By JOSEPH KVEDAR, MD

Of course that is not true, but it seems like that sometimes, doesn’t it?  If you are working to promulgate a solution that promotes health in the context of our current healthcare system, there is no end to the challenges you will face.  Lets think a bit about the various actors, why they should care and why they do not.

I’ll start off with you. No one should care more about your health than you.  But as the behavioral economists remind us, we are not rational beings.  We are more likely to focus on tangible things in the moment rather than long-term uncertain benefits. So we persist in participating in unhealthy behaviors that provide short-term pleasure and lead to downstream sickness.  In addition, we’ve been addled into believing that once we are diagnosed, we are victims and that we can abdicate all responsibility for our care. (see 5-17-2010, Are Individual’s with Chronic Illness More Passive?).  This insidious combination makes it hard to hold ourselves accountable for our own health.  Most times, we’d rather blame the environment, or bad luck, and ask if we can take a convenient pill to make it better.

Next, how about your loved ones?  They are the best targets. In most cases our loved ones (the more current phrase is ‘social network’) can and do affect our health (See Nicholas Christakis’ book Connected and related articles).  It has, however, been challenging to get loved ones to open their wallet to pay for service offerings that improve your health.  In my experience, this is most often because of the same mentality that makes you a passive victim once you get sick.  We feel that society owes a victim.  We all feel like we’ve paid into various insurance programs â€" public and private â€" and that they should be the ones to pay for health-related services, particularly in the setting of chronic illness.  So your loved ones do care, but they have been trained not to open their wallet to support your care.  I can think of a dozen or so business plans I’ve seen over the years where the service to support a chronically ill individual was to be paid for by the “sandwich generation.” There is an appeal to this on the surface, but I haven’t seen one of those businesses scale yet.

What about those insurers then?  They probably care the least.  They see their role as spreading risk over large populations. So they work to recruit and keep healthy people on their rolls.  They work to be as efficient as possible at processing claims and mathematically predicting risk. They only got into the care management business because their customers (employers) demanded it of them.  They invariably vote for commodity or ‘check the box’ solutions.  Keeping cost down is held at a premium compared to improving health. Insurers are hard to engage in a visionary conversation about improving health, even though they’ll admit that in many cases the savings of improving health would accrue to them.

OK, so lets move upstream in the supply chain.  Employers hire insurers to help them with employee benefit health care plans.  Employers are motivated to keep you healthy if for no other reason than you will be a more productive worker if you are healthy.  They even care a bit that your dependents are healthy too, since you’ll be more productive if a sick parent or child doesn’t distract you.  And there is the original reason employers started paying for healthcare in the first place â€" because their benefits packages help them attract a more talented workforce.  The latter has largely been forgotten these past 2-3 years, as we’ve been adrift in a sea of employable people without jobs.  Supply and demand curves to motivate behavior and with such a large supply of workers, benefits are less important. That will change as the economy picks up.

So a high level analysis would conclude that employers are good targets for novel health-improvement interventions.  The challenge is that the direct customer is the human resources professional.  These poor, overworked souls are true generalists. They have to help you invest money in a retirement plan, guide you through how to handle a maternity leave, discipline a difficult employee and, oh yeah, choose your health plan.  Few of them have any training in health so it is natural that they develop trusted relationships with folks at health plans…so they get talked into purchasing check the box, commodity solutions.

Well, for goodness sake, what about your doctor? Your health professionals are there for you.  But they too have perverse incentives.  The most prevalent of these is that they are trained to and get paid well for taking care of sick individuals.  The system does not reward them financially at all for improving health.  They are also big believers in patient accountability and don’t usually buy that victim thing.  So they quickly articulate a treatment plan so they can go on to the next sick person who needs their help.  They expect you, the passive victim, to be proactive about learning everything you need to do to execute that plan and carry it out.  They are not on the same page as society is regarding who is accountable for keeping you healthy. They’d say it’s you, with their help from time to time.

Throughout this piece I have purposefully equated ‘caring’ with ‘spending’.   I suppose this too is controversial, but I think the linkage is fair.  What is the relevance to connected health?  Simply put, connected health interventions promote health over sickness management.  In today’s healthcare marketplace, they’ve been a hard sell.  Most folks I talk to readily agree that connected health as a care model makes sense.  But there is this mystery about ‘who pays?’.  I believe this phenomenon of ‘nobody cares enough about health to pay for it’ helps explain that conundrum.

So it feels a bit like merry-go-round to me, or if you take a more sardonic view, a game of Russian roulette.  So tell me: am I off base?  Who really does care?