FOUNDATIONS OF U.S. HEALTH CARE DELIVERY

FEBRUARY 27, 2014

LET’S DRAW A PICTURE

How would you describe health care today?

Why are people healthy? Why do people get sick?

How is health and sickness addressed in this country?

What role do health care organizations play?

…does the government play?

…do clinicians and physicians play?

…do individuals play?

LET’S DRAW A PICTURE

In a perfect world, how would you describe health?

How would sickness get addressed?

What role would health care organizations play?

…would physicians or clinicians play?

…would individuals play?

What kind of health care organizations would exist?

HOW DO YOU GET THERE?

Is the “ideal” possible?

What would you need to do? What roadblocks exist?

How would you plan health services?

How would you improve health?

WHERE DO THINGS CURRENTLY STAND?

Which of the following statements is true?

“The U.S. has the best health care system in the world!”

“No way, the U.S. health care system is, at best, average.”

It depends on who you’re talking to and about…

Individual?

Population?

It depends on how you define and measure health care…

Access? Cost? Quality? Outcomes? Equity?

UP FOR DEBATE

The health care industry feels strong tensions and conflicting pressures

What is health? What is health care?

Is health care a need? A right? A privilege?

If we think about population health, who’s the population?

What’s the role of health care organizations?

Economic or social benefit?

Reactive or proactive?

WHAT IS HEALTH?

“Last week about 30 of us spent 36 hours in The Hague discussing whether we could produce a new definition of health – and eventually deciding that we couldn’t” (Smith, 2009)

“Defining health appears to be a simple, even unnecessary, matter that does not spark the interest of most healthcare workers. Everybody knows what health is – that is, until they are asked to provide a clear and concise definition of the word. Not only is it hard to provide such a definition but, if past experience is anything to go by, those devised are unlikely to stand up to critical scrutiny well enough to gain general approval However, that is no reason to stop trying” (Lewis, 2013, p. 211)

THINK, PAIR, SHARE

What is health?

How would you define it?

Is it the absence of disease?

Is it an experience?

A physical state?

How you feel?

How would you measure it?

Is it a continuous spectrum?

What variables might affect it?

WHAT IS HEALTH?

“A state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” (World Health Organization, 1948)

“The ability to adapt and to self manage” (Huber et al., 2011)

“A balanced state between physical, emotional, social and cognitive/sense-making domains. Within any local environmental context, a health state exists within a multidimensional phase space of physical integrity, functional performance and subjective experience producing an entropic state most consistent with viability… Health is a complex adaptive state in so far as the inner workings at a psycho-neuro-immunological level maintain a certain homeostasis for self-sustaining physiological function” (Sturmberg, Topolski & Lewis, 2013)

WHAT IS HEALTH?

Does that sound like our system? Is that what it does?

“For most doctors that’s an uninteresting question… doctors are interested in disease, not health. Medical textbooks are a massive catalogue of diseases” (Smith, 2009)

Our system has developed with a focus on disease diagnosis and treatment

Health care in the U.S. has traditionally been governed by the biomedical model

…Health is the absence of illness or disease

Health care delivery focuses on medical or illness care, and prevention of disease and health promotion are secondary

WHAT IS HEALTH?

The WHO definition of health adopts a biopsychosocial model: physical, mental, and social dimensions

Physical

MentalSocial

WHAT IS HEALTH?

There has been a recent growing interest in holistic health

Health indicators include:

self-reported health status

disability

life expectancy

spiritual well-being

social functioning

morbidity (disease)

functional limitations

mental well-being

Physical

Men

talS

ocial

Spiritual

OUT OF BALANCE?

Our adoption of a broader conceptualization of health is a marathon, not a sprint…

“Despite almost universal references to ‘health care,’ ‘health insurance,’ ‘health benefits,’ and ‘reforming the health care system,’ the unfortunate truth is that all these terms are misnomers. The United States has a medical care system focused on diagnosis and treatment of those with disease (or at least ‘dis-ease’), not a health system that addresses the needs of the healthy. However, powerful, effective technology now exists to prevent illness and maintain health” (Peterson & Kane, 1997, p. 305)

THINK, PAIR, SHARE

How should health care be provided if a holistic definition of health is assumed?

WHAT IS HEALTH CARE?

It’s complex

Is it a service? A good? A philosophy?

Is it a process? A system? A one-time intervention?

“…the diagnosis, treatment, and prevention of disease, illness, injury, and other physical and mental impairments in humans. …It refers to the work done in providing primary care, secondary care, and tertiary care, as well as in public health” (Wikipedia, 2014)

“The maintaining and restoration of health by the treatment and prevention of disease especially by trained and licensed professionals (as in medicine, dentistry, clinical psychology, and public health)” (Merriam-Webster Dictionary, 2014)

WHAT IS HEALTH CARE?

A different perspective:

“Health care is a targeted perturbation of the ‘patient system’ that facilitates the system ‘to do the necessary adaptive work’ to achieve (self-)healing. This stands in stark contrast to the prevailing ‘healthcare’ approach of targeted ‘curative interventions’ done to the patient by others (known as healthcare providers). Health care becomes a participatory encounter between two experts who work together to achieve a common understanding of the patient’s disease in the quest to succeed in the struggle for life, and at times, this may entail the ‘passive’ endurance of interventions aimed to maintain one’s life” (Sturmberg, Topolski, & Lewis, 2013)

CHOOSING BETWEEN PANACEA OR HYGEIA?

The divide between health and medicine goes wayyy back to ancient Greece…

Panacea: the goddess of cure and remedy

Hygeia: the goddess of health and well-being

Continues to be reflected in our “dual systems” relating to health care

Curing disease?

Or promoting well-being?

WHAT IS HEALTH CARE?HOW DO WE PROVIDE IT?

Informed by how we view illness and disease

Informed by how we view quality of life

Informed by how we view determinants of health

Informed by our perspective of health distribution

ILLNESS VS. DISEASE

Illness

A person’s own perceptions and evaluation of how they feel

Disease

Based on a medical professional’s evaluation

Falls along a spectrum

AcuteChronic

QUALITY OF LIFE

Overall satisfaction with life and self-perceptions of health

Satisfaction with experience of receiving health care services

Comfort

Dignity

Privacy

Security

Degree of independence

Decision-making autonomy

Personal preferences

DETERMINANTS OF HEALTH

A singular focus on medical care delivery is unlikely to improve a population’s health status

Multiple factors determine health and well-being

A more balanced approach is required

DETERMINANTS OF HEALTH

Environmental factors

Behavior and lifestyle

Heredity

Medical care

Examples:Physical activity Overweight/obesityTobacco use Substance abuseSexual behavior Mental healthInjury & violence Environmental qualityImmunization Access to health care

MARKET VS. SOCIAL JUSTICE PERSPECTIVES

Who should receive the medical goods and services that a society produces?

Market justice perspective

Economics-based (supply & demand)People make rational choices and know what’s best for themMinimal need for government interference

Social justice perspective

Health is a social good, access is a basic rightGovernment is more efficient to allocate health services equitablyNeed for government to plan and deliver health care

MARKET VS. SOCIAL JUSTICE PERSPECTIVES

What are the implications?

Market justice perspective

Individuals are responsible for their health and well-beingSocial problems can be addressed through private solutionsRationing is based on the individual’s ability to pay

Social justice perspective

Society is collectively responsible for its health and well-beingSocial problems require public solutionsRationing is based on health care planning

THINK, PAIR, SHARE

Which makes sense to you?

Should our health care system favor market justice?

Or is social justice the better way?

What do you think?

WE’VE GOT BOTH

Medicare & Medicaid vs. private, employer-based insurance

Government oversight of insurance, payment,new drugs & procedures, medical research,

information systems, quality, etc.

Public health & population health vs. individual interventions

How are we wrestling with this today?

HEALTH CARE INTERVENTIONSPolicy interventions

Community-based interventions

Health care system interventions

Individual-level interventions

Strategies to improve health

Nutrition programs Work/environment safety efforts

Community-based partnerships Prevention-oriented effort

Patient safety & medical error reduction Coordinated care

Chronic disease management Culturally appropriate care

INITIATIVE EXAMPLES

http://www.healthypeople.gov/2020/default.aspx

http://fitcitysa.com/about

IS THERE A REMEDY?What will it take to fix what’s broken?

Can we bend the curve?

To a healthcare system that is…Safe

EffectivePatient-centered

TimelyEfficient

EquitableCoordinatedAffordable

From a system hampered by…Quality concernsIneffectiveness

Patient uncertaintyInconsistency

Redundancies and wasteInequality

FragmentationUnsustainability