Health vs Healthcare

A few weeks ago, I listened to a podcast by the John Hopkins University Bloomberg School of Public Health titled “How to Extend Life Expectancy.” (1) This 15-minute podcast is but one episode of the school’s larger “Public Health On Call” series. In this podcast, Dr. Mai Pham, “physician and president and CEO of the Institute for Exceptional Care”, speaks about the difference between health and healthcare. She argues that while American healthcare dollars go towards funding clinical care visits, tests, and diagnostic practices, the true drivers of health are social: environment, social support, diet, stress, exercise, etc. She discusses several paths forward whereby we may develop a system to support the health of Americans instead of simply improving healthcare. I plan to discuss these paths in this article.

This article is the first of many in a series focusing on “the root cause.” While I discussed this topic briefly in my article “The Root Cause. A Policy Investigation: Gun Violence and Mental Health”, the argument is simple: if politicians are attempting to truly solve an issue, they must focus on its primary cause rather than addressing its superficial manifestation. (2)

The American healthcare system is in drastic need of improvement: in 2021, the US spent 17.8% of GDP on healthcare, almost twice as much as any other developed nation. (3) Below, I include a breakdown of how personal expenditure is spent on healthcare.

From the chart, we can see that over 60% of American personal expenditure is spent on physician and clinical services as well as hospital care. The obvious question that stems from this data is why do we spend so much on healthcare? Remember the analogy from my “gun violence and mental health” article: if policymakers put 1 billion dollars into hospitals and primary care, to sustain that level of healthcare, policymakers must put in that same amount every year (resulting in enormous costs as in the US). If policymakers instead put 1 billion dollars into addressing the root causes of poor health, that amount might be the only taxpayer money ever spent. Dr. Mai Pham discusses three ways to improve health. In this article, I define health as “a range of physical, mental, and social states whereby an individual in ‘good health’ is generally free from illness or injury.”

Personalized Primary Care

When you think about your physician care team, you probably first think about your primary care physician. This doctor checks in on you during your annual visits and is your first point of contact if you need medical care. How many patients do you think your primary care physician (PCP) has? New studies suggest that the average patient load for a PCP is 1000, while the American Association for Physician Leadership suggests that it is closer to 3000. (4) Why might this be the case? PCPs are typically not paid much per patient visit and thus must see many patients in order to profit, resulting in short 15 minute visits per patient. In fact, this payment crisis is resulting in fewer medical students choosing to specialize in primary care, worsening this inadequacy in care. (5)

This system needs to change. PCPs are essential to maintaining patients’ good health and reducing healthcare costs. PCPs are responsible for educating patients about ways to improve their health through proper nutrition, exercise, and developing a good environment. (6) PCPs are also responsible for detecting health issues early and connecting patients to specialist providers to resolve emergencies if and when they arise, before they get out of hand. (7) Thus, ensuring that PCPs have enough time to address patients’ needs is vital.

Dr. Pham argues that in order to keep PCPs in the industry, the amount of payment they receive must double. She also argues that PCPs should be guaranteed a certain amount of money per patient they see so that they may spend more time addressing patients’ needs instead of worrying about their own income. It is clear a PCP shortage is growing in the US; the US government could increase funding and capacity for primary care residency programs to attract more medical students. (8) Healthcare administrators could also financially incentivize students by reducing debt burdens and increasing reimbursement per hour spent working.

Health NOT Healthcare Insurance

In my earlier Medicare for All article, I discuss how health insurance works and the different payment types consumers can expect. (9) Health insurance premiums are set by firms estimating how many medical services you may use in the future. Again, health insurance firms look strictly at medical services (diagnostic tests, clinical visits, etc.). Dr. Pham argues that if the definition of medical services was expanded to include determinants of health, insurance would become a much more effective tool.

So what would be included in this expanded definition? Perhaps some sort of reimbursement for a gym membership or meal plan. Perhaps transportation to and from a local gym or hospital. Perhaps reimbursement for a translator that could assist with hospital visits. Perhaps a community social support group to provide care to elderly individuals.

Health insurance firms bear a portion of the cost incurred when a patient receives medical care. Thus, health insurance firms are most profitable when patients do not need medical care in the first place. Addressing social determinants of health will do just that.

Community Focused Clinics

Dr. Pham’s last argument involves hospitals engaging with local communities. To be considered a non-profit organization and receive a tax-exempt status, hospitals must participate in “community benefit”, whereby hospitals address the needs of local community members. (10) Dr. Pham provides various strategies for hospitals to engage with communities in productive ways: hospitals can invite community members to serve on the Board, hospitals can seek patient feedback, and hospitals can use community benefit dollars to support local organizations that address community health.

To adequately provide for patients, hospital administrators must recognize that partnerships with community organizations in different fields are essential; health is physical, mental, and social and by partnering with social support firms, schools, and faith-based organizations among others, hospitals can provide for patients holistically.

Unfortunately, most hospitals in the status quo do not have the capacity to collaborate with communities. In fact, community benefit dollars are used most often to provide discounts on medical services. If community benefit funding is used to invest in grocery stores for example, Dr. Pham argues that hospitals can subsidize nutritious foods and provide low-income individuals with the means to live healthy lives. If hospitals were to develop community boards with community members on administrative committees as well as specific departments with goals of outreach and community collaboration, perhaps patients will be able to spend less of their income on healthcare as they will receive more holistic and comprehensive care.

The US healthcare system is in urgent need of repair; by focusing on the main drivers of health, hospitals can reduce patients’ healthcare expenses and improve both patient and community health. In prioritizing comprehensive health over profit-focused healthcare/medical care, hospital administrators may develop a more equitable system that prioritizes the patient and the provider above profit.