We should find ways to develop and accelerate a national action plan to improve everyone’s health.
We must find the ethical strength to establish systems to provide care for all that is equitable and of the highest standards. Healthcare delivery is an important part of health…but good health for all is the goal!
Like everything else in our society, good health is attained and sustained in very unequal patterns of income, race, and ethnicity.
As our society grapples with the policy issues that must be resolved in the interest of equal access for all, the best place for action to achieve good health for all will come from the millions of people who work in health care every day: nurses, technicians, dietitians, social workers, nursing assistants, physicians, managers, and executives. If mobilized in a unified way, they can improve the health of our people while the endless debate goes on.
That debate is largely detached from the day-to-day reality of health, healthcare, and people’s lives and experience. That’s because health and healthcare are experienced in the moment.
And we need to decide what to do! We can and we must enable sustained, uninterrupted action: setting goals, learning, study, measurement, sharing, and expanding success.
Last week, I spent some time with doctors and other providers who serve one of the most vulnerable neighborhoods in the U.S. We were having a discussion about a project that this group of providers was undertaking to improve diabetes prevention. With limited human and financial resources, a tireless effort was underway to make calls to a large panel of patients whose records indicated that they were pre-diabetic.
Making such calls and being successful is not simple or easy. Reaching people takes time, and often patients are reluctant to get involved with programs they know little about. The skill, insight, and care that the staff develops through experience are precious and deep.
We know from research and experience that even those who are pre-diabetic can reverse their condition through sustained healthy eating and moderate but regular exercise. (Don’t Let Healthcare Bankrupt America, George Halvorson, p.13). We also know that over 40% of all Medicare expenditures are spent on type-2 diabetes, which is a preventable condition! (Halvorson, p. 11).
Back to the conversation with the caregivers.
I asked if the project they were working on was having success and if it could be expanded. The lead dietician on the project looked at me forlornly and said, ” the staff who was making the calls to patients have been assigned elsewhere…so I don’t know what we are going to do.”.
It is common that when people experience such setbacks, they become understandably frustrated, often angry. I asked the group: “Is it possible to carry on even with this setback?”
The answer back was, “We must find a way; and we will”.
That answer came in response to something else I asked: “Can you think of anything more important to do in your day-to-day efforts than to devise methods and efforts to improve the health of the population you serve? The project you are involved in has that as its central premise.”
While part of their efforts would include making demands on the administration for the staff they needed, they also knew that the likelihood of that happening soon was unlikely. They were determined to get their patients into the clinic for the group meetings that had produced amazing results among those patients who came to their group education sessions on healthy eating and active living. A1c control was being achieved and the patients were thinking about all kinds of lifestyle changes for the improvement of their health. They and we know that for each patient whose health improves, we achieve two things: renewed life and possibility for the patient, and huge savings of money…money that then can be reinvested in effective human and capital investment to do more of the same, more of the same, more of the same.
Our little meeting concluded with a commitment to problem-solving with their colleagues to re-adjust daily priorities and be sure that the calls to patients continued.
This small experience, one which is likely repeated every day in the country among the dedicated staffs and managers of our healthcare facilities, can serve as a call to change…everything: let’s get our priorities right; let’s spend the resources we have on direct action to improve health and question just about everything else that the systems spend resources on!
I have had a lifetime of experience engaged with healthcare providers at all levels in many organizations. There are similarities in the challenges and efforts to meet them from organization to organization. Sadly, most of the challenges are driven by the specific and parochial challenges to the specific health system or facility. Further, my observations are that efforts to address the challenges are in a constant state of flux, leading many long time employees, physicians and managers to suffer what is often referred to as “death by initiative”. Sadly, most employees, managers, and physicians do what they do best each day: they do the best they can, and hope that the latest “death by initiative” will just go away!
Rare is the healthcare institution that is not making efforts to adapt to the demands of a health and healthcare environment which is under extreme stress. Changing financing models, grappling with new technologies, trying to meet competition in the market place, and finding and retaining a highly engaged workforce are among the challenges that thousands of organizations confront separately every day in our country.
Is there any wonder why the fundamental issues of access, cost, quality, safety, and improved health continue to elude us as a society?
We are in a deep danger zone…and more and more people will have failing health. Ultimately, that is the fundamental truth and tragedy of failure.
But, the call is there. The call for action and leadership is there.
We can change the discussion and the emphasis everywhere all at once.
Because of two realities that everyone must learn through a case for change:
1.) We know our system lacks any sense of fairness. The U.S. has one of the largest income-based health disparities in the world, according to a new paper out in the journal Health Affairs. Among the poorest third of Americans studied, 38.2 percent report being in “fair or poor” health, compared with 12.3 percent of the richest third. Only Chile and Portugal have a larger income-based gap in the health status of their citizens.” (The Atlantic, June 5, 2017).
In addition to health disparities driven by income, we also know the deep disparities in health that are driven by race and ethnicity.
2.) We know our system is financed collectively, but does not function collectively.
“At $5,960 per capita, government spending on health care costs in the U.S. was the highest of any nation in 2013, including countries with universal health programs such as Canada, Sweden and the United Kingdom. (Estimated total U.S. health spending for 2013 was $9,267 per capita, with government’s share being $5,960.) Indeed, government health spending in the United States exceeded total health spending (government plus private) in every other country except Switzerland.
The finding that Americans pay the world’s highest health-related taxes conflicts with popular perceptions that the U.S. health care financing system is predominantly private, write Drs. David U. Himmelstein and Steffie Woolhandler, the authors of the study.
Himmelstein and Woolhandler are professors at the City University of New York School of Public Health and lecturers in medicine at Harvard Medical School.
“Direct government payments for such programs as Medicare, Medicaid and the Veterans Administration accounted for 47.8 percent of overall health spending. The analysis also identified two commonly overlooked tax-funded health expenditures – government outlays for public employees’ private health insurance coverage ($188 billion, or 6.4 percent of total spending) and tax subsidies to health care ($294.9 billion, or 10.1 percent of the total). Together, these public expenditures put the U.S. in first place for health care taxes.
Using another yardstick, the researchers note that tax-funded health expenditures in the U.S. accounted for a larger share of the gross domestic product (11.2 percent in 2013) than did the total health expenditures of any other nation.”
The researchers drew upon data from the Centers for Medicare and Medicaid Services, the Office of Management and Budget, the U.S. Census Bureau and the Internal Revenue Service to analyze government outlays for health care costs. They utilized data from the Organization for Economic Co-operation and Development to compare the U.S. data with that of other nations.
“We pay the world’s highest health care taxes. But patients are still saddled with unaffordable premiums and deductibles,” said Dr. Steffie Woolhandler. “Meanwhile, billions are squandered on paperwork, and insurers and drug companies pocket huge profits at taxpayer expense.” (American Journal of Public Health, January 21, 2016).
We can mobilize the millions of people who work in health and health care in one direction and make the hard decisions about what we spend our time and money on.
They need something to believe in and participate in….
Just like the caregivers who are going to find a way to make the life-saving call to their patients, leaders must be held to account to spend the time and resources of organizations in accountable ways: accountable to one direction: improving health.
Indeed there are many factors that will substantially improve health and reduce the cost of care: eliminate fraud and abuse, unnecessary profit, unjustified pricing, high administrative cost, inefficiencies and redundancies. And high on this list is what we call: “missed opportunity”: missed opportunity to prevent disease and injury, missed opportunity to eliminate error and unnecessary harm.
These areas of focus…missed opportunities… can become the unifying theme and action for all actors in the world of health and healthcare.
Let’s eliminate “death by initiative” and instead fully empower our efforts with the inconvenient truths of our health crisis: the money we spend is largely public, and inequality of health should be unacceptable.
There are times when facts, beliefs, and need come together.
From their direct experience, millions sense these truths. That is why we can achieve health for all. We must align action and ideas that people believe in.