Episode #136: ‘Creating a healthcare system based on ‘what matters most to you’ – with Dr. Benjamin Kligler, Veterans Health Administration

Friends,

The first interview we conducted with Ben Kligler (see episode #130) was an introduction to a game-changing humanistic inflection in healthcare delivery called ‘Whole Health’.  If you haven’t listened to it yet, you must. What the VA is deploying on a national scale may be the largest and most significant positive transformation occurring in the American healthcare system. This interview builds on what we discovered in episode 130, but we get a chance to really discover the essence of this life-saving movement. 

In the beginning of this interview, Dr. Kligler lays it out plainly, “…we are creating an actual delivery system built on whole health”.  His response to the ‘why’ question is also straightforward and rings true. “… we’ve gotten to the limit of what disease-oriented care can do in terms of improving our health and well-being…” He goes on to support this statement with statistics and well reasoned arguments. One stat he cites is that the US continues to rank the lowest on multiple domains of healthcare, including health outcomes, when compared to other high-income countries. In fact, the US ranks 37th in the world when it comes to healthcare outcomes, despite grossly outspending every other country.  

I think most of us understand the problem at hand, but we may not really understand the ‘whole health’ solution. Ben does a fantastic job of distilling it down for us, “Our theory is that our legacy healthcare approach is not tapping into one of the most powerful sources of health, which is a person’s ability to make changes in their life and move forward, toward what’s important to them; and to address what’s in their way – what’s keeping them from having a healthy life.  [Whole health] is also a vehicle for addressing the social and structural determinants of health… It’s really the solution to what’s holding our healthcare system back… because managing disease is simply not enough…”

Benjamin Kligler, MD, MPH, is a board-certified family physician who has been working as a clinician, educator, researcher and administrative leader in the field of complementary and integrative medicine for the past 25 years. In May 2016 he was named National Director of the Integrative Health Coordinating Center (IHCC) in the Office of Patient Centered Care and Cultural Transformation (OPCC&CT) as well as Director of Education and Research for Whole Health. In May 2020 Dr. Kligler was named Executive Director of the Office of Patient Centered Care & Cultural Transformation (PCC&CT.) He is a Professor of Family and Community Medicine at Icahn Mount Sinai School of Medicine, and was Vice Chair & Research Director of the Mount Sinai Beth Israel Department of Integrative Medicine. He is currently a core faculty member of the Leadership Program in Integrative Healthcare at Duke University.

In this interview, we’ll hear about:

1. The two questions that form the foundation for the ‘whole health’ program.  I’ll give you a teaser. The first question is, ‘what in your life most matters to you?’ Can you guess what the second question might be?  See below. 
2. The specific domains within the “circle of health” which assist providers and patients in identifying what’s most important and most relevant to the context of patients’ lives.
3. How this program is intent on not only identifying the issues, but also providing the tools and support in attaining and maintaining those personal goals.  
4. The ‘whole health’ outcomes that the VA is measuring and tracking, and those they’re already beginning to see improvements in.  
5. Some of the challenges in studying these outcomes and deploying the program on a national scale, as well as next steps 

There are a few notable comments from this dialogue with Dr. Kligler that stand out for me.  

First – a surprising benefit of the VA’s Whole Health approach is that the providers and staff are also benefiting. The VA is observing an improvement in provider & staff work satisfaction as well as a reduction in turnover. Given the significant burnout (~50% amongst doctors and nurses) and the ‘great resignation’ in healthcare, leaders should take note and consider this Whole Health approach. It should come as no surprise that one of the core defining elements of burnout is depersonalization. 

Second – One of the most surprising and telling stats that Dr. Kligler cites is that people who have a low sense of purpose are two and a half times more likely to die than people who have a high sense of purpose.  Based on that research, he goes on to ask the question ‘why isn’t ‘purpose’ a core vital sign?’.  Well, in the whole health approach it is one of the main domains on the ‘circle of health’. His point is that ‘sense of purpose’ and other non-clinical factors are, in fact, ‘vital’ signs – determinants of our vitality. We’ve known this for years, with mounds of scientific evidence to support it, and yet, we continue to propagate a system that excludes these ‘vital’ signs. Why is that? 

Third – Dr. Kligler points out the critical reason why the VA can pursue a Whole Health contextualized/personalized approach to healthcare, while most other healthcare systems can not. It has to do with payment & compensation. The VA is essentially a value-based, capitated-payment provider – a so-called payvider. What this means is that if the VA prevents a bad outcome, it gets to keep the savings, which it uses to re-invest in its healthcare delivery system. So, in the VA system, prevention has a positive return-on-investment and is consistent with the business model. On the other hand, the overwhelming majority of payment in this country (outside of the VA) is fee-for-service (FFS). You get paid for what you do rather than what you prevent, which makes it financially more difficult to invest in proactive, personalized, preventive care. As he puts it, the VA is not ‘conflicted’ or ‘confused’ by a FFS payment model in which contextual factors of care have little to no return on investment.  For those of you who listen to this podcast regularly, this is a recurrent theme.   

Fourth – Despite the challenges and conflicting incentives of our FFS-based healthcare system, I was very encouraged to hear that others across the country are also developing a ‘whole health’ or ‘whole person’ approach.  Dr. Kligler shares that the National Academy of Medicine (NAM) is planning to publish a report some time next year, providing an inventory and summary of the whole health movement. 

On a final note – I’m writing this on a hot and humid afternoon of July 4, 2022.  I share this with you because Independence Day reminds all of us of the soldiers and veterans who established our independence and continue to defend it. The fact that the Veterans Administration is spearheading the ‘whole health’ approach – rehumanizing healthcare for our veterans – is particularly poignant and special on this day. 

Another connection of Whole Health with this day has to do with the concept of liberty. “We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.”  

We cherish our liberties in this country because they enable us to express ourselves, to pursue our dreams and goals, to achieve and manifest what matters most to us, to be the best we can be, and to live the best life we can. 

I view Whole Health as a public health movement that is based on the principle of liberty – enabling and empowering us to attain what matters most to us. I salute Dr. Ben Kligler and his colleagues, and the brilliantly humanistic leadership of the Veterans Administration for creating and supporting the whole health revolution.

 

Wishing you Whole Health
Until Next Time, Be Well

Zeev Neuwirth, MD