Recently, I attended a dinner and lecture at the local dining venue where they served huge hunks of prime rib and sauteed snow peas from some far away place where it’s spring, and chocolate mousse and wild rice. Global warming increased just slightly due to our excess consumption, but my portion would have been wasted had I stayed home. Beside the food, I was curious to see what the health care lobbyist who spoke had to say about where health care reform is headed. I was surprised to find that he was almost entirely positive about what was going on and that in general he said things that I agreed with.
How could this be? Health care lobbyists generally want the industry they represent to get as much money as possible. I generally want the health care industry to reign in its excesses and be more conscientious and efficient. Clearly there is some agenda here that I don’t understand. Either that or efficiency and reigning in excesses is beginning to align itself with the success of the health care industry.
Paul Lee, the speaker, bravely faced an audience that included many doctors and administrators who believe that health care is going rapidly to the dogs and that the Affordable Care Act (or Obamacare as they prefer to call it) is the end of all that is good. His message was quite succinct and described a scenario in which the growth in health care expenditures would continue to slow and populations would become healthier and more people would be insured and access care in an environment that would include more non-physician caregivers and less specialists.
His visit and presentations were paid for by the CEOs of the three local hospitals who seemed to approve of his message. He showed graphs of trends and briefly touched on the specific issues of rural hospitals, which all three of the local hospitals are. He talked about how new requirements for hospitals to curb complications would lead to a safer environment for patients and fewer unplanned readmissions.
He also used a couple of terms that had the feel of buzzwords, but which were actually very interesting. He spoke of the inevitability of focusing on “population health.” We presently do fee for service medicine, though not entirely (there are health care coops and other pre-paid models and quite a few physicians are salaried.) This means that we get paid when patients are sick. We are moving in the direction of being paid for how well we take care of patients, otherwise known as pay for performance.
According to Mr. Lee we are heading toward a goal of population health which he explained meant taking responsibility for the health of the entire community in which we practice, rather than just taking care of patients when they get sick. There is an article in the Journal of the American Medical Association this month which looks at exactly this. Emma Eggleston MD and Jonathan Finkelstein MD write about how population health could be attractive to the stakeholders who pay lots of money when people get sick, but might be less attractive to entities which make their money only through treating sick people.
Also, if we focus on making everyone healthy there may be a dynamic of requiring people to do certain things that interfere with their individual rights, such as exercising and stopping unhealthy habits. This may not be universally acceptable to Americans.
How it works
I know that in our small community there could be some non-hospital interventions which might significantly reduce hospitalizations.
If physicians or midlevel caregivers would see patients on an emergency basis in nursing homes and maintain good continuity of care with those patients and their families we would see fewer emergency room visits and hospitalizations. If there were a community crisis center that was robust and effective, we would have less emergency mental health visits. If acupuncture and massage were easily available and covered under insurance, we would likely have fewer pain medication prescriptions and fewer hospitalizations for complications of these medications. If our hospital was paid a certain amount of money per year to take care of the patients in the community regardless of whether they were admitted to the hospital, low cost ways to reduce hospitalizations would be very attractive, and the hospital would likely invest in them. If the hospital made money only when patients were admitted, they would not be inclined to do so.
Mental health hospitalizations and emergency room visit are almost always a drain on hospital resources since we don’t have a psychiatrist or mental health capabilities and can’t hospitalize these patients. Traditionally these patients have also been poorly insured or uninsured as well, so there was no hope of reasonable reimbursement for the hours of care (however that may be defined) that they received in the emergency room. Hospitals such as ours might well save money by funding a community crisis center if it actually kept patients out of the emergency room.
A nearly viral piece of news recently was the fact that Utah has drastically reduced homelessness by giving the homeless homes. There is an initiative in Utah, begun 8 years ago, to reduce homelessness and poverty, which has several strategies for reducing costs related to chronic destitution. It costs a significant amount of money to treat the homeless in emergency rooms and intermittently put them in jail, and there is less of that if they live in apartments rather than on the street.
Utah does not provide housing for free, but does make it very affordable, charging about 30% of government funded income. Utah also has programs to prevent homelessness including interventions to keep people in their homes at risk of losing them. President Obama’s 2009 American Recovery and Reinvestment Act (the much derided “stimulus package”) has been partly responsible for funding these projects. This is an excellent example of population health. Not only does it reduce emergency room related costs, but the no-longer-homeless are much more likely to get and hold jobs than if they were on the streets.
The other term that our speaker, Mr. Lee, used at the end of his talk was “compressed morbidity.” He explained that this was the overall goal of a good health care system. Most people, he asserted (and I agree) would like to be sick for the least amount of time possible, and die when they are not yet miserable or have only been so for a short time. The concept of compressed morbidity was first introduced by Dr. James F. Fries, now an emeritus professor of rheumatology at Stanford University, in 1980. He wrote a more comprehensive article on it in 2005. Dr. Fries noticed that almost everyone dies by the age of 110 and most people by the age of 85. As we get better at maintaining health, more people live to be older, but the true maximum age of a human doesn’t increase much.
With better prevention of disease, be it vaccination or quitting smoking, people live to ages that are closer to the maximum age and spend less of their lives sick and requiring medical care. He suggests active encouragement of all of the behaviors that we know make us stronger and smarter, including such revolutionary ideas as providing alternatives to nursing homes as people age. Although we will live longer if we do those things which slow disease and decline, we will overall use less medical resources. This goal is the end result of a population health approach.
I am mostly but not entirely excited about all of this. I personally would like to live healthy and then drop dead, or get eaten by a bear or something, while I remain mostly independent. But I still do respect the rights of people with different values to practice them. That sounds pretty good until I think about the rights of people to become addicted to injectable drugs, get HIV and multiple abscesses all over their body, spend years in the hospital and nursing homes lingering with their stroke related brain damage and chronic pain and eventually die after costing the system multiple millions of dollars.
I suspect that it is not really up to me and does not rest on my sensibilities whether the US moves in the direction of population health and achieves progressive compression of morbidity. It will most likely be determined by how much money we are willing to spend on health care and what kind of overall outcomes we are willing to accept as being adequate for our money.
Janice Boughton is a physician who blogs at Why is American health care so expensive?