December 13, 2022
Missing the Boat: Why Do Organizations and Communities Persistently Fail at Well-Being and Health?
Creating a Better Future
- Why do organizations and communities continue experiencing poor outcomes?
- Is avoiding reality by hoping things will change on their own an effective strategy?
- Does persistent inferiority always need to self-perpetuate?
- Should a good strategy be ignored because it wasn’t ours?
- Is “It has always been this way,” a statement to accept?
Fortunately, organizations, and a small number of communities, break free of the wearisome, stressed present to embrace an energetic future. What makes the difference between success and failure for those that try?
Understanding the Possibilities — Expanding on the Social Determinants of Health (SDoH)
What is the most effective intervention that can help everyone, regardless of socioeconomic status, live a longer, happier, and healthier life? Improving the environment of communities to make the healthy choice the easy choice.
“Class — The Ignored Determinant of the Nation’s Health,” published in the New England Journal of Medicine in 2004, was an early but initially underappreciated recognition for the SDoH. The Community Well-Being Index (CWBI) has reported the factors comprising the SDoH starting in 2006 comprised of over 45 million individual surveys and 600+ publicly available metrics. CWBI admirably provides objective measures from state-wide down to the census-tract level, highlighting the strengths and weaknesses of any geographic area over time.  
If the SDoH were a patient with a problem, the first step would be to make a diagnosis — what is the disease? However, just making a diagnosis is inadequate. Addressing the etiology, providing effective therapy, and sharing a prognosis must follow. We know the treatment for many of the negative SDoH. Solutions are implementable, easy to share, and repeatedly effective. Eighty percent of all disease is avoidable but sadly our nation’s healthcare system has not embraced prevention due to four reasons explained below.
Getting to successful, long-term, cost-effective, and equitable “treatments” of negative SDoH is an excellent solution but so far has not been given a title. And that’s why we need a term for factors that improve health. “Social Multipliers of Health” recognizes both the causes and solutions that can change the course of health and wellness for individuals, organizations, communities, and entire states.
Resistance From Companies and States
“Win-win solutions that improve both societal benefits and profits are easy to adopt, but most companies stop short when they confront trade-offs that require sacrificing profit for improved social or environmental performance. Such trade-offs, however, often can be avoided by collaborating with other stakeholders. In fact, many levers that affect a company’s impact intensity of profit are controlled by only a few external stakeholders,” explains the essential link between environmental, sustainable, and governance (ESG) targets and financial performance in a 2022 September-October HBR article. “Positive outcomes become compatible with profits, and baseline measures, strategies, and investments are developed jointly,” continues the HBR explanation. 
Unfortunately, many companies in most industries regularly miss an opportunity to become thought and market leaders with prevention, well-being and health in their communities therefore sacrificing an opportunity for better recruitment, retention, engagement and satisfaction. This failure is particularly noxious in previously successful medium-sized communities/cities across the Midwest, the former industrial heart of the nation.
Evolving from the economic engine of our homeland to the rust belt was an undeniable tragedy perpetrated by corporations. Current corporations now have the opportunity to take strong first step to address the negative SDoH factors by implementing Healthy Multipliers. Reversing poor health and deteriorating well-being would be an excellent first step to change the tide. Additionally, healthier employees and communities contribute to everyone’s prosperity. The ROI on well-being and health has been documented repeatedly. 
Similarly, the bottom decile states, Alabama, Kentucky, West Virginia, Arkansas, Mississippi, have many positive attributes but are not the most highly motivated to improve. The good news is that the upside potential in those states is much greater than in the top decile states. However, the top states — Massachusetts, Hawaii (a Blue Zones Project state since 2015), New Jersey, Maryland, and New York — are embracing new programs to further enhance well-being and health. Ironically, the best states are motivated to improve and the most challenged remain discouraged martyrs, despite the opportunity for a greater impact.
Leadership Matters & Notable Successes Are Inspirational
A few “heads-up” cities have objectively changed for the better. In 2014, the CWBI ranked Fort Worth, Texas 185 of 190 for large metropolitan areas. With a planned program organized and supported by the largest healthcare system in the region (Texas Health Resources) along with the Chamber of Commerce, Mayor, and large medically self-insured employers, the region’s ranking improved to tie for 31st place in 2018.  
Southwest Florida’s 400,000 folks from across the socioeconomic spectrum added 0.6 years of life expectancy from 2015 to 2020 while the rest of the nation’s life expectancy dropped. During the same time, the region’s rate of heart disease deaths also dropped to the lowest in Florida. Commerce thrived and the population grew. Perhaps these improvements would have occurred without involving almost half of the population in a voluntary program. The following nine basic principles are common in five areas around the world where more people live to 100. These characteristics are: moving naturally (walking), having purpose, downshifting, eating until only 80% full, sticking to a plant-slant diet, enjoying friends at five, “positive pack” meaning being with optimistic folks, embracing loved ones first (family), and participation in a faith-based organization.  
Monterey, California’s two major healthcare systems addressed well-being and health together overcoming the usual market-share competition since they shared a Medicare Advantage plan. Having healthier enrollees is not only altruistic but also improves the bottom line — healthy people consume less healthcare. 
Over seventy-five communities and 5,000 organizations have enjoyed similar benefits. One element common to all of them is leadership. Every community has some folks who promote healthy lifestyles. For success with company or community programs, leaders are needed who not only envision a better life for everyone but also have the political savvy to mobilize organizations and/or their community.
Four Etiologies Explaining the Failure to Progress
If society knows the consequences of negative SDoH and understands how to address them, why don’t they? Communities don’t lack altruism, competence or concern, but lack focus on the biggest issues. Our current mindset can make imagining a better future difficult. The answer is complex but includes a need to focus on the most obvious and overwhelming problems. The way people see things now can make imagining a different future difficult. “It has always been this way,” or “We are just too busy caring for our current stressors to take on anything else right now,” are two understandable human reactions.
1. Profit Margin Squeeze
Typically, at the top of most concerns are inadequate financial resources to fund the programs that create healthy multipliers and healthy environments. Demand for medical treatment shrinks dramatically hence exacerbating already profit margin squeezed physician/non-physician caregivers and healthcare systems. Device manufactures such as hip and knee replacement companies have never done better with an aging population, but if folks stayed healthy and didn’t become overweight then their musculoskeletal systems could age well. Big pharma already spends more on marketing than research with about 68% of the funds directed to influencing physicians. Healthcare insurers takes a percent of the premium and therefore benefits from increased utilization that subsequently increases year-over-year premiums. Obviously, the same percent of a larger number is larger, consequently profiting the insurers.  
COVID, although terrible in all respects, did highlight the frailty of a system dependent on volume. Physicians, hospitals, device manufacturers, and big pharma all suffered economically from decreased demand for elective care. COVID patients did utilize resources and the CARES Act provided generous support for the acute phase. The insurers during COVID, on the other hand, profited mightily by decreased demand for elective care. 
What happens to physician/non-physician caregivers, healthcare systems, pharmaceutical industry, device manufacturers, and the healthcare insurance industry when people stay well all but the last few months of their lives? A large portion of the industry will shrink, profits will drop, and jobs will disappear. What motivation does the industry have to change and what will happen to their funding?
2. Tyranny of the Present
Being overwhelmed by urgent important and unimportant stresses is significant. Just keeping up to date on diagnostic and therapeutic options for physicians requires life-long studiousness. Updating Board Certification has evolved over the past few years but is still labor intensive. However slightly more than half of all physicians are now employed by either healthcare systems or each other, removing some of the hassle of running an office. 
Obsessively, healthcare systems focus on market share and payer mix in addition to demonstrating quality and improving patient satisfaction. Funds spent on billboards, sponsoring sports events, and traditional marketing would be better directed to a prevention campaign. A brand image focused on well-being and health would not only help everyone but also improve colleague and communities’ opinion of an organization.
In the aftermath of the pandemic, labor shortages and burnout top the previous workforce stresses, subsequently making any new initiative requiring people resources taxing in the short-term. Logically, health system leaders should recognize that employee programs would delivery long-term ROI, strengthen the community or the organization. Healthy communities and organizations thrive with more productive and engaged citizens and colleagues, respectively. Additionally, organizations with healthy workforces see improved retention and recruitment.
3. Learned Helplessness
A sad characteristic common to the most resource-challenged communities is ingrained, persistent pessimism. The Oxford dictionary definition of learned helplessness is “a condition in which a person suffers from a sense of powerlessness, arising from a traumatic event or persistent failure to succeed. It is thought to be one of the underlying causes of depression.” Governments, economists and population health researchers have studied regions suffering from multigenerational deprivation, but few well-meaning outsiders can drive change. Just admiring a problem adds to individual, organizational and community frustration, ultimately exacerbating and reinforcing learned helplessness.
For some inner-city or rural regions, the daunting task of raising the entire community’s social determinants of health remains overwhelming and daunting consequently prohibiting even starting. Notable individuals have broken away from multigenerational poverty and embraced the American dream. Most, less fortunate, get drawn into a vortex that remains self-renewing.
4. NIH Syndrome
“Not Invented Here,” comes into play with well-resourced competent entities who want to reinvent the wheel themselves. Typically, large multi-hospital systems extending over large geographic areas have altruistic, competent colleagues who address various aspects of the SDoH for resource-challenged regions. Noble and well-intentioned work to improve housing, food insecurity, violence, addiction and mental health can succeed, but often misses the overarching purpose. Proven, effective strategies to encourage natural movement, work/life integration, social isolation can turn negative SDoH into Healthy Multipliers for not only resource-challenged communities but also resource-rich communities. Having an integrated approach with defined expectations in the beginning removes the frustration of initial lack of progress.
Also, at the start a program must have well-defined baseline metrics so participants and supporters can see progress, but program leaders often overlook establishing those metrics. “If you don’t know where you are going, any road will take you there, but you will never know when you have arrived,” (often wrongly attributed to the Cheshire cat in Alice’s Adventures in Wonderland) comes to mind. Metrics are essential because objective progress fuels future support. Starting processes make organizers feel good about their efforts but objective outcomes reinforce long-term success. Lowering BMIs for individuals, adding years of healthy life expectancy for entire communities are a few examples of outcomes.
A rising tide should lift all boats, which ultimately will help to erase inequality among communities. The resource-rich folks will have more to share with the challenged areas who are also presumably past the tragic learned-helplessness phase.
Forming a coalition is an excellent first step. Teams protect against everyone quitting at the same time. It’s essential to find motivated people who have the political savvy to obtain resources. Typically, one leader emerges who not only understands the value of prevention but also can obtain the resources to start a project.
Early on, excessively optimistic followers typically want to increase the scope of the project, but scope creep can delay or prevent positive outcomes. To avoid overcommitment with its related disappointment, programs should stick to a defined strategy. The adoption curve won’t be linear but once started a flywheel effect will accelerate transformation. Results can take from months to a year to obtain meaningful and measurable results depending on the size of the organization or community. Regular, positive feedback of small and large success encourages expansion.
Presently, many well-motivated folks, organizations and regions are stuck just recognizing challenging SDoH. Identifying and following organized proven strategy will break the ice, overcoming the initial anxiety of trying something new. Many times, well-motivated people are content with processes without metrics. “Activity traps” are everywhere but true outcomes are measured progress.
Don’t miss the boat: Migrating from awareness to embracing prevention comprehensively, using proven effective services will deliver positive results.
- “Class — The Ignored Determinant of the Nation’s Health,” by Stephen Isaacs and Steven Schroeder, NEJM, September 2004.
- “Community Well-Being Index” by Sharecare.
- “The Essential Link Between ESG Targets & Financial Performance,” by Mark Kramer and Marc Pfitzer, HBR September-October 2022.
- “Employee Well-Being: A New Perspective On ROI,” by Jim Purcell, Forbes, February 2020.
- “How is Fort Worth, TX Getting Healthier While the Rest of the County if Getting Sicker?” by Naomi Imatome-Yun, Blue Zones Project.
- “Blue Zones Project Fort Worth,” Texas Health Resources, 2022.
- “Collier County’s Blue Zones Project Sees Rate of Heart Disease Deaths Drop,” by Amy Keller, Florida Trend, January 2020.
- “Accelerating Prevention In Healthcare With Co-Opetition,” by Allen Weiss, Becker’s, February 2020.
- “Churchgoers Live Longer,” by Robert Britt, Live Science, April, 2006.
- “Top 10 Pharma Companies Spent More on Sales, Marketing Than R&D in 2020,” by Maia Anderson, Becker’s, October,2021.
- “Big Pharma Shells Out $20B Each Year to Schmooze Docs, $6B on Drug Ads,” by Beth Mole, ARS Technica, January 2019.
- “Health Insurer Financial Performance in 2020,” by Daniel McDermott, Lina Stolyar, Elizabeth Hinton, Giorlando Ramirez, Cynthia Cox, Jeannie Fuglesten Biniek, Tricia Neuman, and Robin Rudowitz, Kaiser Family Foundation, May 2021.
- “AMA analysis shows most physicians work outside of private practice,” by Robert Mills, AMA Press, May 2021.
- “Decreasing the Cost of Care by Preventing Illness,” by Allen Weiss, NEJM, February 2018.
Read more by Dr. Allen Weiss
Read more by Allen Weiss