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.
The challenge here is not to impose a particular standard of care from the outside (the so-called death panels) but to change the public expectation from, on the one hand, doing everything imaginable to extend life to the last possible minute to, on the other hand, patient-centered care: giving the patient the care that he or she desires. This premise mandates that we develop processes to enable the execution of advance directives by the majority of the population and then store them electronically in a place where they are easily accessed by care providers at the time that they are needed.
The third priority is to reduce waste. It's a widely accepted fact that more than half of all spending on healthcare in the United States—about $1.3 trillion out of $2.6 trillion annually—is wasted: unnecessary, ill-advised or the result of systemic incompetence. The challenge is, therefore, to track and manage expenses and build a patient-centered system.
At Intermountain Healthcare, we've spent decades focusing on this challenge. We've learned that you can't improve what you can't measure. We now have advanced information technology that allows us to analyze every dollar spent in the system. We can chart the best treatment options for patients using information from other patients and team with doctors in our system to develop standardized approaches to common disease states. We analyze trends and, therefore, can quickly identify potentially life-threatening practices. We've learned to measure and evaluate, and, as a result, we've been in the forefront of high-quality lower-cost care.
The recent healthcare reform debate has focused on the federal government, and clearly improvements are still needed there. But the most impactful solutions to our national health and healthcare needs won't be found in Washington. They are in our own hometowns, our hospitals, our doctors' offices, our homes—in our own attitudes toward health and care. By exploring those solutions, we can improve our nation's health, reduce our reliance on healthcare, and provide care that is both accessible and affordable.