by Ramon A. Robertson
In Population Health: Transforming Health Care to Improve Our Health, Dr. Sederer’s central thesis, is that we must expand our collective consciousness (as medical doctors, public health specialist, and private individuals) of the tenants (or determinants) which are ultimately driving our health status outside of provisional healthcare services. Further, we must realize the modicum of worth (10%) that “healthcare” provides to our human experience, and instead, consider more closely, the truly impressive determinants that modulate the crux of our health as a population. 1
He points out that what is actually making us sick, are our poorly self-regulated behaviors and practices — “excessive and poor eating, more than moderate drinking, smoking, [lack of] physical activity, high salt and processed food intake” — that are most responsible for the steady decline in health and growth in illness. 1 Though many fall back on the genetics controlling their fate argument, Sederer points out the reality that though genetic effects are indeed hardwired, they can be modulated by environmental exposures to either remain quiescent or manifest destructively. 1 Sederer also reminds us that this discussion is not merely an academic one, as the gravity of a structurally unsound healthcare system is reflected in our country’s financial statement — in that we spend on average almost a fifth (18%) of our nation’s GDP ($2.7 trillion annually) on healthcare costs — far above any other comparably developed nation in the world. 1
In considering solutions, he offers a health pyramid (a composite of work by the CDC and Dr. Thomas Frieden) that situates drivers of health (based on impact). “Counseling and education (eat healthy, be active) and clinical interventions (prescriptions for high blood pressure and cholesterol)” rank low on the totem pole as drivers of population health, while “changing the context (to make individuals’ default decisions healthy)” and modulating “socioeconomic factors (poverty, education, and housing)” took home the award of having the greatest promise of potential for creating successful population based policy reforms. 1
Sederer then addresses the feasibility of this potential change and argues that we must find a way to make health matter to society—on an individual and collective level. He cites that we already know that “illness is bad for business,” lowering productivity via “absenteeism, presenteeism (showing up but being unproductive)” and that “10 percent of patients account for 75% of [healthcare] cost.” But what we need, is different from what we already recognize: we need to “change behaviors and environments people live and work in,” because unless we do so, there will be a “limited impact on the economic burden on society … we can’t afford to still primarily focus on medical care.”1 He points to a litany of demonstration projects and information technology programs that have been created, and are at work on the ground, to deliberately have a dedicated mission in “shaping public behaviors” to “inform and help improve the health of patients and populations.” These programs are argued to not only help individuals “take control of their health” but also advantageous in helping “state and municipal governments save money and lives.”
Before closing, Sederer gives us pause to realize that this mission must be inclusive of all professional fields to have staying power: “hospitals have to fill beds and do complex procedures … governments have to regulate to try to control costs and quality … businesses [struggle] with [the] growing burden of health insurance … researchers have had little opportunity – or support – to move from controlled, university settings into the barrio.” These are all architectural and functional challenges that face societal restructuring in the best interest of healthcare and must be addressed altogether to effect the population change that we wish to see. Finally, he reminds us that we must refocus our lenses and missions to facets of our human experience that are responsible for the “90 percent of determinants that impact our health, our longevity and our pocketbooks,” for it is only then that our resources can be more directly aligned with producing constructive change in population health that will matter the most.
But there are antagonistic proponents who suggest that the discussion should not be pitched as ‘primary health care versus social determinants of health’, but more productively considered as a complementary approach between the two policies. In Primary Health Care and the Social Determinants of Health: Essential and Complimentary Approaches for Reducing Inequities in Health, Rasanathan et al. make the case for an ‘and/both’ discussion rather than an ‘either/or’ decision between the two paradigms, as there is, they argue, more value in their shared versus sole space. 3
Primary Health Care (PHC), Rasanathan et al. argues, is historically described in the Declaration of Alma Ata in 1978, “as a tool to reach ‘health for all’ (by focusing on health equity, community participation, solidarity and intersectoral action.” 3 This paradigm of healthcare policy has gained traction worldwide, with countries like Brazil, Thailand, Chile and Venezuela (among others) “attempting ambitious recent health care reform inspired by PHC”; China and India are also moving their healthcare missions to be more reconciled with this model “by embarking on renewed efforts to move towards universal coverage by strengthening the first point of contact with their health systems.” 3
This is the same trend of thinking that has been echoed by the “2005 Pan American Heath Organization that produced the Declaration of Montevideo, endorsed by all countries in the region … reiterating support for PHC as a basis of health systems,” and of Director-General of the World Health Organization, Dr. Margaret Chan, who has “placed the revitalization of PHC at the center of her agenda … presenting a vision of how PHC can address current health challenges through reforms around universal coverage, service delivery, public policy and health governance.” 3
What Rasanathan et al. further reminds us, is that the Alma Ata Declaration and the PHC policy that it gave birth to always implicitly extended its umbrella to provisionally cover broader issues outside of the traditional ‘health care sector,’ including issues of “ … industry education, housing, public works, communications … and demanded the coordinated efforts of all of those sectors.” 3 These examples give credence to the intentions and motivations that guide how PHC will serve: less as an adversarial or competitive policy arrangement, and more congruently in sync with their ambitions to “renew the broad commitments to health equity and intersectoral action on SDH [Social Determinants of Health] articulated in the Alma Ata …” 3
To further show the overlap in policy agreement and like-mindedness in vision for population health, Rasanathan et al. point to a few concrete examples of how PHC dovetails with SDH. First, both models underline the reconciliation of health inequities as a primary necessity, and dog-ear this issue “as a core value and focus for policy.” 3 Both sides desire to influence this transition by placing a “strong emphasis on health promotion and prevention, and on increasing the ability of people to access the resources (both within and outside the health sector) required to stay healthy and protect themselves from diseases and illness.” 3 Secondly, PHC and SDH both recognize that advancements in health are not land-locked within the borders of the health care sector.
SDH since its inception always realized and championed that differences in “occupation, education, or income” play deeply-rooted and often restrictive roles in patient health status; the utility of aligning with a PHC model, is that SDH understands that the “health sector has a key role in moving towards health equity and championing intersectoral action” and that “health systems … based on a PHC approach … ensure equity of access and avoid themselves causing impoverishment.” 3 Thirdly, PHC and SDH “both identify disempowerment and alienation of marginalized groups in society as a major obstacle to achieving health equity;” as such, while the SDH is consumed with considering issues of “distribution of resources, empowerment, social inclusions and exclusion, relative social status and community resiliency and support,” the PHC programs are more focused on translating the SDH-invested topics into “service provisions and healthy policy decision making.” 3 With these examples, there stands to reason that there is a synergy between the two policy paradigms that focuses on how their symbiotic relationship can propel their shared interests and missions forward.
The field of prevention and cost-effectiveness also gently wrestles with the Sederer article. Arguably, there are now, a “core set of preventive services” that are considered effective beyond the traditional “stop smoking, lose weight, exercise, and eat [a] healthy diet’ maxim.” 4 Research by the U.S. Preventive Services Task Force and the National Commission on Prevention Priorities (NCCP), now nearly universally support “services that are deemed effective by [these] groups with rigorous scientific standards.” 4 Within these forums, it is widely accepted that screening for “hypertension, high cholesterol, obesity, certain cancers (colorectal), childhood and adult immunizations [and] smoking cessation” are measures that can be taken to reduce the “prevalence and severity of the nation’s major diseases.” 4 According to the NCPP, “100,000 deaths would be averted each year by increasing delivery of just five high-value clinical preventive services.” 4
In studies of cost-effectiveness for this “core set of [preventive] services,” the cost per QALY (CPQ) was generally far less than what would be paid for more advanced stage care. 4 For instance, CPQ for angioplasty “can cost payers $100,000 per QALY or more,” while among 25 strongly recommended preventive services examined in 2006 by the NCPP, 15 cost less than $35,000 per QALY and 10 cost[ed] less than $14,000 per QALY.” 4 Similarly, physician smoking cessation counseling was shown to be “cost saving or [to have] extremely attractive CE (cost-effectiveness) ratios (less than $5,000 per QALY gained).” 4
This data creates some waves through Sederer’s thesis in that these studies help us realize that healthcare dollars spent on managing these social determinants could actually be accounted for as important (and acceptable) spending within healthcare. That is to say that, perhaps the 40% of the pie Sederer shows, could actually be divvied up with a greater portion given to healthcare, as one of healthcare’s greater roles is to manage the risk factors of public health. Therefore, if we could bend the hardline that separates PHC and SDH, as mentioned before, perhaps we would realize that a more robust PHC (greater piece of the spending pie for preventive services) could potentially serve to forward the missions of similarly minded SDH programs.
The thought of the US continuing to throw more money at a sinking healthcare business plan is reckless. Instead there are structural features that a recent JAMA article Eliminating Wastes In US Healthcare brought to the forefront in the $2.5 trillion dollars spent yearly on healthcare. The article breaks the waste down into six subcategories. The first is “failure of coordination ($25 to $45 billion wasted)”: lack of crosstalk between specialist and house staff, patient medical records being unavailable and requiring repeated tests, poor medicine reconciliation, and HIPAA regulations that often make it more challenging to connect the pieces of patient care. 6 Second is “failure of care delivery ($102 to $154 billion)”—because of the inability to capture medical conditions early, they fester and become larger issues that are ultimately more complex and costly to handle. 6 Third is “overtreatment ($158 to $226 billion)”—a big part of which is based in defensive medicine as doctors do everything they can to sidestep being potentially sued; many “incidental findings” ultimately become reason for more invasive tests with results that yield negative endpoints and sizeable side-effects. 6 Fourth is unnecessary “administrative complexity ($107 to $389 billion)”—lots of forms, long wait times to get clearance from insurance companies on “go-slow” and unnecessary and/or “red tape” administrative tasks that take time away from the patients. 6 Fifth and six are “noncompetitive pricing ($84 to $178 billion)” of medical supplies, equipment, tests and “fees” as well as “Fraud and Abuse ($82 to $272 billion)” by cronies who surreptitiously find ways to “extract money from government health programs” and insurance companies. 6
As Merck CEO Kenneth Frazier advises in Health Care Beyond the Fiscal Cliff Requires Structural Changes, the “fundamental causes of our fiscal imbalance is the significant growth in healthcare spending … it is clear that we will only get our fiscal house in order if we make smart, sustainable choices to address health care costs and the impact they are having on Medicare and Medicaid.” 5 One of the solutions he pitches is to “leverage the government’s power to dictate the prices these programs [Medicare and Medicaid] pay to doctors, hospitals, laboratories, home health care agencies, nursing homes, and drug and device companies.” 5 He goes on to argue that we must shift our attention away from short-term fixes and instead consider structural changes that “expand competition, encourage provider integration, and create incentives for better, more efficient care.” 5
I largely agree with Frazier: if you are the captain of a sinking ship in the middle of the Pacific, why not focus your attention on plugging the hole – making sure the people are insured and have access to healthcare to avoid paying for late, expensive interventions. Why not use your power as a government to try to reign in accountability to how hospitals distribute their care practices, and why not create a culture where healthcare is not in the top 10 list of why people go bankrupt? 5 Structural changes are likely what even the most uninformed Americans know we need, but policy change takes time, money, and patience and is often met with resilient resistance (and violent vitriol). But if in the midst of the storm we cannot find a way to work together to manage our collective issues, we will all fall victim to the same unwieldy but correctable fate.
Ramon is a 4th year medical student at Albert Einstein College of Medicine and an MPH candidate at Mount Sinai School of Medicine. His unwavering interest in emergency medicine since childhood, led him to train and serve as an EMT-I at Emory University, and most recently, to become an intern for the New York Mobile Integrated HealthCare Association – a statewide coalition whose aim is to be a leader in the maturing field of community paramedicine and other innovative EMS advancements. He remains confident that CHiPs, House, and Breaking Bad are television series whose brilliance are matchless. He looks forward to watching Usain Bolt run even faster in the Rio 2016 Olympics, as well as the Miami Heat clutch another championship in the foreseeable future.
1 Sederer, MD Lloyd I. “Population Health: Transforming Health Care to Improve Our Health.” The Huffington Post. TheHuffingtonPost.com, 16 Dec. 2013. Web. 28 Feb. 2014.
2 Kolata, Gina. “A Long View on Health Care: Think Like an Investor.” The New York Times. The New York Times, 20 May 2012. Web. 28 Feb. 2014.
3 Rasanathan, Kumanan, et al. “Primary Health Care and the Social Determinants of Health: Essential and Complementary Approaches for Reducing Inequities in Health.” Primary Health Care and the Social Determinants of Health: Essentia… N.p., n.d. Web. 28 Feb. 2014.
4 Woolf, Stephen H et al. “The Economic Argument for Disease Prevention: Distinguishing Between Value and Savings A Prevention Policy Paper Commissioned by Partnership for Prevention.” Partnership for Prevention, n.d. Web. Mar. 2014.
5 Herper, Matthew. “Merck CEO: Health Care Beyond the Fiscal Cliff Requires Structural Changes.” Forbes. Forbes Magazine, 17 Dec. 2012. Web. 28 Feb. 2014.
6 Berwick, Donald. “Eliminating Waste in US Health Care.” JAMA Network. N.p., 11 Apr. 2012. Web. 22 Mar. 2014.