This post is the first in a series on the long-term solution to our healthcare crisis which will require a change in our approach to health and wellness, impossible to achieve through our current delivery model. As Deming put it
“Every system is perfectly designed to get the results it gets,”
Our current health care delivery system exemplifies his quotation. We reimburse health care providers, drug companies and health care systems for identifying and treating disease. We screen for disease even without the knowledge if it is significant (see). We treat disease with expensive drugs and procedures which create their own significant morbidity and mortality. Then we decry how unhealthy the population is and how expensive , unfair, inequitable our health care delivery has become.
We have spent a lifetime learning and teaching those around us that we should have systems in society and industry which addresses problems proactively rather than reactively. The age old words of Benjamin Franklin come to mind that
“an ounce of prevention is worth a pound of cure”
The often quoted fact is that 5% of our sickest chronically ill patients are responsible for 50% of our health care expenditures. What is virtually never asked is how many of these chronic diseases can be prevented with simple much less expensive preventative interventions.
It has been abundantly clear for decades that only 15% of health and welfare is related to health care delivery. The social determinants of health (SDOH) are responsible for 85% of our wellness. The SDOH typically are listed as follows
1) Income and income distribution
2) Environmental exposures, addiction (tobacco, Etoh, SUD )
3) Education
4) Unemployment and job security
5) Employment and working conditions
6) Early childhood development
7) Food insecurity nutrition/diet
8) Housing
9) Social exclusion/inclusion
11) Health services
12) Gender
13) Race
14) Disability
Each one of these variables has been studied extensively and has been shown to have a profound impact on health and wellness, far more than medical care alone.
We currently use a sick care approach: a patient presents with a symptoms/disease and a host of people resources drugs and devices are employed to remedy the illness which are high cost, inefficient, dangerous (medical errors are the third leading cause of death in the US) and completely counterintuitive to a philosophy of prevention.
We can avoid disease and suffering with prevention and limit the need for invasive, dangerous and often toxic treatments. Vaccines are a great example of prevention but consider further how many diseases could be avoided completely if we had safe living spaces, clean water, excellent sanitation and waste treatment.
Why would we treat a disease when we can prevent the vast majority from which we suffer. One significant risk factor for many cancers is obesity , yet less than 1% of dollars spent are for prevention of obesity. 99% of dollars are spent on the tragic sequelae of obesity, diabetes, hypertension, cardiovascular disease, osteoarthritis and cancer.
There are those who announce that the SDOH are unsolvable societal states not in the purview of healthcare providers and subject to political powers not amenable to change. The study of the amount spent by other modern resource rich countries on creating a tighter social safety net shows the profound cost savings that can be achieved with interventions. One of the SDOH most easily addressed is substance use disorder/addiction
Public health interventions including the warnings, education, and taxation of tobacco products have reduced smoking to the lowest level in years currently at 14% and while tobacco kills 400,000 people a year it also creates premature cardiovascular disease, heart attack, stroke, peripheral vascular disease and causes lung cancer, the number one cancer killer in the US, leading to pain, suffering, premature death and billions in healthcare expenditures.
While the return on investment for some SDOH interventions has been questioned, those areas amenable to taxation of deleterious products such as tobacco and low nutrition highly processed and sugar added beverages and foods could be revenue positive and the funds generated could be used to treat addiction and provide healthier food options to the population
How does the current medical system identify and address needs within the SDOH. Clearly there is no specific expertise of medical professionals or the healthcare delivery system to remedy SDOH needs but there are efforts to use the healthcare system to screen for needs and refer appropriately. The two buzz words in this space include “Social Prescribing” and the resource for connecting people to resources are “linked workers”, community health workers or social workers who are aware of the local regional state and federal resources to ameliorate the deficiencies.
Social prescribing is the act of connecting patients to resources to address SDOH needs
No special medical training is needed and anyone within the healthcare team with access to the results of screening for SDOH to direct that individual directly to resources or if warranted to a link worker or equivalent knowledgeable person to mitigate the harms.
There are those who feel the screening need not be done within the healthcare setting and be done when people sign up for health insurance or through confidential means to access resources to address SDOH. Software and apps for the dual purpose of screening for the social determinants of health and connecting people to resources are being developed.
Healthcare providers complain about the increasing burden of data collection for diseases including, public health data, depression, intimate partner violence and many others. Their complaints are justified since this data can be collected confidentially and easily using block chain technology and apps designed to elicit the responses, identify needs and connect to resources to help.
I will be following up this blog with posts on why investing more in hospitals and doctors promotes more disease treatment rather than prevention and promoting wellness. Personalized medicine while wonderful for the individual redirects resources away from population health management and promotes sick care rather than prevention.
I also will address nutrition/obesity as real opportunities to dramatically decrease costs and improve health. Lastly I will look at why value based care is a failed experiment invested in disease rather than prevention and doomed to failure
I am lecturing for free on these and related topics as part of my “Making a Difference Campaign” Please contact me for available dates
Nicolas Argy copyright 2018