Chronic disease is an epidemic. The vast majority of annual health care spending goes toward treating conditions like heart disease, cancer, diabetes and obesity. Yet, despite trillions of dollars spent on management, chronic diseases still cause up to 75% of all deaths in the U.S.
In an episode of the “AMA Moving Medicine” podcast, Richard Milani, MD, chief clinical transformation officer at Ochsner Health System, in southeast Louisiana, addresses the challenges of treating chronic disease in the outpatient setting and makes a case for leveraging behavior change as part of the solution.
Dr. Milani: Let's start off with the outpatient side. No better place to start than what's really encompassing the biggest problem that we face from a health perspective.
If we're taking a step back, and we were to look at the health problems of our nation in 1900, the epidemic of the time from a century ago was infectious diseases. Today, the epidemic that we have today are chronic diseases.
Eighty-six percent of all the dollars we'll spend as a nation in health care—so over $3.4 trillion we'll spend in health care this year—86% of those dollars will be spent on … one set of conditions, chronic diseases. It represents 70–75% of all the deaths. Half of us statistically in this room have it, and it's the number one cause of disability. So, if there needs to be an area of focus that's going to improve the quality and reduce the cost, this is the area.
Moreover, we can't bury our heads in the sand. This is not going anywhere. If you think we have a problem today, buckle up because the problem is only going to get worse tomorrow. So, how do we manage chronic disease?
I know this is stating the obvious, but it's worth stating the obvious. I can't take you to surgery and cure your diabetes. I can't take you to surgery or do some other procedure on you and make your COPD go away.
All I have, all any of us have, is the best pharmacologic therapy and then behavior change, and that's it. There's not a third option.
So, the best pharmacologic therapy, why is that important? Because pharmacologic therapy changes. We have scientific guidelines that are published periodically, and the purpose of these things is to say, "You know what? That therapy is now superseded by this therapy,” or, “That therapy, now we learn, is causing issues, let's stop it,” or, “Let's just use it in this one narrow population.” We have these things in order to achieve the best outcomes for the patients that we have.
Behavioral therapy obviously plays a big role, so how well do we do it?
Finally, there's a third thing that we do, although it's not an intervention. It's surveillance. You've got a chronic disease. Guess what? You're probably going to have it to the rest of your life. I need to survey you periodically to make sure that you’re in bounds or you're heading out of bounds. That's the whole purpose of surveillance. I can't see you once and say, "You are done, your diabetes is done. I'll see you next time you have a problem, show up." How well do we do?
Well, if you look on the medication side, we do very poor. The odds in the United States today of being on guideline-based therapy for any chronic disease condition is less than 50%. I don't care whether you go to Seattle or Boston or Chicago or Florida or anywhere you want to go, anywhere in the nation. You enter a physician's office, the likelihood of you being on the guideline-based therapy, the current guidelines for that condition, is less than half.
In fact, in heart failure, there's a publication about nine months ago that showed it's less than 30%, so we don't do a good job. And we—meaning the world, it's not just the U.S.—but we don't do a good job in getting our patients on the most effective pharmacologic therapy for that condition. And that leads to unnecessary costs, unnecessary deaths, unnecessary hospitalizations.
How about behavior? Well, if you thought we did a bad job on pharmacologic therapy, we do a worse job on behavior change.
This is data from the Google food team and the Yale Center for Consumer Insights. Wellness initiatives fail because they rely on placing too much emphasis on providing information. That's what we do. I give you a handout and I feel good about myself. You get an after-visit summary, a claims handout. Boy, I feel good.
Isn't it amazing that I'm so shocked when I see you back in six months and nothing has changed? Who's the insane person, doing the same thing over and over again expecting a different outcome? It's me.
So, we do a bad job because we gave you information. And by the way, if that doesn't work, I’ll give you more information, and then I'll double that. I’ll double down. So, evidence from behavioral economics has shown that information rarely succeeds in changing behavior, building new habits or food choices. …
And there's a lot of ways that we can change behavior. And I'm not saying we shouldn't give information, because of course we have to give information. But if we think that's going to do it besides our recommendation, then we’re sadly mistaken.
And then finally, surveillance. The third aspect of chronic disease care. The average person with uncontrolled—not controlled, uncontrolled—hypertension, sees a physician four times a year. It's uncontrolled.
Now, I can't see you every day, but the point being is that that's inadequate if I'm going to manage a disease process that's already out of bounds and I'm trying to get you in bounds. And we know data that stroke and heart attack have a significant increase if I don't get you under control within 10 to 14 days. And that's been shown now in large-scale studies.
So why do we fail? Why do we fail in all these aspects of care? And it's not just the U.S., it really is globally.
Well, we face a lot of challenges. Now, I'm not trying to make excuses, but this is the reality of how our practice is. Face-to-face patient care accounts for about half the average work day. If we were to follow the guidelines for just 10 chronic diseases, it would encompass about 10.6 hours a day. We'd have nothing left to do anything else, and we don't even have 10.6 hours a day, in terms of time for our patients.
Secondly, this is pretty tough. We've got a database that's almost impossible to keep up. In 1950, it took 50 years for medical knowledge to double. In 1950. By 1980, that was reduced to seven years. And by 2010, three and a half years. It's a lot of information to keep up with.
I'll say this again and again; the primary care physician is not only the backbone but in many ways to pack mule—and I don't mean that in a disparaging way, I mean that in an honest way—of the health care system. We put more and more and more and more stuff on the primary care physicians' daily routines that make it impossible to be able to keep up with current therapies.
Finally, therapeutic inertia. It's a well-described concept. For the med students in the room, if you're not familiar with that, in any goal-directed therapy—say an A1c, or a cholesterol or a blood pressure. Any of these things where I've got a goal and you're here—therapeutic inertia means I'll get you about halfway there and then for whatever reason it stops. I'll get you part of the way, but I don't get you across the finish line. And that is highly prevalent in most chronic disease states.
And then, finally, the model of delivery. The health care system that we have today, not only in our country, but across the globe, is built on an acute care model. If all of us got in a spaceship and we go to an alien planet and as health care experts, they asked, "Design a health care system for these aliens on this planet," the first question that we would ask is, "Okay. What's wrong with you aliens? What are the things that befall you that we can help fix?"
If we were to build a health care system in 1900, this is exactly the system that I'd want to build. I'd build a box and I'd call it a hospital, and I'd built a bunch of little boxes and call them clinics, and I’d attach a box and call it an emergency room and it's perfect. I break my arm, I get in an accident, I do any one of these acute care events, and I've got a means to manage that. But now the epidemic is chronic. It's process that's changing daily.
And yet I still I'm doing this sort of episodic acute care model that doesn't fit with the problems that our populous has. So, the first is recognizing that we've had a focus, as a nation, primarily on health care delivery and the focus that we have to turn our attention to going forward is the health of the population, especially if we're going to go to a value-based system.
The first question I ask our med students, or even our residents and fellows, is, "What are the determinants of health?"
We are training in med school to diagnose disease and treat disease, and that's appropriate, but we have less training in the conditions that relate to health. If we look at what we do, the health care system, the health delivery system that we're all part of, it represents about 10% of the pie, as you've seen before. But we really have to turn our attention to the rest of the pie if we're going to make a fundamental difference.
So we recognize that social circumstances encompass even a greater portion of the pie than the medical system. Environmental exposure's responsible for one-in-five deaths across the globe. Twenty percent of all the deaths that occur each year across the entire planet is environmental. And you say, "Well, that's just in China and in India." But the truth is it has direct effects in our own country. It impacts heart attack, stroke rates, hypertension and I can go on down the list in terms of environmental exposure in our own U.S.
We know that genetic predisposition plays a role. We used to think that was immutable, and now we know differently. It is mutable.
And then finally, behavioral circumstances. If you look at social circumstances. This is an example of one of our patients getting an iPad. If you have heart failure, come to our hospital, you get an iPad, you answer a series of questions including dietary questions and social, other questions, and we do a sodium survey. And it's a detailed analysis of sodium, and if you score out high, you watch a video about the importance of low sodium and how to do it, but it asks two other questions.
It says, "Does anybody but you buy your food?” And “Does anybody but you prepare your food?"
Simple enough. I can tell you honestly, I'm the fortunate recipient of a wonderful wife who enjoys cooking and unfortunately, I like it too much, and she's good at it, and she likes it, and I like eating her food. But the point is, is that she happens to buy the food and she also happens to prepare the food. So, I'd have to answer yes to both.
But if you answer yes to either one of them, we ask one more question. It says, "Would you mind just providing that person's email address? You don't have to, but we're going to send them a link to watch this video, and all we're going to say in there is that you, Mr. Johnson, or whoever you might be, has a salt-sensitive condition."
That's the only thing we're going to say, and you're giving us permission to say that. We're not going to say anything else about it. It could be your brother, it could be a neighbor that might be buying you food. "Would you mind watching this video for Mr. Johnson?" That's it.
So, you just bring the email address and it will just go out right then. So what? Well, the bad news is [only] about 25% will open the link and watch the video. The good news is if they do, readmissions drop 43%.
Now, that cost me nothing other than producing a video and having the patient put in a name and it just goes out. It took about a couple of hours of computer programming time, and it goes out to everybody that walks in. Forty-three percent reduction.
Why? I think there are two reasons why. One is the obvious reason: The person that is buying or preparing the food is now going to have an interest in making sure it's low sodium. That's the, "Duh, we know that."
But I think the bigger part of this, and I have no proof, but I'll bet my house on it that that person now involved in other aspects of my care that they normally wouldn't have gotten involved. I've invited that person into my life, and now they're saying, "You know what, I noticed you're running low on those pills. Do you need me to go to the pharmacy for you and pick that up? You know, I noticed that you've got an appointment … aren't you supposed to see a doctor? Didn't he say you are to show up in another month? Isn't it like four or five weeks now? And have you done that?"
Those things we've heard anecdotally are happening.
So, what about the biggest piece of the pie? Behavior. Well, this is one behavior: adherence. We know it's a big problem. Fifty percent of patients with chronic disease don't even take their meds.
This is what the World Health Organization had to say. If we did nothing else, we don't have to make a new stent, we don't have to make a new robot. If we just increase the effectiveness of adherence interventions, it'd have a far greater impact on the population than anything else we could do. Just getting people to take the meds that we know work.
It doesn't matter what the disease state is. The chronic disease that was cholesterol, diabetes, hypertension, depression, you can see within 10 months we're below the 50% mark. So, certainly, improving adherence would have a dramatic impact on disease control.
Now, some of you, maybe all of you, are aware of this concept of patient activation. If I break my arm, I'm pretty well activated. I don't know. There is no such thing as patient activation for an acute problem. Patient activation has to do with a chronic problem that you're likely to have either for many years or the rest of your life. How activated are you as a patient in that disease process?
We can take a survey and categorize them in one of four categories. The first being the worst category, and that is they're disengaged and overwhelmed. From their perspective, my doctor's in charge of my health. And we all have patients who are like this. They ask questions from their neighbors. "I'm not sure. Dr. Milan said I should do this, but you know, he's a good guy. Maybe I should do that, but I'm kind of not getting it."
Level two is becoming aware, but still struggling. I could be doing more.
Where we want to get people to is three and four. Number three is taking action. These are people that say, "I'm part of the team. I work with Dr. Milani and Dr. Smith and nurse Betty and whatever it is, and they're helping with me to conquer my diabetes. We're together in this."
And then of course, level four is they're in charge of the team, they're questioning you on every visit, they're asking for second opinions, they're showing you a newspaper article, saying, "What do you think of this?"
And that's what we want to achieve. Now, what's the good of it?
Well, if you look at adherence, the level ones and twos are in yellow, level threes in blue, and gray is level four. And you can see it doesn't matter what the process is, adherence goes up. If I can move patient activation, regardless of what disease I'm dealing with, up goes adherence.
Look what else happens. The adverse things that happen in health care go down. So, the good guys—I should say good guys being more activated—are in gray. The less activated are in blue. Your chance of being readmitted is cut in half. Your chance of experiencing medical error is cut in half. Poor coordination, it's cut by about three-quarters. Suffer of health consequence due to poor provider communication or lose confidence? Dramatically reduced if they're more activated.
So, in our patients, it would behoove us if we knew a way to get them more activated. And, certainly, giving them a handout is not one.
Finally, if you're concerned about costs, guess what? It ties in directly with costs. If you’re more activated, you are in the hospital less. If you are in the hospital less, it costs less, et cetera, et cetera. Moreover, if you move somebody from a low activation to a high activation, their costs go with it.
So, can changing behavior change outcomes? This is 50 years of data, from 1960 to 2010, on public health and what it did to the average American's life expectancy.
As a public health effort across our nation, we put efforts to quit smoking, and it's worked. We've added an extra one-and-a-quarter years to every human being's life in our nation as a result of that, averaged out. And you can see we've gained ground in motor vehicle safety, but we lost a lot of ground in obesity and poisoning. So, we've netted out about a half a year over that 50-year period through these public health measures. These are all behavior changes.
The best study I can quote that looks at behavior change is … the diabetes prevention trial. For those of you who are not familiar with it, these were a large number of people that were prediabetic on the verge of going into diabetes, and they were randomized to good advice versus Metformin. And you could see that Metformin prevented the onset of diabetes. So, the best oral drug we have prevented the onset of diabetes. Look at what this thing did: lifestyle change. It beat that.
Now that we don't have pharma, and pharma reps, showing up at our doorsteps, knocking on there and saying, "Hey, Dr. Milani, how about this great lifestyle change program?" They're not beating us up with that, but the point is that works and it works even better than the best drug.
Now, I'm for the drug. I'm not saying you can't do both, but the point is that don't let anybody say that behavior change can't occur, and, moreover, that it's not effective. It's highly effective. Very cost effective. And, in fact, more so than the best drug we have.
So, how can we encourage behavior change? And here I've got a fat doctor telling a fat patient, "You're fat," that kind of thing. That doesn't work too well.
But what influences our behaviors is driven primarily by the company we keep. It really is, in shockingly scary fashions that we would've never suspected. And I can spend a whole hour on this with you and unfortunately I don't have time to do so, but I can tell you that so much of how you behave every day, in me, is related to the people that I'm with. It changes my weight. It changes my exercise. It changes my eating patterns.
It changes so many of my behaviors and yours, just by the people you're with. And certain people have more influence on you than others based on a variety of factors that are now well described. This is one that I would've never expected. If you were to ask me this 10 years ago, I'd go, "You're out of your mind. There's no way that texting can have an impact.” But it does.
And now there's multiple trials. I think I've just got one to show you, that if I gave you a semi-personal text. Now, what does that mean? If I get a text from Mayo—and I'm a Mayo patient—that says, "Smoking is bad, don't do that," or whatever it might say, some message, it doesn't work very well. But my first name is Richard. So if it said, "Richard, smoking is bad, you'd blah, blah, blah," get the same message, I react. That's been shown in multiple studies. Just a simple programmed text once or twice a week with different types of messages that are semi-personal can have a dramatic effect on multiple conditions—not just smoking, but on exercise, on weight control, on diet and on med adherence.
Patients like apps. There's a lot of lousy apps out there. There's actually over 180,000 health and wellness apps in the app universe today. This is the fastest single segment within the app industry, and there's a lot of bad ones. But guess what? There's also a lot of good ones.
And if you survey people, this isn't whether you like it or not—this is their response to surveys—they'll say, "Yeah, these apps changed the way I manage to think about my health and well-being. And not only did it change it, it positively impacted my health and well-being.”
And it doesn't matter whether it was food and diet tracking, or health tracking, your exercise, your sleep. The point is that patients are looking for something else other than just our advice or a pill. They want to learn how to fish. They're tired of just getting a fish meal. They want to learn how to do this independently.
If you look at 2,000 patients with chronic disease and they're given the option of getting a prescription by you, by a physician, or getting a recommendation for an app by a physician, here's their response: They're much more likely to fill the app than they are to fill script. So they're thirsty. They're thirsty for other ways to change behavior.
Now, you're a health system. There's a lot of apps and devices out there. How do you choose? There's a lot of bad ones, as I said. Well, we came up with this concept called the O-Bar. Now, O stands for Ochsner, since I'm a part of the Ochsner Health System. I guess if I was at Mayo, I'd say the M-Bar, if I was at Harvard, the H-Bar, but you get the idea.
And we stole this concept from the Apple Genius Bar. And the idea is we have iPads set up with a curated set of apps that we know are pretty effective, that patients like them, and they've gone past our subject matter experts, and they say, "This is scientifically pretty good. It's not goofy." And we get continuous feedback, and we continually update them based on feedback that we get.
So, we have geniuses behind the bar, and they can say, "Hey, what do you need? Let me direct you here." And you can play with the apps for free and say, "Oh, I liked that one. I hate this one, but this one's pretty cool.” They'll send it to you. Click off and off it comes in your email.
There's no upcharge by us. If it's a free app, it's free. If it's 99 cents, it's 99 cents. If it's a buck, whatever it is. These are all inexpensive. So, they get to play with them. They get somebody to give them advice. And then we also have connected devices, like wireless glucometers, wireless scales and wireless blood pressure cuffs that go right into the EMR, so that data does not have to be scribed by an individual.
We even created a prescription pad, created this some years ago, and you don't need a prescription to go there, by the way. Anybody could walk up. But their doc can say, "Here's a handout. It's important for you to do this, but go downstairs to the O-Bar, they'll fix you up with a good diet app or a good X, Y, Z app. That will help you.”
So, whereas a hundred years ago, we focused on the human touch and the house call, today consumers expect more digital health services. And even into baby boomers, they're increasingly expecting this.
And again, their expectations are shaped by the experiences, just like yours are. I don't make any reservations by calling anybody anymore, I just go on Open Table. You probably do the same thing. We all use Google Maps or Apple Maps. All these things are just part of our routine, daily lives. But if you come to health care, we're going back in the analog systems, so they're expecting more digital care.
And where do we think that this could have its greatest impact? Now, it will have an impact on everything: on access, on appointments, on messaging. But I think the greatest impact will be in disease process of long duration, which is chronic diseases, which is where we started.
We have programs now live in hypertension. Digital programs. I'll give you an example of that. In diabetes. We have one in pregnancy. We have COPD, head-neck cancer, PAD. We have one that we're rolling out very shortly in chemotherapy.
But let's just focus on one—this was one of our biggest ones—on hypertension. It's the single biggest risk factor leading to death, from a risk factor perspective, across the globe. It's a pretty big one to start with. It's the leading chronic disease in our country. Before the guidelines changed last November, it was one out of three adults. Now, it's 46% of adults in the U.S., if you buy into the new guidelines.
Ten percent—this is their single best statistic, I'll tell you … 10% of the global health care budget is spent on one condition. Ten percent of the entire money spent across the planet on health care is spent on hypertension and hypertension-related diseases. This is a heat map of the U.S. going back to 2010, and you could see that where I am is ground zero, right here. But nevertheless, it impacts all of us no matter where you live.
If you look at all causes of death combined over this period of time, 2000 and 2013—cancer, automobile accidents, murder, heart attacks, strokes, the whole shebang—it was a 21% reduction. You look at hypertension-related deaths, they went up by the same degree. So clearly it is a huge problem to tackle.
This is sort of the blueprint of what we do. I know this looks a little busy, but I'm going to walk you through it very quickly. It's really not as bad as it looks.
The first point—this is our delivery model—the first thing is, I cannot manage a process that's changing daily and getting three of four biologic data points on you a year. "I'll see you back in four months, we'll see how things look."
That ain’t gonna work. That's what we've been doing, and it hasn't worked. Let's just say it that way. I don't have to say it's not going to work. It hasn't worked. I need more data, and moreover, that's an awful lot of data to consume. “I'm a busy guy. I'm a busy woman. My practice, I can't manage all that.”
That's why God invented computers, so we have analytics engines that can consume the data and say, "You're getting worse. You're getting better. You need this intervention. You need that intervention. You need encouragement. You need a text that says, ‘way to go’," whatever it might be.
That then needs to go to what we call a Focus Factory Model. We call it an IPU, an Integrated Practice Unit. And we have pharmacists, we have APPs, we have health coaches, we have nutritionists … that are focused on the two aspects we just talked about: pharmacologic intervention, using the current guidelines, [and] behavior change, using the current science of behavior change. And that's right here, and we use apps, we use texting, we use education, we use social determinants. We impact everything.
We send feedback to the primary care, or whoever referring is. Could be an endocrinologist or a cardiologist. Anybody. And we provide social support for that individual.
Let me give you an example of how that works. This is a patient with high blood pressure. Now, the first thing is there are some misconceptions out there, and I don't think anybody in this audience has them, but you should know that home readings are more valuable than office readings are.
So, this was a call to action by the American Heart Association, American Society of Hypertension: “You've got to get home data. In fact, you want to throw something out, throw out the office stuff.” Not that you should throw it out, but I'm just saying that's the real filet, is the home readings. It's a better predictor of cardiovascular risk than office measurements, more reproducible. It reflects target organ damage to a much greater degree than office does. And moreover, it improves adherence if you can get home data.
That data comes streaming in to us through a set of algorithms, and this is one of our clinical pharmacists that's talking to the patient, and she can make sure that when a patient is enrolled, we stop this, we start this, we adjust this, we get them on the current guidelines.
The first thing is, what do the current pharmacologic guidelines say? … Everybody's on that same sheet of music. The patient’s enrolled through a physician order. I'm an Epic shop, so they have to be active on my chart. If not, guess what? It's free. We make them active. They receive a EULA, which is basically consent. And off they go to the races.
They fill out a variety of surveys online. And this is a 100% virtual program. They never see us. They get sent information about the program. They say, "This sounds good, I'll take it." They get sent to the O-Bar, they get fitted for a blood pressure cuff. The O-Bar does all the technical stuff in five minutes. I've got 9-year-olds that don't know how to email or use Amazon or do any of that stuff. We even measured tech savviness. 16% of our patients are not tech savvy. And you know what tech savviness is? Emailing, texting and shopping online. We're not talking like, "Oh my God, I write Python." We're just talking about routine stuff. If you could do that, you're tech savvy.
So, we have plenty of people that can't do any of those, and they do just fine—and the reason is the O-Bar. Because they can just go there, they don't need to figure out anything out. “Let me have that, I'll show you how to use it until you are comfortable. We'll do all the hooking up, it takes a second. And then we'll show you how to use the blood pressure cuff, boom, boom, boom. And I'm here tomorrow. Don't you worry, it’s a little thing. Or you can call me." We never get problems, it just works.
Online, they take a variety of survey instruments that phenotype them. "This person is consuming too much salt. This person can't afford their meds. This person lives alone, they're socially isolated. This person doesn't exercise. This person, et cetera, et cetera, et cetera."
We measure health literacy. "This person has poor health literacy, they're depressed."
And then this is how we set goals for the team. I give the team, the IPU team, two goals. Not 220 goals, two goals. One is, get them to go. And the second is, increase patient activation. If patient activation goes up, all the boats go up. And there's a science to doing this, and it takes more than a minute by a physician in the office as he or she is getting swamped by all the other things that are happening.
Every patient gets a monthly report—not a newsletter, a monthly report—that details exactly how they're doing. What's going on, the progress they made or lack thereof, additional tips that they can do each month.
And on top of that, they get texts, as they need to. And we communicate by phone. We communicate by every means of communication except face to face. About 40% of patients who want medication reminders? Bingo. Done.
It sounds great. Does it work? Well, this is the blood pressure we collect. We actually looked at propensity, matched them to a usual care group that had the same blood pressure. Same everything, no difference. And I can tell you, if you look at 90 days out, this is typical. I've mentioned the average person in the United States with uncontrolled hypertension sees a doctor four times a year. Well, here you are at 90 days. The average number of biologic data points that I have is not even one …. So, we tell our patients, "You have one thing you have to do. You have to take your blood pressure whenever you want, once a week minimum. If eight days go by, you'll get a text reminder, but we recommend three to five readings a week, whenever you choose. But one is the only requirement. Easy. From your home." …
About 20% of patients that are well controlled in diabetes or hypertension will become uncontrolled each year. What you see is, as I get people to control, other people are falling out of control, but we're collecting enough data where we can keep people in control.
Satisfaction is quite high. Do people hate this? No, they go, "This is great. It's convenient." If you look at activation, remember, that's another goal of the program. We improve activation. And if you look at the percent of people that are low activators, it drops.
This is change in medication adherence … our adherence goes up by about 14% compared to usual care, which is no change or a reduction.
This is CG-CAHPS scores, so you can see, they feel their overall health and mental health have gone up. And in terms of their medication, they're more likely to take their medication and understand their medications better than they did before. This is just some awards. I'm not going to go through some of the recognition we've had, but there has been some recognition.
This is a national survey that looked at why people, why consumers, want virtual care, and the chief reason is convenience. When I started this program, I was pushing like, "You don't want to get a stroke. Heart attacks are bad." That's all true. That's kind of nice. But the moment you say, "It's convenient. You don't have to go in to see your doctor. It could be done. Sign me up."
Convenience trumps my own health benefit, which is amazing. But go figure humans, right?
So, this is how we see this across all kinds of chronic diseases. I just list a few of them: hypertension, diabetes, asthma, CAD. We see the pharmacist responsible for staying on the guidelines. And by the way, when the guidelines change, bingo, we're on the guidelines. We're always using, 100% of the time, the current guidelines.
And then the health coaches are working on everything else. They're working on health literacy, they're working on lifestyle change, they're working on patient activation, they're working on all the factors that play a role in behavior change.