Episode 99 | Sep 26, 2024

Health Coaches vs. AI in Value-Based Care, With Dr. Angela Cudger

In the age of AI, who keeps the ‘care’ in healthcare? This week on Health Coach Talk, Dr. Sandi is joined by Dr. Angela Cudger, founder of the Legacy Holistic Health Institute, to discuss the growing impact of health coaching on healthcare, including how coaches can support patients dealing with social determinants of health (SDOH). Together, they explore the emerging role of AI in healthcare and how it might shape the future of coaching.

“I think that we can use AI, but I also feel we will almost always… need a human being to back that kind of tech, to make sure that it is where it needs to be and it is providing great care.”

Dr. Angela Cudger

Dr. Cudger’s path to health coaching began with her experience as a critical care provider in respiratory therapy and anesthesiology. Seeing the gaps in value-based care first-hand, she sought a solution that could offer long-term improvement for patients, which led her to the world of health coaching. She was inspired to launch her own health coaching practice and later developed a groundbreaking health coach training program at Legacy to address the specific needs of both patients and practitioners. Her work integrates holistic health and education, training over 30,000 health coaches and working toward getting health coaching recognized as a high-demand profession with pathways for insurance reimbursement.

In their conversation, Dr. Angela and Dr. Sandi dive into how value-based care prioritizes outcomes over services, ensuring patients experience real improvement in their health. They also explore how health coaches offer crucial support, guiding lifestyle changes that impact chronic disease management and overall well-being. From the challenge of breaking cultural norms to encouraging physical activity, Dr. Angela shares her own experiences and how health coaches are perfectly positioned to help people make sustainable changes. As AI develops in healthcare, Dr. Angela emphasizes the irreplaceable role of human touch in coaching, with empathy and connection being central to what health coaches offer. Coaches can help navigate the shifting landscape of AI tools, ensuring their role continues to complement technological advancements in patient care.

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Dr. Sandi: Are you familiar with the ways that health coaches can be really instrumental in pursuing the effectiveness of value-based care? Well, we get into this conversation in this podcast episode with Dr. Angela Cudger. We also talk about SDOH, which is social determinants of health, and specifically how coaching techniques can be so important for helping people with social determinants of health. In addition, we talk about AI. Is this the future of healthcare, the future of health coaching? This is an important conversation whether you’re already a health coach, thinking about becoming one, or you’re just curious about the field. Perhaps you are a provider and you’re thinking about hiring health coaches. Well, you will find this conversation extremely inspiring because I want to share her background. Dr. Angela Cudger is amazing. I know her a while back and she impressed me so much. We share the same values, the same commitment to growing the field of healthcare and specifically to growing the field of health coaching as key to effective healthcare.

So, let me tell you about Dr. Cudger. She is the founder and program director of the health coach training program at Legacy Holistic Health Institute. She earned a bachelor’s degree in cardiopulmonary care sciences from Georgia State University and a master’s degree in medical science with a specialization in anesthesiology from Emory University School of Medicine. Her academic background has equipped her with advanced knowledge in human anatomy, physiology, and chronic disease management.

With over 20 years of experience as a critical care provider, she’s also a graduate of the Institute for Integrative Nutrition health coach program, that’s IIN, and holds a second master’s degree in metaphysical sciences. She’s collaborated with large federal and corporate organizations to integrate health coaching into their technology and care models. Her contributions include the creation of a stipend program with the National Board of Medical Examiners and participation in a national initiative that has trained over 30,000 health coaches. Dr. Cudger is also the architect of the first 2,200-hour health coach apprenticeship program which places graduates in healthcare organizations. Currently, she is working closely with the U.S. Department of Labor to recognize health coaching as a high-demand profession and to advance insurance billing in this field.

So, I know you are going to enjoy listening to this episode of “Health Coach Talk” as much as I did recording it. I’m so excited, Dr. Cudger, to be with you. Can you start out by sharing your background and how you came to the field of health coaching?

Angela: Absolutely. Thank you so much for having me, Dr. Scheinbaum. I know it’s been a while since we’ve been able to get together, so I really appreciate this. As it relates to health coaching and my background, I actually am one of those people that came straight from clinical care. And so having a background both in respiratory therapy, clinical research, and then in anesthesiology, I learned a lot about what patients’ needs were and it’s been a long time that they’ve been crying out for value-based care. And so having that background and then having patients come to me wanting alternatives and then as a provider, I didn’t have those answers. And that’s what really led me down the rabbit hole of looking for health coaching.

Health coaching is where I landed, and I learned what health coaches could do, what made their skills absolutely necessary, and then I sought out to actually be one. And then I became a health coach in 2014 and then decided to have my own health coaching practice. And once that did really, really well, I learned that a lot of my colleagues weren’t seeing the same success, and I had to ask questions, “Why am I able to help clients and patients and they’re not?” And it was their knowledge base. And so I decided to start creating or to create a program that would help people really bridge the gap between what my patients were needing in the hospital setting and the skill of what health coaching could provide and make sure that in between there, there was more than enough space to create these healthcare teams of individuals that took care of patients. And that’s how I got into the field and that’s how I created Legacy.

Dr. Sandi: I love it. And we are so similar that we’re both committed to a collaborative care team approach and the effectiveness of that, particularly for value-based care. So, some people might not be familiar with the terminology. Can you explain what value-based care actually is?

Angela: Absolutely. So, one of the things that I always try to let people know is that, if you’re receiving any form of healthcare in the United States, since around the 1990s is when we started to shift from service-based care to value-based care. And what that essentially means is for someone who’s receiving a service from a practitioner, meaning a doctor or nurse, clinician, or someone that basically helps you in return, they receive pay for that service. Now that service may or may not add value to what that client or that patient needs, meaning it didn’t make a change in what I needed the care for. And so right around the late 1990s is when a lot of the health insurance companies and healthcare organizations started to notice that the services that they were rendering, in some cases the patients came back and they needed more care or they were in a state where more was actually needed.

And so we started to shift towards what we call value-based care. And essentially value-based care means that when you come to me as a practitioner or any practitioner in the field, I have to in some way add some kind of value to you, meaning that whatever it is, whatever element you come to me for, I have to move the needle towards making you better. That’s the easiest way I can put that. And so one of the things that started to happen in the late 1990s was a lot of the organizations, especially insurance companies, started to bill less for service-based care or they allowed less reimbursement for service-based care. And essentially they started to view this as, “I want to see these patients get better if these practitioners are going to continue to get paid for the services they provide.”

And so you’ll start to see a lot of the different organizations start to implement things like whole health or the services of health coaching because they know that they have the skills to move the needle towards the value that the patients deserve or towards making them better. And this is more than just their nutrition. This has a lot to do with chronic disease states, and it has a lot to do with diseases that are multi-system, meaning that it costs more to be treated for that specific thing. And so those practitioners must add value towards that care plan or towards that treatment in order to properly be reimbursed now. And so it’s a beautiful time for health coaches who are all value-based care. And I know we’ll get into this, but they are still some of the most underutilized healthcare professionals today that can add tremendous value to the care plan of patients.

Dr. Sandi: Amen. They are the key to value-based care because our present model, as you know, it’s not value-based for the patient. It may be value for the pharmaceutical company because our doctors have eight minutes, seven minutes with somebody. The only thing they could do is pull out their prescription pad and then the patient returns for another prescription for the side effects from the first prescription. And so other than the drugs and the surgical treatments, other procedures, they’re at a loss. How do you provide value? And that’s where the health coach comes in because as we know, value is lifestyle change first. So, can you talk about perhaps there’s three ways that a health coach on a collaborative care team can inform value-based care?

Angela: Absolutely. So, the first thing that they can do is inform and understand the behaviors that led the person to need their practitioner in the first place. A lot of people sometimes feel like health coaching is only for people who are ill, but it can also be very, very valuable for people who want to maintain and prevent illness. So, preventative care is also value-based or tremendous value-add from health coaches. So, they can inform care for the reasons why the person needs a practitioner in the first place. The second thing that they can do is start to be a part of the whole health of that person. That means that many health coaches have the ability to look at lifestyle changes from a multi-faceted point. That means more than what I eat, that means who I’m socializing with, my financial ability to be able to afford to live and be healthy. And it also has to do with my intellectual ability. And what I mean by that is most patients need more than just Google to get the knowledge that they need. And sometimes they’re informing their own care because they’re looking things up that are either obsolete or just not a part of what they need anyway. So, health coaches sometimes have the latest and greatest knowledge to be able to help these clients and these patients or inform their care. The last thing that they can do or the third thing that has to do with the ability to have reimbursement and to lower costs across the board when it comes to the overall care of that patient. And what that means is a health coach, their services are now reimbursable through insurance entities. This means their FSA, HSA, and many of the major carriers now cover some form of the scope of practice that has to deal with health coaching. So, if they’re a part of a care team, they’re able to lower costs across the board when it comes to assisting that patient. And so those are a few ways, there’s several, that they can be a part of a care team and bring costs down while extending value for that patient’s journey altogether.

Dr. Sandi: Well, these are wonderful points. And any health coaches who are listening, if you’re struggling to connect with doctors, you can use these talking points because they are compelling. Doctors are interested in value-based care. They want to serve their patients well. And you as a health coach can be key. And if you’re a doctor listening, also, listen up, get a health coach on your team for value-based care. Everybody will thrive.

Let’s turn to another subject that is also talked about frequently and often overlooked, and that’s social determinants of health. So, can you start by defining what that is? And then we can talk about how health coaches can be really instrumental, the coaching technique in helping people with social determinants of their health.

Angela: Absolutely. I love SDOH. SDOH, essentially, for those of you who are listening and you want to understand what social determinants of health are, social determinants of health have to do with the different things that lead to how we take care of ourselves. And that also includes not just the way we grow up socially and who we’re around. It has a lot to do with our environment. It also has quite a bit to do with sub-forms of cultural bias as well. But these are the different things that determine how we live, work, play, and how we essentially take care of ourselves.

I remember having a recent conversation with someone in kind of a… It’s more of a fitness and health group, health lifestyle group. And one of the things that two of the individuals in the group were, kind of, going back and forth on…well, one person was saying that specific cultural groups, Blacks, Latinas, different groups, she said, “Well, they don’t really like going to the gym because they don’t want to spend the money to go to the gym.” And I thought this is a perfect conversation to talk about SDOH. And the other person said, “Really? I didn’t think that’s the case because these individuals economically may have the resources, but they don’t grow up going to the gym. They don’t grow up walking for exercise. They don’t grow up around ways to swim or bike or run.” And so he said, “Well, I think this might be something that’s cultural, not economic.” And I thought to myself, both of those things are rungs on the ladder for social determinants of health. And I kind of jumped in the conversation and I said, “Well, the ability to work out and the choice to move your body regularly can absolutely be cultural.” And I said, “Then, it becomes economical because culturally people are used to spending their money on other things.”

And so when we think about social determinants of health, we’re looking at ways that these types like the values that could be added to a person’s healthy lifestyle, they make the choice based on what they know. And if they grow up in a specific kind of bias, then they may not be able to make that choice. I’ll give you another example of that. I grew up… And some people know about my story and how I grew up, but I’ve come a long way. We’ll say that. But I grew up in a two-bedroom apartment with about 12 people, right? So, my mom had 11 children. I’m number eight. And so I grew up in an environment where there were no sidewalks outside. There was no equipment for kids to play on. So, I did it. And there was no swimming pool and there was nowhere to ride a bike. So, I didn’t grow up swimming. I didn’t grow up riding a bike. I didn’t learn those things until I became an adult and decided to pursue an active lifestyle. My siblings don’t do that. It’s just not a regular thought for them. And so when we think about why a person may or may not be active or choose to engage in certain activities socially, they’re around environments that just don’t allow it. And this is essentially what we call social determinants of health. And I hope that makes sense. I hope that gave a good idea about how people grow up and how they’re a product of their environment, but then it takes tremendous work to overcome that, to become something other than what you were socialized to be.

Dr. Sandi: First of all, thank you for sharing your personal story. And, yes, that certainly ties into social determinants of health. And, yeah, my background, I was raised by my mother as an only child. My dad died when I was really small. And, yeah, we were quite poor, and an apartment building and it was go play in the alley. So, I never learned to ride a bike. I never learned to swim. I remember I was starting high school and I knew that they were going to have swimming lessons, so I was determined to teach myself to swim, at least a float. But quite sure I didn’t grow up in that atmosphere of tennis. Who knew from anything…? I had nothing like that, so I was not active and always saw myself as non-athletic and very poor in sports. And I wasn’t exposed to that other than in high school gym class, which I hated.

And also friends. So, somebody who graduated high school recently posted a photo, and this was class of ’67. I’m old. And it was striking that everybody in that picture, these were women who hang out together, and they were all white overweight and had the same body shape, very apple shape. So, there’s something about it. Dr. Mark Hyman talks about this a lot. And that is you look at who someone’s friends are, and it takes a lot of courage to go against the grain, against those social norms. When I teach psychology of eating, for example, people are out together and they don’t want to be embarrassed or odd man out to not be eating what everyone else is eating. It’s a lot of pressure socially.

Angela: Mm-hmm, yeah. And you feel like these societal norms police people into being the same. That’s one person becoming a vegan and everyone else is like, “Where’s the meat on your plate?”

Dr. Sandi: Yeah. Angela, how can we generate greater access to functional medicine and health coaching for minority and more marginalized populations, communities that don’t have access to these kinds of services?

Angela: Well, one way to do that is for those individuals who have already graduated in the space of health coaching to really make the effort to put yourself out there. I can’t say that enough. I feel like there are a lot of graduates that not disconnect but they can sometimes get, you know, imposter syndrome or they feel like they don’t have what they need to push forward and help minority populations. And they do, you know? I want them to know that if you know about food, if you know about behavioral change, it’s just a matter of hearing someone else’s story and lending your expertise to be able to help them. Just the health coaches who graduated alone in society, that’s enough to be able to say, “I am here and I’m willing to help a different kind of population.”

The other thing I think would be very beneficial is understanding or having what we to call cultural humility. And it’s just what you were saying, right? And understanding that culture is way more than race. Veterans have a culture. People who grew up you and I, we have a culture of how we grew up and the environments that we grew up in. And so I want those individuals that can assist these different types of cultures to step out and say, “Okay, I’m willing to be able to understand what these cultures need and niche to be able to help veterans, single moms, you know, people who grow up in environments where there is no way to be physically active, right? Being able to meet people where they are has a lot to do with the culture humility. And then it’ll seem a lot less imposter syndrome. It’s just a matter of showing compassion and being able to understand. And then the rest is just lending their expertise. That alone will give us the equitable access that we need for these populations that are just not being served.

The other group of people that I feel the need to speak about is the senior population. I get bombarded with phone calls from assisted care facilities, senior communities of 55 and over saying, “Where are our health coaches? Where are the people who are supposed to help us stay active? We want to be a part of this too.” And I think people shy away from these communities for many different reasons, not understanding that they have budgets for health and wellness, and they can pay for health coaching services. And so we want to make sure that those of us who have the knowledge are out there and we’re actually looking beyond what we know just about ourselves but looking at the communities to see, where’s the greatest need and how can I lend my expertise? And I think that will give us a lot more access or give these communities the access that they need to health and well-being.

Dr. Sandi: Well, I’m so glad that you brought up that population because that’s my era. And a few years back, we had a student who was remarkable. She was in her 80s. She was hard of hearing. She was in an assisted living community, and she enrolled in our coaching program. And she thrived, and this gave her meaning and purpose in her life. She went on to take a specialized program for cognitive decline, and her mission was to help people in her assisted living community. And she’s not an isolated example. I think there are so many people. I don’t know if you’ve seen this in your coaching program, but people come out of retirement because they’re not doing coaching now to have a career. Often they might be on a pension. They have retired from their career. They may have been school teachers, for example, or nurses. And now they just want to give back. They just want to serve. And it is so inspiring to teach these people because it’s just a great way for them to do something with their own lives and help others in the process.

Angela: Mm-hmm. Yeah, I agree. And I think that those individuals this young lady that you just spoke about, imagine how many decades they’ve been alive. They’ve seen so many changes from societal norms to the needs of different populations. They’ve been able to witness so much. And so it makes them an incredible source of knowledge when they’re able to add to that and help other people. It’s just amazing to see.

Dr. Sandi: Yeah, it’s the impact on individual lives but also the greater societal impact because this population is a heavy user of the medical system. And the more you can help people have a health span as opposed to just prolonging life at the end is for the greater good and is reducing healthcare costs. They may need less interventions. And there’s been so much research coming out about the effectiveness of health coaching. Even preoperative coaching can cut down on hospital stays, so many things that coaches can offer. Breathing techniques, relaxation, mindfulness. It’s, as you mentioned earlier, not just telling people about foods and what to eat or coaching them on that because they don’t tell people what to do. They don’t practice that kind of intervention, but they’re guiding people. They’re supporting them on so many areas of wellbeing.

Angela: Yeah, yeah. It’s exciting. Just in the few years that I’ve been a part of health coaching in and of itself, well, it’s been since 2014 so about a decade now. I didn’t really think about that until now, but it’s come a long way in a very short period of time. And we’ve got some incredible people in the field. Now we’ve got to make sure they can access the clients and the clients can get to them.

Dr. Sandi: Yes. Yeah. And I think value-based care, sort of, going back to where we started, is really key to that. But I don’t know if you’ve been following as well the growth of AI. And it seems like almost every day there’s an announcement, a press release, Apple, Samsung’s developing, Google’s got one. Now Thrive Global and OpenAI. Sam Altman. Oh, we’re going to have AI health coaches, and this is going to be the key. This is going to help people be healthier. And so what do you see as the future of health coaching? Is it going to be our bot as our coach or are we going to have a real human being like you and I are having this wonderful conversation?

Angela: Oh, no, this makes for a great conversation. I think that there are enough models out there that have tried the fast-paced, non-human-based approach. And I think that AI can help with a lot of things like pre-diagnosis, quickly triaging a patient or client to the type of care that they need, reducing mistakes that are costly to healthcare systems. There’s a lot of different ways AI can do that and inform care and then say, “Okay, this person qualifies for health coaching. Let’s route them to the right kind of coach.” I think AI can be greatly suited in that space. But as far as compassion, human emotions, and availability, I think that AI can fake it. But in that regard, I don’t think it’ll make it. Let me just say it like that. I think we still need human beings. We still need individuals who can sense, feel, touch, hear, understand, even in someone’s tone of voice, that there’s something that they’re not sharing. It’s something that they may not be as forthcoming with. It’s something that they may be apprehensive about proceeding with in terms of their health. It takes a human’s touch, I feel like, to be able to do those things. And those are used by health coaches.

And so while I feel like AI might have its place, I think that in some cases, at least for the first few decades, it might be limited. And so you will still need to subsidize that care with a human being. Now, what I think would also be amazing is AR, which is augmented reality, as well as virtual reality. And we’ve trialed some of these. We’ve trialed virtual reality at Legacy with the way that we train our health coaches. And people were able to retain so much more. And even though it’s a virtual program, they were able to feel significantly connected to the students and to the group. Now, what I love to see in terms of health coaching and augmented reality is someone being able to sit down at their kitchen table and their coach is there in the environment in an augmented fashion. And that would make them feel connected. That would make them feel the person is with them. And I don’t think AI is able to do that. I think it can inform how we do that but you’d still need a person that someone can establish rapport with and relate to and feel like they’re here with me and it’s real, at least to a certain degree, and feel like they’re getting the care that they deserve. So, I think that we can use AI, but I also feel we will almost always, and hopefully I won’t come back to bite myself on this one, but I feel like we might almost always need a human being to back that kind of tech, to make sure that it is where it needs to be and it is providing great care.

Dr. Sandi: Well, I’m right there with you. I don’t believe that AI can take the place of your AI health coach. It’s not going to take the place of a human being because it is that heart-centered communication as you pointed out. It is the ability to have empathy, to build rapport, to really listen to that individual. And it’s not the same when you know that person. It’s like if you’re going through the phone system with AT&T and you’re going to get through like, “Representative. Representative.” You want a human person. You don’t want to be talking to just the bots, just the computer or the chats.

And the other thing I’ve noticed is that those in development or already here, they misinterpret the nature of coaching. They think it’s about giving advice like, “Oh, eat so many servings of vegetables and fruits every day.” It’s not really that client-centered where you are asking the right questions and having them have the… You know, people get that aha moment, they’re going to change, and you know it’s because of that relationship that’s developed, that trust that finally somebody’s listening to me. Whereas, they went to the doctor and they had five minutes with the doctor. And the doctor left and, “Wait, they didn’t hear my real issue.” So, our system is becoming so anonymous and broken. And that’s where health coaches, what we used to call bedside manner, they bring back. And that is the key, and AI is not going to do that. And we’re so lonely anyways. Loneliness is skyrocketing, and working remotely and disconnected, especially our seniors.

Angela: Absolutely. I completely agree that parts of it can coexist with how we do care, right? We can eliminate some mistakes and things like that, but we definitely need heart-centered care and, as much as we can, put the human back in humanity. And, you know, I feel like with all that we’re doing, we have to make sure that we’re doing that too.

Dr. Sandi: Oh, it’s so well-said. Yeah, because it is AI and health coaching, remote patient monitoring, for example. And precision diagnostics is an area, as you said, that AI is going to be increasingly important. So, it is the combination that will really give people value-based care.

Angela: Absolutely.

Dr. Sandi: Dr. Angela, this has been such a wonderful, inspiring conversation. Where can people find you?

Angela: Well, you can find us across social platforms at Legacy Holistic Health. And that’s pretty much anywhere you look, Facebook, YouTube, LinkedIn, TikTok. We’ve got a presence pretty much everywhere. If you’re interested in having a full scholarship or being part of the program here at Legacy in any way, you can reach us at legacyhealthcoach.com.

Dr. Sandi: Well, thank you. Well, you and I connected a while back, and I really felt that what you do resonated with me so much. And I’m looking forward to our continued association and collaboration.

Angela: Likewise. This has been so wonderful. Thank you so much for having me.