Brent Wallace, MD, is chief medical officer at Intermountain Healthcare, a nonprofit health system based in Salt Lake City, Utah.
Our national debate about healthcare reform continues, and yet that debate—and even the healthcare reform legislation that has emerged from it—has only scratched the surface of the public discussion that needs to unfold further. That legislation focuses primarily on how to increase access to our healthcare system and pay for it. What it doesn't reflect is that access to our healthcare system is just a small component of improving health and healthcare nationally.
The conventional assumption is that healthcare equals health, and that's just not true. Research has shown that in the United States about 40 percent of a person's prospects for health are determined by behavior (how much you exercise, what you eat and drink, sexual behavior, etc.); about another 30 percent is determined by genetics; about 25 percent by public health (sanitation, pollution, etc.), and only 5-10 percent by the healthcare delivery system.
That means that we as a nation—even as we focus aggressively on improving healthcare delivery—need to be talking much more about the other factors that influence public health. In the long run, they will determine whether healthcare in the United States is affordable and widely available.
The answer isn't public lectures on behavior. The answer is to establish national priorities and systems—through active public engagement and discussion—that will lead to better behavior and health outcomes.
At present, we are on the wrong track: headed in a direction that is financially unsustainable. Childhood obesity has reached epidemic proportions in the United States—with about 1 in 3 children or teens overweight or obese, according to the American Heart Association. As many as one in three adults in America could have diabetes by 2050, if current trends continue, according to the Centers for Disease Control and Prevention. In 2010, 26.9 percent of U.S. residents aged 65 years and older had diabetes.
To get on the right track, we must focus on three key priorities—all involving the public:
The first priority is rebuilding the relationship with the primary care physician. Everyone should have a primary care physician and a "medical home", because that's where the best opportunity to prevent illness and reduce destructive behavior exists.
Fortunately, the public values that relationship, even though it is too often absent. If you ask patients thoughtfully, the number one thing they want when they come into a healthcare delivery situation is a relationship with a trusted adviser: typically a physician on whom they know they can rely. That provides an opportunity, because that primary care physician and his or her staff (together the "medical home"), can work with patients to prevent illness, ensure the best treatment when sick, provide patient-centered care, and monitor follow-up activity.
Unfortunately, the United States is experiencing a shortage of primary care physicians—with an estimated 45,000 needed by 2020, according to the Association of American Medical Colleges. Addressing this problem is absolutely crucial. "If every American went to one of these doctors regularly," according to Newsweek, "health-care costs might come down as much as 5.6 percent a year, saving $67 billion, according to one estimate."
The second priority is to understand the implications of what one might call "rescue care"—going to excessive lengths to hold death at bay in the belief that we are somehow less than human if we don't. This includes forcing an elderly patient at end of life to die an excruciating death (at least emotionally excruciating) in an intensive care unit rather than a peaceful one at home.
But if we continue spending scarce resources on briefly postponing an inevitable death, at the expense of access to primary care (and improved quality of life) for others, are we setting the right priorities? Rescue care is not strongly associated with total health, while access to a trusted healthcare counselor, typically a primary care physician, is.