Dr. B’s Thoughts: Healthcare

Intro

“Our system is set up to produce a lot of health care but not necessarily a lot of health” – Dr. Amol S. Navathe, University of Pennsylvania

One solution to improving the quality of healthcare is to increase collaboration between disciplines, so the patient/client quickly receives the expertise that can most effectively deal with their specific problem.  The Electronic Medical Record (EMR) should be a step forward, but real progress can only come with a fundamental change in decades-old practice patterns.

If the US wants to be a healthcare leader and not a laggard, it’s time to think outside the box.

Improvements are needed in two fundamental areas: healthcare process (cost and quality) and societal factors (availability and equity).

Improving the Process

Healthcare process improvements are probably the easiest to achieve. Increasing transparency in outcomes, costs and pricing would benefit everyone.  We have the blueprint*, we just need to implement the necessary changes.  This involves creating a national outcomes database, encouraging healthcare centers to adopt best practices, and improving system monitoring, among other things.  One of the “other things” is changing from a single-minded emphasis on fixing problems, to a more comprehensive approach to promoting wellness and good health.

What is prevention worth ?

Here are some examples of attempts at process improvement:

American Health Quality Improvement Association

Health Resources and Services Administration

What is Best Practice ?

The best care is provided when there is an outcome-based bottom line that is at least as important as the financial bottom line.

Best healthcare practice involves one theme which leads directly to better patient outcomes: fostering a patient-centered environment, based on openness, mutual respect and mutual responsibility.  These qualities apply to provider-patient interactions, as well as to provider-provider interactions, so that healthcare team members share adverse events, as well as expertise, for the benefit of the patient.

 

Can Evidence-Based Care Help ?

Evidence-based care involves thre emain components: the scientific evidence, the patient’s/client’s values, and the experience of the healthcare provider.  Each component is given equal weight in a client-centered decision-making process.

*Center for Evidence-Based Medicine.

Incorporating the latest scientific evidence in treatment planning forces providers to evaluate the scientific literature on behalf of their patients, which means that treatment plans are always compared with current best practice recommendations.

While medicine has come a long way from the College of Barbers and Surgeons, our understanding of the human body’s complex systems, and their even more complex interactions, is still incomplete.  The plethora of healthcare adjuncts and their practitioners (see Glossary) is a consequence of this incomplete understanding. 

It might be said that each of the many providers probably has something useful to offer to a specific patient in a specific state of health or disease. Their contribution should not be dismissed out of hand.  Studying patient-provider interactions correlated with outcomes, may disclose some useful common factors. 

Even if it should turn out that most of the good outcomes are the result of the body’s vast potential for self-healing, and not a specific intervention, we will have learned a valuable lesson.

Changing Society

Societal factors may prove to be more elusive.

From a monetary standpoint, the largest expenditures occur in two situations: near the end of life, and when preventive health care has been neglected, for whatever reasons.

End-of-life issues obviously involve significant ethical and moral considerations and deserve a fuller discussion than this forum.  Access to healthcare is an important factor in preventing chronic problems and reducing societal costs.  Attention to most problems at an early stage can improve outcomes and reduce costs.  For example, a few visits to a physical therapist may obviate the requirement for more expensive and riskier medical care, including surgery.

Lack of preventive healthcare most commonly occurs in groups that have been marginalized in society for various reasons.  Geography, poverty and racism are all factors that lead to neglect.

When a person is forced to use the local emergency room as their primary care provider, and follow-up is limited by lack of transportation, medical costs can skyrocket.  In addition, healthy lifestyle habits are often not encouraged in the food deserts of many of our inner cities.

These issues require us to resolve to make our society more inclusive, a fundamental change that could lead to many benefits, including improved healthcare at a lower cost.

Quality healthcare and access to care are inextricably linked.  Health equity should be one of our strategic priorities.  The Value of Health Equity

Here are some examples of attempts at social change:

Kansas University’s Community Toolbox

CDC’s Healthy Places Initiative (RIP)

Costs

Healthcare in the U.S. is very expensive, compared to most of the world.  We spend more on healthcare, yet we live shorter lives, than people in other developed countries. We must be doing something wrong.  Here’s a chart to prove it.

Actually, we’re doing several things wrong:

1. We should be focused on wellness and preventive care rather than on treating the consequences of neglect;

2. We should acknowledge that most problems can be managed without a visit to the physician’s office or the ER.  The trick is to know which presentations require more advanced care.  So far research supports using lower cost providers, rather than doctors, as the entry point to the healthcare system. At least for orthopedic problems, physical therapists in particular, have been shown to have the training and temperament to perform this task safely and effectively (Pendergast,J et al., 2011; McGill,T, 2013, Bornhöft, et al., 2019);

3. We should incentivize positive outcomes, including self-management, rather than subsidizing endless treatments.

The Bottom Line:

The healthcare system in the U.S. began essentially as an “old boys’ network”, which relied on the good will, camaraderie, and integrity of the physicians who were its originators.  Over time, as healthcare became more specialized and divergent, the basic relations became more fragmented.  Today the average patient is faced with multiple challenges to obtaining good healthcare.  As a country, we face three main challenges: Cost, Equity and Availability.