1. FOUNDATIONS OF U.S. HEALTH CARE DELIVERY FEBRUARY 27, 2014

2. LET’S DRAW A PICTURE How would you describe health care today? Why are people healthy? Why do people get sick? How is health and sickness addressed in this country? What role do health care organizations play? …does the government play? …do clinicians and physicians play? …do individuals play?

3. LET’S DRAW A PICTURE In a perfect world, how would you describe health? How would sickness get addressed? What role would health care organizations play? …would physicians or clinicians play? …would individuals play? What kind of health care organizations would exist?

4. HOW DO YOU GET THERE? Is the “ideal” possible? What would you need to do? What roadblocks exist? How would you plan health services? How would you improve health?

5. WHERE DO THINGS CURRENTLY STAND? Which of the following statements is true? “The U.S. has the best health care system in the world!” “No way, the U.S. health care system is, at best, average.” It depends on who you’re talking to and about… Individual? Population? It depends on how you define and measure health care… Access? Cost? Quality? Outcomes? Equity?

6. UP FOR DEBATE The health care industry feels strong tensions and conflicting pressures What is health? What is health care? Is health care a need? A right? A privilege? If we think about population health, who’s the population? What’s the role of health care organizations? Economic or social benefit? Reactive or proactive?

7. WHAT IS HEALTH? “Last week about 30 of us spent 36 hours in The Hague discussing whether we could produce a new definition of health – and eventually deciding that we couldn’t” (Smith, 2009) “Defining health appears to be a simple, even unnecessary, matter that does not spark the interest of most healthcare workers. Everybody knows what health is – that is, until they are asked to provide a clear and concise definition of the word. Not only is it hard to provide such a definition but, if past experience is anything to go by, those devised are unlikely to stand up to critical scrutiny well enough to gain general approval However, that is no reason to stop trying” (Lewis, 2013, p. 211)

8. THINK, PAIR, SHARE What is health? How would you define it? Is it the absence of disease? Is it an experience? A physical state? How you feel? How would you measure it? Is it a continuous spectrum? What variables might affect it?

9. WHAT IS HEALTH? “A state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” (World Health Organization, 1948) “The ability to adapt and to self manage” (Huber et al., 2011) “A balanced state between physical, emotional, social and cognitive/sense-making domains. Within any local environmental context, a health state exists within a multidimensional phase space of physical integrity, functional performance and subjective experience producing an entropic state most consistent with viability… Health is a complex adaptive state in so far as the inner workings at a psycho-neuro-immunological level maintain a certain homeostasis for self-sustaining physiological function” (Sturmberg, Topolski & Lewis, 2013)

10. WHAT IS HEALTH? Does that sound like our system? Is that what it does? “For most doctors that’s an uninteresting question… doctors are interested in disease, not health. Medical textbooks are a massive catalogue of diseases” (Smith, 2009) Our system has developed with a focus on disease diagnosis and treatment Health care in the U.S. has traditionally been governed by the biomedical model …Health is the absence of illness or disease Health care delivery focuses on medical or illness care, and prevention of disease and health promotion are secondary

11. WHAT IS HEALTH? The WHO definition of health adopts a biopsychosocial model: physical, mental, and social dimensions Physical Mental Social

12. WHAT IS HEALTH? There has been a recent growing interest in holistic health Health indicators include: self-reported health status disability life expectancy spiritual well-being social functioning morbidity (disease) functional limitations mental well-being Physical Mental Social Spiritual

13. OUT OF BALANCE? Our adoption of a broader conceptualization of health is a marathon, not a sprint… “Despite almost universal references to ‘health care,’ ‘health insurance,’ ‘health benefits,’ and ‘reforming the health care system,’ the unfortunate truth is that all these terms are misnomers. The United States has a medical care system focused on diagnosis and treatment of those with disease (or at least ‘dis-ease’), not a health system that addresses the needs of the healthy. However, powerful, effective technology now exists to prevent illness and maintain health” (Peterson & Kane, 1997, p. 305)

14. THINK, PAIR, SHARE How should health care be provided if a holistic definition of health is assumed?

15. WHAT IS HEALTH CARE? It’s complex Is it a service? A good? A philosophy? Is it a process? A system? A one-time intervention? “…the diagnosis, treatment, and prevention of disease, illness, injury, and other physical and mental impairments in humans. …It refers to the work done in providing primary care, secondary care, and tertiary care, as well as in public health” (Wikipedia, 2014) “The maintaining and restoration of health by the treatment and prevention of disease especially by trained and licensed professionals (as in medicine, dentistry, clinical psychology, and public health)” (Merriam-Webster Dictionary, 2014)

16. WHAT IS HEALTH CARE? A different perspective: “Health care is a targeted perturbation of the ‘patient system’ that facilitates the system ‘to do the necessary adaptive work’ to achieve (self-)healing. This stands in stark contrast to the prevailing ‘healthcare’ approach of targeted ‘curative interventions’ done to the patient by others (known as healthcare providers). Health care becomes a participatory encounter between two experts who work together to achieve a common understanding of the patient’s disease in the quest to succeed in the struggle for life, and at times, this may entail the ‘passive’ endurance of interventions aimed to maintain one’s life” (Sturmberg, Topolski, & Lewis, 2013)

17. CHOOSING BETWEEN PANACEA OR HYGEIA? The divide between health and medicine goes wayyy back to ancient Greece… Panacea: the goddess of cure and remedy Hygeia: the goddess of health and well-being Continues to be reflected in our “dual systems” relating to health care Curing disease? Or promoting well-being?

18. WHAT IS HEALTH CARE? HOW DO WE PROVIDE IT? Informed by how we view illness and disease Informed by how we view quality of life Informed by how we view determinants of health Informed by our perspective of health distribution

19. ILLNESS VS. DISEASE Illness A person’s own perceptions and evaluation of how they feel Disease Based on a medical professional’s evaluation Falls along a spectrum Acute Chronic

20. QUALITY OF LIFE Overall satisfaction with life and self-perceptions of health Satisfaction with experience of receiving health care services Comfort Dignity Privacy Security Degree of independence Decision-making autonomy Personal preferences

21. DETERMINANTS OF HEALTH A singular focus on medical care delivery is unlikely to improve a population’s health status Multiple factors determine health and well-being A more balanced approach is required

22. DETERMINANTS OF HEALTH Environmental factors Behavior and lifestyle Heredity Medical care Examples: Physical activityOverweight/obesity Tobacco useSubstance abuse Sexual behaviorMental health Injury & violenceEnvironmental quality ImmunizationAccess to health care

23. MARKET VS. SOCIAL JUSTICE PERSPECTIVES Who should receive the medical goods and services that a society produces? Market justice perspective Economics-based (supply & demand) People make rational choices and know what’s best for them Minimal need for government interference Social justice perspective Health is a social good, access is a basic right Government is more efficient to allocate health services equitably Need for government to plan and deliver health care

24. MARKET VS. SOCIAL JUSTICE PERSPECTIVES What are the implications? Market justice perspective Individuals are responsible for their health and well-being Social problems can be addressed through private solutions Rationing is based on the individual’s ability to pay Social justice perspective Society is collectively responsible for its health and well-being Social problems require public solutions Rationing is based on health care planning

25. THINK, PAIR, SHARE Which makes sense to you? Should our health care system favor market justice? Or is social justice the better way? What do you think?

26. WE’VE GOT BOTH Medicare & Medicaid vs. private, employer-based insurance Government oversight of insurance, payment, new drugs & procedures, medical research, information systems, quality, etc. Public health & population health vs. individual interventions How are we wrestling with this today?

27. HEALTH CARE INTERVENTIONS Policy interventions Community-based interventions Health care system interventions Individual-level interventions Strategies to improve health Nutrition programsWork/environment safety efforts Community-based partnershipsPrevention-oriented effort Patient safety & medical error reductionCoordinated care Chronic disease managementCulturally appropriate care

28. INITIATIVE EXAMPLES http://www.healthypeople.gov/2020/default.aspx http://fitcitysa.com/about

29. IS THERE A REMEDY? What will it take to fix what’s broken? Can we bend the curve? To a healthcare system that is… Safe Effective Patient-centered Timely Efficient Equitable Coordinated Affordable From a system hampered by… Quality concerns Ineffectiveness Patient uncertainty Inconsistency Redundancies and waste Inequality Fragmentation Unsustainability