Sick Care: Is There Any Healing Left in Health?

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Incentive structures in healthcare have to change. Right now, we pay for services, or have a so-called, “fee for service” system. The idea is that the more patients doctors see, the more expensive tests doctors order, and the more patients doctors hospitalize, the more money clinics and hospitals make. This incentive structure has transformed our health care into sick care.

The reality is, in America, we are adept at caring for complicated medical problems that require multiple tests, specialists, long hospitalizations, and frequent clinic visits. We focus a lot of resources and attention on this part of medicine because it is what we are paid to do. And to further our efficiency in providing this model of care, many medical systems have adopted business practices, like Toyota’s Lean Strategy, to run our hospitals and clinics more like factories. We essentially increase the number of cogs, or patients in this case, on our conveyor belt, to increase profit margins.

Now, it is only fair to acknowledge that “Lean” and other strategies to improve healthcare efficiency also have real hopes of lowering healthcare costs. In fact, there may be evidence of that. And streamlining health services so that every patient gets a standard quality of care, will likely create equity in the system and reduce costly medical errors, preventing patients from receiving disparate care based on race, gender, or cultural affiliation.

But as we extol the benefits of these patterns of practice, we must also be critical of their overall impact. Is the way we are paying for medicine coming at the expense of delving deeper into the heart of our field? As care becomes more standardized and protocolized, with each patient treated with machine-like accuracy and precision, we do improve “quality” and efficiency in the system. But where is the healing? Where is the prevention? Where is the practice of medicine caring for the human condition and working to keep us well?

Being well isn’t simply having your diabetes under control, it is preventing you from getting diabetes in the first place. If we continue to commoditize patients, valuing their ailments over their wellness, we miss the opportunity to provide the very care we claim to offer, health.

So how do we re-organize the way we pay for care to build a health care system instead of perpetuating a sick care system?

First, if we recognize that social needs have profound and costly health impacts, then as we transform our payment structures under the Affordable Care Act (ACA), we have to support innovative models that address social inequity. That means, using healthcare dollars that are typically spent on clinic visits and hospitalizations to also pay for education, food, housing, and job creation in low-income communities of color. That also means that in the spaces where we provide medical care, we should also be equipped to address patients associated needs. There are models for this.

Second, we have to change the narrative about what it means to provide care. We need to think about the overlap between natural life processes, like birth and death and medicine, and learn the limitations or boundaries of the medicines we wield. When there are no quick fixes or magic pills, how will we care for the human condition? In the spaces where listening is better than treating and healing doesn’t come at the end of a needle, we need to foster the relationships in our communities that provide healing and build resilience.

Third, it is time to transform the physician-patient relationship, a dynamic historically limited to a clinics and hospitals, to team-based care. In team-based models, physicians use their trusted relationship with patients to lead a team of community health advocates to address patients’ health needs in the places where they arise. Sometimes those places are hospitals and clinics but more often they are in homes and neighborhoods. The future of care, if we are smart, will deploy complex networks of healers that extend the reach of the system into people’s lives, supporting their wellness as we address their disease. This will require thinking across sectors, partnering with unconventional liaisons in the social service and for-profit sector, to have a coordinated approach for health.

Right now, The Department of Health and Human Services (HHS) is doing historic work to re-design how we will pay for healthcare. With the guidance of the ACA, HHS is laying out a plan for a population-based payment structure that incentives providers to be efficient with precious medical resources. Doing less for more means we will have to learn how to keep people well. These new changes have the opportunity to shift the focus of our system, towards health. Looking down the pike, let’s be actively engaged in ensuring quality, efficiency, and equity guide how care and healing are provided.

This piece was co-authored by my friend and colleague, Dr. Jessica Schumer. Follow her on twitter @schumerj.

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Black History Month and Health Inequity: The Connection between Social Realities and Clinical Norms

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Black History Month is probably one of the most underutilized opportunities to re-ignite the national conversation around social justice in America. As it is typically celebrated, like a random recollection of various contributions by “notable” African-Americans, it feels more like a stale tradition on the verge of irrelevance, than the opportunity to engage issues of racism and social inequality as historical American values that continue to define modern American life.

Last year, I shared why Black History Month remains an essential moment to nationally recognize the lives and works of African-Americans. Right? The original #BlackLivesMatters movement started in 1926.

This year, I want to flesh out examples of how historical American values around race continue to inform national issues and particularly examine how those issues impact health. I’ve talked about mass incarceration, gun violence, and gender inequality a bit in the past.

This month, I’m going to take on the industry of poverty, and child poverty in particular, and how national, state, and local public policy may engineer disadvantage in ways that have profound impacts on health. I also want to talk health systems transformation and consider new models for healthcare delivery that may uniquely serve low-income, communities of color.

And lastly, I want to speak openly and honestly about my dismay with the medical community and our lack of public acknowledgement of the deaths of Oscar Grant, Michael Brown, Tamir Rice, and the other recent victims of police brutality. Lest, we begin to believe that police are the only modern manifestation of our nation’s tragic history with race, I am going to talk about institutional racism and how physician bias directly impacts the health of communities of color, threatening their lives in quantifiable ways.

We are never farther than our willingness to look at where we’ve been allows us to be. In our plight for justice, to move forward, we have to understand where we’ve come from. In February, we are sitting in a powerful moment to look honestly at our nation’s troubled history with race and inequality and find clarity around the pressing issues of our time. Join me this month in discussing how those issues impact our health!

And if there are topics you’d like to talk about, join the conversation and leave a comment below.

10 Minutes for Truth on Measles

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To my medical colleagues, fellow health advocates, and concerned community:

As the recent measles outbreak continues to spread, spurred largely by at-risk, unvaccinated or undervaccinated children and adults, it is time to elevate our voice as physicians, scientists, and health advocates to educate the public on the importance of immunization. Let’s counter the misinformation dominating the headlines with the truth about vaccines!

10 Minutes For Truth: Measles
This Friday, Feb 6, 8am PST/11am EST, join the American Academy of Pediatrics, physicians, scientists, and health advocates across the nation in a live Twitter and Facebook storm. For 10 minutes, let’s sound off on measles and why vaccines are vital for the health of America!

The Hashtag
Use the hashtag #10Minutes4Truth AND #MeaslesTruth to create a social media storm. Let’s get the truth about measles trending!

What Should you Tweet or Facebook?
It is important to share the power of science in communicating this message. But also consider personalizing your content, ie “I immunize myself or my children because…” OR “Ask your pediatrician if they immunized their children on time?”

Consider referencing these informational links in your message:

Quick Facts

  • After 1 dose of MMR 95% of toddlers are protected, after 2 doses over 99% of children are protected from measles for a lifetime
  • Getting the measles vaccine is much safer than getting the measles infection.
  • The MMR vaccine is one of the most effective vaccines available today.
  • The risk of the measles vaccine causing serious harm is extremely small – less than one in a million people who receive the vaccine will experience a severe reaction.
  • 1 to 2 in every 1,000 people who get measles will die from it. Children under age 5 are at higher risk for complications like pneumonia
  • Measles is one of the most contagious viruses on earth.
  • Measles remains infective in the air for up to 2 hours in a room after an infected person has been there.

The time is now. Raise your voice and spread the truth! #10Minutes4Truth #MeaslesTruth

Also, we want our impact to be as big as possible, so please share this with your networks, colleagues, and fellow advocates. Thank you!

Rhea W Boyd, MD
Pediatrician, Palo Alto Medical Foundation and UCSF Children’s Hospital Oakland
@RheaBoydMD

Wendy Sue Swanson, MD, MBE, FAAP
Pediatrician, Seattle Children’s Hospital
@SeattleMamaDoc