Monday, October 7, 2013

Trust, Small Decisions, and Improving Health Care

Our lives are built on trust in others. We trust that the person in the car stopped by the red light will not suddenly hit the accelerator and run us over as we cross the street. We trust that the people upon whom we depend, whether they are family members, doctors, grocers, or plumbers, will do their jobs and meet their responsibilities in such a way to help us stay healthy, fed and safe. However, in an increasingly impersonal world, can we still trust? Can we depend on the right things happening, when we don’t know the nurse, the doctor, the plumber and the grocer?

I grew up the son of an immigrant who owned a small “mom-and-pop” grocery store in New York City. My father knew each of his customers, would physically give them the food, and would understand when they couldn’t pay at that moment in time and would try to help them. I vividly remember seeing lists of names—on the backs of envelopes and scraps of paper in the store—of people who owed money from when they needed food and couldn’t pay for it. My father felt he had a responsibility to his customers who needed the food; the fact that they couldn’t pay at that moment, he reasoned, should not stop them from having that food. There was no interest paid or collection agencies. There was simply trust. Sometimes, I would deliver the food to people’s homes when they could not leave the house because they were old or infirm. As a child, I was sometimes a little frightened going into strangers’ apartments in areas of New York that others would consider dangerous. Yet that, too, grew out of my father’s sense of responsibility—and the trust between my father and the people who needed the food.

So what does all this have to do with health decisions? Health is not only about what doctors, hospitals, or any healthcare providers decide. It is about the small decisions people make every day in thousands of ways, big and small. Here at Accolade, we tried to estimate the number of health decisions individuals make every year. We started with claims, as each claim represents a medical service that results from a decision. We added in over-the-counter medication use, gym use, and other “everyday” activities. We left out the decisions around food purchases--even though as a grocer’s son and a physician who is board certified in clinical nutrition, I believe food purchases to be among the most important health decisions. We also left out the decisions we all make around everyday activity, such as whether we park our car in a place far from our office entrance or as close as we can to avoid a long walk. The result: We estimated that the average person makes more than 2,500 health decisions a year. It is, admittedly, a poor estimate-- probably underestimating by a large factor; it also reflects the average person, not necessarily the sick person.

How are all these big and little decisions related to trust? If you want to improve healthcare decision-making, you have to be able to influence those thousands of small decisions—which means you must build trust with the decision-makers, who may or may not be the patient. In many families, the wife and mother is the main decision-maker for the family. It also means that health systems and health policy must support and facilitate good decisions by people even when those decisions are small, whether they are healthy or sick.

Let’s examine nutrition as an example. A recent Health Affairs article about nutrition highlighted the health consequences of an industrialized food industry that processes food—sometimes to increase affordability, sometimes to increase shelf life, and ultimately leads to obesity which leads to disease. Written by two former Secretaries of Agriculture, Dan Glickman and Ann Veneman, the article states:

On the one hand, with obesity-related health costs rapidly rising, the federal government has encouraged people to make healthy dietary choices through efforts such as Let’s Move! and MyPlate. On the other hand, the federal government spends billions of dollars on traditional agricultural commodity programs that fail to reinforce the kind of healthy dietary choices outlined in federal dietary guidelines.”

This article was published at about the same time Sequoia Capital invested in a rapidly growing start-up company, Good Eggs.  Good Eggs is making locally sourced healthier food more available, offering a communication platform and delivery service for consumers with the farmers, bakers, and other food providers that is personal and easy. (Full disclosure: My son Rob Spiro is co-founder and CEO of Good Eggs; my goal is to someday bag and deliver groceries for them so I can go full circle from my youth.)

Good Eggs realizes that the answer is less about programs and more about fostering a personal system in which the local person who advises people and helps them is right there, helping them make better decisions. We need to replace the emphasis on an industrial system that is focused on large production and bulk delivery. We need to foster a trust based on the fact that you know the person who produces your food, that they know you and that you each have the other’s best interests in mind. You meet your local farmer on Good Eggs, can speak to him or her and end up eating healthier foods as a result of that personal trust. This trust, simplification and facilitation of smart, small decisions leads to better eating, lower rates of obesity and lower healthcare costs than any forced weight loss program. It is really about trust and people-to-people communication.

Technology can help facilitate this communication, but can never be the only answer. The folks at Good Eggs have found that they had to use creative and imaginative apps and technology, but that they also had to deliver the food and actually “touch” their customers, person to person. Bryan Shreier from Sequoia Capital in an article linked here talks about the need for tech firms to embrace operations and not assume the tech alone will be the answer. He uses the examples of Good Eggs, as well as Uber, the limousine service, as companies using technology to simplify and personalize a human interaction.

In healthcare, specifically, that need to facilitate the person-to-person interaction, which leads to better decision-making and better health and sickness care is even more urgent—and is our approach at Accolade.

Unfortunately, the health technology industry often seems to only focus on the "big data" and the “apps.” In an article in Fortune Magazine entitled, “Health Apps Don’t Save People, People Do,”, Ryan Bradley reviews a number of studies that show, when it comes to the treatment of obesity and diabetes, apps alone--no matter how enticing and technologically simple--are never as effective as person-to-person interactions. Bringing people together with each other and with educators and professionals on a regular basis positively influences their decision-making, and ultimately, their activities and the choices they make.

At Accolade, we see that every day in the small decisions that our Health Assistants help people make as they live their lives. The people we serve are trying to make a living, feed their families, and choose what to do about their ailments and lifestyle. No matter how big or small those choices are, the answer always lies in the trust and help we give each other. That social interaction gives strength to our fellow  human being, helps them through tough times, shares and celebrates good times—and creates the positive decisions and outcomes that bring better health and better life to people. While we use "big data" and "apps", ultimately we know that Angry Birds alone can’t do that. We know that technology can only be the answer when it is facilitating human interactions.