Dr. Tom Roberts Commentary: “Health vs. Health Care”

In January of this year, the Eastman Kodak Company filed for bankruptcy after 131 years of business. It’s been suggested that Kodak thought they were in the film and chemical industry, when they were really in the business of creating images. When a better way to create these images came along they hadn’t changed and so went out of business.
We’re just beginning to recognize that we have created a similar situation with the business of health. Especially in the United States, we’ve focused on providing health care. What we should be looking for though, is not more and more expensive health care. What we really want and need is our health.
If health care did in fact give us health, then it would be worth continuing our substantial and ongoing investments. What’s becoming more and more apparent though is that health care is only responsible for about 10% of our overall health status. The rest is determined not by the doctor, but by many other factors including our environment, our genetics, our social status and choices we make about lifestyle.
70% of the deaths in the United States and 75% of our medical spending is related to chronic diseases like diabetes, heart disease, and to some extent cancer. Social inequalities have been shown to be much more predictive of illness, disability and death than any amount of health care. Even developing countries are seeing a rising epidemic of chronic disease which now overshadows the old killers of acute infections and injuries. In an aging society, chronic illness becomes the overwhelming factor that determines health and drives health care spending.
Yet, our model of health care remains stuck in the early 20th century when curing acute illness in a predominantly young population was the goal of medical care. We continue to pay mainly for sick visits within our health care system. Only recently have we begun to recognize that what we really should be paying for is prevention and effective management of chronic disease. We pay very high prices to cardiologists who intervene when someone has a heart attack and yet, even now, we fail to pay or pay very poorly for systems of care that deal with the underlying causes of that heart attack.
Medical students today recognize that primary care doctors earn dramatically lower pay than specialists. They tend to work longer hours and their status is lower. It’s no wonder that less than 7% of these graduating students choose careers in primary care. Our entire system is oriented to acute interventions, after disease is already established. Even within primary care offices, we are just now at the very beginning of understanding what we need to do to effectively manage diabetes and hypertension over the long haul, much less how to effectively deal with our current epidemics of obesity, smoking, and a sedentary society. Spending on public health is less than 1% of the total medical budget. And yet we know that effective interventions at this level are the best investment for improved population health.
Meanwhile we are acutely aware that parts of our country which spend more money on the health care industry do not have healthier people. The variability in spending can be as much as 3 times higher in some areas than others, without any noticeable effect on population health or quality of life.
The only reasonable conclusion we can come to is that much of our $2.5 trillion per year spending on health care is unnecessary. It pays for very expensive medical care, much of which we don’t need. That spending instead should be redirected in ways that support prevention and health maintenance.
Yet, despite what we know, this approach comes up against powerful obstacles. Not the least of which is our own social expectations of instant cure and relief of symptoms. The newest drug or surgical intervention is preferred over a careful, steady, and thoughtful approach to diet, exercise, mental health and other prevention activities.
Perhaps eventually, we will come to understand and reward a healthy, community based approach to wellness. Given our current directions, that may still be a long time coming. When and if it does, perhaps like Kodak, our current focus on acute disease treatment rather than health will become a thing of the past.
“What Business Are We In? The Emergence of Health as the Business of Health Care” By Ash and Volpp in The New England Journal of Medicine, September 6, 2012, page 888-9 and
“From Sick Care to Health Care- Reengineering Prevention into the US System” by Marvasti and Stafford in The New England Journal of Medicine, same issue, page 889-91

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