Health and Healthcare

It has been known for a long time that “healthcare” – all the stuff that we do, prescribe and provide – is a minor determinant of how “healthy” any of us is. Overall health, or more technically, the variability in health outcomes, is much more dependent on the combination of genetics, personal behavior (think smoking and seat belts), environmental factors and socioeconomic status than it is on healthcare.

I was thinking about that when I read in the New York Times about how some healthcare provider systems, driven by the need to cut costs, are starting to address some of the non-medical social needs of their patients. These kinds of innovative community-based interventions started to get traction after they were highlighted by an influential profile by Atul Gawande in the The New Yorker. Their diffusion has been driven by the expansion of novel payment models that have started to reward providers for reducing utilization of services like ER visits and hospitalizations, the very services that they have traditionally been paid for.

From a society-wide perspective, all this makes perfect sense and is long overdue. No rational person would want to preserve the situation described the county health official quoted in the Times: “We’d pay to amputate a diabetic’s foot, but not for a warm pair of winter boots.” That said, I see at least two big challenges to straightening this all out.

The first problem in ridding “the system” of the perversion of paying for amputations but not boots is that we don’t really have a healthcare “system.”  We have an unholy mess of independent actors and government agencies without any ability to make it rational from a society-wide perspective. Sure, there are pockets of integration and global oversight, like the Veterans Administration, or State governments, which are responsible for an array of social welfare and health benefits. But even within these bureaucracies, it is a real challenge even for well-meaning individuals to work across the barriers of separate budget lines and programmatic responsibility. It is not a simple matter (and may even be illegal) to transfer funds from, say, a diabetes clinic to a homeless shelter, even if more services at the latter would improve the health of diabetics.

The action lately has largely been to start to hold healthcare providers accountable for health outcomes instead of compensating them for the provision of services. In general, I think that is a good thing, but it raises the second challenge: health care providers may not be any good at providing the non-healthcare services that people need to be healthy. Why should we expect physician practices and hospitals, which have evolved over decades to become what they are now, to be able to morph into effective social welfare agencies?

Frankly, if I were paying the bills (and let’s not forget that as taxpayers, we are all paying part of it) I’d be inclined to pay us less for care and pay others more to improve the social determinants of health.

What do you think?

4 thoughts on “Health and Healthcare

  1. YES….if we spent (our) money for better prevention, rather than disease retention, we would save untold amounts, I believe. The patients I treat daily for conditions that are preventable astound me. Terrible waste.
    Great post….

  2. I have such mixed feelings about this. Like no money to keep feet warm, but lots of money for amputation. My city and VA decided that homelessness is the main cause. It costs at least $70,000 for the fire dept to respond to a down person and take them to the ED. voters approved bonds to house these people-usually diabetics. The PD, FD, vet groups, stores, churches, etc donated dishes, fridges, beds, etc. One man used to be picked up several times a day. Now none-he keeps his Dr. appts.(free city bus pass-visiting social worker, etc) We’ve passed more bonds-the VA joined this program. A company will get together and build one decent house, the city donates the property-children are back with their parent or parents. The next dozen apartments or houses will be for female vets.

    But the drug thing with the DEA is crazy. Stanford UC developed MyCD (My Chronic Pain). This goes with your auxiliary support services for patients to improve health, quality of life, etc. Georgia seems to have dropped the program. It had another name, but the Stanford site no longer lists Georgia as a client. Other names disappeared from Stanford’s clientele list. Basically, a person in chronic pain is supposed to say, “100 minus 3 = 97, minus 3 = 94 minus…..” or say the alphabet with flowers: Aster, belladonna, crocus, etc. and you’ll feel like vacuuming too. I was honestly told that I could vacuum. I found other problems, as did other people. .

    We need to be careful, and try to use some common sense in what we do. A person needs to feel that they are getting something from this. The older diabetic isn’t sprawled out on a sidewalk because he can keep his insulin in a fridge and cook a simple healthy meal when he’s hungry. He gets a lot, and went through long evaluation sessions to see if he could succeed. Things can be worked out, if people work together.

    1. The Fire department and the city’s ED staff put this program together-took it to the mayor and the city council-$20,000 for the FD and $50,000 @ the ED.

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