A recent study in the New England Journal of Medicine concluded that Oregon’s expanded coverage had no significant health benefits on low-income adults in tests for hypertension, cholesterol and diabetes treatment — all manageable chronic conditions given proper care.
The problem with the focus of Oregon’s experiment is that it ignores other core issues necessary to improve the U.S. healthcare system. Universal coverage is an important step toward social justice, but we need to make substantial changes to the system’s fundamental approach to chronic disease treatment. America needs to shift its focus to preventative care.
Dr. Nick Yphantides, UCSD alumnus and chief medical officer of San Diego County, noted in an interview with the Guardian that our current healthcare system is the product of the past. Historically, most medical issues were related to infectious, catastrophic or industrially caused ailments — all of which are transient, impermanent cases. However, in modern-day medicine this approach is inadequate because the majority of health problems are chronic conditions — issues of lifestyle choices and behavior. Dr. Yphantides offers a simple mnemonic: 3-4-50. Three behavior-related risk factors — poor nutrition, a sedentary lifestyle and tobacco — use contribute to four chronic diseases: heart disease/stroke, cancer, Type 2 diabetes and respiratory conditions like asthma. These four diseases constitute 50 percent of all deaths in San Diego.
The problem in our current healthcare system is its focus on “sick care,” fixing maladies that have already occurred, rather than preventative “health care.” According to Dr. Yphantides, less than one percent of this “sick care” medical expenditure goes toward modifying behavior. This is problematic because behavior is the root cause for the four chronic diseases that guzzle 75 percent of American healthcare spending. The U.S. currently spends more baseline healthcare dollars per person than any other country in the world and almost doubles that of the next highest country.
The way to implement change is by transitioning from episodic, volume-based sick care to a more proactive, value-based system using financial incentives. One method is through the use of Accountable Care Organizations, held responsible for the quality, appropriateness and efficiency of treatment. If we incentivize the delivery of services to patients by focusing on the value of treatment — for example, if a doctor successfully encourages a patient to lose weight and manage diabetes — the system saves money, and the doctor should be rewarded. A value-based system will lead to improved quality of life and significant taxpayer savings.
Dr. Yphantides woefully suggests that it may take crisis for change to occur, because people are unwilling to change their behavior until disaster strikes. Let’s hope we’re wiser than that.
