Freakonomics & Healthcare
The 1st half is all about why Randomized Control Trials (RCT) are important and that if we use them for medical treatments, why aren't we using them for healthcare delivery ... blah blah blah, super important concepts, but here's the juicy bit:
"There's a special place in heaven for delivering better care at lower cost, but there's certainly no business model for it" - Dr. Jeffrey Brenner
I almost exploded in joy. Change docs are going to heaven (or any self-subscribed utopia of post life) - and we won't die of poverty.
Change is trying to do part of what Dr. Brenner is hoping for. It's the little engine that could. Small and steady, better care, at lower cost, with an adaptive business model. Maybe one day, we'll be in a RCT to take us from ideology into evidence.
We need to show the Canadian Government that investing in health relationships saves money and lives.
Why do we need studies that prove that consistent relationship-based care works? Because the systems currently in place don't serve us well. They are expensive to run, cost tax payer dollars (or high personal spending) and aren't actually helping people become healthier in mind, body or pocket. In addition when a Medicaid Expansion (socialized healthcare) took effect in Oregon, Emergency Room (ER) use INCREASED by more than 40%!
Increasing access to healthcare without considering context of care, encouraged those who use the ER to use it more often and it didn't decrease morbid conditions nor medication use.
Socialized healthcare does reduce depression by 30% and improves financial stability significantly - and that ain't no drop in the bucket.
But still, why isn't "free" healthcare helping people's physical health?
The reality is that the poor are disproportionately unhealthy, and thusly use more healthcare services but don't have family physicians. The ER is their most familiar point of contact. When it becomes "free", the ER becomes overloaded with complex cases that require more than a stethoscope and prescription.
Maybe Amoxicillin will cure your itch, and Metformin & a Glycemic Load chart will help your Diabetes, but will they help you find a new home so you don't itch so much or make sure you are eating well and exercising?
Medicine is more than medicines.
It includes teaching people how to be their own helpers. Why?
Because, the top reasons for going to the ER in Camden (the city where Dr. Brenner's RCT was held):
- Head Cold
- Viral Infection
- Sore Throat
At the Emergency Room.
Come on people! Why are we not making it easier for people to reach out to a family doctor? To have a health advisor? To have care coordination?
As Brenner saw it, the problem was twofold - at the very least.
One: a certain kind of patient was consuming a ton of health care treatment but still not getting healthy.
And two: the health care delivery system, the hospitals in particular, were set up to profit from these super utilizers - and profit they did, at the expense of the taxpayers. - Stephen J. Dubner.
Dr. Brenner has focused on the super utilizers (the low-income, medically complex), to help them manage themselves, so they need the hospitals less. His group, the Camden Coalition, set up a program called Link2Care that provides care coordination on a regular basis.
Together with Amy Finkelstein's research skills, Dr. Brenner is looking into multi-disciplinary teams working with regular contact for 3-4 months post hospital visit, to ensure quality care, often to poor, homeless, medically & socially complex cases.
What they found (and are still uncovering) is that the participants of this care model are often ill & lonely, eager to talk to a compassionate listener.
They need someone who has medical knowledge and understands how medical needs interact with the trials of a given life.
The obstacle to getting healthier is the lack of high-quality care coordination.
The aim of this particular study is to build patient Autonomy, Independence and Self-Efficacy within these months, and then graduate them.
"The treatment is very helpful... And they feel like family." - patient from Link2Care.
Now, isn't that en route to success?.
"Evidence alone is not enough to fix a complicated problem. I think you need to have the combination of evidence and advocacy.
At some point the American public needs to stand up and say "We're sick and tired of being cut, scanned, zapped and hospitalized in a 2.8 trillion dollar industry that's running out of control and is not taking good care of us. - Dr. Jeffrey Brenner, MD
Even for those above the poverty line, budgeting for a health advisor is difficult. The importance of a health guide is underestimated and unless budgets allow for high cost concierge medicine, a health advisor relationship is not an option.
- The socialized system doesn't compensate family doctors for building a relationship.
- In this, the patients needs get lost.
- The concierge system sets doctors up as a personal assistant.
- In this, the doctors lose autonomy.
Change is focused on building relationships for people who are willing to budget the cost of care, so that both doctor and patient are served and respected. No magnifying glass analyzing the doctor's services & billing codes, and no clock ticking on health connections. Small scale allows self managed billing and a contract of fair use between the two.
5 Ways that Change is Different from Brenner's Model.
Change doesn't look for funders. We are not reliant on insurance, grants, donations of fluxing governmental budgets. We are community supported; exchanging medical skill for membership.
Change asks for a relationship between the doctor & patient right from the financial level.
- Change is in-office, solo practitioner (not in-home, multi-disciplinary) care that focuses on helping navigate health concerns with lifestyle, diet, exercise, medicinal options and poly-practitioner care.\
- Change is not cheap or low-cost care. It is built for those who want a doctor who knows them like family, and who are willing to budget the cost over time from their own pockets.
- Change is not made of weekly visits, is not highly structured or algorithmic. It is flexible (up to a point) in the quantity and types of service/health advice provided.
It is the best of privatized and socialized healthcare.
We don't need to scale this to succeed. We just need to make mezzo-practice membership a thing. Go deeper, not bigger. Less is more.