The Triple Aim of improving quality, improving patient care and reducing costs is a noble mission, but can we expect the current vendors of medical services to take the lead in reducing costs?
There is so much to debate in healthcare regarding where to focus reform efforts. Many will look at the high costs of caring for chronically ill patients and conclude that that the segment that accounts for the greatest share of expenditures must surely be the target for cost savings and disruption. It’s difficult to argue against the need to continually improve how we care for the acutely and chronically ill. However, to use one analogy, we can’t continue to get better at putting out fires once they are in full burn without equal or greater efforts devoted to preventing fires. For the population as a whole, the benefits of prevention far outweigh the benefits of incremental improvements in managing chaos.
Given that hospitals and physician practices exist to perform medical interventions, how can we expect these organizations to lead the efforts in reducing demand for their services by promoting wellness and patient education programs? We can’t. The same logic applies to patient engagement. How can we expect provider organizations to lead efforts that ultimately will reduce the demand for medical services? We can’t. Instead, we have patient engagement programs that predominantly target medication adherence.
Granted, there are attempts at creating patient-centered medical homes and accountable care organizations (ACOs) that have incentives to better coordinate care and attempt to reduce duplication of tests, overtreatment and medical errors, all things that should help reduce overall costs. But, it would take some pretty massive incentives to ask physician practices to become public health promotion centers. In fact, the pendulum is moving away from primary care physicians’ offering even basic preventive health services. One data point to support my statement: vaccinations are moving from primary care facilities to pharmacies. One anecdote: my mother’s primary care physician effectively refused to give her a shingles vaccine on two occasions, saying she’d be better off getting it at CVS. My mother interpreted the doctor’s comment and attitude to mean that the vaccine isn’t medically important, even though the doctor more likely was trying to save my mother some money (CVS charges less than $100; the doctor’s administrative staff could only say that depending on her insurance, the cost to her could be as high as $300).
So, if we want to make a serious dent in the level of health care expenditures in the US, we’re going to have to bolster our public health efforts and educate and engage the greater population on how to adopt behaviors that help maintain health and avoid disease. Harvard School of Public Health received a gift of $350 million this week. That’s an encouraging sign. To quote the benefactor, Hong Kong billionaire Gerald Chan, “While medical doctors give health benefits to individual patients, public health is a field that helps to give benefit to the whole population”. [1]
While we still need better one-on-one communication between physicians and patients, we can’t expect a meaningful reduction in healthcare expenditures until we reduce the demand for medical services. And, we shouldn’t expect the providers of those services to lead the efforts to reduce demand.
[1] Source: http://www.bostonglobe.com/metro/2014/09/07/harvard-school-public-health-gets-largest-gift-university-history/YixNC3xkBfMtg3mrSmE6zJ/story.html See also: http://www.thecrimson.com/article/2014/9/8/chan-gift-public-health/