The Limits of Medical Care

Wayne Myers, MD, Look What's Coming columnistby Wayne Myers

In my last column I referred to Perry County, Kentucky as a caricature of the country.  By that I meant an extreme example with characteristics of much of the rest of the nation.

A recent analysis found that Perry County had the shortest life expectancy for women, and the third shortest for men, of all the counties in the United States.  Hazard, the county seat, has an abundance of doctors and a large, sophisticated hospital.  It had a nurse practitioner training program in the 1990s until the regional need seemed satisfied, and has a patient navigator program.  A new osteopathic medical school that is oriented toward rural primary care opened less than 50 miles away, about 15 years ago.  Hazard has a family practice residency.  On balance, Hazard has an abundance of medical resources.  While all these resources were developing, the life expectancy of people in Perry County was getting shorter.

Details about the local medical care and patterns of mortality don’t add much to this discussion.  Suffice it to say the community is long on referral specialists and arguably short on primary care.  Diseases related to inactivity, smoking, excess weight and prescription drug abuse start among the young and affect many.

In America, if something is wrong with people’s health we assume they need more medical care. But I don’t think doctors—clinicians—can solve the problems that are causing early death in Perry County or in much of America.  Medical care isn’t working, or at least isn’t sufficient.

Granted, I’m just stating the obvious, given all those clinicians and all those relatively young people dying.

Our “medical model” is based on the idea of “healing the sick”: more precisely, healing one sick person at a time.  A basically healthy person gets an illness or injury.  S/he goes to the clinician who hears the story and makes some observations and a diagnosis.  The clinician does something therapeutic and the patient is restored to health.

This model just doesn’t fit when many members of the community—individuals and families—have multiple habits that are damaging over most of their lifetimes.

At a lecture at Harvard in 2007, Dr. Steve Schroeder estimated that 10 percent of premature deaths in America are due to inadequate medical care, while 40 percent are due to the choices people make—how active to be, how much to eat, how fast to drive.  I think the percentage in a lot of our high poverty communities, where there are obstacles to making the healthiest choices, is even higher. Behavior and personal decisions are at least four times more powerful than medical care.

In Perry County, as in much of America, medical care is losing to unhealthy behavior.

Clinicians aren’t trained, nor is our clinical system structured, to accomplish changes in long-term cultural behavior, or to respond to the needs of groups of people. Certainly the 15-to-20-minute acute care visit is a poor situation to try to work with a person on diet, level of activity, his/her addictions. We can’t modify family and social patterns with tools developed to treat strep throat, sprained ankles or breast cancer.

By the time a person, even a 12 year old, has Type 2 diabetes or hypertension because of excess weight and inactivity, lots of damage has been done.  The body has used up its adjusting and coping reserves over several years.  These are late stage diseases.

We need major new approaches to keep people healthy at all stages of life.

We’ll need a lot more health educators, community health nurses and nutrition educators.  These people should and can be trained from within the communities.  The community college system is the base upon which to build partnerships with professional schools.

Who’s going to pay for this work?  I’m optimistic that the Center for Medicare and Medicaid Services (CMS), will realize that sick people cost them money, and will try to reduce their numbers.   The argument goes like this.

As the Affordable Care Act gains enrollees, CMS’  “book of business” will shift from old people on Medicare toward younger people on Medicaid.  When the main business of CMS was Medicare, the rational business strategy was to seek the most economical quality care for those with only a few years to live.  If CMS were in the fire insurance business it would be looking for more economical ways to fight fires.

As the business shifts toward Medicaid and subsidized private insurance customers, the rational business strategy for CMS shifts toward preventing chronic disease.  From an insurer’s point of view, a 70-year-old obese hypertensive diabetic is a self-limited problem.  S/he’ll die soon.  A 30 year old with the same diagnoses will be a very long-term financial drain.  It will be good business for CMS to keep their “covered lives” healthy.  In the fire insurance analogy, fire prevention becomes reasonable.

This argument never worked with the private “health maintenance organizations.”

They argued that subscribers jumped from company to company so a particular firm was unlikely to benefit in the future from an investment in keeping a person well.  The current writing of the Affordable Care Act keeps CMS involved in financing the care of people and families as much as four times the federal poverty level.  That gives a lot of room for economic mobility.  Health preservation will be good business, though it will mean spending on the currently sick while preventing future disease.

I’ve argued that the community hospital should take the lead in this effort.  Though the hospital will have to learn a lot of new things, the hospital culture speaks the basic language.  The hospital’s traditional inpatient role is shrinking.  Other candidates, schools and health departments, though valuable collaborators, are overwhelmed.  The hospitals have ties to most sectors of the community and a payee relationship with CMS.

Foundations working in high mortality regions should develop model programs and show the effectiveness of the approach.  Within a decade or so this issue can perhaps be raised in Washington.

We need new approaches to keeping people healthy, instead of trying to heal them after they get sick.  Clinicians can’t change the way people live and raise their kids, even if some of the choices the parents make turn out to be pretty dangerous for the kids.  These are sensitive life and death issues.  We need to tackle them.

Wayne Myers is a retired pediatrician and rural medical educator. He directed the federal Office of Rural Health Policy from 1998 through 2000, and was President of the National Rural Health Association in 2003. He and his wife, JoAnn, farm in rural Maine.

Opinions expressed in this column are those of the author and do not necessarily reflect the views of the Rural Assistance Center.

Dr. Myers welcomes your feedback. Comments and questions can be sent to him at myers@raconline.org.


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