual characteristics and behaviors. This is what should be labeled, “health care.” Our health is primarily determined by our behaviors and the environment in which we live. How we live ‘upstream’ will greatly impact how polluted the ‘downstream’ will become.

DOWNSTREAM: 20 Percent is ‘Medical’ Related

In 2018, the U.S. spent nearly twice as much on medical care per person as did comparable countries ($10,637 compared to $5,527 per person, on average). These expenditures relate to the care we receive from our doctors, hospitals, pharmacies, etc. The healthcare prices we pay in the U.S. are higher because of administrative waste and because prices are naturally higher for hospitalization, physician services, and, of course, the medications we purchase. Numerous sources report this, but a good primer comes from the Peterson-KFF Health System Tracker.

The amount we spend for the “medical care” we receive downstream is different from the aforementioned “health care” found upstream. The high expenditures for medical care paid in Iowa and the U.S. is really for “sick care.” Medical care, for the most part, represents the consequences of our poor efforts upstream. If we fail to make the appropriate investments upstream to promote healthy living environments and behaviors, we eventually pay a proportionately larger price downstream. We all know how that is going for us, right?

In 2016, I co-authored a blog with Dr. Yogesh Shah, Chief Medical Officer and Vice President of Medical Affairs at Broadlawns Medical Center. The blog, “Time to Move Upstream and ‘Invest’ in our Health,” shows just how little the U.S. invests in the social determinants of health issues upstream when compared to other wealthy countries.

The Commonwealth Fund released an issue brief in early 2020 that confirms this troubling trend persists. “The U.S. spends more on medical care as a share of the economy — nearly twice as much as the average Organisation for Economic Co-operation and Development (OECD) country — yet has the lowest life expectancy, the highest suicide rates and the highest chronic disease burden and an obesity rate that is two times higher than the OECD average among the 11 nations.”

The U.S. under-invests in spending for modifiable contributors to healthy outcomes compared to other advanced countries. By under-investing in the ‘social determinants of health,’ we are relegated to pay bizarre prices for a sicker population that uses more medical care. Over decades, we unrealistically rely more heavily on our health providers to ‘fix’ our upstream shortcomings. In the U.S., reimbursement practices reward intervention – or sick care – far more than prevention. This is not an indictment on our health providers, but on our convoluted healthcare ‘system.’

In short, we grossly overspend on the downstream consequences to mask our poor investment efforts upstream.

Summary

We must look upstream to find effective ways to address the social determinants described earlier. There are pockets of health systems and states that are making attempts to alter the environments in which we live, work and play. We live in a world of trade-offs. Trading wasted care (and its associated cost) with preventive health-related strategies seems to make a lot of sense.

As our blog concluded five years ago: “Spending for the ‘right’ community measures that impact health will provide better health outcomes for Iowa and our country. Such expenditures will take time to translate into positive health outcomes but we need to start investing now. It will take cost-shifting from inefficient healthcare spending to re-allocating funds for social determinants that matter most, such as nutrition, adequate housing and education. By doing so, we will make our communities and state both healthier and more productive.”

To stay abreast of healthcare-related issues, we invite you to subscribe to this blog.

Telehealth – Will the Pandemic Reveal its Potential?

By: David P. Lind

Telehealth has been around for at least a few decades, but its’ steady growth trajectory was injected with rocket fuel a year ago when the pandemic erupted. Most every medical provider was thrust into embracing telehealth services, and for many, a rather uncomfortable, but necessary pivot to serve patients. Going forward, one key question to address will be if the outcomes of telehealth are at least as effective as in-person visits. 

Technology and Reimbursement Concerns of Telehealth

For telehealth to become deeply rooted in the long-term medical-delivery process, a few important barriers will need to be addressed. Making the telehealth technical systems easy to use – for both physicians and patients – will require additional tweaks to simplify the physician workflow process and patient acceptance. Additionally, physicians desire to have a more-intimate rapport with patients, such as reading body language, listening to breath sounds while providing an actual physical examination.

But the elephant in the room regarding the growth of telehealth is simply this: the complicated challenges of reimbursements from payers – a key component that could determine long-term adoption. State telehealth commercial payer laws vary. For Iowa, the legislature is considering a payment parity bill that would treat telehealth reimbursement no differently than in-person care (HF294).

Telehealth Outcomes – What is Known Today

Is the quality-of-care provided remotely at least comparable to in-person care? Are patients satisfied with telehealth? There are some studies, all from the pre-pandemic period, that evaluated patient outcomes between telehealth and in-person visits. Rest assured, new pandemic data on telehealth will eventually emerge to help connect the dots on satisfaction, safety and outcomes.  

For now, pre-pandemic outcome results appear to be tepidly encouraging. The federal Agency for Healthcare Research and Quality (AHRQ) provided funding to the Pacific Northwest Evidence-based Practice Center to produce two reports on telehealth. Each report provides helpful insights on how telehealth can positively impact appropriate and safe care.

STUDY #1: Telehealth: Mapping the Evidence for Patient Outcomes from Systematic Reviews (2016): This report included over 950 studies of telehealth based on data from 58 systematic reviews published between 2007 and 2015. High-level findings show that telehealth is beneficial for specific uses and patient populations. In fact, “There is a large volume of research reporting that clinical outcomes with telehealth are as good as or better than usual care and that telehealth improves intermediate outcomes and (patient) satisfaction.” Benefit evidence was concentrated in specific uses of telehealth services for: 

  • Remote, home monitoring for patients with chronic conditions, such as chronic obstructive pulmonary disease and congestive heart failure
  • Communicating and counseling patients with chronic conditions
  • Providing psychotherapy as part of behavioral health
STUDY #2: Telehealth for Acute and Chronic Care Consultations (2019):  This report includes evidence about telehealth for acute- and chronic-care consultations from research published between 1996 and May 2018. The findings from this study provides overall conclusions that are relevant to telehealth expansion during the COVID-19 pandemic. Twenty-one studies evaluated remote intensive care units (ICUs), showing lower, statistically significant inpatient and ICU mortality rates and small, nonsignificant reductions in length of stay. Only one study specifically addressed adverse events, reporting lower rates of complications with remote ICUs.

Other Resources for Telehealth Outcomes

A few other 2018 studies also provide insight on telehealth care:

  1. Impact of Telemedicine on Mortality, Length of Stay, and Cost Among Patients in Progressive Care Units: Experience From a Large Healthcare System (2018) – Finding: Telemedicine intervention decreased overall mortality and length of stay within progressive care units without substantial cost incurrences.
  2. Effect of the School-Based Telemedicine Enhanced Asthma Management Program on Asthma Morbidity (2018) – Telemedicine intervention significantly improved symptoms and reduced healthcare utilization among urban children with persistent asthma.
  3. Telemedicine in the Mangement of Type 1 Diabetes (2018) – Finding: “Specialty diabetes care delivered via telemedicine was safe and was associated with time savings, cost savings, high appointment adherence rates, and high patient satisfaction. Our findings support growing evidence that telemedicine is an effective alternative method of health care delivery.”
  4. Telemedicine and Mobile Health Technology are Effective in the Management of Digestive Diseases: A Systematic Review (2018) – Finding: “Telemedicine and mobile health technology may be effective in managing disease activity and improving quality of life in digestive diseases.”

What Can Be Learned?

Overall, these pre-pandemic reports suggest that when patients and clinicians had a choice or when telehealth addressed an access issue, benefits of telehealth occurred. Further, this research found evidence that telehealth might benefit groups of patients during the pandemic when expanding critical care, help speed emergency care decisions, and reduce exposure to infection when replacing face-to-face care. But AHRQ issued an evidence summary report in April 2019 cautioning that more rigorous research will be needed to fully comprehend the effectiveness of telehealth consultations.

The rapid expansion of telehealth during the pandemic may provide better opportunities to learn whether telehealth is an appropriate application to use in given medical situations. Measuring the most appropriate outcomes will be extremely important for researchers to assess and analyze.

Summary

Most people agree that telehealth is here to stay. Two important influencers on telehealth growth will likely include documented health outcomes and third-party reimbursement levels. Telehealth usage will not remain at the elevated levels that COVID-19 required, but it will reach a more reasonable level and then grow where it makes most sense. Applying telehealth wisely will be important to research goals coming from the pandemic experience. New research with rigorous and detailed telehealth models will be needed to help answer these questions, and the answers may very well depend on what type of care is given under various specialties of care.

To be sure, the pandemic will reveal important findings that will determine how telehealth will expand in the future.

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Exercise, Diet and Weight Control
Time-Tested Advice

By: David P. Lind

On a recent blustery January day, I decided to seek some preventive medical advice that would sharpen my understanding on how to live a healthier life during a rather static time spent at home throughout this pandemic.

I picked up a monthly periodical entirely dedicated to the wisdom of living a healthier life, and it provided some timeless gems for our lives in 2021.  I found in-depth insight about nutrition, weight control, hypertension, heart disease, emotions, chronic ‘tiredness’ and a host of other factors affecting our physical and mental well-being.

One particular article was chock-full of wisdom that was shared by the “world’s most famous heart specialist” about maintaining a healthy heart through diet, appropriate exercise and weight control.

The kicker is that this particular periodical, Wisdom Magazine, was published 60 years ago. Wisdom Magazine, by the way, ceased publication in 1964. The May 1961 publication spent a sizeable portion on just one man, Dr. Paul Dudley White, who, at the time, was considered to be one of America’s top cardiologists.  Until I opened this periodical, I was unaware of him, nor of his substantial contributions.

Below are just a few arbitrary pearls of wisdom that he shared. Although many sound rather elementary for us in today’s world, they are worth repeating:

  • We know a thousand times more about diseases than our predecessors did generations ago, but apparently infinitely less about health.
  • The greatest challenge of public health today is keeping the middle-aged physically fit.
  • America is physically unfit as a nation and heart disease is definitely on the increase.
  • I have long advocated moderate exercise as one of the best ways to keep the heart in good condition.
  • We must give first priority to research in preventive medicine.
  • In this push-button age, man is overeating and pampering himself and “the life of Riley” often leads us into the lot of early coronary disease, high blood pressure and diabetes.
  • I would like to emphasize the beneficial effect of work on body, mind and soul in any occupation in which it is possible for a cardiac patient to engage. Idleness breeds unhappiness and is actually bad for the health.
  • Overeating may play even more of a role in the destiny of the world than the under-nutrition of hundreds of millions…As a result, the problem of overeating is far broader than that of the so-called starving millions…
  • Exercise is one of the best ways to counteract nervous tension and the best antidote is physical activity when one feels tired.
  • Just how much heredity actually counts in any given case remains for future researchers to discover, but that it plays a most significant role is a certainty.
  • Our medical ancestors were obliged to exercise much more than is the custom of most inhabitants of the so-called more-civilized countries of today.
  • Activity, both physical and mental, within reason, is important for health at any age and I think it is actually helpful for longevity. Many retire long before they should.
  • It is true that those who smoke most heavily are more likely to live shorter lives and also to have trouble with their hearts.
  • I would like to put everybody on bicycles, not once in a while, but regularly as a routine. That is a good way to prevent heart disease.
  • The easiest exercise of all, requiring no equipment except shoe leather, is walking.
  • Improvement of health in middle age and old age in this country today is greatly needed and must begin with well-established habits in youth.
  • One is never too old to exercise.

 

Dr. White was born the same year as my paternal grandmother, 1886, and was President Dwight D. Eisenhower’s physician during his heart attack in 1955.

White’s accomplishments were enormous. He helped create the International Association of Cardiology and International Cardiology Foundation, in addition to serving as executive director of the National Advisory Heart Council and chief consultant to the National Heart Institute. He was one of the founders of the American Heart Association and influential in establishing the National Institutes of Health. He wrote many papers about how lifestyle affected coronary artery disease. An avid walker and bicycle rider, he reportedly inspired Lyndon B. Johnson to return to the Senate in 1955 after his heart attack. Later in 1964, President Johnson presented Dr. White with the Presidential Medal of Freedom.

In countless ways, the world has immensely evolved over the last 60 years. Yet, when it comes to Americans’ health, the challenges we face today with diet and exercise remain daunting. Unfortunately, the population health metrics have changed dramatically during this span of time. In 1960 America, 54.2 percent of adults were not overweight or obese, yet by the year 2020 (60 years later), only 31 percent met this measurement. Conversely, over 14 percent of Americans were either obese or extremely obese in 1960. Today, this number stands at 42.4 percent.

Despite the knowledge that we had in the middle of the 20th century, positive health trends remain elusive from what has been recommended. Until Americans can connect the dots to transform personal behaviors into healthier lives, it is quite evident that Dr. White’s admonishments – multiple decades ago – will continue to be largely ignored and yet stand the test of time.

We should heed the advice of our medical ancestors, who apparently knew more, or at least preached and practiced more than we, a program of positive health habits. The habit of adequate exercise, for example, is just as important, I believe, as one’s sleep, one’s work and one’s food. – Dr. Paul Dudley White

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Surprises Should Only Come in Packages, Not from Medical Bills

By: David P. Lind

Surprises come in all shapes and sizes…and in the latest coronavirus stimulus package passed and signed into law in late December, there is at least one medical-related surprise – and it’s a pleasant one.

Many goodies are included in this massive legislation, much of it related to jump-starting an economy adversely impacted by the COVID-19 pandemic. After two years of debate in Congress, one long-standing issue that has been elusive from legislative action has now become law – curbing surprise medical bills.

The End to Surprise Medical Billing

Also known as the ‘No Surprises Act’, consumers (patients) will no longer receive unexpected ‘balance bills’ when seeking ‘emergency’ care, such as air ambulance transportation, or when receiving ‘nonemergency’ care at an in-network hospital. A balance bill represents the difference between the provider’s charge and the allowed amount (negotiated between the insurance company and providers). This law will take effect in 2022.

In a survey released in early 2020, about 18 percent of emergency room visits resulted in at least one surprise bill. In the past few years, about 1-in-5 insured adults had an unexpected medical bill from an out-of-network provider.

Typical scenarios occur when patients are required to pay additional costs due to the contract between the network provider and a non-network provider who will not accept the insurer’s negotiated fee. Prior to the enactment of this new law, the non-network provider could legally bill unsuspecting patients their non-negotiated fee. When this law takes place, patients will pay only the deductibles, coinsurance and copayment amounts they would under the in-network terms of their insurance plans.

How Non-Network Providers Are Paid

Going forward, non-network providers will need to work out acceptable payments with the affected patient’s insurer. If the patient is uninsured, then all providers are considered out-of-network, and this will require the secretary of the Department of Health and Human Services to create a provider-patient resolution process for billing purposes.

Balance billing for air ambulatory transportation, a frequent and egregious practice, will not be allowed under the new law. A far more commonly-used service, ground ambulatory transportation, has not been addressed under this legislation. However, an advisory committee will be established to recommend how to solve payment for this service.

Can Patients Still be Balanced-Billed?

In nonemergency circumstances, physicians can balance-bill their patients for services, but to do so, they must obtain consent in advance of the medical procedure. As an example, a patient may want to seek care from a non-network physician, such as a surgeon. The surgeon will need to provide a cost estimate and get the patient to consent at least 72 hours before treatment. If the turnaround time is shorter than this, the patient must receive the consent information the day the appointment is made. Additionally, the estimate must be made in good faith.

Many types of physicians, however, may not be allowed to seek consent to balance-bill for their services. Among these include: anesthesiologists, radiologists, pathologists, neonatologists, assistance surgeons or laboratories.

For Providers and Insurers – ‘Devil in the Details’

With patients being held harmless, the struggle is really between how much non-network providers will be paid by insurers. Hospitals and physicians have opposed any kind of benchmark or standard to determine the amount of the bill, while payers argued for benchmarks. The legislation found a middle ground, giving insurers and providers 30 days to negotiate payment of out-of-network bills. Should this fail, an independent dispute resolution process with an arbitrator would make the ultimate decision.

Needless to say, there are other provisions within this legislation that flesh out many other details on how to settle payment disputes between providers and payers. Thankfully, this backroom process of payment details will not require undue anxieties from innocent patients.

Summary

The No Surprise Act will fundamentally fix a problem that existed for a long time. Surprises should only come in packages we receive on special occasions, such as birthdays, anniversaries, or holidays. An unwanted invoice in the mail sent by a non-network provider will hopefully be a thing of the past.

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Lobbying for Social Determinants of Health?

By: David P. Lind

In healthcare, there is a HUGE amount of money flowing in many directions. The law of gravity determines the flow, originating with the lobbying that is directed to those we elect to state and federal offices. In healthcare, somewhat similar to the trickle-down theory of economics, lobbying efforts grease the skids for how money eventually changes hands.

Effective lobbying, therefore, can establish who gets paid and by how much.

Open Secrets – Center for Responsive Politics

Lobbying Congress and federal agencies to influence decisions made by the government comes at a price – but it can be worth the ‘investment.’ According to OpenSecrets.org, a nonpartisan, independent and nonprofit organization that tracks money in U.S. politics, the top 13 sectors in 2020 shows that ‘Health’ is the top lobbying sector, spending over $464 million so far this year. Since 1998, this sector has dished out over $9.5 billion, edging out ‘Misc. Business’ ($9.4 billion) and Finance/Insurance/Real Estate ($9.36 billion).  ‘Health’ lobbyists represented include the American Medical Association, American Hospital Association, pharmaceuticals, and so on.

In the $3+ trillion healthcare industry, lobbying efforts can pay off handsomely. The ‘investments’ mentioned above are merely a drop in the bucket for the eventual returns that will come sometime later. Please understand, I am not suggesting that lobbying ‘investments’ are illegal, they usually are not.

Social Determinants of Health (SDOH)

According to the National Academy of Medicine, clinical care accounts for only 10-20 percent of healthy outcomes, while our behaviors, physical environment, and social and economic factors determine the other 80-90 percent – widely known as ‘social determinants of health’ (SDOH). Using the Centers for Disease Control and Prevention’s definition, social determinants of health are “conditions in the places where people live, learn, work, and play that affect a wide range of health and quality-of-life-risks and outcomes.” In short, SDOH are all external factors that affect our health outside of the hospital or doctor’s office.

To reign in ever-increasing healthcare costs and enhance better population health, why not explore new solutions ‘upstream’ to invest in our collective health and well-being? It’s about using our limited resources more wisely on key determinants of overall health that can ultimately improve health and control healthcare costs.

When comparing the U.S. to other wealthy industrialized countries, medical spending in the U.S. accounts for a greater share of gross domestic product than social services spending. Other countries spend more of their GDP upstream attempting to address the SDOH issues that directly and indirectly impact the health of their population.

Unfortunately, such investments are often viewed as ‘socialism’ or something worse in the U.S. As Dr. Donald M. Berwick published in JAMA this past summer, The Moral Determinants of Health, “…SDOH is motivated by an embrace of the moral determinants of health, including, most crucially, a strong sense of social solidarity in the U.S.” This solidarity, by the way, includes the removal of institutional racism. Until this happens, we may not have the necessary push to pursue SDOH.

Value-Based Care

Value-based care (VBC) has become a large focus for Medicare and private payers. VBC is a payment approach by which purchasers of healthcare hold the healthcare delivery system (physicians and other providers, hospitals, etc.) accountable for both the quality and cost of care. In fact, VBC programs are all about improving population health management strategies and center on how well healthcare providers can improve quality of care based on specific measures, including the reduction of hospital readmissions, using certified health information technology, and improving preventative care. VBC is the new-age approach to replacing the now-ancient fee-for-service payment arrangement in the U.S.

Healthcare providers are justifiably uneasy because they are being required to somehow ‘fix’ the social infrastructure by improving population health management. This is made more difficult when our own legislators and political system have problems agreeing whether the sky is blue or not on any given day. As mentioned earlier, a healthier population comes from non-clinical environmental determinants that influence how people live their lives. As a result of the ACA, all not-for-profit hospitals, since 2014, have been required to conduct a community health needs assessment every three years and implement a strategy to meet those needs.

What if…

What if healthcare lobbyists leveraged their efforts to meaningfully impact SDOH? Why couldn’t healthcare lobbyists on the Hill take half of their lobbying energy and financial resources and repurpose it into a lobbying campaign to address SDOH problems, such as availability of healthy food, improved education, access to housing, transportation, safe neighborhoods, etc.? If improving community health is the direction in which VBC is moving, and health providers are being financially incented to move this needle to improve population health, perhaps healthcare lobbyists SHOULD push legislators in this new direction to help move an otherwise unmovable mountain. Set a deadline to initiate SDOH programs – perhaps in the next five or seven years. Would it be possible for legislative gridlock to succumb to bipartisan support if powerful lobbyists sang from the same sheet of music?

One example of a similar approach, as reported by Modern Healthcare, comes from Louisiana-based Ochsner Health, which is pledging $100 million over the next five years to help eliminate healthcare disparities. Obviously, there is a huge need for the healthcare community to improve SDOH challenges in the communities they serve.

The potential ‘return’ for this new approach could be massive, for both the healthcare establishment and for all Americans. If healthcare providers serve as ‘repair shops’ to mend those needing care, and are ‘graded’ and subsequently paid on how well the health of the community has improved, local and national policies must be in place to make this happen.

This may sound too straightforward and, perhaps somewhat naive. But thinking ‘differently’ may prove to be worthwhile for what ails our healthcare system. Maybe Dr. Berwick’s morally guided campaign for better health is a great start.

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A Compendium of Patient Safety Concerns for 2020…and Beyond

By: David P. Lind

According to a March 2020 report by non-profit, independent organization, ECRI Institute, diagnostic errors and maternal health issues are considered to be the top two patient safety concerns for healthcare organizations. This report, however, was released prior to Covid-19 becoming the national focal point in the U.S.

ECRI’s list of the top 10 patient safety concerns was based on analysis of more than 3.2 million patient safety events recorded via the institute’s reporting program.

The list (in order) is as follows:

    1. Missed and delayed diagnosis.
    2. Maternal health across the continuum.
    3. Early recognition of behavioral health needs.
    4. Responding to and learning from device problems.
    5. Devise cleaning, disinfection and sterilization.
    6. Standardizing safety across the system.
    7. Patient matching in the Electronic Health Records.
    8. Antimicrobial stewardship.
    9. Overrides of automated dispensing cabinets – This refers to overrides to remove medications from a computerized drug storage device before pharmacists have reviewed and approved the move.
    10. Fragmentation across care settings.

11 Takeaways for the #uniteforsafecare Public Awareness Campaign

The World Health Organization designated September 17 as World Patient Safety Day to raise awareness of healthcare safety and its importance. During that virtual event, the Patient Safety Movement provided 11 takeaways on its Patient Safety Blog for the public, patients and their families to understand while seeking care:

    1. Recognize that the system is not perfect.
    2. Stay engaged in your own health care process.
    3. Recognize that your voice matters.
    4. Don’t be intimidated.
    5. Get a second opinion.
    6. Don’t be afraid to “shop around” for healthcare.
    7. Follow your gut.
    8. Double-check everything.
    9. Minority communities must be cognizant of the social disparities in patient care.
    10. Keep in mind that health workers are not to blame, the system is to blame.
    11. Remember that we’re all in this together.

The Joint Commission’s Seven Most Common Sentinel Events

Through the first half of 2020 – ending June 30 – The Joint Commission (TJC) reviewed a total of 437 sentinel events, with 85 percent being voluntarily self-reported by an accredited or certified organization. A sentinel event is a patient safety event that results in death, permanent harm, severe temporary harm or intervention required to sustain life. That total of 437 is a very low number because it is a grossly underreported by medical organizations. In fact, TJC estimates that only two percent of all sentinel events are reported.

The most common sentinel events for the first six months of this year are as follows:

    1. Care management – 165 reported events
    2. Surgical or invasive procedures – 131
    3. Unassigned events at the time of the report – 46
    4. Suicide – 41
    5. Protection events – 38
    6. Environment events – 12
    7. Product or devise – 4

New National Action Plan for Patient Safety

To combat preventable medical harm, the Institute for Healthcare Improvement (IHI) released a National Action Plan on September 17. The report, “Safer Together: A National Action Plan to Advance Patient Safety” was arranged by 27 federal agencies, safety organizations and experts, and patient and family advocates. The plan focuses on four key areas:

    1. Culture
    2. Leadership and governance
    3. Workforce safety
    4. Learning systems
Keeping patient safety front and center is critical to force-needed changes within our healthcare environment.

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