A patient with asthma visits the doctor, and is prescribed a nebulizer. She returns home to climb four flights of stairs to her damp and mouldy apartment, where she can’t use the nebulizer because her electricity was cut off weeks ago.
Scenarios such as this happen frequently. Doctors write prescriptions which are medically appropriate, but practically irrelevant in a patient’s life. There is little point in treating an illness only to send patients back to live in the conditions that made them ill in the first place.
You may be thinking that this is an obvious point. It is. I have yet to meet a medical professional who disagrees that living conditions, poverty or nutrition play a significant role in determining health. Yet if the point is so obvious, why do our healthcare systems largely ignore it?
A healthcare system focused on health, rather than on care, would look routinely at the wider context of patients’ lives. It would be as normal for doctors to prescribe referrals to specialists in domestic mould problems as to specialists in diagnosing lung problems.
At Health Leads, we mobilize college students as volunteers to work with healthcare providers to help patients address the factors that underlie their health problems, from housing conditions to exercise to finding a job and affording food.
This isn’t a controversial idea among medical professionals. It is well documented and widely known that only about 10% of a population’s health levels can be attributed to medical treatment. The remaining 90% can be attributed to various socio-economic factors and personal behaviour.
In a 2011 survey of 1,000 primary care physicians by the Robert Wood Johnson Foundation, 80% of respondents said that patients’ social needs are as important to address as their medical conditions – yet 80% also reported that they did not feel confident in their capacity to meet these needs. And, if they do attempt to solve these problems, they are easily sidelined from delivering the clinical care they were trained to provide.
In healthcare systems around the world, incentive structures have evolved to prioritize care over health. A doctor who prescribes a patient six courses of antibiotics in a year will typically earn more than a doctor who prescribes one course of antibiotics and helps the patient not to get sick again.
If we are to make healthcare systems prioritize health over care, we need to figure out how to align incentives. There are no easy answers, but there are promising experiments under way. In the US, for example, Medicare recently stopped reimbursing hospitals for readmitting patients within 30 days of discharging them, creating a greater incentive for hospitals to help patients stay healthy after discharge.
Various models of “value-based payments” are also being tested, the basic principle being that doctors are allocated a sum per patient a year and rewarded according to whether they spend more or less than their allocation on treatment. While these models are still nascent, they promise to incentivize medical professionals to promote wellness in the process of treating illness.
Payment represents only one of the “Four P”s of healthcare that we need to re-envision, the others being product, providers and points of delivery. The product of healthcare systems should not only be medical treatment but also access to all the resources necessary to be healthy; as well as doctors and nurses, providers should also include community workers and advocates, and anyone who can connect people to those resources; and points of healthcare delivery must go beyond doctors’ offices and into homes and communities.
There are powerful opportunities for advanced economies to learn from systems in developing countries, which often do a much better job of integrating the medical system with the public health system and using community workers as a first port of call.
Crucially, this need not entail spending more. As Elizabeth Bradley and Lauren Taylor showed in their recent book, The American Health Care Paradox: Why Spending More is Getting Us Less, rebalancing what we spend on medical care and social services can potentially deliver better health outcomes at lower cost. Cracking this code is a challenge that should concern us all.
Author: Rebecca Onie is the co-founder and CEO of Health Leads, and a World Economic Forum Young Global Leader. She is participating in the Annual Meeting 2014 in Davos.
Image: A patient with MRSA is pictured through the window of a hospital door in Berlin, 29 February 2008. REUTERS/Fabrizio Bensch