This post originally appeared in the Houston Chronicle
There is a clinic in northwest Houston that treats children who have asthma. The clinic follows appropriate medical protocols, prescribing medications to improve lung function and reduce the severity of asthma attacks. Yet some patients still experience severe asthma attacks that send them back to the clinic repeatedly, or even to the hospital.
The doctor suspects that the attacks are triggered by mold or other conditions in the children’s homes. What is the responsibility of the clinic in this situation? Is it simply to prescribe medicine, or is it to figure out why patients continue to suffer and do something about it? Is our health system responsible for delivering health or just health care? And do we know the difference?
We Americans have confused health with health care. We use the words interchangeably; we talk about health care as if it were the same thing as health. We have a pretty good grasp on health care: hospitals and clinics, physicians and nurses, labs and MRIs, surgery and pharmaceuticals. High tech, increasingly expensive. Health is a much broader concept: in the words of the World Health Organization, health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.
Health care is a means to an end, and health is that end. There is no inherent value in health care, apart from its impact on health. Because we talk about health care as if it were the same as health, we miss out on opportunities to improve health that fall outside of the health care paradigm. We’re so worried about health care costs that we’ve forgotten to look at health.
If we are interested achieving health, we must understand the factors that contribute to good health outcomes, so that we know what’s important. Many factors, including health care, contribute to health outcomes. Yet decades of research have shown that social factors like income, education, housing, community safety, individual behaviors and the environment account for 80 percent of health outcomes. Health care accounts for only 20 percent.
The United States spends $3.3 trillion each year on health, significantly more than any other country. This includes payments by government, businesses and families for hospitals, doctors and prescription drugs. That’s a lot of money — it amounts to 17.9 percent of gross domestic product — almost one-fifth of our economy. Of that $3.3 trillion, 97 percent is spent on health care. If health care accounts for only 20 percent of health outcomes, should we be spending 97% of our health expenditures on health care?
While we spend more money on health care than any other country in the world, our health outcomes lag those of nearly every other developed country. Among 34 member countries of the Convention on the Organization for Economic Co-operation and Development, the United States ranks 25th for maternal mortality, 26th for life expectancy, 28th for low-birth weight newborns and 31st for infant mortality. Other developed countries with better health outcomes spend a smaller percentage of GDP on health than the United States and devote a larger share of GDP to social spending — including the factors that account for the 80 percent impact of health outcomes — than the United States spends. More important, the countries with better outcomes devote proportionately more money to social spending than to health spending. Our country has the lowest ratio: approximately 50 cents in social spending for every dollar in health spending. All but two of the 34 member countries spend at least equally, and most spend more, on social factors.
Part of the reason America lags in health outcomes is that we incentivize the health sector to focus on health care instead of health. If the health care delivery system isn’t being paid to deliver health, it will continue to focus on providing what it is being paid for: health care. It doesn’t have to be this way. First, we must acknowledge that health is the endgame. That’s the value we are paying for.
Next, we must redirect some of our $3.3 trillion to factors that are more influential on health. We can do this by giving those who receive the health dollars incentives to invest in non-medical solutions that solve health problems. If we as payers — government, businesses, families — insist that our dollars are spent on improvement in health outcomes rather than delivery of medical services, providers will respond by investing in non-medical services. The movement toward value-based payments is a step in the right direction. We must take this opportunity to pay providers for improving health outcomes, including through non-medical interventions.
That clinic in northwest Houston decided that its responsibility was to make kids healthy, not just give them health care. They would no longer send patients home with medications knowing that the real solution lay outside the clinic. Clinic staff began visiting patients’ homes to find and fix the asthma triggers. The clinic is now working with an insurance company that understands that home repair is the best medicine for some patients. We can accelerate this kind of system change by making the conversation about health, not just health care.