The U.S Health Care Paradox: Why Spending More is Getting Us Less

The AmericanHealth Care Paradox: Why Spending More is Getting Us Less1

OutlineUnraveling the paradox

Recurrent themes from service US providers and users

Learning from abroad

Homegrown innovations here in the US2The Paradox3

THEN THERES THE PROBLEM OF RISING COST. WE SPEND ONE AND A HALF TIMES MORE PER PERSON ON HEALTH CARE THAN ANY OTHER COUNTRY, BUT WE ARENT ANY HEALTHIER FOR IT.

- JOINT SESSION OF CONGRESS ON HEALTH 9/9/09High Spending on Health Care4Per capita data downloaded from OECD.StatExtracts. Available at stats.oecd.org 4US Poor Ranking among 34 OECD Countries5Source: OECD, Health at a Glance 2009: OECD Publishing

6What could help explain this paradox?Incorporating Social Service Spending7

In OECD, for $1 spent on health care, about $2.00 is spent on social services

In the US, for $1 spent on health care, about $0.55 is spent on social services

8 Methods and FindingsUsing OECD pooled data from 1995-2007 on 29 countries, multivariable regression with 5 health outcomes

The ratio of social to health spending was significantly associated with better health outcomes:- Less infant mortality, low birth weight, premature death; longer life expectancy- Non-significant for maternal mortality

This remained true even when the US was excluded from the analysis9Bradley et al., BMJ Qual and Safety 20119Why do we do it this way?Health care and social service sectors grew up fairly independent from one another

Social services, in contrast, were conceived of the poor or aged and the target of charityHealth care grew professionalized and fit into a marketable, valued commodity for purchase

10Different in values, target, funding, types of professionals, and goals10Recurrent Themes from Provider Interviews1. Frontline personnel are stretched to respond to the concerns of service users with limited resources.

2. A more holistic approach was desired by both health care and social service providers.

3. Difficulties in establishing relationships between social services and health care have many roots.

11Frontline Personnel Stretched I am sitting here writing a prescription [for] this person who has limited ability to afford the medication or have insight on the situation, who cant go outside because the neighborhood is unsafeand I am totally unable to do my job. -Internist

12We have a client who was hospitalized three times in 72 hours because they didnt take the time to really look at what the problem was. They sent her home at midnight. The next morning before seven, an ambulance come to get her again. -Social WorkerMore Holistic Approach is DesiredWhat we do is an all treaters call -- everyone who is involved with the person, we will sit down at the table and discuss the person, what is the best care that we can give them.We can get three or four agencies working simultaneously side by side for one person; the key is communication and cooperation because if you dont cooperate, it doesnt get you anywhere.- Case manager

13Many Barriers to Holistic CareLack of resourcesDifferences in cultural and professional normsTechnological and data limitations

Even if you got past the privacy issues, it is very hard to tie in all of the information that was useful for the hospital based provider, the outpatient based provider, and social services to be able to capture what an individual is thinking or feeling at a given point in time, to know what intervention is necessary.-Social worker

14User submitted comment The National Memo

this thesis is starting to be accepted. You can see it in the models being rolled out in NY StateRebalancing what we spend on medical care and social services can potentially deliver better health outcomes at lower cost. Cracking this code is a challenge that should concern us all.Huffington PostExperience in Other High-income Countries16

As soon as you get off the plane in Denmark you see this is a country seeking to keep me healthy The area is whistle cleanYou take the stairs, not escalators elevators off to the sideBathrooms at regular convenient intervals Food choices fresh and healthy A good long walk to the outside

The experience repeats itself again and again and even as they budget and manage their health services, the social services are integrated in the beginning, middle, and end at the country level by locally elected officials (decentralized, democracy, with heavy social welfare state)

It is about values - 16Conception of HealthYour health means everything.- Winthrop University Hospital

People should know that health is not the goal of life. But health is definitely a means that you can use to choose exactly the life you want because if you dont have health, then your possibilities cannot flow and grow. -Danish Health and Medicines Authority Executive 17Joint Planning and BudgetingIt is a closed system where 80 percent of the decisions, even those they are decentralized, are made within the public integrated system. Soif one departmentgoes beyond its budget, somebody else will have to be below it.- Denmark, senior health policy analyst18Comparisons in Values(Scandinavia versus U.S.)19Differences (P