What Would I Prioritize to Reform Health Care?

Last night at a gathering with friends I was asked what best addresses the problems in healthcare. I’m writing this now because my answers left me feeling like I had not done my best.

My first response is a good one… “it depends on your goals.” Financial sustainability? Improved health of a community? Lower death rate? Adequate preventive and chronic care? Access and equity for the vulnerable/uninsured? Your goals depend on your vision for society. Social justice? Respect for personal autonomy? Promote public best interests? It’s very hard to debate healthcare policy without addressing our underlying interests and vision for our society.

My subsequent replies jumped too quickly to point solutions. They’re not wrong (invest in non-medical determinants of health, move healthcare financing to capitated and value based payments where possible) but are perhaps too wonkish to be persuasive. This is a hard subject to address given the complexities of the healthcare economy.

Let’s say the goals above are as good as any to get started. A more coherent answer is this:

Moving healthcare forward depends on a few guiding ideas:

  1. Healthcare is local… what is best in one community may not be in others
  2. Discovering “what works” is difficult to find, but critical to use
  3. Healthcare is a highly interdependent system… individual solutions fall short
  4. Non medical determinants influence health more than medical care does

It’s one thing to have ideas about what you’d do, it’s another to put them to a test. The ReThink Health Model allows such experimentation. The model draws on evidence based interventions (“what works”) cataloged here and summarized here. The best outcome achieved prioritized the following interventions for Anytown, USA is:

  1. Enable healthy behaviors (eating, exercising, smoking, drugs, alcohol)
  2. Improve hospital efficiency (processes to reduce length of stay and improve quality)
  3. Recruit primary care providers to FQHCs (supports most disadvantaged)
  4. Create medical homes (strengthen primary care, use evidence based medicine)
  5. Coordinate health care (avoid redundant care)
  6. Gather innovation funding (gets the process started)
  7. Reinvest healthcare savings (only a portion goes to medical care)
  8. Global payments (removes volume incentive of providers)

The model graphs how the interventions performed against your goals. The answers may be different when data unique to your community is used. It was quite striking how unbalanced/uncoordinated investing would create a “pitfall” in the model: shortage of primary docs, unsustainable financing, or runaway chronic health conditions. Back to the drawing board. It takes dedication to find a sustainable solution without “pitfalls.”

The non-medical determinants—healthy behaviors and reinvest healthcare savings—have the largest ROI. The measures for justice include the % uninsured and the % disadvantaged. There is evidence that good health is a precursor to moving out of a disadvantaged position in a community. While one can’t achieve everything, all at once, now, steady investment can move many of the objectives forward over time.

The last part of this is crucial. None of this works unless a community works together to prioritize where the investments go… and stay until outcomes are sustainable. How best to do that? It is my belief it can come from any stakeholder, but surely anchor employers, in particular, have a unique catalytic role in mobilizing commitment to prioritized interventions.

Are there other areas besides the above that clearly need work? Of course. Some of those areas can be addressed concurrently; for example, leadership development and governance reforms for provider organizations, and medical school reforms (greater emphasis on primary care and non-medical interventions) come to mind.

Ultimately, we need to develop our own understanding of the issues and the interventions. We need to determine for ourselves what works in our community, what policies are needed at all levels of our society, and most of all, get involved and learn how to influence others effectively to move it there. And when you’re asked what you’d do, you’d be ready.

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