A new way to tackle chronic diseases: Using whole-person care models in the GCC

GCC health providers can use customized whole-person care models (WPCMs) to care for subpopulations that are at disproportionate risk of, or suffering from, non-communicable diseases. WPCMs have five elements: a care coordinator, a multidisciplinary healthcare team, care collaborators, informatics, and incentive structures. Providers also need foundational capabilities, with digitization as a core aspect of these capabilities.

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A new way to tackle chronic diseases Using whole-person care models in the GCC

Strategy& is part of the PwC network


About the authors

Beirut Gabriel Chahine Partner +961-1-985-655 gabriel.chahine @strategyand.pwc.com Walid Tohme Partner +961-1-985-655 walid.tohme @strategyand.pwc.com Chicago Mike Connolly Senior Partner +1-312-346-1900 mike.connolly @strategyand.pwc.com Akshay Jindal Principal +1-312-346-1900 akshay.jindal @strategyand.pwc.com Dubai Dr. Nikhil Idnani Principal +971-4-390-0260 nikhil.idnani @strategyand.pwc.com

New York Gil Irwin Senior Partner +1-212-697-1900 gil.irwin @strategyand.pwc.com Joyjit Saha Choudhury Partner +1-212-697-1900 joyjit.sahachoudhury @strategyand.pwc.com Sundar Subramanian Partner +1-212-697-1900 sundar.subramanian @strategyand.pwc.com San Francisco Thom Bales Partner +1-415-421-1900 thom.bales @strategyand.pwc.com

Gabriel Chahine is a partner with Strategy& in Beirut. He leads the firm’s consumer and retail and health practices in the Middle East. He specializes in strategybased transformations, strategic planning, and marketing. Dr. Nikhil Idnani is a principal with Strategy& in Dubai. He specializes in strategic planning, operating model design, and performance management for healthcare providers and regulators.

This report is based on “Healthcare for Complex Populations: The Power of Whole-Person Care Models,” by Joyjit Saha Choudhury, Sundar Subramanian, Samir D’Sa, and Gayatri Rajamani, Strategy& 2013. Jad Bitar also contributed to this report.



Executive summary

The delivery of healthcare is changing significantly because of medical and technological advances. Healthcare policymakers who understand these changes, and alter their organizations and funding models accordingly, can provide better quality of care and improved health outcomes. These changes are particularly important for healthcare systems in the Gulf Cooperation Council (GCC).1 Health providers in the GCC have to care for subpopulations that are at disproportionate risk of, or suffering from, non-communicable diseases (NCDs). These diseases lead to increased healthcare spending and less economic activity. The most significant change is the shift from focusing on curative care to preventative care — from treating sickness to promoting “wellness.” This involves a stress on continual management of a person’s health, including incidents of sickness. One such continual care approach is whole-person care. This model contains five elements: first, a care coordinator, who oversees the patient’s care; second, a multidisciplinary healthcare team including medical, behavioral, and long-term-care experts; third, care collaborators, such as government agencies, charities, and the patient’s family and friends; fourth, informatics, such as digital tools for more effective patient monitoring and engagement; and fifth, the correct incentive structures that reward all team members for improved health outcomes. Healthcare providers will need to customize the whole-person care model to different segments of the population, as each has markedly distinct needs. To succeed with whole-person care models (WPCMs), GCC providers must develop a set of foundational capabilities that apply to all WPCMs, with tailored capabilities for those at risk of NCDs. Digitization is a core aspect of these capabilities because it enables a more coordinated, real-time, and holistic approach to healthcare while optimizing the amount of contact between the healthcare system and the patient. The national screening programs that currently exist in the GCC countries could serve as stepping stones toward such whole-person care models.



From intervention to continual care
The delivery of healthcare is undergoing significant changes thanks to advances in medicine and technology. These changes have important implications for patient care, as well as for how healthcare systems are organized and funded. Healthcare policymakers who grasp the nature of these changes, and are able to tailor their organizations and funding models accordingly, will be able to provide better quality of care with improved health outcomes. This is particularly relevant for health providers in the GCC dealing with subpopulations at risk of, or affected by, NCDs. These illnesses, also known as chronic diseases, are now the leading cause of death in the GCC. NCDs have a substantial impact on healthcare spending and economic activity. Patients with these diseases typically consume a large volume of healthcare services. The result for the country is higher healthcare costs and less economic activity.2 The most significant change is that healthcare is moving from focusing on curative care to preventative care, from treating sickness to promoting wellness. In the past, the healthcare system dealt with individual instances of sickness. There was an assumption that patients did not require monitoring in between illnesses — a person who was well did not need to see a physician. That approach is increasingly being abandoned in favor of a stress on the continual management of a person’s health, including incidents of sickness. Two factors are driving this shift, a changed understanding of how diseases progress and cost pressures. Advances in medical science have enhanced our understanding of how diseases progress and the risk factors behind them. This is particularly important for NCDs whose incidence globally is rising, including in the GCC. Linked to the wellness approach are the cost pressures on healthcare systems. Treating sickness tends to be expensive as it requires more frequent and complicated secondary inpatient care. By contrast, managing patients’



health involves the consumption of primary and outpatient care, which is cheaper. Health outcomes are likely to be better if the healthcare system identifies disease risk factors and manages them, rather than paying attention only when the disease becomes full-blown. There is tension in a healthcare system designed for sickness but seeking to deliver wellness. Healthcare systems were typically designed and built with the sickness model in mind. Healthcare delivery in this setup revolves around large hospitals that are expensive to build, equip, and run and that provide secondary, tertiary, and sometimes quaternary care. Primary-care facilities, that are smaller, less expensive, but also less visible to constituents, receive less attention and investment. This applies also in the GCC where governments are correctly seeking to improve health outcomes and develop the local healthcare sector. Such a mind-set leads to considerable impetus behind hospital building programs that will provide much-needed employment and economic impact through the whole cycle of laying out infrastructure, construction, and operation. By contrast, it is institutionally more difficult to approve training programs that may have great value in terms of improving the quality of care. This tension is exacerbated by the manner in which even the best designed healthcare systems can be fragmented, to the detriment of patient care. In the GCC, there are multiple types of fragmentation; for example public versus private providers, tiers of service (primary, secondary, tertiary, etc.), and competing medical institutions in the same city that barely coordinate despite serving the same population. Fragmentation also leads to patchy coverage, with care provision gaps in some areas and redundant, overprovision of services in others. Administrative fragmentation means that there is no single patient record. This leads to costly errors, such as prescriptions for medicines that interact badly with other medications a patient is taking, or unnecessary duplication of tests. Moreover, in many countries, healthcare systems, such as physical and behavioral, operate separately; providers from different systems rarely talk with one another. Thus, for example, a doctor may not be aware that a patient with severe diabetes has depression and therefore lacks the will to follow the daily exercise regimen or blood-sugar monitoring the doctor has suggested. Finally, the incentives in the system are not always aligned — for example, a nursing home may not have the financial incentive to prevent the deterioration of a patient’s health in order to avoid hospitalization.



The whole-person care model

Our view is that integrating the healthcare system to adequately meet these patients’ needs and ensuring the sustainability of that system should not be mutually exclusive goals for providers, whether public or private. To consolidate these goals, however, they must apply what we call next-generation whole-person care models (WPCMs), meaning a coordinated approach that addresses medical, behavioral, and other needs of complex populations, tailored to specific subpopulations within the patient universe. Complex populations have healthcare needs that require a variety of different forms of care, such as physical, behavioral, long-term assistance, and social support. The concept for WPCMs derives from a recent Strategy& research effort in the U.S. (see “About our research,” page 17). We observed that by deploying these models effectively, U.S. health plans can reduce costs while boosting quality of care and patient satisfaction. Similar results can be achieved in the GCC in terms of effectiveness of treating NCDs and restraining cost growth. Our analysis shows that successful WPCMs must comprise five building blocks if health providers are to deliver the best care and do so profitably and efficiently (see Exhibit 1, page 7). Optimizing the model requires integrating all five blocks. To be sure, in the U.S. we can see some portions of this model are being applied in small pockets today, but the concept needs to be scaled up broadly in a sustainable and cost-effective way. In the GCC, we have yet to see such a model emerge, although it holds promise in terms of treating NCDs and the broader reshaping of the healthcare system.



Exhibit 1 A whole-person care model for complex populations includes five elements

2. Multidisciplinary healthcare team - Approach patient care as a team - Seamless handoffs among care providers Physical health: - Primary care - Dietitians & fitness - Pharmacy - Specialists - Hospital - Lab Behavioral health: - Education system (for children and their parents) - Employers (for adults) Long-term care: - Long-term-care facility (hospice, nursing home)

3. Care collaborators - Nonmedical entities - Personal care needs Community groups Family State agencies Accessibility remodelers Translator/interpreter Home aides Transportation Furniture movers Educators Care givers HR staff in companies (corporate wellness programs)

1. Care coordinator 4. Informatics Health risk assessment tool Remote patient monitoring, emergency signaling Stratification and predictive modeling Workflow and notifications Accessible patient information systems Mass screening programs to identify those suffering from NCDs and those at risk Deals directly with the patient Strong primary-care physician involvement Develops personalized care plans Integrates multidisciplinary teams 5. Incentive structures - Single accountable entity - Organization level: preventive health, behavioral health, and long-term-care providers - Individual level: care coordinators, care team

Source: Strategy&



1. Care coordinator This individual is the central figure in the WPCM who can coordinate information and action among the healthcare providers working with the patients and individuals at high risk of contracting NCDs. This person also works with informal caregivers such as family members, friends, neighbors, and local charities. The care coordinator may be an employee of the provider, a doctor or registered nurse from a healthcare provider organization, or an individual from another type of organization in a patient’s community — depending on the patient’s needs. Regardless of their organizational affiliation, care coordinators stay in regular touch with their patients. They perform a range of activities: remind the patient to take prescribed pills, contact family members or neighbors in emergencies, coordinate healthcare providers, help the patient find needed resources, and ensure that medications are reconciled. The best care coordinators are often from the same locality and share cultural similarities or even life experiences with their patients. For example, some pilot studies in the U.S. suggest that mental health patients have stronger bonds of trust with care managers from the behavioral health system.3 In the GCC, young people at risk of developing NCDs may respond better to caregivers with a background in nursing or social work. Such caregivers have a good understanding of how to communicate the need for healthier behaviors and better eating habits to young people. 2. Multidisciplinary healthcare team This team consists of the medical providers (including primary-care physicians and specialists such as ophthalmologists treating diabetics), those working on the behavioral changes required of patients with NCDs or at risk of contracting them (such as caregivers for young people), and long-term-care facility providers who work closely together to serve patients. Providers may deliver care in a wide range of settings in addition to hospitals, clinics, and nursing homes. For instance, visiting primary-care physicians (PCPs) may see patients at an adult day-care center in the local community, backed by on-site care coordinators who provide services such as blood pressure checks.

The best care coordinators are often from the same locality and share cultural similarities or even life experiences with their patients.



3. Care collaborators These are external entities: government agencies, community groups, patients’ families and friends, and social workers. Care collaborators could include educators and the human resources (HR) departments of employers, which have a built-in incentive to encourage a healthier lifestyle among employees. The value of the informal caregiver network cannot be overemphasized, as collaborators perform a wide range of critical (and often nonmedical) tasks. Examples include volunteers who drive patients to doctors’ appointments and adult day-care centers; social workers who visit patients at home or in the hospital to help them learn about and gain access to government services; teachers who get children involved in physical activity and ensure healthy meals are available, especially for those liable to develop NCD risk factors such as obesity; or HR managers who ensure their employees follow up on the results of screening programs. 4. Informatics The savvy use of informatics enables all players in the system to gather, generate, and respond to data, such as real-time alerts of unfilled prescriptions. Informatics also support patient profiling and segmentation, such as identifying people at risk for NCDs through mass screening programs, or those who have difficulty gaining access to healthy nutrition. Innovations in remote monitoring, such as wireless blood-pressure monitors and scales that transmit real-time data to the care coordinator, streamline the monitoring of the patient’s condition. Electronically programmed pillboxes “beep” to remind the patient to take medications. Video and tele-health systems set up in patients’ homes reassure them that help is at hand and make them feel less isolated. In addition, analytics about emergency room visits for specific areas enable providers to set up primary-care interventions in the field that triage patients before they end up in the emergency room. Prudent use of informatics can significantly optimize the productivity of the care team and make interventions more cost-effective.



5. Incentive structures Designed by the health provider, the right incentives encourage effective behaviors on the part of care coordinators, care collaborators, and healthcare providers. Examples include performance bonuses for care teams that reduce the number of amputations, infections, and hospital admissions for people with diabetes; and referral fees for social workers who connect diabetics to treatment teams. Forward-thinking providers will design compensation for all involved — care coordinators, physicians, home health aides, adult day-care staff, tele-health professionals — based on the patient’s overall set of outcomes, both clinical and financial. This can be assessed by a combination of outcome metrics, such as the number of ER visits or hospital admissions, and process metrics, such as prescription refills and medication reconciliation within a few days of discharge.



Tailoring WPCMs to subpopulations
Segmentation of the population plays a key role in the application of WPCMs. Subpopulations within the overall population market have decidedly different needs, so providers need to tailor their WPCMs accordingly. For example, take a representative GCC population with four major subsegments: nationals, Arab expatriates, Western expatriates, and Asian expatriates. The subsegment that drives the most substantial part of the cost is nationals. They may account for a proportion of inpatient and outpatient visits that is more than two times their share of the overall population. This is a result of numerous factors. First, nationals are more likely to pay for healthcare and they have their families in close proximity so they are unlikely to go elsewhere for care. Second, the population of nationals spans the entire age range. The elderly and the very young consume more healthcare than young adults. Third, the prevalence of NCDs is higher among nationals. By contrast, expatriates tend to be young adults, the stage of life in which people consume the least healthcare. Western expatriates represent inpatient and outpatient visits equal to their share of the population. Arab expatriates are underrepresented when it comes to inpatient care. This is in part because they sometimes prefer to have inpatient visits in their home country as this is where their family members are located. Asian expatriates are similarly underrepresented, more so in terms of inpatient visits. Their large numbers mean that they are the second most significant group in terms of inpatient and outpatient visits. Their preference for outpatient care relates to the relatively simpler medical problems that they encounter, issues that are dealt with through outpatient care.



Very often, patients span multiple categories — which further complicates their healthcare needs and amplifies the care management needed. Consider patients with diabetes mellitus. This can be a lifethreatening condition if the patients fail to manage the disease properly. Preventable hospitalizations and emergencies stem primarily from not monitoring blood sugar levels. This can result from not eating frequently enough. Or the insulin pump may appear to be working, but is not injecting insulin because the blood vessel congealed when the diabetic changed the battery in the pump (the brief interruption in insulin flow can be sufficient time for the blood vessel to close up). To effectively serve diabetics, providers need to customize their WPCM to the unique challenges facing these patients. For example, care coordinators can check in with diabetics known to face issues with monitoring their own health. The coordinator can, for example, remind them of how to manage their condition while away from home and on long journeys. Using mobile technologies, which are widely adopted in the GCC, the coordinator can be in direct contact with patients when they are replacing pump batteries or doing new punctures, thereby ensuring that they double check their insulin flow. The care coordinator can also ensure that the patients’ workplaces, families, and others for whom they have given consent to receive the information, are engaged in overseeing aspects of the patients’ care.



Digitization: The key to integrating the building blocks
Providers stand the best possible chance of adequately and efficiently managing the care of complex populations if they take responsibility for putting the five building blocks in place and fostering their integration. Indeed, integration is critical for making the model work holistically and for addressing the lack of coordination currently characterizing many healthcare systems. Digitization can play a central role in achieving this integration. This is because digitization optimizes the high level of touch required to effectively and efficiently cover care for complex populations, which helps make the programs cost-effective to administer and adds a degree of real-time care coordination (see Exhibit 2, page 14). Consider a GCC school pupil, a hypothetical 17-year-old who is overweight. A mass-screening program identifies the student’s risk factors — including a history of heart disease in the family. The student’s geographic location provides information on what food is available in local shops, which for this student means a risk of poor nutrition. In addition, there is insufficient transportation, which means the family is apt to miss medical appointments. The pupil attends a school in which there are inadequate facilities for physical exercise. All of these elements flag the pupil as being at risk of developing type 2 diabetes in the medium term and heart disease over the long term. The pupil’s care coordinator calls the parents and the pupil to check on his general health and to make suggestions about how to increase physical exercise and improve nutritional intake. The coordinator alerts the family to new shopping opportunities and means of ordering deliveries of fresh fruit and vegetables to their door. During the call, remote monitoring allows the coordinator to detect any changes in blood pressure, an advance indicator of the onset of diabetes. The coordinator also checks on the pupil’s weight and height as a means of measuring the pupil’s Body Mass Index. Realizing that the pupil is experiencing higher blood pressure, the coordinator immediately sets up an appointment for the pupil with the PCP and books a taxi on the Web to take the pupil to the appointment. The PCP prescribes medication to lower the pupil’s blood pressure. The pupil’s father fills the prescription on his way home from work. The pupil’s pillbox has
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technology that scans medications and sends high-resolution images to the provider to ensure that the box has been filled correctly. The box also sends alerts to care team members if it remains filled with pills — suggesting that the pupil is not taking the medicine. The coordinator also calls the pupil’s school to talk to the teachers and other caregivers. The purpose is to encourage a gradual and sustainable increase in physical activity. In tandem with this effort, the coordinator encourages the pupil to use an exercise app that allows the pupil to win virtual badges and to compete with others in a game-like atmosphere (so-called gamification) and post the results to social media. The coordinator is able to keep an eye on the pupil’s progress by monitoring social media and maintaining contact with the school through email.

Exhibit 2 Digitization of the care model optimizes the “level of touch” in caring for complex populations

Hot-spotting Mapping city blocks to provide information on nearby food, exercise, and transportation locations GCC school pupil - 17 years old - Overweight - Family history of diabetes and heart disease

Wireless patient monitoring Glucose readings and vitals (blood pressure, weight, caloric intake, exercise, etc.) transmitted electronically

Personalized predictive analytics Risk stratification analytics that flag patients at risk for certain conditions

Electronic alerts Electronic alerts from care team on relevant services available nearby (e.g., home delivery of fresh produce)

Virtual follow-ups Skype sessions with care team and family

Appointment and logistics services Online booking of appointments and taxi services Prescription medication pillbox Pillboxes that chime or send high-resolution images to call centers for adherence checks

Proxy education and engagement Informational videos for diabetes management

Source: Strategy&



Building the right capabilities

To operationalize the new care model, providers must develop capabilities that are foundational across user segments, while ensuring that they can still tailor the model to the needs of specific patient groups (see Exhibit 3, page 16). Foundational capabilities include elements that support coordinated care, such as remote patient monitoring, tele-health solutions, and tools to support caregivers. Providers can also drive patient engagement through capabilities such as alerts when specific health conditions escalate, and they can improve patient outreach by coordinating with physicians through, for example, mobile diagnosis and treatment solutions. Informatics are critical as well; capabilities such as geo-demographic analytics will allow providers to assess populations, segment patients, more effectively predict diseases, and better manage cases. In addition to establishing these foundational capabilities, healthcare organizations should build on this infrastructure and improve capabilities that support specific user subsegments. For example, a care model focused on the segment affected by NCDs could emphasize areas such as wireless monitoring of patient conditions and assessing the effectiveness of providers like home care coordinators. It could also develop advanced analytics to track patient patterns such as calorie intake, blood pressure, and blood sugar readings, and specialized case management to care for chronic conditions and co-morbidities, among others. To implement these capabilities — and their supporting technologies — organizations need to adopt a structured approach. They should aim to achieve quick, early wins while ensuring progress toward the longterm vision. Specifically, organizations need to do the following: • define the right care model strategy across relevant stakeholders • identify supporting capabilities required to deliver the new care model • develop a business case and define a road map for implementation • develop target-state operating models, which includes defining the right organizational structure, supporting business processes, and technology architecture
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Exhibit 3 Sample foundational capabilities for WPCMs, with segment-specific specialized capabilities

Care collaborators Collaborators

Outreach and integrated-care coordination Patient Care coordinators Provider

Aligned incentives Patient
Healthy lifestyle rewards

Informatics Payor
Health risk assessment tools

Multichannel information access Mobile diagnosis and treatment tools for care providers Patient monitoring and connectivity tools (including tele-health) Care plan personalization Educational tools Motivational tools Caregiver decision support tool

Segment-Specific Specialized Capabilities (e.g., young and with NCD risk factors)
Wireless monitoring systems

Health dashboards School health programs

Provider and caregiver service outcomes and incentive tracking tools Member feedback tracking on provider/caregiver experience Predictive case management

E-prescription management Predictive disease and case management Geo-demographic analytics Customer stratification tools Electronic medical records

Foundational Capabilities

Real-time service personalization Auto alerts on patient escalations Admission and discharge management

Community programs outcome tracking

Benefits education Auto alerts on patient escalations Access to patient support groups Patient–collaborator social networks Integrated wellness platform Interlink with providers and payors Electronic medical records/integration Near real-time reporting Business rules management Business process automation Digital knowledge management Integrated patient health history and claims data Integrated provider network and care coordinator information Encrypted data access through secure tunnels Provider-toprovider connectivity

Replacement tracking for medical devices

Personalized predictive analytics

High-risk/specialty case management


All patients

Certain patient segments

Source: Strategy&



About our research
To develop our WPCM concept, we conducted a study from May 2012 through February 2013 in which we examined the total spend on patients who qualify for both Medicare and Medicaid programs in the U.S.4 We wanted to know how those dollars are distributed across the estimated 9 million persons in the U.S. who are currently eligible for both programs. We found that 20 percent of them account for almost two-thirds of the cost, whereas the healthiest 50 percent consume just 9 or 10 cents per dollar of total healthcare costs. Clearly, patients in the 20 percent represent the focus area with the greatest cost-cutting potential. These are the complex populations in which a well-deployed WPCM can help. We also evaluated care models currently in use at 23 healthcare plans and other organizations in the U.S. that bear the risk for patient care for complex populations, including those for specific groups such as the mentally ill and elderly. We identified the most successful models — those that generated results in the form of both lower costs and better outcomes — and assessed the innovative methods they deployed. We collected the innovations or best practices across these models and synthesized the key themes. Finally, we determined the drivers needed to deploy these care models in a sustainable, cost-effective manner.




In the past, the care for complex populations has been unmanaged and, in many cases, insufficient. However, public and private providers now have tremendous incentives to start coordinating care and managing these populations more effectively. In the U.S., many plans are already racing to develop such capabilities, and their efforts thus far will give them a head start — and raise the bar for all providers. Although each health system has unique features, these trends in dealing with complex subpopulations have important implications for other health providers grappling with similar problems. In particular, health providers in the GCC, with the encouragement of health authorities, should actively be investigating how to use and customize the WPCM to change the delivery of healthcare and to treat the rising incidence of NCDs.




The Gulf Cooperation Council consists of Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates.

“The $68 billion challenge: Quantifying and tackling the burden of chronic diseases in the GCC,” Strategy&, 2013.

Social Work Leadership Institute of The New York Academy of Medicine, “Who is qualified to coordinate care? Recommendations presented to the New York State Department of Health and the New York State Office for the Aging,” 2009 (http://www.nyam.org/social-work-leadership-institute/ docs/publications/Recommendations-on-the-Qualified-Care-CoordinatorFINAL-9-10-09.pdf).

Medicaid is a U.S. government program that provides healthcare to the needy through a means test. Around 54 million U.S. citizens are enrolled in the Medicaid program. Medicare is a U.S. government program that provides healthcare to retirees, the young disabled, and those with specific health conditions. Close to 50 million are enrolled in Medicare. Those eligible for Medicare or Medicaid can participate in both programs and can also have private insurance.



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This report was originally published by Booz & Company in 2013.

© 2013 PwC. All rights reserved. PwC refers to the PwC network and/or one or more of its member firms, each of which is a separate legal entity. Please see www.pwc.com/structure for further details. Disclaimer: This content is for general information purposes only, and should not be used as a substitute for consultation with professional advisors.