Your role in healthcare

What role should the individual have in their own health and healthcare? If we operate under the assumption that healthcare is not meeting our needs, then who is really to blame? It seems that there is often a balance between pointing the finger at the role of the individual on their health, and the role healthcare has on the individual.

Let’s take on personal health first.

It is well established that 40% of the reasons people die prematurely are directly related to their health behaviors. From the highly cited article:

“The leading causes of death in 2000 were tobacco (435 000 deaths; 18.1% of total US deaths), poor diet and physical inactivity (400 000 deaths; 16.6%), and alcohol consumption (85 000 deaths; 3.5%). Other actual causes of death were microbial agents (75 000), toxic agents (55 000), motor vehicle crashes (43 000), incidents involving firearms (29 000), sexual behaviors (20 000), and illicit use of drugs (17 000). ”

No doubt that we are becoming increasingly unhealthier. Just consider the rising rates of obesity from the CDC that show how one-third of U.S. adults (33.8%) are obese. The statistics are not much better for kids where 17% (or 12.5 million) of children and adolescents aged 2—19 years are obese.

When one considers that the total economic cost of obesity is now in the range of $300 billion per year. It doesn’t take much to begin to connect the economic costs of a particular health condition back to rising healthcare costs. Once individuals begin experiencing the health problems secondary to their health behaviors (obesity in this case), their decisions on what to do (or not do) when sick can also be a driver of healthcare cost. When estimates comes in that “healthcare costs for chronic disease treatment account for over 75% of national health expenditures”, we might have a bit of a problem.

So yes, we are not doing ourselves any favors here by having increasingly unhealthy lifestyles. Additionally, we are using the healthcare system only at times when we are sick, and not considering how we can prevent sickness. This, in part, is why many individuals refer to the healthcare system as the “sickcare” system (because it mainly focuses on what happens when one is sick) or the “wealthcare” system (because often one doesn’t get paid unless there is a problem or one is sick).

As Dr. Howard Luks said in a comment on this siteover the weekend:

“…until folks are willing to focus on healthcare except at the moment when they need it… the movement — will not move.”

Now, consider the impact healthcare has on our health.

The late Dr. Barbara Starfield, ever the champion for primary care, said it best:

“…the overall health of Americans is relatively poor. In 2000 the United States ranked 23rd in the world for male and female life expectancy. Many people—even public-health experts—attribute this to disparities in health care among racial, ethnic, and income groups, and to the self-destructive behaviors of individuals. But none of these explanations really adds up. Even the white American population has a lower life expectancy than the population of any country in Western Europe. As for behaviors, the American population smokes less than people in most countries and is less likely, on average, to drink alcohol. And while it is true that residents of the U.S. states with the most social inequality have the poorest health, international comparisons suggest that differences in social inequality alone are not to blame.”

I have always loved Paul Krugman’s “inverse miracle” take on US healthcare:

“It’s not news that something is very wrong with the state of America’s health. International comparisons show that the United States has achieved a sort of inverse miracle: we spend much more per person on health care than any other nation, yet we have lower life expectancy and higher infant mortality than Canada, Japan and most of Europe.”

Krugman concludes his write up explaining how we have not helped ourselves out any in improving the population’s health with our behaviors. But for a second I want to go back to Starfield’s point about the healthcare system (deep breathe):

“Why, then, is the American health-care system so bad for our health? There is no single or simple answer, but a large part of the story—and a part that is commonly overlooked—is precisely the predominance of specialist care over primary care.”

She continues:

“Primary care deals with most health problems for most people most of the time. Its priorities are to be accessible as health needs arise; to focus on individuals over the long term; to offer comprehensive care for all common problems; and to coordinate services when care from elsewhere is needed.”

While many posts on this site will undoubtedly cover the importance of primary care, I want to make sure that the point here is clearly seen – having the healthcare system (primary care in this case) be able to provide comprehensive healthcare and a level of continuity (read relationship) with a patient is essential! When fragmentation abounds and does not allow this to happen, the system begins to negatively impact our health.

There are many more healthcare system issues that I will not go into here (e.g., health insurance, access). Since there is no simple answer why the US healthcare system is so bad for our health, we must continue to look for ways to be more effective and efficient.

So while we should continue to demand more of our healthcare system, shouldn’t we also be demanding more from each other? By doing so it appears that the responsibility for ensuring good health and healthcare always comes back to us. Shouldn’t we be thinking of health and healthcare all the time other than just “the moment we need it?”

Dr. Miller has his doctorate in clinical psychology and is an Assistant Professor in the Department of Family Medicine at the University of Colorado Denver School of Medicine where he is the Director of the Office of Integrated Healthcare Research and Policy. His core task is to integrate mental health across all three of the department’s core mission areas: clinical, education, and research. Opinions expressed here are his own and not those of his employer.

Tagged with: , , ,
Posted in Health behavior, healthcare
  • Frank Reed

    As long as we, in the words of TR Reid, are willing to “periodically kick the responsibility for healthcare down the road” (to the next fiscally responsible entity) and avoid a vested comprehensive lifetime payment approach, we will be hard pressed to engage patients as partners in being healthier. If the business community and payment system continue to view health expenditures in terms of annual “loss ratios” can we really expect the public to be less than cynical and disengaged, even at their own peril? A perverse “annualized” payment system that doesn’t reward people (or docs) for staying healthy long-term, coupled with unrealistic expectations about what the system can do to rescue everyone from the brink, regardless of cost, conspire to produce much of the public inertia we see in my view. The “just in time” approach works great for inventories in manufactuering but in our world of healthcare, guarantees suboptimal outcomes and escalating costs for us all.
    If we can align the long term interests of the payment system and the patient for a healthier life, there is hope for “a real miracle.” I happen to believe that with appropriate relationships and a rational clinical-payment partnership we can reach the goal of longer and happier lives at affordable costs envisioned by Barbara Starfield, Don Berwick, and others.
    In the meantime one can hope that the current economic shocks of outrageous cost will produce at least a modest amount of effort by the public to be healthier. After all, no one likes to step on the third rail. One hopes that ultimately there are better ways to contain costs and improve population and individual health than pain avoidance and “self-rationing.”

  • Gary Oftedahl

    The need to address “health” as opposed to primarily addressing “health care” and our health care system, begins to reshape the conversation, and force us to address what some might call “unaskable questions” and “unavoidable conversations.”

    Whether it be the preponderance of a specialty heavy health care system, a misaligned payment system, a fragmented and disjoint approach, a culture of entitlement and disengagement, or one of many other possibilities, we need to begin to ask different questions, and engage in different conversations, and consider unheard and unthought of options if we’re to do more than just put “new wheels on a horse and buggy” model.

    The Social Power article is but one example of an evolving and provocative shift, which while uncomfortable and antethetical to many of us “seasoned” health care veterans, is real. As Clay Shirky notes in his book title “Here Comes Everybody” and the world will never be the same.

    But what it will look like, the intended and unintended consequences of the movement toward individualism, transparency, connectedness, flattening of the hierarchy remains to be seen. We in health care need to engage in that “wild, wild west” which is exploding around us.

    I look forward to further opportunities and many shocks to my well developed, mature, previously successful value and belief system. Ouch, change is sometimes painful.

    • Frank Reed

      Well said, and your comments raise the question of just how much primary care and healthcare in general can accomplish in making folks healthier. Family medicine, as the most population oriented branch of the “care” system, still has substantial limits in it’s ability to create “health;” precisely your point as I take it.
      There is a substantial amount of social engineering needed outside of healthcare that must be part of generating more personal responsibility and healthier behavior.