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Tuesday, October 13, 2009
Greater than the Sum of the Parts: Creating an integrated health care system.
By Laura Davie, UNH Institute for Health Policy & Practice
When we look at the factors that affect our health we find that the most important factor is behavior (which accounts for 50% of health outcomes). That is followed by Environment (20%), Heredity (20%), and finally use of the Health System (10%). The stunning fact in light of these realities is that we spend 90% of our health care resources on medical care. We are a country that consumes twice the Gross National Product of all the industrialized countries on Health Care, yet leaves 20% of our citizens without coverage. This system does not support developing a healthy population. It is expensive, increasingly exclusive, and focuses on the treatment of illness rather than the improvement of health.
The Oct 20th NH Citizens Health Initiative/NH Public Health Association Fall Forum, New Hampshire’s Health System: Realizing a Goal of an Integrated Public Health and Personal Health System, offers an opportunity to look at programs addressing the system imbalance of treatment focus over health focus (http://www.unh.edu/chi/media/pdfs/fall-forum-2009.pdf) . It includes a keynote presentation from Assistant Surgeon General, Rear Admiral Michael Milner, who will be speaking about federal and regional perspectives that highlight the importance of this integration. Additionally, presenters will discuss seven New Hampshire programs that are also focused on this shift in paradigm. Our state is doing much to advance health reform on many levels, but without a thoughtful process and engaged dialogue from all, we may fall short of what we can truly accomplish.
During the year, the Citizens Health Initiative’s Health Promotion and Disease Prevention Pillar Project meetings have centered on the topic of integration of the personal health system (represented by the medical model) and the population health system (represented by the public health model). As part of those meetings, several programs that seek to promote the integration of personal and public health were presented. Programs included North Country Health Consortium’s Flu Vaccination Clinic, Mid-State Health Center’s Integrated Behavioral Health Program, and the University of New Hampshire’s Healthy UNH initiative. The main question for discussion as we heard from those programs was — and still is — How does each program intersect the individual health and population health systems? And we have found that there is also the question: How do we know the intersection when we see it?
I worked for almost twenty years in the medical system as a physical therapy assistant. Working one-on-one with patients and creating team environments with other medical health professionals was very rewarding. I transitioned away from both direct care and the medical system when I returned to school to study Health Management and Policy. I recall an essay that we read in one of my classes, titled “Who will build the fence?” The essay focused on how the traditional U.S. medical system is located at the bottom of the cliff. The system does everything it can to establish a strong infrastructure and resources to help those who fall off the cliff and injure themselves. It is important that we now focus on integrating systems to give us an opportunity to intervene before the fall. Thus, it is worth asking “why don’t we build that fence at the top of the cliff?” We have heard the reasons: “It costs too much”, “The fence is not in my backyard, so why should I care”, and “Stop policing me”.
Unhealthy alcohol use is an example of an issue for which there is a solution to integrate the population health and the medical systems. Unhealthy alcohol use is the third leading actual cause of death in this country and is a common focus of public health intervention. There is good research on the efficacy of Screening, Brief Intervention, Referral, and Treatment (SBIRT) in Primary Care Settings to reduce unhealthy alcohol use. SBIRT includes public health principles of screening and brief intervention, but goes further to identify treatment (the medical system). Implementing SBIRT into primary care requires system changes. SBIRT requires additional time spent during office visits, which needs to be accounted for in the payment structures for reimbursement for services. This brings up many questions—does this cost too much? Are people going to react negatively to being “policed” by their physician about drinking? Should insurance costs be impacted by a problem that is a behavior? SBIRT, when done correctly, addresses the public health issue of unhealthy alcohol use in the medical system before the issue leads to the medical disorders of the liver that are the consequences of the risk behavior. Chronic liver diseases are far more expensive to treat than the intervention that prevents them. How do we create a system that allows upstream intervention?
Several questions need to be addressed as we move forward—what programs, both medical-based and prevention-based, have proven to be effective? What are the barriers to wide-scale implementation? What is the best measure of a program’s cost-effectiveness over time? Does a certain prevention strategy infringe on personal rights and responsibilities? The questions should never go away. Instead, we need to continuously evaluate the outcomes of our interventions and identify changes needed to align with the best science. A recent Robert Wood Johnson Foundation Policy Brief “Cost savings and cost-effectiveness of clinical preventive care,” (http://www.rwjf.org/pr/product.jsp?id=48508) sheds light on efficacy, cost-effectiveness, and utility of many clinical based prevention programs.
If we are going to bridge the gap between the medical system working at one end of the spectrum and the public health system working at the other, we need to determine what the ideal system looks like. Both systems are important, but currently, at the state and federal level, there is no balance. Research is one piece, but sharing, evaluating, and implementing change in New Hampshire will take all of our attention. Devoting attention and resources to this will create an integrated system that truly is greater than the sum of its parts.
Tags: Fall Forum, Healthy UNH, Individual health, Integrated Health Care System, Laura Davie, population health, prevention, UNH, University of NH