Friday, July 31, 2015

In Sickness and in Health

Published in VC's Notes on July 31, 2015

In Sickness and In Health

Our health-care system is good.  In many cases it's excellent.

But it has a host of well-documented problems.

Health care is often too expensive.  The quality is not always what it needs to be.  The resources are fragmented and unevenly distributed.  And far too many people have difficulty with access, because of where they live or how much money they make.

And then there's the matter of perspective.

As health-care providers, our focus has been on what happens when things go wrong…when diabetes appears, when a motor vehicle crashes, when a heart defect is diagnosed.

Even though our ability to attend to such things is vitally important, what about the rest of the story?

Notice that I have been talking about "health care."  Increasingly, our focus is turning beyond health care to "health."

Why?

Because if we are engaged with our patients when they are essentially healthy, then we can intervene earlier when problems appear.  In most cases, we can steer them back to health and avoid an expensive hospitalization.

For patients with a chronic illness like diabetes or heart disease, close monitoring can keep their condition stabilized and, again, can prevent more serious interventions that require a hospital stay.

To fully realize this new perspective on health, in an ideal world, certain conditions would have to be met.

Everyone would have a "medical home."   This is where patients receive primary and preventive care.  It's their "go to" place when they are sick; otherwise, they may end up in a hospital emergency department.

Having spent much of my career in emergency medicine, I have seen first-hand what the lack of basic health care looks like. And while I applaud all who work in emergency medicine, the ED is not the same as a medical home.  But too often it is viewed by a patient as the only option when the foot ulcer has become infected or the chest pain has gone on too long or the mass didn't go away.

Clearly, this is a major problem for Mississippi, where rural hospitals are struggling and many communities in the state are without a physician.  Aside from educating more providers, we are exploring new models of care that can substitute for the traditional medical home.  If a community can't support a hospital, for example, maybe it can support a clinic with front-line providers and a telemedicine link.  If it can't support a clinic, then perhaps a mobile unit staffed with advanced practice providers can make regular visits.

Everyone would have health insurance.  This is the ticket to ride the health system, and if you're not riding, then you are back to getting your primary care from the emergency department - if you're lucky enough to live near one - or you are delaying a visit to the doctor to address that chronic cough because of the out-of-pocket cost.

Insurance - whether it's government-sponsored, employer-sponsored or third-party - is becoming the primary means by which price/quality competition is injected into the system.  Increasingly, provider groups are being asked to accept responsibility for the health status of a set of patients in exchange for a single payment, rather than being paid for each episode of care.  That's why it's incumbent upon us to manage our costs, improve our quality and be engaged with our patients beyond the four walls of the hospital or clinic.

Caregivers would attend to the patient and to the context in which the patient lives.  Accepting responsibility for the patient's overall health, and not just his or her episodes of illness or medical need, requires us to think about all the factors that influence health status.  Among these non-medical "social and behavioral determinants of health" are the patient's income, education and health-related behaviors such as smoking, exercise and diet.

For example, it may not matter whether a patient has health insurance if he rarely gets any exercise and eats a high-calorie, low-nutritional diet consistent with obesity.  On the other hand, if he lives in a crime-ridden community, even the simple act of taking a walk may not be feasible.  If we are accountable for that patient's health, then we will be engaging him in strategies that support a healthy lifestyle.

These three broad areas I've discussed may seem far away, but we have many initiatives in place that are preparing us for this future state.  We have nurses in schools.  We have inner city clinics.  We are training laypersons as community health advocates.  We are helping people find medical homes (our Department of Family Medicine has just been recognized as a "patient-centered medical home").  We are visiting rural areas in a clinic on wheels.  We are connecting our patients to healthy lifestyles through wellness programs.  We are deploying telemedicine to underserved areas.  And we are continuously raising the bar on quality and managing our costs.  The list goes on and on.

One of my goals is to get all of these activities connected as part of a single, over-arching strategy for population health.  Many people will play a role in this, but two key leaders are Dr. Bettina Beech, associate vice chancellor for population health and professor of pediatrics and family medicine, and Dr. Josh Mann, who recently joined us as professor and chair of the newly reconstituted Department of Preventive Medicine in the School of Medicine.  Among their priorities, in addition to this extensive focus on our patients' health status, will be to add layers of education and research to all our activities in this domain where they are not already present.

As we look to the new "state of health" in Mississippi, it will take more than our efforts alone to achieve our goals.  We will work collaboratively with many others.  And not all the factors I've discussed above are under our direct control.  But we will be the leaders of this movement, on our path to A Healthier Mississippi.



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