home email us! sindicaci;ón

Healthy Lifetime Partnerships — The Ultimate Healthcare Reform

by Scott MacStravic

While practically everyone, particularly the aspirants to the American Presidency in 2008, seems to have a solution in mind for the “healthcare crisis”, one thing seems clear.  Any real solution will have to include a cost-effective strategy and program to dramatically increase the proportion of Americans who live healthy lifestyles, for as much of their lifetimes as possible.  The epidemic of unhealthy living that has been growing for decades has created a ticking time bomb of people who already have or are on the path to having chronic conditions that increase their, and the country’s need, demand, and expenditures for healthcare far past the affordable level.

Pursuing “healthy lifetimes” should be something that could at least be made appealing to most people, and the benefits of such made appealing to most organizations.  There is already growing in this country what hopefully will turn out to be the “critical mass” of stakeholders needed to not merely motivate but integrate sufficient effort to make the changes needed.  It would certainly have been better if we had started on a national, integrated effort much earlier, but it is, we can at least hope, not too late.

From the vast amount of research that has been done on the subject, it also seems clear that managing chronic diseases that already exist, in the senior population in particular, is truly the “last resort” in terms of cost-effectiveness.  Research reports continue to be published indicating that Medicare demonstration projects are not working.  Managing chronic diseases in the senior population seems to cost far too much money, and save far too little.

The net effect of this combination is a continuing series of disappointments.  While participants in these projects gain improved quality of care, and often of health and life, as well, the federal government and taxpayers gain little if anything.  It is difficult to say if it is the challenge of old dogs and new tricks, of limited opportunities once chronic diseases are well established, of disease management suppliers who haven’t figured out cost-effective approaches, or some other intractable difficulty.

In any case, what a number of analysts, including myself, are beginning to advocate is a far more proactive approach to the problem, namely reducing the incidence and prevalence of chronic conditions (and acute disease as well) across the entire population.  Instead of being guided by the Willy Sutton principle (rob banks because that’s where the money is), work with the entire population, as early as possible in their “health development”, to minimize the number who become sick, and maximize the number who stay well.

It is perhaps understandable that insurers and governments have waited until people get sick before trying to do something about it.  There are far fewer people to deal with that way.  Often the proportion of a population who are at high risk or high cost already is less than 10%, often more like 3-5% when younger populations are concerned.  This seems more efficient than having to worry about everybody.  And when the proportion already adhering to healthy lifestyles is considered, that usually amounts to an equally tiny proportion of the population, meaning that practically everyone needs some attention.

The American medical care system suffers from one major cost fixation that may make sense in sickcare, but is both unreasonable and horribly inefficient in healthcare.  This is that there is one high standard of quality that should be delivered to all patients regardless of their ability to pay.  We do make some exceptions in the form of “VIP” levels of care for the wealthy, “executive health” programs for the important, etc., but otherwise demand that all have access to a high and expensive level of sick care.

This is not a fixation that makes sense in healthcare, nor is it affordable.  The challenge in healthcare is to create and execute population health strategies that can be customized to individuals, based on their risk/reward potential and personal idiosyncrasies, so that cost-effective and successful healthy lifestyles can be achieved and maintained by as many as possible.

This means beginning the effort as early as possible in the lifecycles of each of us, as early as pre-pregnancy, for example.  Minimizing the number of babies born before fully developed, or with congenital problems is one of the first places to begin.  Promoting healthy child development, particularly avoiding the recent epidemic of overweight/obese children is another, since weight problems early on tend to persist and create high risks of diabetes as well as psychological and social problems.

While the federal and state governments take on some responsibility for healthy pregnancies and child development through Medicaid, the rest of the population is pretty much left to their own devices, with medical care focused almost entirely (roughly 95% in terms of expenditures) on “sickness procedures” rather than on promoting and maintaining healthy lifestyles from the beginning of life.  And waiting until people become “government wards” at the age of 65 is easily the most inefficient possible approach.

The recent introduction of legislation that would give employers tax incentives to promote the health of their employees is one example of how governments could join with private business in promoting healthy lifestyles earlier.  Rather than waiting to inherit an entire population of mostly sick people, the federal government should, ideally, by promoting research that identifies the most cost-effective approaches to promoting healthy lifestyle in young and employee populations, in order to inherent healthier seniors.

Fortunately, America has a history of public/private partnerships for the most serious challenges in the most serious situations, such as the one that created a winning military capabi