The American
Health Care Paradox:
Why Spending More is
Getting Us Less
1
Outline
Unraveling the paradox
Recurrent themes from service US providers and users
Learning from abroad
Homegrown innovations here in the US
2
The Paradox
“THEN THERE’S THE
PROBLEM OF RISING COST.
WE SPEND ONE AND A HALF
TIMES MORE PER PERSON ON
HEALTH CARE THAN ANY
OTHER COUNTRY, BUT WE
AREN’T ANY HEALTHIER FOR
IT.”
- JOINT SESSION OF CONGRESS ON
HEALTH 9/9/09
3
High Spending on Health Care
$9,000
$8,000
$7,990
$7,000
$6,000
$5,000
$4,000
$3,000
$5,348 $5,135
$4,225 $3,711
$3,379 $3,252 $3,035
$2,000
$1,000
$923
$0
Per capita data downloaded from OECD.StatExtracts. Available at stats.oecd.org
4
US Poor Ranking among 34 OECD
Countries
35
30
31st
25th
26th
28th
25
20
15
10
5
0
Maternal
Mortality
Life Expectancy
Low Birth
Weight
Infant Mortality
Source: OECD, Health at a Glance 2009: OECD Publishing
5
What could help explain this paradox?
6
Incorporating Social Service Spending
35
30
25
20
Total Social Service
Expenditures
15
10
5
Total Health
Service
Expenditures
0
7
In the US, for $1 spent on health care,
about $0.55 is spent on social services
In OECD, for $1 spent on health care,
about $2.00 is spent on social services
8
Methods and Findings
Using OECD pooled data from 1995-2007 on 29 countries,
multivariable regression with 5 health outcomes
The ratio of social to health spending was significantly
associated with better health outcomes:
- Less infant mortality, low birth weight,
premature death; longer life expectancy
- Non-significant for maternal mortality
This remained true even when the US was excluded from
the analysis
Bradley et al., BMJ Qual and Safety 2011
9
Why do we do it this way?
Health care and social service sectors grew up fairly
independent from one another
Health care grew professionalized
and fit into a marketable, valued
commodity for purchase
Social services, in contrast, were
conceived of “the poor” or aged
and the target of charity
10
Recurrent Themes from Provider Interviews
1. Frontline personnel are stretched to respond to the
concerns of service users with limited resources.
2. A more holistic approach was desired by both health
care and social service providers.
3. Difficulties in establishing relationships between
social services and health care have many roots.
11
Frontline Personnel Stretched
I am sitting here writing a prescription [for] this person
who has limited ability to afford the medication or have
insight on the situation, who can’t go outside because
the neighborhood is unsafe…and I am totally unable to
do my job.
-Internist
We have a client who was hospitalized three times in 72
hours because they didn’t take the time to really look at
what the problem was. They sent her home at
midnight. The next morning before seven, an
ambulance come to get her again.
-Social Worker
12
More Holistic Approach is Desired
What we do is an “all treaters” call -- everyone who is
involved with the person, we will sit down at the table
and discuss the person, what is the best care that we
can give them….We can get three or four agencies
working simultaneously side by side for one person;
the key is communication and cooperation because if
you don’t cooperate, it doesn’t get you anywhere.
- Case manager
13
Many Barriers to Holistic Care
- Lack of resources
- Differences in cultural and professional norms
- Technological and data limitations
Even if you got past the privacy issues, it is very hard
to tie in all of the information that was useful for the
hospital based provider, the outpatient based
provider, and social services to be able to capture
what an individual is thinking or feeling at a given
point in time, to know what intervention is necessary.
-Social worker
14
User submitted comment
The National Memo
“…this thesis is starting to be accepted. You can see it in
the models being rolled out in NY State…”
Huffington Post
“Rebalancing what we spend on medical care and
social services can potentially deliver better health
outcomes at lower cost. Cracking this code is a
challenge that should concern us all.”
Experience in Other High-income Countries
16
Conception of Health
Your health means everything.
- Winthrop University Hospital
People should know that health is not the goal of
life. But health is definitely a means that you can
use to choose exactly the life you want because if
you don’t have health, then your possibilities cannot
flow and grow.
-Danish Health and Medicines Authority Executive
17
Joint Planning and Budgeting
It is a closed system where 80 percent of the
decisions, even those they are decentralized, are
made within the public integrated system. So…if one
department…goes beyond its budget, somebody
else will have to be below it.
- Denmark, senior health policy analyst
18
Comparisons in Values
(Scandinavia versus U.S.)
World Values Survey, an
international open source of
empirical data measuring
individuals’ values
In-person surveys of about 1,000
randomly selected respondents
in 55+ countries
Data represent Sweden, Norway,
and United States
Differences (P<0.05)
Scope of social contract
Views of income, equality
and social mobility
Degrees of trust in “the
other”
19
Is there any good news?
20
Homegrown Innovations
•
•
•
•
•
Public and private sector
Non-profit and for-profit
High and low-income clientele
A range of business models
Geographic diversity
– New Haven, CT
– New York, NY
– Portland, OR
Partnership between health care
– Santa Monica, CA and social service providers  TODAY
21
C-TRAIN (Portland, OR)
• Academic medical center
• 570-bed facility
• 33% of patients are un- or
under-insured
• 501c3 serving Portland
• Serving individuals and
families facing
homelessness, poverty
and addiction
• Affordable housing is
primary service, plus
health care, recovery
services and employment
assistance
22
C-TRAIN Leadership
Dr. Honora Englander,
Assistant Professor of
Internal Medicine, OHSU
These interdependencies between
medical care and social
determinants of health exist
whether we want to acknowledge
them or not… So I figured that if
we’re not getting the outcomes we
want by not acknowledging these
interdependencies, maybe we
should try something different.
23
The C-TRAIN Model
Key features
(1) Built on hospital emphasis on discharge planning
(2) Assignment of a transitional nurse
(3) Prescription assistance for patients
(4) Sustained primary care at Central City Concern
- Also access housing resources, insurance
programs, financial and legal services etc.
Outcomes
RCT has found C-TRAIN patients experience lower
mortality and improved quality of care; hospital is
funding expansion
24
Project HEARTH at OPCC
(Santa Monica, CA)
• Part of Sisters of Charity
Catholic Health System
• 266-bed facility
• Commitment to investing
in community benefit
programs
• Over $33 million in
community benefit
spending in 209
TEAM PHOTO
• 501c3 serving Santa
Monica, est 1974
• 10 main services
including homeless and
domestic abuse shelters,
addiction programs etc
• Serves more than 8,000
individuals a year, 98% of
whom fall below poverty
line and 20% are <21
25
Project HEARTH Leadership
Our population is
really defined by this
tri-morbidity, in terms
of medical conditions,
mental illness and
then substance abuse.
So we’ve really tried
to integrate our
response.
John Maceri, Executive Director of OPCC
26
Bradley/Taylor: Inadequate attention
to and investment in services that
address the broader determinants of
health is the unnamed culprit behind
why the United States spends so
much on health care but continues to
lag behind in health outcomes.
Pow!
I can never consider U.S. macrohealth spending again and ignore
this piece of the puzzle.
- John McDonough, Boston Globe
27
Connect with the Authors
Learn more at: theamericanhealthcareparadox.com
Follow Betsy Bradley on Twitter @ehbyale
Follow Lauren Taylor on Twitter @LaurenTaylorMPH
28
Thank You
29
But if we add in social service
spending…
30
Washington Independent
The flawed American health care system is not
exclusively a problem of the “poor.” Those at greater
risk in the system also include relatively isolated people
at many income levels who lack supportive family and
friends…these vulnerable people often call for an
ambulance when what they really need is a shoulder to
lean on and emotional support.
Amazon review
Spending on health care cannot be looked at without
considering the investment in social services that
impact public health. This is all too often missed. The
consequence is that governments like the US spend
more money on treatment...than on dealing with the
underlying factors that cause those health issues in the
first place.
Final Thought
This is work with a different set of values from the
ones that medicine traditionally has had: values of
teamwork instead of individual autonomy, ambition
for the right process rather than the right
technology, and, perhaps above all, humility—for
we need the humility to recognize that, under
conditions of complexity, no technology will be
infallible. No individual will be, either.
- Atul Gwande, The Velluvial Matrix
33