As a nation, we have committed to a social imperative for education — an aspirational vision, based on its broad social benefit, for universal literacy and numeracy of our citizens — as manifested in our systems of mandatory K-12 education.
While this vision remains a work-in-progress — there are significant inequities and differences of opinion as to the process and content of education — the shared value of, and responsibility for, our educational infrastructure remains largely undisputed: every child has access (and attendance mandates) to schools and licensed teachers.
While the locus of control over these systems has traditionally been at the state level, federal influence — for better or worse — has tried to reduce state-to-state variation in educational outcomes that have hindered work-life success for some citizens.
However, with regard to the health of our citizens, we do not have a parallel commitment.
Currently, in the United States, there remain opposing sides to the question as to whether we, as a society, want people to be sick or well. In fact, there are individuals and organizations who are willing to use their power and influence to sustain avoidable suffering, disease, and disability (and their otherwise avoidable costs) in our communities by denying coverage, creating barriers to access, and undermining the expertise of health care professionals.
Health care economics — financing, cost control, and payment reform — has dominated our national conversation. These discussions are fundamentally flawed because we’re more focused on how we pay for care than how we care. The problem of health care costs can only be solved by determining what we want our investments in health to return. Before designing any framework or platforms for “universal coverage,” perhaps there needs to be a clear understanding of what we expect such coverage to accomplish and how.
Health economics has driven care delivery redesign, especially around the concept of value-based care. However, “value” is currently grounded in a financial calculus of efficiency and managed resource utilization, based on the willingness to take financial risk or measures of evidence-based practice with known health-economic value. This focus puts patients and professionals in a subordinate position because, even in the face of improved access, there remain significant health care disparities among millions of Americans whose health and well-being are far below quality standards.
Just as there is value to society when everyone knows how to read, write and do basic math, there is a collective value from investments that improve quality of health to enhance the capacity of individuals to contribute emotionally, socially and economically as active, productive members of family and community. It’s health, not health care, that creates value.
A 2020 McKinsey report Prioritizing Health: A prescription for prosperity makes it clear that the economic benefits from improving health are substantial: reducing disease burden and preventing or attenuating health-related disruptions to work and family life improves the economic strength of our communities. The economic return is estimated at $2 to $4 for each $1 invested in better health, with expanded participation in the workforce and increased productivity contributing to a projected 8-10% increase in GDP by 2020.
Perhaps it is time to transcend the idea of health care as a “right” and consider “quality of health” as a social imperative on par with our social imperatives for education and law enforcement, based on the value to society of a healthy, literate, and secure citizenry.
Achieving a social imperative for health will face several challenges, not the least of which are the limitations of the current organizing principles of our systems of care. There also may be significant resistance to change by commercial and professional networks of self-interest embedded throughout the health care ecosystem.
However, there are three key and largely non-disruptive steps that can be taken immediately.
First: A universal framework for care planning; an information architecture that allows everyone’s health to be assessed — and goals set — through the same set of categories: universal, characteristic-based, and condition-indicated preventive measures, condition management, and compassionate care strategies.
Goals of care would seek to effect change on the biological, environmental, social, or behavioral determinants of the patient’s current state toward aspirational goal-states for risk level, the burden of illness or disability, functional capacity, or emotional well-being.
Aggregating and analyzing data from a universal care planning framework would allow us to rationally determine the requirements, priorities, and value of investments to improve the health of our citizens.
Second: The use of that care plan as a “single source of truth” to orchestrate the activities and contribution towards the goal of all the members of a patient’s health-resource community, irrespective of institutional affiliation and inclusive of family, friends, and community.
As we know from the symphony, orchestration is difficult without a common score that integrates the diverse instrumental voices while accounting for their different but potentially harmonious roles. Equally, truly integrated care is impossible without a similar single source of truth for a patient’s health-related goals and associated plans of care.
A universal care plan architecture would integrate and facilitate collaborative, coordinated, and economically efficient care between all the members of a patient’s health resource community. It would also solve the problem of patient-data sharing by putting that data in a standardized accessible and usable architecture.
There are decisions as to how we work that are independent of how we are paid. As a professional community, we can choose to deliver care in a disciplined, structured way of our own design.
In this way, the health care professional community could wrest control of the way we deliver care and the definition of value — revaluing ourselves in society and the marketplace. Such a dramatic reconsideration of the organizing principles and interaction design of our systems of care has the potential to equitably and efficiently improve our capacity to improve the quality of health of individuals and communities and achieve a social imperative of health.
Steven Merahn is a physician and health care executive.
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