In the last blog post, we took a look at the results obtained by Safeway: an effective 40% reduction in cost and high patient satisfaction. Smoking and obesity in their employees is 70% the national average. All the more remarkable, this was done without any direct intervention in the delivery of "medical" care. No mandates on hospitals, no physician incentives for "performance", no imposition of order. What is this telling us??
Many people tend to use "health care" and "medical care" interchangeably. In the Introduction to "The Measurement of Health: Concepts and Indicators" by James S. Larson, the first sentence reads: "The measurement of health is a complex affair". Writing in 1991, Larson states:
The defining of health is, at best, problematic. Its definition is dependent upon the historical period in question and the culture in which it is defined. For the past 150 years, rising expectations have changed the definition of health in the United States from "survival" to "freedom from disease: to an ability to perform "daily activities: to a sense of happiness and "well-being". Americans expect their health to be not merely adequate, but good if not excellent.
Is it "medical care" that produces "health"? Is health "simple", "complicated", "complex" or "chaotic"?? By now, most of you will realize in my estimation, it is complex. Health is an emergent property that results from interaction of people with each other and the system in which they live. Unfortunately, it is a limited property that inevitably is lost over a lifetime. A part of the system in which they live involves interaction with what can be called the "medical system".
At least in the Safeway view, 74% of health care resources are expended for 4 chronic conditions: cardiovascular disease, cancer, diabetes and obesity. What is more, 70% of health care costs are the direct result of behavior. Even if the number was half that, it would be significant. If so, let me ask you: can the medical system control your behavior? How can it do that? For sure, education and what is placed under the umbrella of "preventive care" may influence behavior. How do we amplify that "attractor"? How do we hold someone else accountable for what you do? Is that efficient or effective? In my way of thinking, the only way to do that is for you to forfeit, voluntarily or involuntarily, your liberty--you have to be compelled to stop acting and interacting in a complex way and start acting in a simple way. Even if that were possible, is that worth the trade off? Would it not be more acceptable to amplify the attractor for your own behavior instead of trying to do it through someone else? Remember, 78% of the Safeway employees thought so, and 76% actually wanted the attractor increased. But the company is constrained from doing that because of governmental regulation.
Think about that for a moment: we have spent 10 months attempting to craft a complicated solution to a complex problem while all along the same government that was attempting to do this also actively dampened an attractor that was working. Maybe viewing the Childrens' Party should be a requirement to hold public office: http://www.youtube.com/watch?v=Miwb92eZaJg
But even if you agree with this so far, what about the studies that show life-expectancy and infant mortality in the US are below even some Third World countries? Isn't that a horrible indictment of medical care in the US and evidence that the entire medical care system needs to be changed? Well remember Larson's first sentence: "The measurement of health is a complex affair".
Ronald Bailey has some very interesting comments on this at: http://reason.com/archives/2008/06/17/accidents-murders-preemies-fat#commentcontainer As it turns out, if deaths due to accidents and homicides are taken out of the equation, life expectancy in the US would be at the top of developed countries, not near the bottom. Regarding infant mortality rates, if the US had the same low-birth weight incidence as Canada, the infant mortality rate would be less than that of Canada (though still far above Iceland, Singapore, Japan and a bunch of other countries). Low birth weight is associated with teen pregnancy as well as lack of proper pre-natal care. Likewise, the US attempts to save many low-birth weight infants who, in other countries, would be assumed lost already and therefore not counted as a "live birth". For example, Iceland, Finland and Japan have a much higher stillbirth rate than infant mortality rate http://www.who.int/making_pregnancy_safer/publications/neonatal.pdf whereas in the US, the stillbirth rate is lower than the infant mortality rate. Is it more logical to assume that mothers in these countries have some unusual characteristic that causes stillbirth to relatively increase, or that a different terminology is used in counting?
Let there be no mistake: there ARE problems with both "health" care and "medical" care worldwide, and particularly in the US. Change is needed. Medical care particularly needs to add VALUE. Porter and Teisberg's recommendations must be followed, and the sooner the better. What is the evidence, however, that artificial imposition of order on "medical" care will cause a significant increase in "health" care? Both are complex. Both respond to attractors, not imposition of order. Now is the time to be smart. That is the topic for the next entry.
Comments (2)
Russel, I enjoyed this piece very much. Here is an interesting thought. In ancient China, a doctor in the village received an income from the villagers, until someone became ill. This meant that the doctor had to focus on increasing health and preventing illness. Rather than getting wrapped up in how to define health, doctors in the village made it their business to study movement of healthy animals and healthy people. This led to such physical exercise practices as Qigong and Tai Chi that are now several thousands year old.
The logic is simple. Keep your body supple and blood can freely flow through the body. And where blood flows, oxygen flows and where oxygen flows disease has less of a chance. Simple, plausible and in those days all what was needed to get scores of people involved in daily physical exercise.
What if we would remunerate health care providers on the basis of how they prevented disease rather than attempting to cure it?
Unfortunately, for example, good education on diabetes for an ordinary patients, gets a backseat to learning how to measure blood sugar levels and how to administer medicine. While this is important, we don't remunerate doctors for taking a good chunk of time with patients to teach them how to prevent diabetes and how to prevent complications once they have it. Instead we gladly pay for expensive leg amputations as a result of high blood sugars and turn doctors who do this into highly paid heroes.
To turn 'sick' care into true health care we need to look at the broader picture and that includes looking at how we subsidize the food industry and for example what we incentivize through our remuneration systems in health care. We need a whole systems approach rather than a piecemeal approach and recognize the complexity that Russell so aptly describes.
Modern medicine has brought us amazing miracles. Traditional Chinese medicine cannot reattach an accidental cut off finger which Western medicine can. But when it comes to dealing with chronic diseases, our current approach falls short. As Russel indicates 70% of our (preventable) health care costs are due to our behaviors. And behavior change to prevent chronic diseases is possible. It just requires our undivided attention. If we don't give it the attention it needs, chronic diseases will bankrupt our society. Perhaps it is time to entertain this interesting practice of remunerating doctors on how good they are in preventing disease. It would be nothing less than a complex paradigm shift in our society.
A final note on adding value vs integrating value. Taking care of health in our societies should be an integral part of how we in our societies subsidize the food industry (read Michael Pollan's books), build bicycle paths in our cities to promote bicycling and educate children on healthy food and living etc. Looking at health care in an isolated fashion, compartmentalizing it, is denying the complex relationship health has in all our domains of living and political policy formation. Hence, health care should not offer value added, but offer integration of value in all our domains of life. Now, that truly is a complex challenge.
Posted by Boudewijn Bertsch | January 26, 2010 1:05 AM
Posted on January 26, 2010 01:05
You raise some good points, despite the fact that I reckon your entire analysis is undoubtedly off base, high quality write-up though, great job. Zoe
Posted by Reta Homrighaus | August 30, 2010 5:44 PM
Posted on August 30, 2010 17:44