Health care? Rhode Island says: Wellness

WASHINGTON – Have you ever heard of Governor Don Carcieri, Republican of Rhode Island? Well, if you have not, read on, because there are very good reasons why you should become acquainted with his administration’s work on “wellness education”, as opposed to issues pertaining to containing the cost of services related to health care delivery.

Unfortunately, right now the focus is entirely on the fate of the Obama health care reform plan and the abundant speculation on the political ramifications of victory or defeat on this signature issue for the President himself, for the now wary Democrats and for the re-emerging Republicans. Because of this, a revealing segment dedicated to health care issues, within the recent meeting in Washington of the National Governors Association, got no attention.

The “Rhode Island Revolution”

And it is really too bad because at least one Governor brought up the real fundamental problem pertaining to health in this forum featuring all his colleagues from around the USA. It is all well and good, said Governor Don Carcieri of Rhode Island, to talk about best practices and innovative ways to improve quality, while reducing cost of the delivery of health care. But shouldn’t we be talking also about how to intelligently reduce demand for health care services?

In other words, shouldn’t we be focusing on ways, including prevention, broader health education, encouragement towards healthier life styles that would yield a healthier population thus preventing some illnesses, while delaying the onset of many others? Wouldn’t this be a good way to deal with the health care crisis, by having overall healthier people, thus reducing total demand for services and ultimately the size of the ensuing cost pressure?

Talking with the experts

Governor Carcieri’s questions, accompanied by examples of what his administration is doing in the general areas of the promotion of wellness in Rhode Island, including something called “Rewards for Wellness Program”, took place in the context of a Q & A following two very thoughtful presentations to the assembled Governors by Dr. Jack Cochran of Kaiser Permanente and by Dr. Atul Gawande, Professor at Harvard and now media celebrity for his insightful ideas about, among others, surgery protocols that can save lives.

The two Doctors talked eloquently to the assembled Governors about rationalization and streamlining of systems, about increasing transparency, so that everybody knows what is being done in the context of delivery of health care, about egregious problems that should be avoided and best practices. But, being physicians, both of them talked mostly about issues pertaining to what should be done when they and their peers as care givers are called upon to provide care. All very important no doubt. But the focus was entirely on how to improve on the “supply” of medical care.

What is the role of “wellness education”?

This is all fine, said Carcieri in the discussion phase. But why is it that we do not focus equally on the “demand” side for medical care? If people are healthier and stay healthier for a longer period of time, this is good for them personally, for their families and, as a significant added bonus, a healthier population is a welcome consequence with a positive impact on a the financial burden of the health care delivery system; a system that we are desperately trying to make more cost-effective, while expanding its reach, by providing insurance to millions currently without insurance coverage. To put it simply: healthier people need less health care. They cost less. Focusing on how to contain cost, without ways to address in a meaningful way how to reduce demand, is really dealing with the wrong end of the issue, the consequences, (illness), rather than the contributing factors, (life style, behavior, etc.).

Just like fighting drugs, we focus on the consequences, not the causes

It is a bit like the drug addiction epidemic, I would add. Our focus is entirely on the (mostly criminal) consequences of addiction, (jailing offenders), and on how to improve drug interdiction, (beefing up police actions, the Drug Enforcement Agency, etc). But are we really trying to understand why is it that so many people are attracted to drugs and become addicts, thus fueling this gigantic criminal trade that we are desperately trying to stop? If we could understand what its it that causes demand for drugs and if we could miraculously drastically reduce interest in drugs, (that is the demand side of the equation), we would have solved a huge public health, treatment cost, law enforcement and incarceration problem, all at once.

What causes our health care crisis?

Fine, may be the two issues are quite separate and the comparison does not make a lot of sense. But the prevailing attitude on both issues is the same: we focus on something only after it has become a huge problem with nasty financial and public policy consequences. Just the same as with drugs, we are focusing our attention on health care because of a cost explosion. As the problem seems to be cost, we are hoping that we can deal with cost as a self-contained issue. We are hoping that we can find ways to reduce it, therefore avoiding financial disaster. As with drug abuse, somehow we assume, implicitly at least, that the level of demand for health care services is fixed, (and in fact growing, given the larger and larger numbers of elederly citizens as a percentage of the total population).

Reduce demand for services: this is a good approach

But the Governor of tiny Rhode Island suggested that reduction of demand for services is at least equally important. Just as the First Lady defined the problem of children obesity as an issue that needs to be addressed by focusing on all the environmental and behavioral factors that influence attitudes and eventually lead to bad habits and obesity, following the same logic we should understand that, if people realized how important it is to learn and follow practices that allow them to stay healthy, this would be good for them and for this overstressed health care system.

The Doctors agree: wellness should be center stage

So, the Governor of a small state, certainly not a well known politician and chief executive on the national stage, made his observation to the assembled Governors. But this is not the end of the story. Much to my astonishment, as I was watching the proceedings thanks to C-SPAN, the two Doctors, replying to his comment, showed to be in perfect agreement.

Dr. Jack Cochran, in fact, added that, if we look at the whole continuum of what impinges upon health, the delivery of health care services counts for somewhere between 10 and 20%. And the remaining 80%? Oh well, some of it has to with your DNA, that is with heredity. But quite a bit, added the Doctor, has to do with the quality of the general environment in which the person lives, with habits and personal behavior. Dr. Atul Gawande indicated that he was in full agreement with this assessment of what is it that bears on wellness.

Health care is only about 20% of the problem!

So, two recognized, eminent medical authorities confirm that most of the issue is outside their immediate field of action. They, along with all the other practitioners and the whole system built to support them, (hospitals, nurses, administrator, pharmaceutical companies), cover only a small part of the problem.

Come again?

Only 20% of the problem rests with the delivery of health care services? OK, let’s add some more, just to be conservative. Let’s say it is 30% or even 40%. This would be still less than half. Is this not astonishing? Wouldn’t this invite a reconsideration of what is it that we are trying to fix? Are we trying to ensure that people stay healthy; or are we concerned only with containing the cost of services when people who have adopted unhealthy life styles get sick? And if the latter is true, isn’t this approach faulty?

Unfortunately, what is on the table now –good or bad as it may be— in terms of a health care reform plan, does not recognize the fact that the primary (not the only) issue is that we should focus on how to keep people away from doctors and hospitals, as opposed to laboring on solutions aimed at reducing the cost of your stay, once you are sick and have to be in the hospital. What is on the table right now focuses almost entirely on how to contain health care delivery cost.

Only 20%? But then we are not focusing on the remaining 80%

So, without any controversy, a Governor and two eminent medical authorities, with all the other Governors listening in, affirmed that the crux of the problem is really in education on how to stay healthy; not in dealing with the problem (illness) after it has manifested itself. Now, in terms of the broader public policy implications, this is the equivalent of the discovery of electricity or any other epochal, truly transformative breakthrough, given the enormous cost (more than 15% of GDP) of health care services in the United States. This affirmation and recognition of what the real issue is, should be a game changer. You would expect  people either to vehemently disagree or to say: “Oh Lord, and all this time we were focusing on something else. Let’s go and change everything”.

Well, oddly enough, that did not happen.

New, revolutionary truth affirmed, but no reaction

Astonishingly, after this recognition as to where the real problem is, nothing further was added. Nobody else, no other Governor had anything to say on this. This affirmation is the equivalent of saying in the XVII Century that it is the Earth that rotates around the Sun and not vice versa, as we used to believe. But it was greeted with quiet indifference by the otherwise keen audience of Governors.

Is it because they did not really understand what was said? Or is it because they are so used to look at the problem in terms of bills,  Medicare and Medicaid budgets, numbers of practitioners and actuarial statistics, so that something like “wellness education” seems nice but hazy and thus probably not that important?

And yet, official science, via the two Doctors, endorsed the concept. Via the delivery of health care, we are dealing with 10 to 20% of the problem. The rest should be dealt with as well.

Intellectual inertia?

OK, let’s be clear. Obviously we need health care facilities. We need doctors and the best doctors at that. But we should not start dealing with health only when it is gone, because of the onset of disease. We should do all we can to educate people on the “value” of health and thus on how to keep it, preserve it and maintain it for the longest time.

We must change the objectives of medicine and its role in society

As Doctor Gawande said in a different context, until now we have paid doctors “more” if they do “more”, in terms of numbers of interventions (this is the prevailing “fee for service” approach for the payment of medical services). Now we should shift and understand that we should pay doctors “well” to do “well”, that is helping a person to stay well. Keeping a person healthy, so that he/she does not become “a patient” should be high on the list of what doctors do. Unfortunately as the system is currently conceived and organized it is not.

Notwithstanding the profound implications of what was said in the context of this meeting of the National Governors Association, Washington, (and everybody else, with the exception, apparently, of Rhode Island), is still focusing on the old stuff.

Will we ever learn?


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