Health improvement not quality improvement: a call to action for Medicaid.
Dr. Goodarz Danaei at Harvard recently published a study that estimates that one out of every five Americans dies as a consequence of tobacco use. One out of six Americans will die as a result of poor blood pressure control, and one out of 10 deaths is caused by lack of physical fitness. Unfortunately, these risk factors and conditions are more common in low-income populations, and our current health care model rewards treating rather than preventing disease.
Life expectancy is shorter and general health worse, for low-income populations. With nearly a trillion new dollars pumped into health care over the next 10 years, most of which will be invested in care for low-income populations, we should articulate a prioritized focus on reducing preventable causes of disability and death.
It is surprising, but most health insurers do not hold themselves accountable for maximizing the health of the populations they cover. Rather, the predominant model for payers and providers is to improve the quality of services rendered. This focus on quality improvement is very important, but it is only a small element of a health improvement strategy. Health care quality efforts largely focus on the process of care--treatment, screening, diagnosis, treatment and follow-up, rather than the outcomes--changing the health status of a person or population. Quality improvement efforts also tend to be more palatable to health care providers because they focus on changing their own behavior rather than the behavior of their clients. These well-intentioned efforts may crowd out activities that would have a far bigger impact on health status.
One example of the emphasis on treatment-centered quality is the current focus on adult onset diabetes, in which a series of coordinated efforts are underway to narrow the gaps between guidelines and treatment. These systems of care will improve sugar, lipid and blood pressure control. However, adult onset diabetes is largely a preventable disease through weight control and physical fitness. The health care industry is organizing itself to deliver excellent care for a disease rather than focusing equal or greater energy on how to prevent the disease. Furthermore, payers of care, such as Medicaid, perpetuate disease rather than promotion of health through payment policies.
Achieving improved health will require payers and the health care profession to take on greater accountability for health outcomes and for promoting and maintaining changes in clients' behaviors. Yes, changing behavior is exceedingly complex and difficult, but that is no reason for its exclusion. Payers and providers can play a much more critical role in promoting health and preventing disease. Moreover, community health and individual responsibility efforts, along with providers, play equally important roles. Renewed partnerships with state and county public health, social services, and education initiatives around maximizing the well-being, functioning and self-sufficiency of low-income populations follows naturally when Medicaid's focus shifts from health care to health.
A first step is to agree on goals. We propose that private insurers and government programs, like Medicare and Medicaid, be held accountable for achieving HealthyPeople 2010 (and soon to be published HealthyPeople 2020) goals. This initiative has largely been the province of public health, but we believe that health care insurers and providers should similarly align their goals.
Our Colorado Medicaid program, like several other states, has started analyzing and publishing our performance against HealthyPeople 2010 goals and collaborating with payers, providers and communities to improve health while managing our quality and cost goals. We have released health profiles for children, maternity, adults, and clients in nursing homes and compared the Medicaid population to statewide and national averages. Through this effort we have identified a focus on T.O.U.D.D.: tobacco, obesity, unplanned pregnancies, depression and dental caries.
We have an opportunity to make health care reform mean more than expanding coverage for the uninsured; let us use this opportunity to also achieve one of the world's longest life spans instead of the 42nd in the world. Health care reform in America should first be about the health of Americans.
Sandeep Wadhwa is Colorado's Medicaid director and the chief medical officer at the Department of Health Care Policy and Financing.
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|Title Annotation:||health care|
|Publication:||Policy & Practice|
|Date:||Aug 1, 2010|
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