Q&A: Deconstructing the American Healthcare Paradox

by Shannon Firth  Contributing Writer
Shannon Firth

America spends more on healthcare than any other developed nation and yet our performance is middling.

According to well-publicized data, per-person healthcare spending in the U.S. is more than twice the average for other countries in the Organization for Economic Cooperation and Development (OECD). The U.S. also spends roughly 17% of its GDP on healthcare, according to the OECD’s 2009 estimate. Yet average health in the U.S. is not dramatically better than in other industrial countries – in many respects, it’s worse.

To help explain this conundrum, MedPage Todayspoke with Elizabeth Bradley, PhD, faculty director of the Yale Global Health Leadership Institute and author of “The American Health Care Paradox: Why Spending More Is Getting Us Less” with Lauren Taylor, MPH.

Bradley began to tug at the issue of health costs and outcomes while teaching a public health policy class at Yale University in 2006. Nearly a decade ago she asked herself, “How could we be spending so much on healthcare but not be healthy?”

After much research, Bradley realized the common vision was too narrow. She and others were neglecting key factors that make a population healthy or unhealthy, such as housing, education, nutrition, and jobs – the things that are beyond medical care.

So, instead of looking at healthcare costs alone, she combined them with the cost of social services and compared that sum to what other countries were spending.

“[I]t suddenly seems to break the paradox open,” Bradley said. “Actually, we don’t spend more than anyone else. We just spend more on medical care.”

This conversation with Bradley has been condensed for length.

What’s the greatest barrier to integrating social services and healthcare?

We don’t have one congressional committee that can actually budget for healthcare education, nutrition, and income support. Those are all separate committees.

We also don’t measure the same things. Healthcare performance is measured by meeting clinical guidelines. Housing quality, for example, is measured by the number of homeless people in a town.

Whether you are delivering healthcare or providing housing, we’d be a lot closer to being able to integrate these sectors, if they were incentivized by the same performance goals.

What might that look like?

This is very out there, but imagine a world in which there was a small amount of reimbursement that was driven by a set of measures like the percent obese in your catchment area or your client base, or the percent depressed, or the percent on target to finish high school.

If the goals were joint goals, the hospital would suddenly have board members communicating with job training agencies, and housing supervisors would begin talking to providers about depression outcomes, as result of homelessness.

If you had a set of measures that everybody was held responsible for, it would force people to work together. We just don’t have a system like that anywhere, yet, but maybe someday in the future.

Your book was published in 2013. If you were adding a new chapter this year, what would be its focus?

We have a study underway right now where we’re looking at the counties in the U.S. that have every risk factor for being obese but they happen to not be obese. They’re in the bottom quintile for obesity in the country. So, to be able to study more examples of great practices in the U.S., I think that would be great.

Also, our states are quite different in terms of how they invest in healthcare services and social care services, and we’re correlating that to health outcomes in states.

We started a study looking at the social and healthcare services, state by state to understand if they track with the state level variation.

Those are chapters I would like to add if we could.

Why did you choose to write about the Scandinavian model of healthcare?First we picked them because the social democracies of Scandinavia (Sweden, Norway, and Finland) over decades have had lower costs and better outcomes than most of the Organization for Economic Cooperation and Development (OECD) high income countries.

We make no recommendation in the book to adopt a Scandinavian model. None. But what we try to do is hold it up and say “What can we learn from this?”

One thing we thought we could learn is that they get together at a county level and they budget and regulate their social services and their health services together in a very transparent method by elected officials.

We won’t do that with our government, but we could maybe do it at the more local level, even with employers.

We’re already starting this with Centers for Medicare and Medicaid Services (CMS). A lot of their innovations have been to give a geographic area a certain amount of money and say, “meet these quality targets and do it anyway you can. We’ll be flexible on whether you spend the money on housing or healthcare, for instance.”

Do you feel like we’re spending too much on innovation? How do you feel about President Obama’s Precision Medicine Initiative?

Two different things are happening.

One is using basic science to create better medicine in the future.

I would say the Precision Medicine Initiative is a very good investment. First of all, $215 million is not that much compared with our whole health system, which is trillions of dollars. But I think it does hold great promise.

But we also have a tremendous amount of innovation like level 2 mammography or really intensive PET scanners that are really good and efficient when they’re used on patients for whom they’re really needed, but the kind of financing system we have makes it hard for physicians and patients to restrain themselves from just using them all the time.

It’s like we said in the book, if you have a hammer, everything looks like a nail.

Did you and your co-author have concerns that your book and your research might be misinterpreted?

We were worried that people would think this was all just about poverty and how to care for poor people better.

There’s no question that drives some of this, but we wanted to make a bigger case that even among the fully insured middle class, we tend to turn very quickly to medicine. We tend to say, “My shoulder hurts. Gee, I better get an MRI,” as opposed to “maybe I need to work on my core.”

Even in our middle class, we’ve created such a huge medical care system and given people access to it, that it masks what we could do ourselves to sustain our health in a cheaper way and one that is more effective.

We were also concerned that people would think we were calling for a huge social welfare state, and that wasn’t the message at all.

What we were really saying is we need to take the money that we are spending and spend it more wisely. That means reminding medical care systems that they can work at some of the social sides of health and coordinate better with them. We might get better outcomes for the same costs.

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