Making our Health Better

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Dr. Bob Crittenden serves as Cambia Grove Executive in Residence and brings a wealth of experience and knowledge as a practicing family physician and as a senior policy advisor. Dr. Bob’s blog series weaves learnings from his career while highlighting broader barriers to health care innovation and possible paths forward. Read more about Dr. Bob and his writings here. 


Jake had diabetes, a job, health insurance and yet still had a fear of getting sick and going broke. Why is this happening to people like Jake?

A health system is designed to ensure that people like Jake have the health services they need so they can live their life to the fullest. As Dorothy Teeter mentions, our health care system in the U.S. has made significant improvements over the past thirty years. Technology, medical informatics, and new procedures have all helped make our care more effective. Federal policies, including the Affordable Care Act, are seeking to change policies to help incentive health. Unfortunately, we have not improved as much as other countries and we certainly have deficits in our system that we know of now that need fixing.   

Even with all of these improvements, Jake and many people like him are at great risk of falling victim to a system that doesn’t work. The problems that are facing us now are vast including poor outcomes for diseases and problems amenable to treatment, opiate use, homelessness, food insecurity, affordability of health care, income inequality, high pharmaceutical costs, among many others. While all of these greatly affect the health of people like Jake, they are not well addressed by our health system.

Are we destined to be a healthier country? Can Jake expect a better future and fewer worries? 

A bit of perspective… The US was one of the healthiest countries in almost all measures in the 1950’s. Since then, we have improved, but other countries have improved more. Now, all developed countries, and many developing countries have a longer life expectancy than the United States .  Countries that focused on improving health have raced by us. Even our wealthiest people have poorer outcomes than people in other countries. Mortality has been improving, albeit slower that other developed countries, but now even that key trend line is plateauing and appears to be worsening.

All of our peer countries successfully focused on health which includes access, cost, health outcomes, improved health systems and social issues that affect health – things we know we can improve. The people working on health care transformation have recently made huge strides through the ACA and other laws – better access, an increasing focus on mental health, more improvements in case management and care coordination and initial steps to improve the social, housing and community issues that are critical to health. 

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To catch up with peer countries, we need to do more than mimic what they have done. We need to pair their best practices with our creative innovations to imagine a new state of health.

First, we need to understand what barriers are present that prevent us from progressing. From 30,000 feet, the problems in our health care may seem insurmountable, but in almost every case we have examples of successful improvements. So, what are those barriers? 

One major barrier is the high cost of health care for individuals. High deductible health insurance plans make people feel like they have no insurance and act accordingly, delaying care. Also, the high cost of current and new drugs is only growing - and individuals are bearing a growing share of that cost. Compared to the income of many families, the combined costs of health insurance, medicine, and out of pocket costs can break the bank. 

People living normal lives often face huge barriers, ranging from low incomes that are stagnant for half of the people in US to the high cost of housing to poor air quality (think asthma) to poor food access and to limited access to exercise opportunities. In each of these areas, interventions are possible.

From a local level, improvements are needed  in our social fabric. Examples are social services, which could be delivered more efficiently, integrated with health care more seamlessly and impact health more effectively. For example, almost all affordable housing projects require an incredible stack of programs and subsidies to develop just one project – federal subsidies and tax breaks, state grants and support services, local tax and zoning changes, interested and willing private investors, and a stream of operating support from the federal, local and philanthropic worlds.

Health services need the personal touch of humanistic providers and the efficiency of well-oiled organizations. Both are possible, but payment systems often block needed health system changes because the payment is tied to services and limit adoption of new approaches.

For example, telemedicine is growing slowly when covered by the fee for service payment system. It is growing more quickly in systems where the payment is included in the cost of care and the more flexible and less costly telemedicine is used to improve access. Also, new processes in primary care are often blocked by payment systems that do not cover a new more efficient approach to existing problems. For example, providing mental health care or substance use care with the needed social referrals and connections is almost impossible in a fee for service environment.   

All the above problems – and many of which we are unaware – are solvable.  All will take innovative approaches in direct health services, financing, monitoring and overcoming known barriers.  We will need people applying their many skills, borrowing from successful models, building new solutions and building on the present to a better health system in the future. 

Where does this leave Jake?

At the center of this wilderness remains the patient. How can Jake thrive? How will his children benefit from downward trendlines? Future posts will focus on how together, we can identify and remove the barriers for Jake and help him achieve a healthy and hopefully successful life. 

This series will explore issues that are affecting Jake and what we may do to make his health better. Topics we will address in future articles range from system problems in payment and delivery, care management, primary and personal care, specialty care, pharmacy innovation and costs, rural health, social determinants and reducing barriers to innovation.  

Feedback or suggestions are appreciated on these issues. Contribute to the conversation by joining Dr. Crittenden at his next Barriers to Innovation Roundtable or via email.

 

About Dr. Bob Crittenden

Dr. Bob Crittenden joined the Cambia Grove as the first-ever Executive in Residence. He has practiced as a family physician for over 28 years in central and southeast Seattle with urban underserved populations, worked for the state legislature, been a Robert Wood Johnson Health Policy Fellow with Senator George Mitchell, was special assistant to Governor Gardner for health, and is a Professor Emeritus in the Departments of Family Medicine and Health Services at the University of Washington.

His work on projects at the local, state and national levels focuses on improving the access and effectiveness of health services for all populations. Most recently, he served as Gov. Jay Inslee’s Senior Health Policy Advisor, where he was instrumental in the implementation of the ACA in Washington state and the successful Medicaid Transformation Waiver. He has also played a key role in initiating the Kids Get Care program, actively participating in rural and urban underserved health systems improvements, and working with insurers, employers and providers in improving systems of care for chronic conditions.

 

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