Saturday, January 11, 2014

Improved Healthcare for 2014

As we begin 2014 I want to have frank discussion and have Salus play a key role in helping to craft a transformation in the American healthcare system that results in better health outcomes, a more effective and efficient delivery model and improved access for undeserved populations, specifically those living in urban environments. This must include a dialog about changing behaviors both of how people access the healthcare system as well as how they act individually. In a recent OP-ED that was published in the Philadelphia Inquirer I discussed the attributes of a Patient Centered Medical Home (PCMH) and how this model was being effectively deployed in the Military Health System. I mentioned how people enrolled in such a model tended to use the Emergency Room less frequently (in locations where a PCMH was established, ER visits decreased by approximately 30%) and health outcomes appeared to be better. I firmly believe that this model, where primary care providers to include physicians, physician assistants, nurse practitioners, optometrists, podiatrists, nutritionists, mental health specialists, etc. serve as the primary conduit into the care system should become a centerpiece for our national healthcare system. But even as we craft an improved delivery system, we need to take a very frank and candid look at ourselves as a society and address our expectations of the healthcare system, how we utilize and access healthcare and some of the underlying behaviors that are the subsequent causes of disease that cost us all so much.

First and foremost we need to change the culture of healthcare from one of being reactive to proactive. Prevention and the preservation of wellness must be front-lined and in order to do that, must be incentive-based. Stronger policies combined with new, innovative behavioral health programs that integrate specialties such as clinical psychology, nutrition, social work and specially trained counselors are needed to help people change lifestyles that contribute to poor health such as alcohol consumption, smoking and obesity. While many states are making efforts to reduce smoking, there are fewer policies to tackle the harmful use of alcohol in the U.S. than you would find in other OECD countries, such as higher taxes on alcohol or minimum prices. 

The most commonly used measure of weight status today is the body mass index, or BMI.  BMI uses a simple calculation based on the ratio of an individual’s height and weight.  Research has shown that BMI provides a good estimate of being overweight and also correlates well with important health outcomes like heart disease, diabetes, cancer, and overall mortality.  Healthy BMI for adult men and women is between 18.5 and 24.9. Overweight has been defined as a BMI between 25.0 and 29.9; and obesity, has a BMI of 30 or higher. Unfortunately, obesity rates have, for the most part, stayed constant since 2003, they have more than doubled since 1980. They remain the highest among all of the high-income countries in the world.  Literature suggests that about two out of three U.S. adults are overweight or obese (69 percent) and one out of three are obese (36 percent). The American Medical Association has recognized obesity as a national epidemic and has declared it a disease to help change the way the medical community addresses the issue.     This is also recognized by the American Public Health Association. While appropriate medical intervention is imperative, I believe we also need to incentive those stricken with the disease to be proactive in managing it. People need to have “skin in the game” if theyre going to change behaviors. Those who have the lowest risk factors would pay less while those with higher risk factors would pay more for health and other types of services.  Since obesity is associated with so many chronic and acute diseases that cost society a fortune to manage, this requires attention now.  My belief is that people who are obese must be both cognizant and accountable for the associated health ramifications and costs in order for many of them to change behaviors and lifestyles.  Since more fuel is required to move more weight in airplanes, trains, cars, buses, etc., Ive often thought that when one purchases tickets to fly on an airline or on another form of mass transportation, fares could could be adjusted based on a sliding scale of Body Mass Index (BMI). Only after people change their own personal behaviors will be begin to realize substantive changes in the overall health our the population; this, combined with appropriate medical and behavioral health supervision is one way to help move us in that direction. 

Concurrently, we need to be working on how a PCMH model can be rolled out nationally.  It's my sincere hope that we can help to validate this model at Salus, working with local partners and integrating our clinical programs in the Oak Lane section of Philadelphia.  The opportunity to develop a Medical Home in an urban, undeserved area of Philadelphia will reap benefits from a broad health perspective as well as economically. As I mentioned earlier, data shows that when populations are enrolled in medical homes, emergency room and urgent care visits drop dramatically, thus saving valuable healthcare resources as well as improving the overall quality and continuity of care patients ultimately receive. We've got all the right players to model this and prove it’s efficacy at Salus working closely with our academic partners in Philadelphia.  

So, that's my long-winded pitch for today. 2014 needs to bring about change in the healthcare delivery paradigm, by changing behaviors, making people accountable for their own health, and making primary care the centerpiece of our access model through a Patient Centered Medical Home. 


  1. What is being said it's true, but who likes the truth?
    ...Getting a fine for bad behavior always helps, nobody likes to pay out-of-pocket! This could be a way...
    Would people who lack DISCIPLINE & ACTION and loose control over their bodies, like to be ordered (told) what to do? Some of us who have family members in the fat/obese situation, know there is little to do when body takes control over the mind. Perhaps mental counselors/ specialists need to employ conversations, dialogues & patience (not prescribing drugs) in their therapies as a way to pursue change in patients' behavior.
    Greed may also play a factor: why go for a smaller plate, when bigger & more (for the same price) is better?
    May be all in our brains, if we can train the mind...

    1. Great point L! Not too long ago I was in a coffee shop and here came a lady with a young daughter who in my opinion was over weight for her age, ironically though, the mother stood there and asked her to order WHATEVER she wanted!! If parents learn to train their children from young age to eat healthy and exercise (play more outdoor games than couch games), I believe we will raise a healthier future generation. The only bigger issue would be trying to give more complex and maybe medical help for the older over weight individuals!

  2. Great points! Management of obesity must include an interdisciplinary approach to include behavioral health, nutrition and primary health care specialists. Additionally, family members must be brought into the loop so afflicted people have the appropriate support mechanisms at home. Additionally, there are socioeconomic factors that we cannot ignore such as having access to the healthcare and counseling mentioned previously, and the ability to purchase healthy foods in local neighborhoods. As you allude, this is an extremely complex issue the will require a multifaceted approach both from the medical as well as social aspects. Behaviors need to change but along with that we need to ensure people have access to adequate medical and concealing services.

  3. Sounds like Patient Centered Medical Home (PCMH) model! Good luck with this endeavour!

  4. The primary challenge, in my view, on this topic is cultural mentality. Many of those individuals who will be needing long term care for multi-system problems do not have an appreciation for the value of prevention. Further, our health care system does not have an emphasis on prevention. In the 1980's our national health priority was the training of sub-special providers. The result of that emphasis has lead to a provider community that cannot meet the health care needs of our current society-particularly the rapidly growing population of "Boomer Elderly."
    The Affordable Health Care Act (AHCA), in my view, is an attempt to balance these inequities. We have a test population of 40M people who had no health care coverage-now they can. It is a reflection of the population health emphasis to note that- not ALL of these people are lining up for health care, or even agree with the concept. Only those who currently have health care issues understand the value of the AHCA, and the healthy individuals see it as an infringement on their constitutional rights, and are fighting its implementation. Large health insurance organizations need FULL participation, and healthy, younger people, enrolling in these plans so that they can balance profits. If they do not get people who are healthy participating, they will probably make adjustments by increasing rates or delaying provider reimbursement (this has been dramatically increased since 2011).
    I agree that the emphasis should be on prevention, and that the current disciplines and programs at Salus are in a unique position to participate and contribute to this evolving process. Skilled care facilities are also a wonderful test bed for interdisciplinary cooperation in patient care. In Delaware we implemented such a model that involved optometry, physicians, OT, PT, nursing and pharmacy-the patient centered model was tested for 9 years. We learned a very important lesson from this demonstration-administration must have a vested interest in its success, and this typically involved legislated (and enforced) mandates.
    What a WONDERFUL public health question-thank you!

  5. I think you're spot on. The training models of the past for physicians have certainly contributed to today's primary care physician shortage. Compounding this has been the reimbursement rates for primary care services; something that has lagged significantly behind those of the specialty services, thus acting as a type of disincentive or providers to move in the primary care direction. Employing physician extenders such as Physician Assistants and Nurse Practitioners will help to mitigate the shortage of primary care physicians that's projected to extend beyond 2025 but the key to success will be instilling the culture of wellness and prevention to American society. This will take a generation, or more. In the meantime, it's going to be essential to develop healthcare delivery mechanisms provide easy access and incentivize health, prevention and wellness. I believe it's our responsibility as public health professionals working within a major health science professions university to develop models that faciltiate this and more. Thus, the impetus to establish a Patient Centered Medical Home located in the center of an underserved, yet robust section of our city. The Patient Protection and Affordable Care Act focuses on children's vision needs in addition to attempting to capture those 40 milliion uninsured in our country. We need to capitalize on all the potential good this brings and leverage it towards establishing the model that can work.