Foundational Values for Whole Person Health 

Abstract 

The success of care models that address each person’s holistic health and wellness needs lies in managing tensions between promoting quality care through standardization (such as following treatment protocols) and customizing services that meet individual needs (such as offering culturally appropriate services in different languages). This brief identifies beliefs and common practices in health care culture that the authors suggest have hindered the spread of these models, as well as opportunities for the policymakers and influencers, payers, and clinicians to support whole-person health. 

Introduction 

Health and well-being derive from attention to issues that are broader than managing specific chronic or acute illnesses and include dimensions such as disease prevention, supporting the furthering of life goals, and addressing non-clinical (social) drivers of health such as employment, housing, and social connection.  Since these concepts of “whole-person health” began gaining attention over a decade ago, some exemplary care models such as one sponsored by the Veterans’ Administration started putting these concepts into practice.¹ Their success lies in managing long-standing tensions between promoting quality care through standardization (such as following treatment protocols) and customizing services that meet individual needs (such as offering culturally appropriate services in different languages). But adoption of these models has not scaled, despite new technologies such as telehealth and artificial intelligence tools that theoretically make it easier to tailor services to individual patients’ circumstances.  

We posit that certain beliefs and common practices are so deeply seated and revered in health care culture that they pose inadvertent and invisible barriers to scaling these models. Beliefs such as the primacy of expert knowledge in clinical decision-making have merit; they exist for a reason. But unless explicitly acknowledged and balanced with new beliefs and practices – such as giving equal weight to a patient’s lived experience and personal priorities in decision-making – the health care system will not achieve broad systemic changes to achieve whole-person health.  

Health Care Beliefs and Common Practices in Need of Balance 

Professional expertise. While leveraging professional expertise is essential for integrating copious medical information, it can lead to suboptimal or even harmful decisions if not balanced by honoring patients’ expertise. Patients often have the best insights about what they need and would work best for them. These insights may be intuitive rather than clearly articulated, but incorporating patient wisdom into the design of everything from clinic intake forms to practice workflows and personalized care plans improves the likelihood of “fit to purpose” solutions. At a macro level, health systems, health plans, and government agencies should also routinely partner with patients in designing policies and programs.  

Practice guidelines. The health care system’s reliance on practice guidelines in care delivery and accountability mechanisms has proved useful for ensuring evidence-based decision making in specific situations but may impede consideration of human diversity and the meaningfulness of clinical decisions as perceived by patients. An approach that more accurately reflects clinical and personal complexities could change how high-quality care and standards of practice are defined. Payers could promote wider use of patient-reported outcome measures and/or measures that focus on attainment of a patient’s clinical or non-clinical goals, as well as de-emphasize disease-specific guideline-based measures anchored in general probability estimates. 

Quality of Life Assumptions. Health care professionals’ tendency to project assumptions about a person’s quality of life can be useful in allocating resources such as organ transplants but can discourage consideration of the sanctity of human experience as perceived by individuals. For example, in the early months of the COVID-19 pandemic, many hospitals de-prioritized allocation of ventilators and critical care beds to people with intellectual disabilities on the assumption that they had lower quality of life than others,² contributing to intellectual disability becoming the strongest predictor of COVID-19 mortality other than age.³ If clinicians and health care administrators routinely try to understand and value on how people experience a meaningful life in their unique circumstances, that could change how they allocate resources and train clinicians. This understanding could be fostered among clinician trainees by providing positive exposure to the rich, daily lives of people with intellectual and/or developmental disabilities (IDD). Likewise, developing clinicians’ skills to discuss serious and terminal illness can improve outcomes and facilitate more meaningful connections with patients.⁴ 

Medical Model of Health. Reliance on a medical model of health clarifies what lack of disease looks like as a normative standard but sometimes sacrifices respect for a person’s health goals and how they want to reach their full potential. Medical care drives less than 20% of variation in health outcomes and may not be their priority.⁵  Greater emphasis on biopsychosocial models of health  that look beyond pathophysiology to include environmental, relationship, and vocational factors in health assessment, for example in clinical training, could change how clinicians take patients’ life goals into account.  

Assumptions about Patient Capacity to Manage Their Care. As experts, clinicians may make assumptions about a patient’s capacity to manage their own care, often based on brief interactions. When this results in withholding detailed information about therapeutic options, clinicians reduce patients’ agency. Examples abound of patients’ ability to absorb complex concepts and make difficult decisions when they receive medical information in plain language and have their questions answered. Healthcare leaders can design medical devices and written materials in an inclusive way, for example by using icons and language at the fifth-grade reading level. Generative artificial intelligence makes it possible to produce such materials much more efficiently and adaptively than in the past. 

Standardized Workflows. Reliance on standardized workflows in clinical settings gives staff predictable processes but can dehumanize patients if not balanced with flexibility to respond to individual needs. This could mean greater emphasis on training teams to handle unusual situations, such as accommodating patients who require longer visits or less sensory stimulation. Making such shifts requires changes in payer payment policies to support time-based billing that could vary across visits rather than on static measures of patient need and complexity.⁶  

For decades, payment levels have been primarily based on input costs of a given service (whether accurately estimated or not). This was the foundational assumption of Medicare’s Resource Based Relative Value Scale that led to the Medicare Physician Fee Schedule and its derivatives in Medicaid and commercial insurance. This provider-centric approach attempts to remain agnostic with respect to the clinical or policy value of a service but inadvertently signals to the marketplace little incentive to favor services that improve health. Indeed, resource-based pricing methods have become unreliable in themselves, as distortions in cost estimates have led to gross overpricing of many procedures and under-pricing of many cognitive services. But fundamentally, resource-based pricing needs to be balanced with consideration of the health contribution of different services. Policymakers have taken some steps in this direction, for example, with Medicare’s Quality Payment Program which adjusts service fees based on a provider’s performance on quality measures or in alternative payment models, but the health system needs to place much greater weight on health impact to counter the financial allure of input-based prices. 

Serving Typical Patients. Lastly, most health care structures and processes are designed to serve typical patients. Doing so helps simplify workflows for providers. But the efficiency of this approach is illusionary when managing long-term chronic conditions because it sacrifices attention to tailoring care and building inclusive processes that serve everyone, including people at tail ends of the bell curve with multiple chronic conditions. For these patients, long-term care planning is needed to reduce the need for multiple short-term visits and care coordination.  

Health Care’s Evolution 

US health care needs to modernize its standardized evidence and transaction-based approaches. With personalized medicine, generative AI, and commitment to inclusive engineering and design, health care is well-positioned to strike a sustainable balance between standardization and personalization. We can build the health care equivalent of ramped curbs, which increase opportunities for all pedestrians without removing choice, and leave fewer people behind. 

Health care’s evolution toward a system that produces whole person health will require concerted policy leadership to explicitly codify and promote the integration of new values and practices. Most critically, policymakers need to set clear expectations for payers and providers to center on the priorities of individual patients. Government agencies, accreditors, and professional associations could set standards for meaningful patient engagement in decision-making, both within their own organizations⁷ and in the organizations that they represent and/or govern. 

Policymakers should ensure that results of research truly reflecting patient priorities are systematically incorporated into practice rather than leaving their adoption to chance. For example, the Patient Centered Outcomes Research Institute (PCORI) has generated volumes of important research and patient engagement findings that need to be systematically integrated into the healthcare ecosystem. The Food and Drug Administration could apply PCORI findings in drug and device approvals and labeling, and health plans could incorporate these innovations into provider contracts. PCORI could also better elevate community perspectives in setting research priorities, so their influence matches that of researchers. This would increase rigor and community relevance in research.  

As adoption of more balanced values and patient-centric practices spreads, payers can partner with stakeholders to define criteria for centers of excellence in whole-person care and reward them financially or through means such as steering more patients to them. Payers should gradually shift payment policies and pricing to reward outcomes (including patient-defined goals) rather than just service delivery. Reauthorization of the Quality Payment Program presents an opportunity for Congress to consider broader reforms to Medicare’s fee schedules and quality accountability approaches.  

Such shifts in values and common practices will only be sustainable if supported by a broad regulatory and financing framework (such as tax incentives for investors, payers, providers, and local governments) to steer investments toward the infrastructure, services, and talent necessary to reorient our system toward producing health.⁸ The National Academy of Medicine outlined priority areas for investment. For example, amplifying funding for and the roles of community-based organizations and non-traditional service providers such as child life professionals or peer counselors could rebalance public and private spending away from disease-focused services to those that promote health. Similarly, engaging a community-governed, multi-stakeholder coalition that engages people with the greatest health risks in key decisions about allocating health resources can drive focused change in places that experience the worst health status. And creating and requiring the routine use of “health impact assessments,” similar to environmental impact assessments, to ascertain the implications of policies or business activities on health would incentivize upfront considerations of a community’s whole health. Such leadership, combined with thoughtful applications of technology, could embed the values needed for a healthier nation. 

Endnotes