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Tuesday Jul 09, 2019

Why Do We Neglect Our Health System's Foundation?

When the walls come tumblin' down
When the walls come crumblin' crumblin'
When the walls come tumblin' tumblin' down
-- John Mellencamp

[board game jenga tower of wood sticks]

I recently participated in a panel discussion as part of The Hill's Future of Healthcare Summit.(thehill.com) The event was extremely well done, featuring members of Congress, representatives from across the health care industry and patient advocates. And I always enjoy the opportunity to sit down with The Hill's editor-at-large, Steve Clemons,(thehill.com) (we both spent our formative years in Oklahoma) and discuss big issues.

The event focused on what our health care system could or should look like in the future. Many of the speakers focused on innovation in the pharmaceutical, biologics and digital health fields. My comments were obviously more focused on the delivery of care and the formation of a health care system that was foundational in primary care.

I am often asked some variation of this question that Clemons posed to me and my fellow panelists: What will our health care system look like five, 10 or 20 years from now?

It's an interesting question to ponder, and as I prepared for this panel discussion, a few themes immediately jumped out. My framing thought was this: The challenges facing our health care system and the overall health of our citizens are not associated with a lack of investment in the complex services provided at the top of the health care pyramid, they are the result of the systemic underinvestment in the foundations of our health care system. We have sat idly by for multiple decades and watched as policymakers and certain segments of our health care system robbed Peter to pay Paul.

Guess what?

Peter is dying.

Why is this occurring? First, at some point we decided to stop providing "health care" to people and instead started providing "health services." This shift from care to services dehumanized the patient population and turned them into multiple components (organ systems, disease state, health condition, etc.), and our health care system happily adjusted to focus on these components and began providing a plethora of services to each patient -- often with little evidence that such interventions were actually beneficial to the health of the patient as a whole. This approach required new sources of funding. We needed new equipment, new facilities, new research and a new workforce. Financing had to be found.

Financing of our health care system, in the past 20 years, has come to resemble a game of Jenga. We have slowly, yet systematically, pulled planks from the foundation of our health care system and reallocated those resources to the top of the structure. Slowly and systematically, we have destabilized the foundations of our health care system -- family medicine/primary care, general surgery, obstetrics and psychiatry -- in favor of an intense overspecialization of the physician workforce and, thus, an overspecialization of our health care system.

There are valid reasons why this has occurred, including an explosion of innovation in diagnostic testing, new pharmaceutical and biological treatments, new surgical techniques and equipment, and greater access to health care for all populations. We should be thankful for these innovations and advances because they have created chronic conditions from what were previously causes of death. However, these advances created a mentality among many that is revenue-centered, not patient-centered.

The advances achieved, and the mind-shift that accompanied them, lead me to my second observation: Our health care system has become entrenched in the "hero mentality," essentially abandoning the role of the "helper." (I have adapted this analogy of the hero and the helper from Propp's Character Theory.(www.academia.edu))

Our health care system today thrives on the hero mentality. We have developed a system that is designed, financed and incentivized to provide heroic measures to patients. We celebrate it on billboards, fake rankings in magazines and through the advancement of our oral urban legends.

We see this all around us. I am not suggesting that this is always a bad thing, but I think it explains how we have allowed those Jenga planks to be taken from the foundation of our health care system and reallocated to the top of the pile.

The problem is that to finance these heroic interventions, we drain resources from the health care interventions and physician services that offer the best opportunity to prevent disease, maintain health and promote longitudinal health across a majority of a lifespan.

Know where those things come from?

You guessed it -- primary care.

It is likely not uncommon for our current health care system to spend more on a patient in their final 48 hours of life than we spent on primary and preventive medicine for that same individual during the rest of their life.

The concept of hero versus helper plays out in every health policy debate in Washington, D.C., and state capitals across the country. A perfect example is the Medicare physician fee schedule. The amount of treasure we invest in primary care versus procedural specialties is the perfect real-world example of the hero versus helper pattern. What we do not celebrate and finance are those activities that help individuals and populations maintain health, prolong the onset of disease and live healthier, more productive lives. There are quantifiable negative impacts that derive from the way we allocate health care resources, yet we continue to fill our collective national ego via celebrating heroic measures in health care, not by celebrating the promotion and maintenance of health.

So, how did I answer the question of what our health care system will look like in the future? Here are the two predictions that I shared at the event:

If the previous 20 years were defined by centralization and specialization, the next 20 will be defined by decentralization and generalization (primary care, general surgery, etc.) of health care. I have pretty strong opinions that there is an opportunity to implement the "leftward shift" of health care in the next few years -- using technology, artificial intelligence and machine learning to expand the comprehensiveness of services provided by family physicians and, thus, eliminating the reliance on the dozens of "ologists" that have come into favor during the past 20 years. The transfer and portability of knowledge is going to decentralize and democratize knowledge, and family medicine is poised to be the single-source, comprehensive provider of care to most people. The AAFP is leading this charge, and I am personally excited to see what happens when we appropriately fund and equip family physicians.

Patients will play a more active role in their health care. Patient-physician coproduction of health care will become commonplace. Just as the decentralization and democratization of knowledge will allow family medicine to expand and provide a more comprehensive suite of health care services, the same concepts will allow patients to be more active in their health care and in decisions about their health care. The relationship between patients and their family physicians will be a partnership, not a commercial transaction. This is good, in my opinion.

But for now, our health care system is teetering on a few unstable planks.

Posted at 06:48AM Jul 09, 2019 by Shawn Martin

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ABOUT THE AUTHOR



Shawn Martin, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy.

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