April 16, 2019
I’m not sure what the relevant analogy might be, but I’ll take a shot, nonetheless.
Let’s say we poured billions of dollars into improving highways and city streets, but the local commute for residents continued to get longer, more frustrating, less effective.
Or, maybe we also dumped billions into school systems, but student test scores only got worse.
I ask if these comparisons are relevant after reading about a recent study published in the Lancet, which suggests that poor diet and lack of exercise kill more people globally every year than even smoking, the go-to bogeyman for all negative health indicators. For all the truckloads of cash we continue to push toward improving medical technology and technique, building different organizational structures and making Crocs mandatory healthcare footwear, the biggest bang for the buck remains diet and exercise.
How unsexy is that?
What the evolution of transportation, education and healthcare in the United States all demonstrate is that more money does not equal better overall outcomes. It’s not like this is a recent revelation.
“The United States spends more on health care than any other nation in the world, yet it ranks poorly on nearly every measure of health status. How can this be? What explains this apparent paradox?,” asked Steven A. Schroader, MD, in a 2007 New England Journal of Medicine article. “The two-part answer is deceptively simple — first, the pathways to better health do not generally depend on better health care, and second, even in those instances in which health care is important, too many Americans do not receive it, receive it too late, or receive poor-quality care.”
Schroader is telling us that we’ve equated better healthcare with better health when we should be looking at better choices/options and access to necessary care as the essential keys to a healthier population.
What would that look like in practice? More focus on population health and universal health insurance and less on perfecting physicians using carrots and sticks.
Instead we have a healthcare system that asks physicians to click hundreds of boxes with little evidence that the constant clicking creates better outcomes. Indeed, one could argue that our current goal of improving the provision of care is misplaced, making the strategy (clicks) used to get there irrelevant.
“For starters, we know that 70 percent to 90 percent of health outcomes are determined by socioeconomic and lifestyle factors,” writes W. Ryan Neuhofel, DO, MHP. “Appropriate health care, particularly primary care, can tilt the odds toward better outcomes through medical intervention, lifestyle guidance, and advocacy. Primary care can improve individual lives and help budgets by reducing the likelihood of more expensive downstream care.”
This is not to say that healthcare shouldn’t be working to improve by eliminating errors and making it easier to identify the most appropriate patient treatment. But the greatest improvement for the greatest number of patients/citizens is in thousands of daily choices that don’t directly involve a doctor.
Looking again at the study in the Lancet, researchers found that citizens of countries that follow a Mediterranean diet—whole grains, fruits and vegetables, heart-healthy fats and small amounts of lean protein—are the healthiest. Israel came in first, followed by France (no, they don’t eat triple-cream brie, baguette and Bordeaux at every meal) and Spain. The U.S. ranked number 43.
According to study estimates, we can attribute 3 million global deaths annually to too much salt, another 3 million to too few whole grains, and still 2 million more to not enough fruit.
Perhaps, America is just too much about the specific. We’re working to develop personalized medicine. We dream of individual genetic profiles and miraculous stem cell therapies. We’re trying to develop healthcare IT systems that are customizable to the particular needs of the clinician.
Again, these efforts are not inherently bad, but neither are they the keys to improving health for wide swaths of the public any more than is a strict blueberry diet.
“I love blueberries, wild and cultivated, but they are a fruit like any other,” writes professor and author Marion Nestle. “Their antioxidants may counteract the damaging actions of oxidizing agents (free radicals) in the body, but studies of how well antioxidants protect against disease yield results that are annoyingly inconsistent. When tested, antioxidant supplements have not been shown to reduce disease risk and sometimes have been shown to cause harm.”
Like blueberries and the human body, healthcare IT systems are not a cure for all that ails the body medical. We’ll eventually develop EHRs that doctors like to use, but if they don’t somehow create unforeseen behavioral changes en masse, the health of the general American populace will remain stubbornly in the 40s on a global scale.
Where linked computer systems really excel, however, is in the collection of large amounts of data and identification of trends. Sure, an EHR may remind Dr. Smith that Mrs. Jones is allergic to penicillin, and that will be great for Mrs. Jones and for Dr. Smith but will do little for overall health and mortality rates.
So, healthcare IT platforms have to remind Dr. Smith of crucial information about Mrs. Jones AND collect information to be used for information campaigns, vaccination efforts and resource allocation decisions. They need to alert an ER doc to this particular patient’s opiate addiction AND public health officials of a spike in measles cases. Integrated IT systems can also provide data on social determinants of health like income and family situation, which reliably predict illness across communities.
These systems need to contribute to making both healthcare and health better, but they’re virtually powerless absent good policy, effective implementation and comprehensive education.
Improvements in health and reductions in healthcare costs will come from several different inputs, including sound public health policy, preventive care, comprehensive insurance coverage, better personal choice and integrated healthcare IT.
In absence of these complementary factors, we’re left to hope that those blueberries really are a miracle cure.