David D. Pope, PharmD, CDE

wellness (n): the state or condition of being in good physical and mental health. 

With its highly ambiguous title and wide-reaching goals, the wellness movement has officially arrived in the United States. From the multibillion-dollar organic food industry to Fortune 500 companies paying for wellness services, corporate America has finally come to the realization that health care dollars spent on the front end ultimately save them in the long run. Patients have even jumped onto the wellness bandwagon as they become responsible for a greater percentage of health care costs. For example, according to an August 2014 article in 

, the International Federation of Organic Agriculture Movements determined that the industry’s worldwide revenues were a record of $63 billion in 2012 and predicted that the market may grow by 14% by 2018.

 With a strong background in patient education, screenings, and monitoring, pharmacists have become leaders within the wellness movement. Pharmacies and pharmacy organizations should see the health care industry’s movement toward an emphasis on wellness as an opportunity for pharmacy. The wellness movement is focused on 3 specific areas: information, encouragement, and accountability. The vitality and viability of the pharmacy may very well depend on its response to this latest shift in the marketplace.

Obesity and Smoking: Catalysts of the Wellness Movement

 As the nation falls deep into a chronic disease crisis, insurers, accountable care organizations (ACOs), private businesses, and even the federal government have begun to focus on developing wellness solutions in order to prevent and treat chronic disease. Obesity, one of the primary drivers of several chronic diseases, has sharply increased over the past decade. Between 1960 and 1980, for example, obesity prevalence rates in the United States only increased 2% (13% to 15%). According to a JAMA study, however, obesity rates have increased almost 270% (35% of all US adults were estimated to be obese in 2015).

 This statistic only includes those individuals with a body mass index greater than 30 and does not include those considered “overweight.” If those individuals were included, the number of individuals who were overweight or obese would encompass approximately 70% of America. How does this affect overall health care costs? According to the Centers for Disease Control and Prevention (CDC), the estimated annual medical costs for people who are obese are $1429 higher than those of normal weight.

 Obesity is a contributing factor to some of the leading causes of chronic diseases, including type 2 diabetes and heart disease. Chronic diseases currently account for 86% of our health care costs and are responsible for 7 out of 10 deaths in the United States each year.

Smoking cessation has also played a primary role in developing the wellness revolution. While it may seem archaic, our grandparents almost assuredly viewed smoking as an aristocratic way to socialize amongst friends. As studies began to show the harmful effects of smoking, however, corporate America began to slowly encourage employees to quit the habit. According to a July 2012 article by Rebecca Veseley with 

, the modern worksite wellness movement began in the late 1960s and early 1970s as companies such as Boeing launched anti-smoking campaigns .

The Chinese use 2 brush strokes to write the word 'crisis.' One brush stroke stands for danger; the other for opportunity. In a crisis, be aware of the danger

This quote from the former president of the United States is a strong reminder that resilience and innovation are necessary to confront a crisis. The wellness movement’s effort to combat chronic disease began to unfurl in the United States in a similar manner to the environmental movement of the 1980s and 1990s. Groups of health care professionals, dedicated to fighting both the clinical and financial repercussions of chronic disease, began to devise solutions that would identify, treat, and monitor the employees of large employers. In 1997, a group of pharmacists in Asheville, North Carolina, developed a solution for the employees of the city of Asheville. The Asheville Project connected employees living with diabetes and other chronic diseases with their local clinical community pharmacist for pharmaceutical care services. The results of this program are still used as standards today, as the study showed that total mean direct medical costs decreased by $1200 to $1872 when compared with baseline.

 This study, along with others, also served as a catalyst to determine effective ways to incorporate wellness solutions in effort to lower overall healthcare costs.

According to a 2013 RAND Corporation white paper, worksite wellness was estimated to be a $6 billion industry in 2012.

 Additionally, a meta-analysis that showed a reduction of medical costs of $3.27 for every $1 spent on a worksite wellness program and a decrease in absenteeism costs of $ 2.73 for every $1 spent.

According to the Harvard Business Review, moving 10% of employees from high- and medium-risk to low-risk status yields a return on investment (ROI) of 6 to 1.

 In virtually every study, using the worksite as the platform for improving overall wellness has resulted in both clinical and financial improvement.

Independent and chain pharmacies have also joined the worksite wellness movement. Many pharmacies have the clear advantage of owning locations that are physically near the employer and have strong community connections. Imagine how a pharmacy could develop a simple worksite wellness program: with a single day of health screening, the pharmacy could easily categorize patients according to a disease-management solution for conditions such as diabetes, heart health, obesity, or a lifestyle-management arm. The pharmacy could then implement technology solutions as well as in-person and group meetings with the pharmacist to improve control of chronic diseases and lifestyle modification. With regard to the pharmacy, this adaptation of the wellness movement has incredible potential for both ROI and clinical improvement.

One area of explosive growth is in the area of mobile wellness. More than 100,000 health apps are available in the iTunes and Google Play stores, and the overall health app market is expected to be $26 billion by 2017, according to Research2guidance, a mobile market research firm.

 Now that 90% of all US adults have a cell phone (and 64% report having a smartphone), the possibilities of mobile health are endless.

For centuries, actuaries have utilized predictive modeling to determine relative risk. Why? Obviously, insurers weren’t able to physically track each person and effectively predict risk. With the explosion of mobile phones and mobile health, or “mHealth” apps, however, insurers can now track patients’ lifestyle habits, such as nutrition and exercise, and provide both “carrots” and “sticks” to improve health, thereby decreasing overall medical costs. 

The Carrot of Mobile Health Accountability

As a consumer, would you be willing to allow a “big brother” approach and provide personal habit data, such as smoking, nutrition, and exercise, to an insurance company or ACO? Most of us would probably reject the offer and cite it as an intrusion into our personal lives. If there was a significant carrot offered as a result of your data, however, would you reconsider? With premiums, deductibles, and co-pays skyrocketing beyond the point of affordability, a significant reduction in health care costs may alter your perception. This trend toward offering discounts for accountability has already begun, as HumanaVitality now offers a 10% reduction in co-pays in return for data that prove users have exercised or chosen healthy foods. For example, insurers can track exercise through an app that counts the number of steps a user takes or even via wearable technology that tracks specific exercises, such as the FitBit or Apple Watch. Partnerships have even begun with the grocery industry as incentives for choosing healthy foods are utilized by tracking food purchases.

Insurers and ACOs aren’t the only ones who are asking for this type of patient data, however. Over the past few years, pharmacists have taken on the role of community health coach for patients living with chronic diseases. Therefore, having data that support their ability to assess and monitor patients is vital to driving successful outcomes. While our nation’s medication experts focus heavily on ensuring proper treatment algorithms and minimizing adverse events, pharmacists are now adopting a new area of focus: ensuring effectiveness of the treatments. By having specific “wellness” data at their fingertips, pharmacists can affect patient outcomes in powerful ways.

 While health care providers, hospitals, and ACOs can utilize mobile accountability to improve health through positive interventions, they can also spur patients to improve their wellness by developing penalties or other unwanted intricacies in order to ensure wellness. For example, co-pays could be raised for patients who don’t adhere to specific stipulations, such as purchasing foods high in nutritional value or exercising. As for pharmacists, there is the strong potential that they will ultimately be held co-responsible for patient outcomes. Currently, Medicare’s star ratings program measures medication adherence among patients in a health plan, awarding more stars to insurers with higher adherence rates. However, as the wellness movement continues to evolve, pharmacists may be judged on whether a patient is reaching defined clinical outcomes, such as a glycated hemoglobin goal. 

 In order to compete in today’s ever-changing landscape, today’s pharmacists and pharmacy executives must embrace the idea of the wellness movement. In order to do so, pharmacists must be given training and access to patients. New forms of communication between pharmacists and their patients must be utilized. One example of a new form of communication is the Spark Health platform from Creative Pharmacist. This platform is essentially a fitness tracker that sends data to the user’s health coach, the clinical community pharmacist. The platform also creates a customized experience for the patient based on their chronic disease states. 

In addition to new forms of communication, pharmacists must be eligible for reimbursement for assisting patients in improving overall wellness. A model recently adopted by the Centers for Medicare & Medicaid Services for reimbursement can be loosely associated with the wellness model. Chronic care management (CCM) services were adopted for payment to physicians in 2015. CCM codes, eligible for reimbursement under Medicare, cover non face-to-face interactions with patients living with 2 or more chronic care conditions.

These codes are payable on a monthly basis and could serve as an example of how pharmacists may be reimbursed in the future. Joe Moose, PharmD, owner of Moose Pharmacy in North Carolina, recently stated, “Pharmacists aren’t going to be paid more for doing the same service. Pharmacists, however, can be paid differently.”

This quote by one of the thought leaders of this generation of pharmacy defines the reimbursement of the wellness movement quite eloquently. In order to be paid differently, pharmacists and pharmacy groups must be able to show both clinical and financial value in their unique approach. 

Food, Family, Pharmacy, and the Customized Approach to Wellness

Let food be thy medicine and medicine be thy food.

Over the past few years, the wellness movement has caused millions of Americans to realize the relative lack of nutrients in their daily meals. Diet plans based almost entirely on raw vegetables and lean meats are now supplanting traditional weight-loss diets that are based solely on calorie-counting. Even fast food stalwarts, such as McDonalds, have begun to embrace the wellness movement by offering low-calorie fruit options. Mid- to large-market grocery stores have also capitalized on the demand for healthy foods by offering additional organic and healthy choices traditionally only stocked by health food stores, such as Whole Foods. Pharmacies located within grocery chains have a distinct advantage within the wellness movement as they are able to offer information on chronic diseases as well as offer specific food choices within the same location.

The dawn of mobile health accountability through the wellness movement has unveiled a unique and opportune time to be in the pharmacy industry. Pharmacies looking for potential areas of differentiation in the marketplace will utilize the avenues of worksite wellness programs, technologies, partnerships with grocery chains, and other areas that define the pharmacy as a wellness destination. If you’re the leader of an ACO, insurance entity, hospital, or pharmacy group, encourage your members to adopt and engage in the wellness movement. Determine your target population, define the technology needed to develop your solution, and begin the process of partnering with your patients. 

David D. Pope, PharmD, CDE, is chief of innovation and cofounder of Creative Pharmacist.

		Whole Foods Market: victim of success. 

.  www.economist.com/news/business/21610289-peddler-pricey-organic-and-natural-foods-finds-it-has-competition-victim-success. Published August 2, 2014. Accessed September 13, 2015.

		Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011-2012. 

. 2014;311(8):806-814. doi: 10.1001/jama.2014.732.

		Flegal KM, Carroll MD, Kit BK, Ogden CL. 

2012;307(5):491-497. doi:10.1001/jama.2012.39. 

		Adult obesity facts.  Centers for Disease Control and Prevention website. www.cdc.gov/obesity/data/adult.html. Published September 21, 2015. Accessed September 22, 2015.

		Chronic disease prevention and health promotion. Centers for Disease Control and Prevention website. www.cdc.gov/chronicdisease/. Published September 17, 2015. Accessed September 22, 2015.

		Vesely R. Shaping up: workplace wellness in the 80s and today. 

 website. www.workforce.com/articles/shaping-up-workplace-wellness-in-the-80s-and-today. Published July 18, 2012. Accessed September 13, 2015.

		Cranor CW, Bunting BA, Christensen DB.  The Asheville Project: long-term clinical and economic outcomes of a community pharmacy diabetes care program. 

		RAND Corporation. Do workplace wellness programs save employers money? www.rand.org/content/dam/rand/pubs/research_briefs/RB9700/RB9744/RAND_RB9744.pdf. Published 2013. Accessed September 13, 2015.

		Baicker K, Cutler D, Song Z. Workplace wellness programs can generate savings. 

. 2010;29(2): 304-311. doi: 10.1377/hlthaff.2009.0626.

		Berry LL, Mirabito AM, Baun WB. What’s the hard return on employee wellness programs?  

. https://hbr.org/2010/12/whats-the-hard-return-on-employee-wellness-programs. Published December 2010. Accessed September 13, 2015.

. www.research2guidance.com/shop/index.php/mhealth-report-2. Published March 4, 2013. Accessed September 13, 2015.

		Smith A. US Smartphone use in 2015. Pew Research Center website.  www.pewinternet.org/2015/04/01/us-smartphone-use-in-2015/. Published April 1, 2015. Accessed September 13, 2015.

		Marshall A. Chronic care management services: CY 2015 medicare physician fee schedule. Centers for Medicare & Medicaid Services. www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/2015-02-18-Chronic-Care-Presentation.pdf. Published April 1, 2015. Accessed September 13, 2015.

		Moose J. Rethink pharmacy. ACPE-approved CE presented at National Community Pharmacists Association Convention; October 2014; Austin, TX.

Articles

With its highly ambiguous title and wide-reaching goals, the wellness movement has officially arrived in the United States.