Health and Health Care…
Email This Post
Print This Post
In June, the New England Healthcare Institute published a study called “The Boston Paradox: Lots of Health Care, Not Enough Health.” Basically, the study said that Boston’s status as a world class health care center had not stemmed a rising tide of preventable illnesses and chronic disease throughout the local population.
I bring this study up because it includes a chart that I found fascinating. The chart lists the things that determine health status on the left, and the things we spend money on to improve health status on the right. One has almost nothing to do with the other. 50% of health status is determined by healthy behavior. 4% of health care spending supports healthy behavior. 20% of health status is driven by environmental issues. We spend almost nothing on this. 20% of health status is driven by genetics. Needless to say, we spend precious little on this, either — as I pointed out in an earlier post on how often people collect family histories as part of their own health status check-up.
So where does all the money go? Access to health care services (88%), which this report suggests is a small determinant (10%) of health status.
Health care is a continuum. Many people, in fact most, move from healthy to vulnerable to affected without complications to affected with complications, and back again over the course of their lifetimes. We spend next to nothing on helping people stay healthy, or on helping them get from “vulnerable” back to healthy again — and a great deal of money on them once they are sick, with and without complication. I can’t help but wonder if we would have fewer people moving down the continuum if we worked harder — and definitely smarter — on helping folks stay healthy, or get that way.
Harvard Pilgrim has done some work in this area with some of our employer accounts — focusing on either helping a company’s employees get healthier, or helping ones to stay that way. It’s a lot of work, and it’s been pretty effective, but it’s very hard to replicate. Thoughts/ideas on how to get more people to focus on “health” and less on “health care” are welcome. With our demographics here in New England, we’re going to need all the “health” we can get.
Those relationships (or lack thereof) would seem to demolish one of the main arguments for insuring the uninsured, and for adopting a western-eurpoean style healthcare system The argument is that, a) other countries have a state financed system of universal health care and b) those same countries have longer life expectancies (and various other health metrics can be superior to the US as well), ergo c) the difference in life expectancy results from the difference in the two healthcare systems and ergo d) we would be healthier as a society if we simply adopted their system. The argument is usually not stated by the proponents as a syllogism but it is clearly implied so that the average listener on the left tends to believe it is a proven proposition. But, because there are other reasons why many people want such a system (most people will shift their direct costs to someone else), I am sure the data and the implications won’t penetrate the discussion very far and we will continue to have policies advocated on the basis of myths rather than truth. As JFK said, the biggest enemy of the truth is not the lie, it is the myth. Thanks for your efforts to keep us informed.
I’ve been consulting in the healthcare arena for over 15 years and many of the people I speak with feel they do not have adequate support from their primary care practitioners. What I mean by this is that typical patients do not have enough time and/or access to their primary care Dr’s/NP’s/PA’s etc. This lack of time usually results in a poor understanding of the patients history, lifestyle and the possible results of a properly managed disease state. I truly believe that the busy schedules of patients and practioners alike contribute to many of the rising healthcare costs in this nation.
Let’s take bariatrics/obesity. Many of these patients do not visit their primary care physicians on a regular basis do to embarrassment, lack of adequate transportation or just because they feel hopeless. What they end up doing is avoid the preventative options available and wait until something serious occurs where they then need to be admitted etc…. resulting in legnthy stays and expensive healthcare costs.
It would seem that a parallel exists between the points brought up by MT and Mr. Koziol. Healthcare in this country continues to become more and more consumer based. At the heart of this consumerism is the concept of patient choice. Patients have been steered away from the concept of a traditional family practitioner, and more towards a delivery system in which, due to multiple factors including network limitations and affordability, one may change their primary care physicians several times in the course of several years.
While it would be unrealistic to expect patients to forfeit this freedom of choice, it could be argued that one of the benefits of a state run, or “western European-style healthcare system” would be to foster a more “traditional” relationship between patient and practitioner. This would come from implied nature of a national network, without limits. Patients, while having the option to see whomever they choose, would be less likely to change their primary care physicians, and more likely to develop a comfort level allowing them, in essence, better access to their healthcare at an entry, or preventive level.
Now, it could be argued that our healthcare system could not handle a shift towards the preventive, due to the strain that already exists within the primary care community. However, with the development of retail clinics and their potential to lessen the burden on primary and ambulatory care facilities, coupled with the cost benefits of removing even a small percentage cases from the further stages of “the healthcare continuum,” this specific aspect of such healthcare reform could have the potential to provide substantial benefits.
Even if placed within our current healthcare system, incentives to develop such patient/provider relationships would seem to translate to similar cost and treatment benefits.
Derek
You make interesting point(s). Note that they are actually two separate points: 1) system-imposed barriers to access by patients; and 2 patients’ self-imposed barriers to optimal care, notwithstanding access.
I noticed I did that MT. Typing too quickly and forgot to bridge my thoughts.
Subject: Ethnic health, science ed, and a job for PBS
Hispanic residents of Boston generally live longer than whites. I’m glad that the “Boston Paradox” article mentioned this. It’s a clear case, I believe, of genes overriding socioeconomic factors.
Another interesting case is the lower rate of atherosclerosis among African-Americans. This is due to lower average rates of triglycerides [TGs], and higher HDL.
What’s particularly interesting about the ethnic health issue is that it seems that whenever one ethnic group has a distinct health advantage, it is for reasons that others can replicate, especially if they know the science.
For instance, non-Africans may not have just the form of LPL (lipase) that enables many African-Americans to keep their TGs reasonably low. But TGs can be lowered by other means, such as exercise, weight loss, perhaps eating fewer carbs and taking a little fish oil. (But don’t believe me. See a health provider, the Mayo Clinic website, etc.)
Anyway, the science of ethnic health differences might make for some good television programs. No suggestion that anyone’s inferior, superior, or perhaps even unduly burdened, once we know the science. (I’ll admit that I’m not quite crazy about the minor burden of having to exercise a bit more than my Italian neighbors do, since I have the “Thrifty Gene” and they haven’t). But the differences are interesting and I think well suited to PBS. And knowing the science can lead people towards healthier behavior.
Footnote: I’m shocked. “The Boston Paradox” mentioned the [sometimes] need to lower cholesterol, but omitted to mention TGs. Other than that, an excellent article.
This is a good discussion to have. In my mind, the quick question is what “triggers” can we use in the system or through other non-claims data to pro-actively push timely information to patients around healthy behavior.
Most companies (that I have ever worked with) are hesitant to spend money on preventative care given employee turnover and/or changes in payor.
http://www.patientadvocate.wordpress.com
With the upcoming presidential election and the slew of health care proposals that are coming with it, the breakdown of health care spending on health status is becoming an increasingly relevant factor to look at. It’s very interesting to see how our current structure of spending does little to improve health outcomes. I agree with the point of the article; the model of preventative care needs to be the focus of our system. The current focus of just treating disease and illness after the fact leads to worse health outcomes and puts much great financial strain on the system. When patients come in only when acute conditions arise, doctors in many cases can only alleviate symptoms and the number of hospital stays greatly increases. If we invested our money on prevention in the short-term, we could greatly improve health status and save a ton of money in the long term. There’s is a few goals that should come from preventative care. First, if we focused on establishing long lasting, consistent primary care connections for all Americans, we could do a great deal in avoiding acute care situations. Some of the writers above noted this point, and I wholeheartedly agree. I also believe that on epidemiological level, we need to find health solutions that can be applied on a more global scale. This can be done through more of focus on epidemiologic research and the use of the entire public health system in implementing change. Although, the points made in this article give us insight into how we can improve the efficacy and focus of health care spending, I think that there is an important caveat that needs to be noted first. It’s noted above that this article shows that we don’t need a drastic shift in our health care structure, specifically in insuring the uninsured and under-insured. The idea that we can greatly improve health status with preventative medicine is predicated on first improving quality, accessibility, and frequency of visits with a primary care provider. In the current system, they are significant obstacles that many Americans face because of health care premiums, uninsurance, structural barriers, socioeconomic strains, etc. Therefore, I totally agree with the central argument in the ‘Boston Paradox’ article, but a new system that really deals with the problems of health access is needed to fully realize the power of preventative care.