Health Affairs arrived in the the mail today.
I pulled it open like an excited kid opening a birthday gift. Despite my affection for all-things-digital, there is something to be said for propping my feet up on the coffee table and reading insightful work on important subjects.
This paper describes a compelling story that I'll try to paraphrase - as it introduces the concept of PROTECTION that I'd not previously considered.
The authors consider three possible interventions to improve the health status of a population:
- Coverage (increasing the scope of insurance coverage)
- Care (facilitating providers and patients to follow best practices for preventive and chronic care)
- Protection (enabling healthier behavior and safer environments)
The paper describes the results of a modeling exercise in which a population receives one, two or all of these interventions. The results predict that expanding coverage would result in modest improvements in health status and cost, Coverage PLUS Care results in better health status and reduced cost - and (after a 3 - 5 window of increased cost) Coverage + Care + Protection results in MUCH better overall health status and reduced cost.
So what? This study reminds us that:
a) Expanded coverage is not the only answer. In countries with universal coverage - we see good validation of this unfortunate reality.
b) Better care is also a necessary but incomplete solution.
c) The hardest part - and likely most essential - is that we need a cultural shift in how we can create and maintain a healthy environment.
How do we get there from here?
My intuition is that we treat the nation (globe) as we would an addict. We have become addicted to certain behaviors that we know to be destructive. Yet we continue. Smoking, obesity, lack of exercise, over-eating ... these are all key components of our addicted nation.
Years ago, I became impressed with the work of William Miller, Marian Stuart, and James Prochaska - and used their techniques successfully in my practice. The common thread is that we understand and support our patient's interest in following a path toward better health. This is terribly hard to do in a manner that isn't judgmental. But when we judge ("this is bad behavior") we alienate the patient - and make collaboration more difficult. It is only when we are open to the outcome - but not focused on one outcome in particluat - that we collaborate toward success.
So when the patient is a globe or a nation or a community - how might we mive forward?
a) Recognize and reflect. "Is this how you want to be living? Is there anything you would like to be different?"
b) Celebrate Success. "How have you been successful in the past? What might you try again in the future?"
c) Offer tools and support. Reminders, suggestions for alternatives, skill-building.
I often notice that many communities have built such traditions that they don't even know how to behave differently.
In our industry - HIT - I think that be most productive use of our time is to focus on (c) - so that we can help providers and patients collaborate (a) and (b).
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