June 19, 2020 by Marshall Snipes
Black Jet Theory – Volume 2020-8 – Is the Healthcare System Broken? Part III – How to Change the Delivery of Healthcare Services
Only 11% of a person’s Health Status is determined by the healthcare they receive, according to studies by the Robert Woods Johnson Foundation and the Henry J. Kaiser Family Foundation,[1]. Yet the U.S. healthcare system is designed to take care of patients when they become sick or injured (episodic care) and more recently to deal with chronic care and check-ups (routine care). So why is it when we discuss “healthcare reform” we only talk about who is going to pay for the healthcare we receive. What about the other causes of one’s health status?
The Black Jet Theory[2] would seem to suggest that we need a healthcare system that addresses those other determinants in addition to the care we receive once we become sick, injured or suffer from chronic disease. Common sense would dictate that we should focus on the cause rather than just the symptom. What are those causes that represent the other 89%? And how can we reorganize the healthcare system to address those causes?
The other causes or determinants of one’s health status are (1) personal behaviors – 36%, (2) social circumstances – 24%, (3) genetics – 22% and (3) physical environment – 7%.[3] All of these determinants can be addressed in a healthcare system that is based on the following three pillars.
Pillar I – Integrated Delivery Model (“IDM”). If 67% of one’s health status is based on personal behaviors, social circumstances and physical environment, doesn’t it make sense that the healthcare system addresses those factors in a coordinated process? In today’s environment, a person whose health is impacted by these factors has access to the health and human service and mental health bureaucracies. However, the process can be confusing, uncoordinated and inefficient. Common sense would dictate theses inefficiencies drive up cost and weaken health outcomes.
IDM starts with the initial point of contact, the primary care physician, and continues through a model similar to the Home Health Model with significant differences. Under IDM, the primary care physician would coordinate a patient’s interaction with the physical health, mental health, and human service bureaucracies, follow up with a patient’s health plan compliance, and schedule and monitor a patient’s interaction with any required specialist. The primary care physician would be responsible for a holistic approach to their patient’s health status. The goal is to improve health not just care for the sick and injured.
IDM changes the dynamic from how the system works today to a patient/primary care centric system that makes the patient experience as effective as possible. Although ideas like online scheduling, evening and weekend access to the system, redesigned patient friendly waiting and check in areas, and the virtual rendering of services are not new ideas, the implementing and execution of those ideas have been slow to develop. In IDM, those functions are required. However, with the emergence of COVID 19, there has been a significant shift in the use of virtual services. Recent studies show that “one-third of Americans say they are likely to opt for telehealth visits over in-person visits once the outbreak subsides.”[4]
Pillar II – Health Literacy. If 36% of one’s health status is based on health behaviors, then it makes sense that we should have a healthcare system that educates patients not only on the treatment they receive but on the prevention of disease. It may seem obvious that most people know to eat healthy, exercise, sleep an appropriate amount of time and drink a lot of water, but the healthcare system needs to do better in teaching, training and holding its patients accountable to do those things. We still live in a free country, so patients have to be motivated to subject themselves to the accountability of the healthcare system. Incentives that are aligned to achieve accountability, the subject of next week’s article, are needed.
Studies have proven that when a person takes responsibility for their health, they become health literate, their health status improves and their cost of care decreases.[5] It is not rocket science to understand that the more informed someone is, the better decisions they make. Most people abdicate their health decisions to their doctors. This needs to change. “A significant health literacy gap exists as 30-60% of people have limited health literacy when facing difficulties managing their health and navigating health systems.”[6] There are options to treatment, prevention and decisions the patient makes – those decisions are better served when the patient is more health literate.
Pillar III – Access. If the positive results of the IDM are to be achieved, then the patient has to have access to this reformed system. Access is about the shortage of primary care doctors not only in underserved rural and poor neighborhoods, but also in most all neighborhoods where there are shortages of primary care doctors. “Estimates from the Association of American Medical Colleges (AAMC) indicate that the U.S. could face a shortfall of between 21,000and 55,000 primary care doctors by 2023. Add to this the spikes in demand from COVID 19 and any future epidemics, and the challenge might seem insurmountable”.[7]
Residency programs for primary care are lacking and underfunded. “While U.S. medical school enrollment has increased, averting a physician shortage now depends on more residency training slots. The number of residency positions has increased only 1% a year far lower than the 52% growth in medical school spots since 2002”[8] And most importantly, primary care education and residency programs need to include the holistic approach of IDM.
If the U.S. healthcare system is not reformed to address the determinants of one’s health, to improve the literacy of its citizens, to recruit and retain primary care physicians and to assure access to existing health and human services programs, then health status will continue to lag the rest of the civilized world, be expensive and void of improved results for the patient. Key stakeholders in the private and public sectors …. must join together and collaborate far more effectively than in the past to achieve real progress.”[9]
Don’t take my word for it, think for yourself.
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[1] McGovern, L., Miller, G., and Hughes-McCormick, P.2014. “The Relative Contribution of Multiple Determinants to Health Outcomes” Health Affairs/Robert Wood Johnson Foundation: Policy Brief. And, Heiman, H., and Artiga S.2015. “Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity”. The Kaiser Commission on Medicaid and the Uninsured: Issue Brief. Menlo Park, California: The Henry J. Kaiser Foundation.
[2] The Black Jet Theory is “the notion that most of what currently happens, when viewed through the filter of common sense and critical thinking, leads to a different conclusion, than the widespread view of current thinking by those who control the dissemination and content of information (academia, the media, politicians and other “experts”)”. “Black Jet – Volume 2020-1, May 1, 2020 by Marshall Snipes.
[3] See Endnote 1 above.
[4] Harris National Survey Conducted April 11-13, 2020. Public Opinion Strategies.
[5] “Investing in Health Literacy and the Social Responsibility and Sustainability Agenda” by Kristine Sorensen PhD, MPH, Global Health Literacy Academy, Riskov, Denmark. Going International health information services. https://www.goinginternational.eu/wp/de/investing-in-health-literacy-and-the-social-responsibility-and-sustainability-agenda/
[6] Ibid
[7] “New Findings Confirm Predictions on Physician Shortage” April 23, 2019 Association of American Medical Colleges and “The Problem with U.S, Health Care Isn’t a Shortage of Doctors” by Christopher Kerns and Dave Willis, March 16, 2020 Harvard Business Review. https://hbr.org/2020/03/the-problem-with-u-s-health-care-isnt-a-shortage-of-doctors
[8] “More medical students than ever, but more residency slots needed to solve physician shortage AAMC says” by Joanne Finnegan, July 26, 2019 Fierce Healthcare. https://www.fiercehealthcare.com/practices/more-medical-students-than-ever-but-more-residency-slots-needed-to-solve-physician
[9] Statement by Lawrence Prybil, PhD, LFACHE Professor Emeritus, University of Iowa, Community Professor, University of Kentucky June 13, 2020.