health care

Moving Care Upstream, Addressing Social Determinants

By Michael Dowling

Health care in the US is not a system so much as it is a series of experiments—a constant state of flux where professionals are trying new ways to improve and deliver care. While there are certainly inefficiencies and we can do better than we have, what we do in health care is not only quite valuable but also quite extraordinary. We have developed a complex modern medical health system that is incredibly expensive but is also extremely productive.

The new American medicine is proactive. Physicians work in teams with nurses and other caregivers to guide patients along a pathway to health and wellbeing. Our main obstacle? It may be the stasis that sometimes grips major stakeholders—a group too entrenched in “the way we’ve always done it.” While progress has been made in crossing the chasm to a payment model in which providers are reimbursed based on their success in managing people’s care, the system still relies heavily on an outdated fee-for-service model that pays doctors and hospitals for the volume of services provided. While it may have served its purpose in the past, it’s a financially unsustainable model that has grown unwieldy through the years, like an invasive species wrapping itself around the care delivery system and choking out payment reform innovation.

As suffocating as that methodology may have become, there is a way out. When you change the way doctors and hospitals are paid, you change the way doctors practice and the way patients are cared for.

A value-based payment model promotes better coordination of care and reduces the incentive to refer patients for unnecessary tests and procedures. The goal is to create a proactive care approach to managing the overall health of individuals and communities. It is a methodology that promises high quality and efficient care with minimal waste and delay.

Truly taking care of a community by addressing the social determinants of health like income, access, and education, among many other factors, may be the most disruptive challenge to the US health system. That’s where the innovative spirit—long a core characteristic of American medicine—will need to be stronger than ever.

It is a revolutionary idea and it’s not easy to accomplish, but getting people to take a hard look at their lifestyles and how their choices are affecting their short- and long-term health has the potential to drive meaningful change. If we look at health care in terms of a river analogy, the goal is to have physicians lead, partner, and support efforts to move care upstream and prevent problems from occurring at their source. As the analogy goes, it is easier to rescue someone if you prevent them from falling in the river in the first place instead of trying to pull them out of the water downstream. When it comes to health, it’s a strategy that makes good sense. As the medical adage goes: an ounce of prevention is worth a pound of cure.

The two innovations are interconnected. Changing the payment model will cause a domino effect that results in an overall change to our national approach of health and well-being. That’s because when you change the way providers are paid, it means that clinicians will change their focus to more proactive care, which in turn means going back upstream and targeting social determinants.

There is no doubt that we need to fix those areas that need fixing. But changing the way we look at health and well-being is an important first step. By opening the door to change and innovation and looking at things differently, we create possibility.

For instance, at Northwell Health we’re knocking down the wall between psychiatrists and doctors treating physical maladies. Instead of psychiatric care being something apart from the normal practice of medicine, we’re incorporating primary care into psychiatric consultations. For every $1 spent on collaborative care, health care organizations gain back $7 in cost savings over the next four years. That makes good health and economic sense.

While cynics may adopt a show-me-first attitude, true innovators don’t wait. They are busy leading the way forward. One only has to look at our recent past to see just what the innovative spirit at the heart of American health care can accomplish. When it comes to the heart, for example, the progress we have made treating heart disease is one of the great triumphs of modern medicine. The age-adjusted mortality rate for cardiac disease has been reduced by about 50 percent over the past 50 years.

But the medical disrupters haven’t stopped there. They’ve improved health care in America – by improving quality, safety, and access. In addition to heart disease, we’ve also seen advancements in the treatment of cancer and stroke care, and the emergence of bioelectronic medicine, among so many other innovations that hold the promise of reducing our reliance on prescription drugs and all of the side effects that come with them. It has been an amazing run. And I think we’re in for another.

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