Why the book “More than Medicine: the Broken Promise of American Health” is important to the future of behavioral medicine, health psychology, and public health

Kaplan’s book, “More than Medicine”, importantly argues to communicate cost-effectiveness of implementation costs and medical cost offsets to increase the adoption of behavioral interventions.

Abstract

In his book, “More than Medicine: The Broken Promise of American Health,” Robert Kaplan brings together extensive data to make the case that healthcare priorities in the USA need to place greater emphasis on behavioral, social and environmental determinants of health. Kaplan argues that the effect sizes for health outcomes resulting from environmental exposures, stress, and socioeconomic status are all much larger than are many traditional biological risk factors. There are discrepancies between estimates of how much the National Institutes of Health spends on behavioral and social sciences research, but an independent evaluation suggests it is <5% of the entire budget. Addressing this neglect requires advocacy and bringing together of like-minded organizations to promote more funding for behavioral interventions, health promotion and public health policies to address important contextual factors such as poverty, lack of education, and poor environmental conditions. Importantly, Kaplan argues that several metrics to integrate life expectancy and quality of life have been proposed and allow healthcare providers to prioritize the value of health over the volume of healthcare delivered. Although standards exist, there are still a limited number of studies on the cost-effectiveness and cost-utility of behavioral and public health interventions.

Implications

Practice: Delivery of behavioral interventions to patients receiving medical care has a high potential to improve a wide range of health outcomes and to reduce unnecessary healthcare utilization.

Policy: The ability for our field to communicate cost-effectiveness data to policymakers, employers, and insurers that incorporates implementation costs as well as medical cost offsets and broader impacts across both health and nonhealthcare sectors is central to the likelihood of our interventions being adopted

Research: We need continuing efforts to utilize dissemination and implementation models and to guide the process, evaluation of interventions as well as the cost-effectiveness, cost-utility, and cost-savings of health interventions.

COMMENTARY

In the USA, the demand for expensive treatments exceeds the financial resources available to pay for them. This has resulted in a need for healthcare economic policy that covers treatments of demonstrable effectiveness. In his book, “More than Medicine: The Broken Promise of American Health” [1], Robert Kaplan brings together extensive data to make the case that healthcare priorities in the USA need to place more emphasis on behavioral, social and environmental determinants of health, rather than focusing primarily on biomedical research which has only had limited impact. Although the USA spends considerably more on healthcare per capita than does any other country [2], <5% of the National Institutes of Health budget is spent on understanding social and behavioral determinants of health that could ultimately lead to better preventive efforts for reducing morbidity and mortality at a population level [3].

There is mounting evidence that some of the most profound influences on health outcomes come from outside of the healthcare system [4]. Kaplan argues that environmental exposures, stress, and socioeconomic status all have profound effects on health. And, in fact, estimates of the proportional contribution of clinical, social, environmental, genetic, and behavioral domains to health status and premature death suggest that only about 10% of the variance in health outcomes is linked to the delivery of healthcare in clinical settings [5]. This distribution presents a tremendous opportunity within the disciplines of health psychology and behavioral medicine to better understand and influence the range of health-promoting interventions delivered in a broad range of both clinical and nonclinical domains. One of the most striking examples provided by Kaplan is the gap in life expectancies of individuals leaving in adjacent Philadelphia zip codes. The difference in life expectancy of those who live in zip code 19106 is 20 years more than those who live in 19132, just 5 miles apart. To put the 20-year discrepancy in context, Kaplan cites other data suggesting that regularly screening for breast cancer increases life expectancy by about 1 month, or that screening and treatment of high cholesterol increases population life expectancy by less than 1 year. Underlying factors accounting for the Philadelphia disparities have been reported to be lack of education, unsafe and unhealthy housing, lack of supports for physical activity, exposure to toxic agents and pollutants, residential segregation, and less access to primary care doctors, and public transportation. These data show the strong associations of environmental exposure, stress, and socioeconomic status on health and longevity. This argument is consistent with a growing evidence base that suggests that environmental interventions have a high potential to be cost-effective compared to other types of clinical and medical disease prevention programs [6]. These, like other examples provided in Kaplan’s book, call for more attention to sociocultural and societal level factors that require multilevel approaches to improving the health and wellbeing of individuals, families, and communities.

Given the growing evidence base that behavioral, social and environmental factors are critical for health outcomes, Kaplan calls for more research on these issues. This requires like-minded organizations to come together and promote more funding for behavioral interventions, health promotion and public health policies to address these important contextual factors such as poverty, lack of education, and poor environmental conditions. Behavioral interventions have been shown to be effective in the context of these health inequities and this is another opportunity for behavioral medicine and health psychology researchers to continue to build the evidence base supporting these effects. Yet even the most effective behavioral interventions are rarely used in modern health care. Only 50% of current smokers, for example, are advised to quit by their healthcare providers [7].

Kaplan addresses the “act of well-being” in his book, which while familiar to many in our field, brings an important message that should get more broadly communicated to policy makers, healthcare providers, and decision makers. Repeatedly, information is summarized in this section that shows the number of deaths that could be prevented if critical behaviors such as drug abuse, smoking, physical inactivity, and poor diet were addressed on a routine basis. To make these arguments more clear, the cost-savings of engaging in behavioral lifestyle changes and prevention efforts are provided making the case for addressing these health behaviors early in the lifespan. However, there are important economic analyses that should be considered in our field as we try to promote behavioral, social and environmental interventions for improving population health [8–11]. Although cost-effectiveness standards have been established in many fields the field of behavioral medicine and health psychology lag behind in applying such standardized methodologies.

While behavioral interventions can be offered within a wide range of contexts, including public health, medicine, surgery, physical rehabilitation, nutrition, and other health services, different health interventions compete for the same resources. However, it is difficult to compare the value of the diverse interventions. Thus, rethinking the definition of health, as Kaplan proposes, may be an important step in advancing the uptake and utilization of behavioral interventions on a broad scale. Importantly, Kaplan argues that several metrics to integrate life expectancy and quality of life have been proposed and allow healthcare providers to focus on prioritizing how interventions improve health from the patients perspective rather than counting the volume of services delivered by providers. A well-designed measure of life quality considers the disabling and diminishing consequences of disease. The best measures place levels of wellness on a continuum from 0.0 to 1.0 with the higher end of the scale representing the highest level of health. Quality-adjusted life years (QALYs) have been used in quality-adjusted survival analysis as outcomes to place individuals on a continuum between death and perfect health. Both the benefits and disadvantages of health interventions can be measured in common QALY units making comparisons across multiple treatment options more feasible and useful to decision makers. This reconceptualization of health should be strongly considered by behavioral medicine researchers and health psychologists as an important opportunity for increasing the likelihood of our behavioral interventions being adopted into routine medical practice.

The path forward is going to be challenging given the exceeding costs of healthcare in the USA. In particular, Kaplan implies that a cost-effectiveness analysis that typically quantify the outcomes of a healthcare intervention in terms of QALYs can be used by providers of services in making sound decisions on where to place resources. Budgets are limited, and it is not possible to pay for all the services or programs that might produce better population health. Facing these challenges requires application of these new economic analysis tools with the goal of producing the most health for the most people, given the limited resources available. Although standards exist, they have only rarely been systematically applied to understanding the cost-effectiveness and cost-utility of behavioral and public health interventions [8–11]. These methods should become the standard for all behavioral medicine researchers and health psychologists who are working on dissemination and implementation of health interventions.

A final critical insight provided by Kaplan concerns restructuring our healthcare system. More attention is needed to address unsafe care and lack of preventive services as well as poor healthcare coordination. In addition to the problem of poor healthcare access, we also face a crisis of overtreatment. Some patients with serious healthcare needs are excluded from care while others get costly and unnecessary treatment. A clear example of how these policy and cost considerations could help to reduce overall spending in the USA is provided. This again provided opportunities for thinking about not only how our field can contribute, but how we as behavioral medicine researchers and behavioral scientists can play a role in collaborative care models [10]. Collaborative care has been widely studied from an economic perspective. Many previous studies have demonstrated its relative cost-effectiveness per QALY and some studies have also shown cost neutrality or cost-savings. Among the major contributions of health psychology and behavioral medicine is evidence demonstrating the benefits of behavioral and psychosocial interventions that may be provided in conjunction with primary and specialty medical care [12, 13]. Delivery of these interventions to patients receiving medical care has a high potential to improve a wide range of health outcomes and to reduce unnecessary healthcare utilization. However, the adoption of many of these interventions as part of routine medical care has not yet been demonstrated [12, 14].

In summary, “More than Medicine: The Broken Promise of American Health” [1] is an important book for the field and a unique perspective is provided by Kaplan after having served as Chief Science Officer at the U.S. Agency for Health Care Research and Quality (AHRQ) and Associate Director of the National Institutes of Health, where he led the behavioral and social sciences programs. The issues raised in the book highlight the need for addressing social and environmental determinants that behavioral medicine and health psychologist researchers are well equipped to do. We need continuing efforts to utilize dissemination and implementation models and to guide the process, evaluation of interventions [15] as well as the cost-effectiveness, cost-utility, and cost-savings [1] of health interventions. The ability for our field to communicate cost-effectiveness data to policymakers, employers, and insurers that incorporates implementation costs as well as medical cost offsets and broader impacts across both health and nonhealthcare sectors is central to the likelihood of our interventions being adopted.

Compliance with Ethical Standards

Conflict of Interest None declared.

Ethical Approval This is a commentary on a book that reviews many empirical studies. To the best of my knowledge all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent This is a commentary on a book that reviews many empirical studies To the best of my knowledge informed consent was obtained from all individual participants included in the study. No animals used in this study.