Population vs. Patient Care — art no more


The U.S. has always been concerned about population health but mostly in terms of clean water, safe food, and safe medications.  Outside those areas the art of medicine was left to doctors.   There have been lots of medical discoveries in the past 20 years.  But, one quiet discovery may be the most important:  medical care is not art.  It may be industry or business or paint-by-numbers but it is not art.  There are rules and there are expected outcomes.  And, most importantly, the rules can be applied to populations.   For example, there are necessary vaccinations, unacceptable blood pressure levels, excessive weight ranges, best ways to remove gall bladders, and the correct frequency for pap smears.   There is a glimmer of hope that a focus on population health management will reverse the trend of rising health care cost.

An article from the University of Rochester Medical Center is a very nice perspective on population health.   They see the future of health care in systems of buildings, information technology, and organization of primary care.  The theoretical underpinning is reliability, interchangeable parts and operational efficiency.  The tools are there for controlling cost.  But, those tools currently are used to increase profits,  somewhat like letting the fox guard the chickens.

Patient-centered care  emphasizes efficiency and satisfaction at the point of care which mirrors our cultural view of individual importance.  In some respects this is consumerism or “give the patient what they want”.  Quality is the byword and standards for such care have been outlined by the National Committee for Quality Assurance (NCQA).  Important aspects of care include evidence-based guidelines, access to care, timely appointments, after-hours care, coordination of specialty care, continuity of care with one provider, cultural sensitivity, and good record keeping.  All laudable goals but mostly unconcerned with cost.

Each country must find its own path to good quality low-cost health care.  Our neighbor to the South, Cuba, is an interesting case.  The Cuban medical system now has twice the number of doctors per person as in the U.S.  so Cubans have better access to care than we do.  They even have lower drug costs because the government manufactures low-cost medicines.  The path they took is not likely the one the U.S. will follow since Cuba has poor sanitation, high poverty, 70% of employment is by the government and doctors are only paid $20 per month.

The cost of care must always be considered.  The population health advocates assume good systems and management will lower cost.  The patient-centered advocates assume quality care is less expensive care.  The path the U.S. needs to follow should include a blend of both, plus guaranteed (not theoretical) cost containment.  The cold hard fact is our health systems must be trimmed, our provider workforce must be expanded with less expensive providers, and new drugs must cost less.  This is a hard pill to swallow but we just need to take our medicine.

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