FOUNDATIONS
OF U.S. HEALTH
CARE DELIVERY
FEBRUARY 27, 2014
LET’S DRAW A PICTURE
How would you describe health care today?
Why are people healthy? Why do people get sick?
How is health and sickness addressed in this country?
What role do health care organizations play?
…does the government play?
…do clinicians and physicians play?
…do individuals play?
LET’S DRAW A PICTURE
In a perfect world, how would you describe health?
How would sickness get addressed?
What role would health care organizations play?
…would physicians or clinicians play?
…would individuals play?
What kind of health care organizations would exist?
HOW DO YOU GET THERE?
Is the “ideal” possible?
What would you need to do? What roadblocks exist?
How would you plan health services?
How would you improve health?
WHERE DO THINGS
CURRENTLY STAND?
Which of the following statements is true?
“The U.S. has the best health care system in the world!”
“No way, the U.S. health care system is, at best, average.”
It depends on who you’re talking to and about…
Individual?
Population?
It depends on how you define and measure health care…
Access? Cost? Quality? Outcomes? Equity?
UP FOR DEBATE
The health care industry feels strong tensions and conflicting
pressures
What is health? What is health care?
Is health care a need? A right? A privilege?
If we think about population health, who’s the population?
What’s the role of health care organizations?
Economic or social benefit?
Reactive or proactive?
WHAT IS HEALTH?
“Last week about 30 of us spent 36 hours in The Hague
discussing whether we could produce a new definition of
health – and eventually deciding that we couldn’t” (Smith, 2009)
“Defining health appears to be a simple, even unnecessary,
matter that does not spark the interest of most healthcare
workers. Everybody knows what health is – that is, until they
are asked to provide a clear and concise definition of the
word. Not only is it hard to provide such a definition but, if
past experience is anything to go by, those devised are
unlikely to stand up to critical scrutiny well enough to gain
general approval However, that is no reason to stop trying”
(Lewis, 2013, p. 211)
THINK, PAIR, SHARE
What is health?
How would you define it?
Is it the absence of disease?
Is it an experience?
A physical state?
How you feel?
How would you measure it?
Is it a continuous spectrum?
What variables might affect it?
WHAT IS HEALTH?
“A state of complete physical, mental, and social well-being
and not merely the absence of disease or infirmity”
(World Health Organization, 1948)
“The ability to adapt and to self manage” (Huber et al., 2011)
“A balanced state between physical, emotional, social and
cognitive/sense-making domains. Within any local
environmental context, a health state exists within a
multidimensional phase space of physical integrity,
functional performance and subjective experience producing
an entropic state most consistent with viability… Health is a
complex adaptive state in so far as the inner workings at a
psycho-neuro-immunological level maintain a certain
homeostasis for self-sustaining physiological function”
(Sturmberg, Topolski & Lewis, 2013)
WHAT IS HEALTH?
Does that sound like our system? Is that what it does?
“For most doctors that’s an uninteresting question… doctors
are interested in disease, not health. Medical textbooks are a
massive catalogue of diseases” (Smith, 2009)
Our system has developed with a focus on disease diagnosis
and treatment
Health care in the U.S. has traditionally been
governed by the biomedical model
…Health is the absence of illness or disease
Health care delivery focuses on medical or illness care, and
prevention of disease and health promotion are secondary
WHAT IS HEALTH?
The WHO definition of health adopts a biopsychosocial
model: physical, mental, and social dimensions
Physical
WHAT IS HEALTH?
There has been a recent growing interest in holistic health
Health indicators include:
self-reported health status
Physical
disability
life expectancy
Mental
social functioning
Social
spiritual well-being
morbidity (disease)
functional limitations
mental well-being
Spiritual
OUT OF BALANCE?
Our adoption of a broader conceptualization of health is a
marathon, not a sprint…
“Despite almost universal references to ‘health care,’ ‘health
insurance,’ ‘health benefits,’ and ‘reforming the health care
system,’ the unfortunate truth is that all these terms are
misnomers. The United States has a medical care system
focused on diagnosis and treatment of those with disease (or
at least ‘dis-ease’), not a health system that addresses the
needs of the healthy. However, powerful, effective
technology now exists to prevent illness and maintain
health” (Peterson & Kane, 1997, p. 305)
THINK, PAIR, SHARE
How should health care be provided if a holistic definition of
health is assumed?
WHAT IS
HEALTH CARE?
It’s complex
Is it a service? A good? A philosophy?
Is it a process? A system? A one-time intervention?
“…the diagnosis, treatment, and prevention of disease, illness,
injury, and other physical and mental impairments in humans.
…It refers to the work done in providing primary care, secondary
care, and tertiary care, as well as in public health” (Wikipedia, 2014)
“The maintaining and restoration of health by the treatment and
prevention of disease especially by trained and licensed
professionals (as in medicine, dentistry, clinical psychology, and
public health)” (Merriam-Webster Dictionary, 2014)
WHAT IS
HEALTH CARE?
A different perspective:
“Health care is a targeted perturbation of the ‘patient system’ that
facilitates the system ‘to do the necessary adaptive work’ to
achieve (self-)healing. This stands in stark contrast to the
prevailing ‘healthcare’ approach of targeted ‘curative
interventions’ done to the patient by others (known as healthcare
providers). Health care becomes a participatory encounter
between two experts who work together to achieve a common
understanding of the patient’s disease in the quest to succeed in
the struggle for life, and at times, this may entail the ‘passive’
endurance of interventions aimed to maintain one’s life”
(Sturmberg, Topolski, & Lewis, 2013)
CHOOSING BETWEEN
PANACEA OR HYGEIA?
The divide between health and medicine goes wayyy back to
ancient Greece…
Panacea: the goddess of cure and remedy
Hygeia: the goddess of health and well-being
Continues to be reflected in our “dual systems” relating to
health care
Curing disease?
Or promoting well-being?
WHAT IS HEALTH CARE?
HOW DO WE PROVIDE IT?
Informed by how we view illness and disease
Informed by how we view quality of life
Informed by how we view determinants of health
Informed by our perspective of health distribution
ILLNESS VS. DISEASE
Illness
A person’s own perceptions and evaluation of how they feel
Disease
Based on a medical professional’s evaluation
Falls along a spectrum
Chronic
Acute
QUALITY OF LIFE
Overall satisfaction with life and self-perceptions of health
Satisfaction with experience of receiving health care services
Comfort
Dignity
Privacy
Security
Degree of independence
Decision-making autonomy
Personal preferences
DETERMINANTS OF
HEALTH
A singular focus on medical care delivery is unlikely to
improve a population’s health status
Multiple factors determine health and well-being
A more balanced approach is required
DETERMINANTS OF
HEALTH
Environmental factors
Behavior and lifestyle
Heredity
Medical care
Examples:
Physical activity
Tobacco use
Sexual behavior
Injury & violence
Immunization
Overweight/obesity
Substance abuse
Mental health
Environmental quality
Access to health care
MARKET VS. SOCIAL
JUSTICE PERSPECTIVES
Who should receive the medical goods and services that a
society produces?
Market justice perspective
Economics-based (supply & demand)
People make rational choices and know what’s best for them
Minimal need for government interference
Social justice perspective
Health is a social good, access is a basic right
Government is more efficient to allocate health services equitably
Need for government to plan and deliver health care
MARKET VS. SOCIAL
JUSTICE PERSPECTIVES
What are the implications?
Market justice perspective
Individuals are responsible for their health and well-being
Social problems can be addressed through private solutions
Rationing is based on the individual’s ability to pay
Social justice perspective
Society is collectively responsible for its health and well-being
Social problems require public solutions
Rationing is based on health care planning
THINK, PAIR, SHARE
Which makes sense to you?
Should our health care system favor market justice?
Or is social justice the better way?
What do you think?
WE’VE GOT BOTH
Medicare & Medicaid vs. private, employer-based insurance
Government oversight of insurance, payment,
new drugs & procedures, medical research,
information systems, quality, etc.
Public health & population health vs. individual interventions
How are we wrestling with this today?
HEALTH CARE
INTERVENTIONS
Policy interventions
Community-based interventions
Health care system interventions
Individual-level interventions
Strategies to improve health
Nutrition programs
Work/environment safety efforts
Community-based partnerships
Patient safety & medical error reduction
Chronic disease management
Prevention-oriented effort
Coordinated care
Culturally appropriate care
INITIATIVE EXAMPLES
http://www.healthypeople.gov/2020/default.aspx
http://fitcitysa.com/about
IS THERE A REMEDY?
What will it take to fix what’s broken?
From a system hampered by…
Quality concerns
Ineffectiveness
Patient uncertainty
Inconsistency
Redundancies and waste
Inequality
Fragmentation
Unsustainability
Can we bend the curve?
To a healthcare system that is…
Safe
Effective
Patient-centered
Timely
Efficient
Equitable
Coordinated
Affordable