You ought to get it and read it (and pay it forward). Again, my larger concern has long been that we focus too much on technological and process improvements at our policy peril. Toxic organizational dynamics and socioeconomic considerations (the latter addressed at cogent length in The American Health Care Paradox) are equally important, IMO.
CHAPTER 7: CONTINUING THE DISCOURSEThis is an excellent piece of work. Of particular interest is their detailed assessment of the Scandanavian nations Denmark, Norway, and Sweden. We share much more in common with these countries in terms of political, cultural, and economic philosophies than in commonly believed (a reality sure to be summarily dismissed by our willfully ignorant wingnut partisans, to be sure). We would do well to adopt many of their health care system funding, governance, and organizational practices.
How could the United States devote so much money to health care and yet rank so poorly relative to other industrialized countries in key indicators of the nation’s health? Per capita, the United States spends nearly double what some of its peers spend, but Americans lag behind in terms of life expectancy, infant mortality, low birth weight, injuries and homicides, adolescent pregnancy and sexually transmitted diseases, HIV/ AIDS, drug-related deaths, obesity, diabetes, heart disease, chronic lung disease, and disability rates ... We have suggested that previous calculations have omitted an aspect of spending that is critically important for national health outcomes. This is spending on social services, an area in which the United States spends far less relative to its GDP than its peer countries. The new math unraveled the paradox. If we add together what countries spend on health care and what they spend on social services, the United States’ place in the ranking of industrialized countries shifts considerably. This sum of spending is what might be called the national investment in health. In looking at the sum, no longer does the United States appear to be a massively big spender. Americans’ spending on social services is far less per capita than that of counterpart countries...
This finding is consistent with what experts in public health have argued for decades: health is determined by far more than good genes and medicine...
A comparative analysis of Scandinavian and American values, however, reveals the depths of the United States’ challenges in casting a health care model to improve its population’s health. Although Scandinavians and Americans shared similar views about personal freedom, competition, political action, and investment in technology, conceptions of health differ markedly... Americans lack the trust in each other and in government enjoyed in Scandinavia. This distrust may explain the American resistance to shared accountability for health needed to address the social, environmental, and behavioral determinants of ill health...
IN THE YEARS WE HAVE spent conceiving of and writing this book, we have had ample time to consider the criticisms its ideas may face. We have wrestled with our own, similar doubts from time to time. We have wondered if the scope of the work is too large, the goals too lofty, or the implications too dire. At the same time, we have wondered whether we paid adequate attention to certain flash-point issues, such as mental health and chronic illness, which represent obvious intersections of health and social services. Reconciling and, at times, adapting our views in light of these concerns has been a meaningful exercise that strengthened the logic of our thinking. No doubt, the challenges that lay ahead are considerable, but confronting the deep roots of the spend more, get less paradox is a productive step toward effective reform. At this stage, we thought it wise to include discussion of some of the most pressing and enduring issues, which could not be fully addressed here, to prompt among readers a more authentic analysis of and continued discourse about core challenges ... we worry that some readers will become impatient with the lack of a quick fix, and hence withdraw from the national dialogue surrounding national health investment strategy. Last, we are concerned that readers will recognize the advantages of a more holistic approach to health but find the economic reordering that might ensue unpalatable, despite the promise of sustained benefits...
Although the scientific literature provides robust evidence regarding the influence of social, environmental, and behavioral factors on people’s health, 5 comprehensive evaluations that quantify the precise costs and health impacts of broad-based, nonmedical health interventions are less available. Solid housing, a nutritious diet, stable home life, a reasonable amount of sleep, and a steady job have all been linked to improved health so many times6 that the studies are becoming uninteresting for new researchers to pursue ... Unemployed and underemployed segments of the population have been shown to die younger and be in worse health throughout their lives than are those more gainfully employed, and this finding is persistent across countries and times.
More relevant for our purposes, studies are beginning to show that increased education can lower health care spending. For instance, in a study of older adults with asthma or hypertension, those with more versus less education were significantly less likely to be high spenders in health care. A recent Robert Wood Johnson Foundation report highlighted research that demonstrated that lack of college education accounted for up to 35 percent of the variation in premature death rates in the United States, and each added year of postsecondary school education was associated with a 16 percent decline in years of life lost before the age of seventy-five...
The desire for certainty is in part an artifact of the scientific approach to health care. The scientific method calls for researchers to establish controlled experiments that provide unbiased and generalizable conclusions. These standards are considered appropriate for biomedical research, but can be unduly constraining in a study of complex human behavior that is replete with any number of dynamic and unpredictable processes. Reducing such complexity to a controlled intervention to which people are assigned randomly, or to a reliable set of quantifiable values, is often an impossible challenge...
...while the scientific approach has fueled unprecedented medical and technical progress in many arenas, it has been of less value in conferring data that identifies a prescription for optimally addressing the multifaceted causes of ill health. Scientific methods are touted for their ability to identify the effect of a specific treatment controlling for all the other social, environmental, genetic, and lifestyle factors that might influence the health outcome. In examining broad health interventions, however, recognizing the impact of these larger factors is critical. What might be dismissed as a factor to control in a biomedical experiment, such as the presence of a family support system, is often a fundamental facet of the intervention from a complex systems perspective...
To address the challenge of multiple moving parts at once, researchers often turn to statistical regression analysis, which seeks to distill effects of jointly occurring factors into their component parts. Yet, these methods are less powerful in the face of feedback loops and nonlinear effects inherent in complex systems. As James Gleick, author of Chaos: Making a New Science, writes, “Linear equations are solvable . . . [They] have an important modular virtue: you can take them apart and put them together again. The pieces add up. [But] nonlinear systems generally cannot be solved and cannot be added together. Nonlinearity means that the act of playing the game has a way of changing the rules.”
All this is to say nothing of the ethical challenges researchers confront performing studies in which key social services are withheld from participants in need so as to study their impact on health...
Additionally, we worry that readers will misconstrue the implications of our analysis as little more than a call for more robust safety net services to complement the current health care sector. This would be a misinterpretation of our work. The data we have outlined and the reasoning we have presented are relevant for all Americans, regardless of income bracket. As already noted, the discrepancy in health between the United States and its peer countries is apparent even among wealthy, well-educated, and white subgroups of the American public...
Certainly, for people who are poor, social services, such as housing, nutrition, and safe neighborhoods, are essential. Often, these services must be financed by taxes or philanthropy and supported by governmental policy and action. Hence, our reference to social services may summon for some readers images of government handouts, the “dole,” and bloated bureaucracies...
We anticipate that some readers will become immobilized by the complexity of the issues and will settle for responding haphazardly to the matters at hand rather than seeking a strategic approach ... Some would say this is the American way. Speaking to this point, one health and wellness center service user (ID 59) declared:
The United States is the ultimate in ADHD [attention deficit/ hyperactivity disorder] investing. [LOL, what have I been saying? -BG]The American preference for focusing on the immediate or impending source of pain without attending to underlying causes reflects a type of national investment myopia. This term refers to conditions in which people focus so intently on one aspect of a problem that they neglect other critical data in the landscape. Steven Most and Brian Scholl, professors of psychology at Harvard and Yale University, respectively, have referred to this phenomenon as “inattentional blindness.” ... Generally speaking, Americans are an impatient and skeptical lot, focused mostly on actions that will render immediate and impressive results...
Nevertheless, we purposefully have avoided offering straightforward solutions for which we recognize the public is thirsty. If our book disappoints in this way, it is because of our deep belief that simple prescriptions will not be effective. Rather, we believe that changing the dialogue around health to be holistic and inclusive of nonmedical contributions is paramount to resolving the spend more, get less phenomenon in American health care. Only in the wake of such a shift will scalable and sustainable solutions emerge.
Increased public dialogue about the consequences of overreliance on individualism and medical approaches, and underinvestment in social capital, may help the country to recognize that the difference of opinion among Americans, regarding whether health is better addressed through individual or collective action, represents a tension to manage, rather than a problem that can be solved. Going forward, Americans would be wise to accept responsibility for patiently managing this tension, rather than aggressively aiming to solve a fictitious problem.
In calling for a reconsideration of social services and social capital in the United States, we are grappling with a timeless tension between individualism and community orientation...
A final concern is that some readers will find the economic consequences of slowing health care expenditure too great a price to pay for better health nationally. The US health care industry has evolved to serve a purpose. Occupying 17.9 percent of the GDP in 2012 and employing one in eight working Americans, 24 the health care industry returns significant profit for any number of professional guilds, health care organizations, and publicly traded corporations. If embracing a holistic vision of health and developing shared accountability results in a shift of funds from health care to social services or a repurposing of health care funds to achieve population health outcomes, a substantial number of Americans may stand to lose...
We do not disagree with the statement that Americans spend more on health care and have worse health outcomes than our peer countries. But we do disagree with the common belief that the solution to this problem lies in reforming the health care sector in isolation...
No health care system in the world is perfect. All have advantages and disadvantages, and all manage the tensions inherent in rationing schemes built into the fabric of their designs. For the most part, the approach to promoting health that countries employ reflects the value base of their citizens. For decades, the United States has relied on reforming various methods of paying for health care or organizing its delivery, when in fact the problem has run deeper. Larger change, extending well beyond the scope of traditional health policy, will be required...
Recognizing its social, environmental, and behavioral dimensions and embracing the need for both personal and shared accountability to address these elements of health runs counter to the American affinity for individualism and threatens a large, profitable medical industry.
It remains an American choice to forego taking bold action and to continue instead on the current path; however, the monumental costs associated with preserving the status quo continue to grow, and relief from the national health burden is unlikely without a new approach. To devise this new approach on the basis of evidence rather than ideology would represent a courageous step in the history of American health policy. To that end, an ever-growing body of literature suggests that broadening Americans’ historically narrow focus on medicine in pursuit of improved national health may ultimately hold the key to unraveling the spend more, get less paradox.
I am blessed to have a number of Swedish and Norwegian friends and acquaintances. I find them uniformly among the most amiable, calm, industrious, and creative people I know.
The endnotes documentation in Bradley and Taylor's book just seems to go on forever. I read all the way through them. e.g.,
42. The Gini coefficient in this context is a measure of income inequality. A Gini coefficient of zero expresses perfect equality, where all values are the same. A Gini coefficient of one (100 on the percentile scale) expresses maximal inequality among values; R. V. Burkhauser et al., “Estimating Trends in US Income Inequality Using the Current Population Survey: The Importance of Controlling for Censoring,” Journal of Economic Inequality 9 (2011): 393– 415; Census Bureau, Historical Income Tables: Income Inequality Table H-4 (Washington, DC: US Census Bureau, 2011); OECD, OECD Factbook 2011– 2012 (Paris, France: OECD Publishing, 2011).
57. In his New Year’s Address on January 1, 2013, by the prime minister of Norway, Jens Stoltenberg, agreed with the notion that the American Dream may be easier to achieve in Norway, saying, “The Americans have their American Dream. We have the Norwegian model. Our model may not sound as exciting, but it makes up for this by providing security. In a society where freedom goes hand in hand with security, more people are able to realize their dreams. What I am saying is this: It is easier to realize the American Dream in Norway than it is in America. We should be proud of this.” (Oslo, Norway: Office of the Prime Minister, 2013), accessed February 27, 2013, http:// www.regjeringen.no/ en/ dep/ smk/ Whats-new/ Speeches-and-articles/ statsministeren/ statsminister_jens_stoltenberg/ 2013/ prime-minister-jens-stoltenbergs-new-yea.html? id = 710868.
3. “Total quality management” (TQM) is a management approach to long-term success through achieving customer satisfaction. In a TQM effort, all members of an organization participate in improving processes, products, services, and the culture in which they work. http:// asq.org/ learn-about-quality/ total-quality-management/ overview/ overview.html.
“Six Sigma” at many organizations simply means a measure of quality that strives for near perfection. Six Sigma is a disciplined, data-driven approach and methodology for eliminating defects in any process— from manufacturing to transactional and from product to service. http:// www.isixsigma.com/ new-to-six-sigma/ getting-started/ what-six-sigma/.
“Toyota Lean” describes a philosophy that incorporates a collection of tools and techniques into the business processes to optimize time, human resources, assets, and productivity, while improving the quality level of products and services to their customers. http:// www.sae.org/ manufacturing/ lean/ column/ leanjun01. htm. Some of these, particularly TQM and Toyota Lean, originated in Japan. For more reading in this area, see W. E. Deming, Out of the Crisis (Cambridge, MA: MIT Press, 1986); K. Ishikawa, What Is Total Quality Control? The Japanese Way (Upper Saddle River, NJ: Prentice Hall, 1985); A. V. Feigenbaum, Total Quality Control (New York: McGraw-Hill, 1991); J. M. Juran, Juran on Leadership for Quality: An Executive Handbook (Detroit, MI: Free Press, 1989).
33. R. C. Fox, “The Medicalization and Demedicalization of American Society,” Daedalus 106, no. 1 (1977): 9– 22; I. Illich, A. Cochrane, and R. Williams, Medical Nemesis (Sydney, NSW: Australian Broadcasting Commission, Science Programmes Unit, 1975); H. Waitzkin and J. D. Stoeckle, “Information Control and the Micropolitics of Health Care: Summary of an Ongoing Research Project,” Social Science & Medicine (1967) 10, no. 6 (1976): 263– 76; H. Waitzkin and B. Waterman, “Social Theory and Medicine,” International Journal of Health Services 6, no. 1 (1976): 9– 23; P. Conrad, Identifying Hyperactive Children: The Medicalization of Deviant Behavior (Lexington, MA: Lexington Books, 1976), xvi, 122.
19. The IOM Report of 2009, For the Public’s Health: Investing in America’s Future, highlighted the woefully inadequate investment in public health and recommended doubling the investment and stabilizing Congress’s financial commitment to public health services. The United States devotes less than half of 1 percent of the $ 2.5 trillion spent on health care per year to public health efforts. The sentiment we describe is noted in Theodore Brown’s history of public health, which describes the national support for public health as occurring only in times of crisis and fear of epidemics, bioterrorism, and the like, rather than as a constant source of support for a healthy population. E. Fee and T. M. Brown, “The Unfulfilled Promise of Public Health: Déjà Vu All Over Again,” Health Affairs, 21, no. 6 (2002): 31– 43.Kudos to these authors for doing all of this voluminous research and publishing this book. Whether it gets any policy traction amid our current Clown Car political Idiocracy environment remains to be seen. One certainly hopes so. Had I the money, I'd buy a copy for every member of Congress.
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NOTE: MY "FAIR USE" EXCERPTS POLICY__
As my regular readers know, I cite a ton of books, news, and web sources spanning the breadth of relevant technical and policy domains, sometimes at substantial length (albeit still relatively small excerpts, percentage-wise). I believe I remain well within the bounds of "Fair Use," as [1] I am not doing any of this for profit, [2] I always provide attribution and links -- which, [3] far from negatively impacting any copyright holders' commercial interests, might actually increase traffic to and interest in their offerings.
It is conventional in the press to cite short snips -- a sentence or two -- and then opine on them at length. I cite authors' works because I think they provide information of clear value having no need of my oh-so-wise clarification. I let them speak for themselves without my Bible-thumping interpositions. I am not a Preacher.
Below, some of my recent healthcare related reading list, spanning the gamut from technology and process QI through clinician cognitive burden issues and organizational factors to socioeconomic considerations (the principal topic of the Bradley-Taylor book cited above). I've discussed some of these on the blog from time to time, starting with my total tech fav.
I should be getting click-through money for all these cites, lol...
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UPDATE
One more book on the way via Amazon Prime. Should be here today (Friday, 11th).
A quick diversion back to my other Jones, financial fraud. I have her book "It Takes a Pillage" on my Kindle. Excellent writer.
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More to come...
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