By Ted A James, MD, MHCM, FACS
May 31, 2018
The Paradox of U.S. Health Care
We are not as good as we should be. Despite incredible technological advances and high-levels of spending, compared to other countries, the U.S. health care system fails to achieve superior outcomes on many key health indicators including life expectancy, infant mortality, and preventable disease. Although we are capable of delivering some of the most exceptional care in the world, we do not do so reliably or in a well-coordinated manner. According to recent studies from the Commonwealth Fund, the U.S. tends to excel in doctor–patient relationships, wellness counseling, shared decision making, and chronic disease management. However, we operate in a system plagued with major disparities in access to primary care and gross social inequities. Innovations in our approach to health care are required in order to address these challenges and remove the barriers they present to providing reliable and sustainable care for all patients.
Health care does not exist in a vacuum separate from the rest of society. The socioeconomic environment has a powerful influence on individual behavior, disease burden, and health status. Upstream strategies consider the social determinants of health and aim interventions at the root causes of health problems in order to prevent or reduce the downstream impact—ultimately improving the health and well-being of individuals and the population. Our patients may be treated in hospitals, but their overall health is determined by their community and social context. Understanding this provides tremendous opportunity for optimizing health care.
This type of ‘big picture’ approach has been successful in other areas of public policy. For example, the main reason that fatalities from automobile accidents fell significantly over the past century is not necessarily because we are better drivers, or because we are better at resuscitating trauma victims; it is because we enacted legislation to create safer driving conditions (e.g., safer roads, traffic lights, collapsible steering columns, airbags, and child care seats). By recognizing the importance of not only the driver, but also the vehicle and the highway environment, policies for road safety became more effective. Likewise, successfully improving U.S. health outcomes will require approaches that incorporate social conditions.
Many progressive hospital systems are leveraging upstream thinking by addressing the social, economic, and environmental conditions that contribute to poor health outcomes, shortened lives, and higher costs. Kaiser Permanente’s Center for Total Health seeks to better the community through initiatives focused on preventing violence, narrowing disparities in cancer care, promoting thriving schools, and creating healthy workplaces.
“We need to collaborate with local business and community leaders, and even our competitors, to create communities that are among the healthiest in the nation.” —Bernard Tyson, CEO, Kaiser Permanente
Other examples include Beth Israel Deaconess Medical Center’s Food is Medicine initiative, and Boston Medical Center’s investment in stable housing. These community outreach programs are having a positive impact on health outcomes; however, institutions receive little if any direct financial return for their contributions to improving the health of populations. Greater alignment of financial incentives with social efforts is needed in order to address the “wrong pocket” problem, in which the savings that accompany health improvements do not accrue to the investor.
Improving Policy, Improving care
Our health care policies should be informed by empirical data and the best available knowledge from objective program evaluation. Examining the health policies of countries with higher quality outcomes may provide insight into strategies to help improve the U.S. health system. Research from Elizabeth H. Bradley, a professor at Yale School of Public Health and director of the Yale Global Health Initiative, examines how other countries succeed in advancing health outcomes. Although not without their own flaws and challenges, countries that invest in robust social services and safety net systems have significantly greater public health outcomes. Even within the U.S., basic measures of health were more closely and positively associated with social service spending than with health care spending. Other lessons from successful countries include ensuring universal access to care and addressing inequity in health care. Still, these efforts alone will have limited results in improving health outcomes in the U.S. unless we simultaneously find ways to improve our education, employment, regulatory, and judicial systems. We need evidence-based policy to address poverty, gun violence, opioid addiction, and discrimination. A data-driven approach to studying the global community and adapting best practices and proven strategies could be beneficial as we seek to redefine health care delivery in the U.S.
Call to Action: Our Social Responsibility
Leaders in health care and health policy have a unique opportunity to shape the future of our health care system and determine if it will reach its full potential in improving health outcomes. We need health care heroes to help promote screening for social determinants of health in routine clinical practice, conduct research on solutions to the equity gap, educate our students about the influence of society on health, engage in community outreach programs, and lend a voice to raising awareness and helping direct policies that benefit the public. By recognizing the importance of social reform as a means of achieving better health, we can become advocates for building a healthier society.
- Schneider EC, Squires D. From Last to First—Could the U.S. Health Care System Become the Best in the World? N Engl J Med. 2017.
- Bradley EH, Canavan M, Rogan E, Talbert-Slagle K, Ndumele C, Taylor L, Curry LA. Variation in Health Outcomes: The Role of Spending On Social Services, Public Health, and Health Care, 2000-09. Health Aff (Millwood). 2016.
- Bradley EH, Elkins BR, Herrin J, Elbel B. Health and social services expenditures: associations with health outcomes. BMJ Qual Saf 2011.
- Manchanda R, Hochman M. J. Improvement happens: impacting health at its roots. Gen Intern Med. 2014.
Dr. Ted James is a medical director and vice chair at BIDMC/Harvard Medical School. He is an alumnus of the Harvard Health Care Management program and is involved internationally in leadership development and health care transformation. Follow Dr. James: LinkedIn / Twitter
Dr. James blogs about health care transformation. To see more of his posts, click on his name in the tags below.
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