Starting With Curious

Imagine if William Shatner were your doctor.  Crazy, no?  What about buying your health care from him?  After all, he has been the face of PriceLine.com, where you can bid on hotels, flights, cruises, etc.  Almost anything but healthcare.

Until now.  Along comes MediBid™, an online auction for medical care including physician services, hospital stays, durable equipment, etc.  Sounds like something from The Onion, but it’s real.  According to their Web site, “MediBid offers cash paying patients seeking care the ability to find the medical practitioner who best fits that patient’s set of criteria.  Criteria that can include price, location, time-to-treatment…. even professional credentials.  Unlike traditional network sources, your healthcare decisions are in your hands, not someone else’s.”

Prospective patients enter a request for a procedure such as MRI or knee replacement, and providers may then submit bids for that procedure.  MediBid charges fees for both requestors and bidders, but otherwise does not get involved in the transaction.  They do not handle any payments, and make it clear that they do not do any background checking or verification of a provider’s credentials.  So let the buyer beware.

It sounds radical, maybe even a little creepy.  And I’m not sure this is truly taking off; one article from October 2013 says that since its founding in 2010 MediBid has connected 1800 providers and patients.  But Star Trek communication devices and talking computers seemed far-fetched in the days when William Shatner played Captain Kirk.  Let’s not laugh this one off just yet.

The link between socioeconomic status and child health has long been appreciated at least intuitively, but the details of that link are becoming clearer.  Two recent studies in the journal Pediatrics provide specific details about aspects of poverty that adversely affect the health of children.  Such knowledge, in turn, can inform policies aimed at making kids healthier.

1.  A study from Cornell University examined the relationship between income inequality and child abuse.  Looking across all 3142 US counties, there was a linear relationship whereby the counties with the highest levels of income inequality had the highest rates of child maltreatment.  The effect was independent of other factors such as absolute levels of poverty and education.  This confirms other studies that have shown that not only income but income inequality affects the health and well-being of individuals.

2.  Researchers at American University reported that, among households at below 300% of the federal poverty level, food prices are associated with rates of overweight children. Specifically, higher local prices of fresh fruits and vegetables correlate with higher weight and body mass index (BMI); conversely, lower prices for soft drinks correlate with higher weight and BMI.  The authors exploited the fact that the database they used tracked children over time.  Not only was the relationship between fresh food price and weight true when looking across children who live in different areas, but it also held when they examined children who had moved over time; such children’s weight trajectory was different depending on food cost differences between old and new areas of residence.  Again, this bolsters our previous understanding about how lack of access to fresh foods can adversely affect child health.  Fortunately, the 2014 farm bill contains some provisions that may mitigate this, including increased support for organic farming, ability to use food stamps at farmer’s markets, and programs getting schools to grow their own food.

I consider myself somewhat  risk averse.  For example, my brother-in-law is an entrepreneur who is borrowing and putting a good bit of his savings to start a new craft brewery; as much fun as that sounds, I don’t have the stomach for that kind of gamble, and I suspect the majority of people don’t (that’s why most of us are not entrepreneurs).  On the other hand, lots of people buy lottery tickets, which also seems like a pretty risky gamble.  So what’s the difference?

The answer may lie in prospect theory, as explained in a recent JAMA article.  Building on work by behavioral economists Daniel Kahneman and Amos Tversky (and laid out in more detail in Kahneman’s book Thinking, Fast and Slow), prospect theory is a framework for understanding choice.  There are several basic tenets.  First is that people tend to simplify complex choices by focusing on key differences, while ignoring similarities.  For example, when deciding on a vacation destination, if choice A will cost $2000 and require 8 hours of travel, while choice B costs $5000 but only 7 hours of travel, the difference in travel time will likely not even be considered in the decision, which then becomes simpler.  Second, choices are made with regard to a reference point, not on the absolute value.  Two candidates for a position will see a salary offer of $50,000 very differently if one is currently making $40,000 and the other is making $60,000.  This may seem obvious.  In health care, treatment outcomes are going to be weighed against that reference point, which may be a patient’s current state of health, or a remembered past state of health.  Difference in reference points explain some of the difference in risk tolerance between individuals.  A corollary to the concept of the reference point, one that is backed by a good deal of experimental evidence, is that people tend to prioritize preventing a loss over achieving an equal gain.  This is called the endowment effect – we feel the loss of something we already have more than the regret at not getting something we only hoped for.   In one interesting experiment, people were offered the chance to buy a mug a coffee mug, or given the mug and then given the chance to sell it.  People were willing to pay on average about half as much to acquire mug they didn’t have, compared with what they would accept to part with the one they had gotten for free.  It appears that a bird in the hand is quite literally worth two in the bush.

The third element of prospect theory is that, after simplifying and framing the choice, people consider the desirability and probability of each outcome and estimate the expected value of each choice.  However, there are many cognitive inconsistencies and biases that creep in.  For example, we tend to place more weight on proportional than absolute differences.  A difference between winning  $1 and $3 is not treated the same as the difference between $98 and $100, even though each results in someone being able to buy one additional cup of coffee the next day.   Conversely, very small probabilities are difficult to deal with intuitively.  We tend to either ignore them completely (as in, my chance of winning the lottery went up 10-fold, from 1 in 10,000,000 to 1,000,000 – it’s still nearly impossible so I’m still not buying a ticket) or blow them out of proportion (as in, Did you see that the size of the pot is at a record $700 million – how could you not buy a ticket!)  Prospect theory only helps us understand decision-making.  It doesn’t actually make it rational.

These insights into how we, and our patients, make decisions may help us in practice.  There are several studies showing that parents and physicians differ in the values they assign to various short- and long-term outcomes, presumably because of different reference points.  Parents and patients also make different choices when the decision is framed in terms of a gain or a loss, for example, chance of survival versus chance of dying.  This all suggests a need to see the world through someone else’s eyes if we want to help them come to the best decision for them.  We need to understand the filters – theirs and ours.

It also helps us potentially make better business decisions.  Prospect theory suggests that in the face of a small chance for a large gain, we tend to reject choices with a much greater degree of certainty for something that is less lucrative.  For  example, if offered $2 in cash or a $2 lottery ticket, most people would take the ticket.  We don’t see either choice as a loss, and from our reference point the high likelihood of the small gain may not be worth forgoing the small chance to hit it big.  But a forgone gain IS a loss (I gave up a free cup of coffee).  This argues for a rigorous process for providing an objective calculation of the actual expected value of  each of the possibilities in a business decision.  As another example, “cutting one’s losses” may be the best strategy for avoiding further losses.  But we know that, because of the endowment effect, we tend to overvalue what we already have, which makes it emotionally difficult to let go even when that would make the most sense.

In  the meantime, while starting a brewery may not be in my risk comfort zone, the Old Bust Head beer is pretty tasty – trying one is no gamble at all.  (Alas, it’s only available in Virginia for now….)

Daniel Patrick Moynihan, former NY senator and UN ambassador, once said, “Everyone is entitled to his own opinion, but not to his own facts.”  This came to mind immediately when I saw the results of a recent Kaiser Family Foundation poll on health reform.  The poll, which has been tracking public opinion about the Affordable Care Act (a.k.a. Obamacare) for the past four years, found that support remained anemic at 47% overall favorable.  As Moynihan said, everyone is entitled to his or her opinion.  (Disclaimer: I was not originally a big fan of the ACA – I didn’t think it went far enough – but have come to think it’s better than nothing.)  But two other statistics caught my eye.  Half of all respondents believe that health care costs are now rising faster than usual since Obamacare was passed, and 48% think that Obamacare is the primary reason.  That’s playing with the facts.

The reality is that healthcare costs have actually risen more slowly since 2009, a trend that has continued for four years.  Moreover, we need to distinguish the different ways this is often expressed.  First is overall healthcare spending.  That has risen, an average of 3.7% annually since 2009, compared with an average of 6.1% for the four previous years.  More importantly, for the first time in decades, health care spending grew slower than overall GDP in 2012.  As a result, the proportion of all US spending that goes to health care decreased from 17.3% of GDP to 17.2%.  Not exactly time to spike the football (the next highest country is still only around 11%).  But it’s clearly the opposite of an increase.

Of course, overall spending is a factor of a number of things – population, price, and utilization.  Some of the overall increase is a result of more people, so when we look at total spending per capita, the story is even more dramatic: a 1.9% annual increase since the ACA, compared with a prior average of 3.9% per year.  And arguably, price is the thing that people are most concerned about – how much is the same service going to cost me?  Medical price inflation was only 1.7% in 2012; after decades where health care price increases outpaced general inflation, it is now essentially the same.  And when parsing how much each of the factors contributes to the overall increase in healthcare spending, price increases now account for 50% of the increase, in contrast to the 80% proportion in earlier years.

There is a good deal of debate about why health care spending increases have slowed.  Among the factors postulated include: the generally bad economy (though the decreases have persisted despite 3 years of solid albeit suboptimal economic growth); the shift to high-deductible health plans (i.e., more consumerism), a trend driven in part by the so-called “Cadillac health plan tax” in the ACA; and some provisions of Obamacare such as accountable care organizations, Medicare payment changes, and penalties for hospital readmissions.  The consensus seems to be that the ACA itself has probably played a minor but real role.

So let’s have a debate about why spending has slowed down.  Feel free to opine about whether Obamacare is good policy, whether it will do what it set out to do, whether the roll out could have been handled better, or even whether you like the name.  Those are all fair game, and I myself have mixed feelings about all of these.  But regardless of the degree to which you credit Obamacare for the decrease in spending growth, you cannot blame it for the faster spending increase, which didn’t actually happen.  That’s just making stuff up.

Remember when you could fairly easily disappear?  When I was a kid we’d go for long bike rides, and our parents couldn’t get a hold of us until we got home – and didn’t expect to.  Even during residency, I carried a pager, but I had to keep a quarter taped to the back so if I got a page outside the hospital I could use a pay phone.  Immediate connectivity was not part of the picture.

There are some real advantages to cell phones and other means of constant communication, but I don’t think it’s a secret that there are serious problems as well.  According to several studies, a large majority of American workers check email in off hours and on vacation.  Among the effects are decreased job satisfaction, personal and family stress, and burnout.  Not exactly what we aim for with our value of health.  What can we do to disconnect from time to time?  Some companies, beginning to recognize the downside of constant connectivity, are encouraging employees to refrain from email away from work, and implementing policies to reduce the volume of electronic communications  in off hours.  But as individuals we can take the initiative in reaching a healthier harmony between our work and non-work lives.  While I am no expert, I am pretty satisfied with my work-life balance, and here are a few things I’ve tried:

1.  Find, and schedule, leisure activities that require you to unplug.  Some of mine are exercising, playing music, and cooking.  It’s hard to check email or respond to texts when blowing a horn or stirring a risotto.  One caveat: many of us like to listen to music when working out, but if you’re using your phone as an MP3 player,  you run the risk of an interruption.  Try putting the phone on airplane mode – iTunes yes, text messages no.

2.  I’m a fanatic about to-do lists, both at work and at home.  I list my leisure activities on here right along with the chores.  When things are particularly hectic, I put “relax” on the list.  It may sound like an oxymoron, but it works.

3.  Let yourself be OK with not being available all the time.  I try to put some reasonable limits on the number of hours a day I’m available for non-emergencies.  If I’ve been in the office for 11 or 12 hours, I try hard not to do email after that.  If I have other things I need to do on my computer or tablet at home, I’ll turn off Outlook.  When I do look at email in the evening – and I do, if the work day was shorter, or there’s something pressing going on I need to keep an eye out for – I have become pretty disciplined about what I will respond to.  Unless it’s something that truly can’t wait until morning (which is frankly rare), I save it until the next day.  Responding to email at 10:30 in the evening only encourages people to send you more of them.

4.  When going on vacation for a week, it can be really tempting to just check the email to see if anything important came through.  Next thing you know, you’re reading all 200 messages that came in the day before to find the important ones, and responding to them.  I set up a separate email account that only my assistant knows.  When I’m away, she knows that if someone really, really, really needs to get me, she can send a message to that account.  I can easily see if there are any messages in there (so far there have never been any), and blissfully ignore the regular accounts until I get back.  If you can’t be disciplined enough to do that, go someplace without Internet or cell phone coverage.  (West Virginia is great for that!)

To avoid the “but there will be 2500 messages waiting when I get back and I’ll never get through them all so I better keep up” trap, schedule 2 hours when you get back to go through the backlog.  It never takes longer than that, since most of the messages are either junk in the first place, or will have been taken care of by the time you’re back.  One trick is to sort by subject, and start with the latest message in the thread.  You can probably read only the last one and delete the rest without opening.

5.  If you are away from the office now and reading this, turn off your device, and go for a walk.  Without your phone.

Picking up a medical journal can be humbling.  Easily ¾ of the medications and therapies I read about, including entire classes of drugs, didn’t exist when I was in medical school.  At the same time, the basics of what I do as a clinician, and what we do as a hospital, are fundamentally unchanged: patients come to us, we assess and treat them, and we bill for the services which are largely paid by some form of insurance.  But now that health care expenditures exceed 17% of GDP, a tipping point seems to have been reached, forcing changes in the basic model of health care.  While we are confronted daily with innovations in clinical care, most of the innovations in care delivery haven’t yet reached pediatrics, and certainly not our market.  But there are numerous novel approaches to delivering value in healthcare.  Here’s a brief view of some of what is happening elsewhere.

1.  Retail clinics.  CVS recently announced that they would stop selling tobacco products at its 7600 stores around the US.  The prime driver is the desire to be seen as a legitimate healthcare provider.  CVS, Walgreen’s, Walmart, and others already offer medical services, including both episodic urgent care and chronic disease management.  Such arrangements raise legitimate questions about continuity of care, but they have been highly successful.  The number of retail clinics climbed 8-fold from 2006 to 2013, with over 1600 such clinics today, and over 6 million visits in 2012.  The key drivers are convenience and access, though cost is also a factor.  In the US, only 35% of primary care physicians have after-hours care arrangements, compared with 95% in the UK and the Netherlands.  Retail clinics are simply filling an unmet demand.

2.  Concierge medicine.  This term covers a wide range of practices, from One Medical group, encompassing 25 primary care practices in five markets, where patients pay $150-$200 per year for enhanced direct access to and longer appointments with their physician; to the $25,000 a year to be one of only 400 patients to have a physician essentially at your beck and call.  Again, the drivers are access and experience.  While the rise of these niche services raises questions of equity, in medicine as in so much of the rest of the economy there will undoubtedly be a role for services that cater to those who can afford them.

3.  House calls.  Remember Marcus Welby, black bag in tow, seeing patients in their homes? Increasingly, physicians or other providers are going back to the future.  Not only the old fashioned way, but also using phone or Web contact to bring care not only closer to home, but into the home.  Employers are also bringing healthcare into the workplace, with on-site primary care clinics for employees and families.  Wisconsin-based Quad Graphics, a large printing company, started this and now operates Quad Medical, which provides these services for other employers.  Access and experience, anyone?

4.  Price transparency.  Many elements of health reform, including high-deductible plans and healthcare exchanges, have the goal of containing costs by promoting price competition.  It’s hard to do that, though, if the person doing the buying has no idea what the price is, which has led to numerous efforts are making that information more accessible.  CMS, for example, has made publicly available charge data from Medicare providers on 130 common procedures.  Some hospitals are starting to do the same, publishing their prices up front. 

5.  On-line access.  My Chart, the patient portal for the Epic EHR, is only the start.  Other patient-centered innovations include free-standing patient health records (which are owned by the patient and pull data from all different sources), direct patient access to their records with the ability to edit them, provider-facilitated Web searches for health related information, and shared medical decision-making tools.  Interestingly, a JAMA study showed that access to such online tools actually increased patient visits, rather than supplanting them.

I’m not trying to suggest that all, or even any, of these is something we want to embrace.  We do, however, need to be aware of what is happening in the market.  At the very least, it tells us what our patients and families are seeking.  We, then, need to figure out how to meet those needs.  To do that, we need to be creative.  Selected for success in science and math, many of us in medicine are fairly “left-brained” types; creativity and original thinking often don’t come naturally.  We need to be more intentional innovators.  To do so, it will be important to think outside the clinic.  Leaders in healthcare need to look to other industries to identify trends and come up with new approaches.  We also need to tap into talent from outside healthcare.  The rest of the economy has been focused on value for a long time.  We have a lot to learn.

Picture this sampling of families one might run into in the ER or clinic:

A single woman with 6 children in the exam room.

A couple, both lawyers from Whitefish Bay, with their daughter who was injured in figure skating competition.

A teen couple with a three year old, and mother is pregnant.

You probably had an image of each of these families in your mind before meeting them.  You made some assumptions about their race, education, and social status.  And for most of you, I suspect that your image didn’t match the reality: the woman with the 6 children is a Latina, a PhD social worker with kids from 2 families who were involved in a car crash.  The couple from Whitefish Bay are an Asian and an African-American, both men.  And the pregnant teen mother with the three year old is the white daughter of a professor at an Ivy League school.

We are constantly making assumptions about people based on little to no knowledge.  Daniel Kahneman, in his book Thinking: Fast and Slow, refers to heuristics, the mental shortcuts we employ as a means of efficient mental processing.  This is the “thinking fast.”  When we look outside and see the vapor coming from the heat vent, we don’t first check the thermometer to make the assumption that it’s cold outside.  A barking dog with bared teeth elicits an immediate “I’m outta here” without waiting to see if he wants to play fetch.  The basic mental mechanism is an adaptive response; early humans whose brains were wired to assume that saber-toothed cats were dangerous and to be avoided were more likely to live to reproduce.

But what is beneficial in one context can cause problems in another.  Kahneman documents may examples where these heuristics lead to troublesome biases.  That’s why we have also evolved other mental systems – reflective, analytic, “thinking slow” – to question the snap judgments we make based on heuristics.  In the context of human interactions, this contributes to all kinds of biased thinking: racism, classism, sexism, etc.  As Kahneman shows, we often fail to call on our analytic side to question our biases.  Even when we think we are being objective and rational, we are more prone to bias than we realize.  While the specific biases are not hard-wired, the tendency toward them is.  It’s simply difficult to overcome assumptions.  But the cost of not doing so is high.  As individuals, it can lead us to make stupid investment decisions, choose poorly in everything from clothing to careers, and take both too many and too few risks.  For society, the costs are higher.

I learned an important lesson about making assumptions from a professor in medical school.  One day we had a prisoner admitted to the ward, and someone made an offhand and derogatory comment.  The attending told the team about the time he was attending a conference with colleagues.  In the evening they were walking on the boardwalk, casually dressed, when a police officer approached him, the only African-American in sight.  They were looking for a suspect in a crime, and he “matched” the description.  He described his complete humiliation as he was handcuffed, frisked, and released only when his white colleagues vouched for him.  “You don’t know this patient, and don’t assume you do.”

As the old joke goes, when you assume you make an ass of u and me.  Or perhaps far worse.  So if you have to assume, assume the best.

Children’s Hospital of Wisconsin has a vision that the children of Wisconsin will be the healthiest in the nation.  By some measures we do pretty well, though we continue to struggle with a higher level of disparities than other states.  For example, according to the National Initiative for Children’s Healthcare Quality (NICHQ), Wisconsin has a lower rate of obesity/overweight among children (31%) than the national average; our ranking is 12^th best, and has improved since 2003.  However, when we look at the disparity in obesity, we fare poorly: 17 of 22 when measured by race, and 32 of 35 when based on income.

But let’s step back a second.  Is it really OK to have almost one-third of our 10-17 olds overweight?  Consider this: Oxfam reports the US ranks 121 out of 125 nations in its rate of diabetes and obesity.  I’m not sure it’s enough to aim to be the best in the nation.  That would still leave our kids in sad shape from a global perspective.  Indeed, despite high ratings for food quantity, quality, and affordability, the US is ranked only 21^st in the overall index, due to abysmal statistics on health impact of the food we (over)eat.

And let’s be clear – this is not solely, or even largely, an issue of poor choices or lack of willpower.  It’s primarily a societal issue.  First, while on a global scale obesity is largely associated with affluence, within the developed countries there is an inverse relationship between income and obesity.  Much has been written about “food deserts” in inner cities – neighborhoods without access to healthy food options.  But even when there is such access (and Milwaukee actually does not have food deserts as defined by the USDA), healthy foods may be out of reach.  A study from University of Washington showed that the most energy-dense foods, high in saturated fats and low in other nutrients (think potato chips, Oreos, and Hot Pockets) are 10 times less expensive than the least energy-dense (salad, fresh fruit) on a per-calorie basis ($18.16/1,000 kcal as compared to only $1.76/1,000 kcal).  Worse, the most nutritious foods rose in price by almost 20% over a 2-year period, while the least nutritious actually got even cheaper.  No wonder people with limited income or food stamps pick “junk food” – it may be the only way to afford enough calories to feed the family.

In part, this reflects basic economics – junk food is simply cheaper to produce than the healthy stuff.  But it’s made worse by national farming policy (as enshrined in the latest farm bill), which continues to subsidize industrial producers of products destined to be converted to, in Michael Pollan’s memorable phrase, “edible foodlike substances.”

What can we do?  We already have made important steps, like providing healthier food choices for patients, families, and staff.  Here are some additional suggestions:

• Let’s increase awareness of nutrition as an issue we ask about at patient encounters throughout the system.  We can be intentional asking patients and families about food insecurity, or concerns about their child’s weight.  And it needs to start early; this week’s New England Journal of Medicine has a study demonstrating that childhood obesity is largely present by age 5.
• We can leverage our considerable organizational expertise in feeding and nutrition by creating a pediatric nutritional program of excellence, which can be a resource for providers, patients, and families.  Then we need to steer them toward educational resources to counter the massive advertising by the “edible foodlike substance” industry, and help them identify nutritious yet affordable alternatives.

We can support local efforts such as Fondy Food Market, Walnut Way, and Growing Power, all of which are working to provide affordable access to healthy foods in our poorest communities, in large part by promoting people to grow their own food.

Favorite things about doctoring:  coming up with a diagnosis; simple but gratifying procedures like pulling random objects out of a kid’s ear; getting a high five from a four year old when she’s leaving the emergency department; working with really smart and dedicated people.

Least favorite things about doctoring: not getting to work outside; paperwork.

Now, I have nothing against paper, or work, or working with paper.  But I do have a problem with things that at best add no value, and at worst diminish it.  Paperwork too often falls into that category.  (I recognize the term “paperwork” is undoubtedly passé, as most of what we call paperwork is done on an electronic device of some sort.  But given the bureaucratic connotations of the term, I’ll stick with it.)

The EHR is rapidly becoming a prime source of dissatisfaction for providers across the spectrum of professions and specialties.  A 2013 RAND report, based on interviews and surveys of a representative sample of hundreds of physicians, found a good deal of support for EHRs in principle, and their potential to improve care and facilitate greater to access to information.  But in actual practice, the current state of EHR technology is often plain unfriendly to the provider.  As the report says, “Poor EHR usability, time-consuming data entry, interference with face-to-face patient care, inefficient and less fulfilling work content, inability to exchange health information between EHR products, and degradation of clinical documentation were prominent sources of professional dissatisfaction.”  Providers often spend more and more time simply entering information, leaving them less time for the things they were trained for.  Less doctoring, more paperwork.

In the face of a shortage of physicians, especially those in primary care, one solution is to reduce the waste of this resource, as suggested in a recent Health Affairs article – hand off the administrative and clerical tasks to allow the provider more time to provide care.  An increasingly common solution to the inefficiency of the EHR is the use of scribes.  Several companies now supply scribes to hospitals and physician practices; primary care and emergency departments are among the heaviest users.  The scribes, who typically undergo 3-4 weeks of training in medical terminology and the use of EHRs, accompany the providers into patient rooms and transcribe the history and exam findings simultaneously with the provider’s assessment.

I’ve heard this concept before, and have to admit to being a bit of a skeptic.  First of all, our ED group has developed sufficient templates that for the overwhelming majority of my patients, the documentation is no more burdensome than it was before we installed our EHR, and perhaps less so.  I was also leery of having another person present when I am evaluating a patient.  Would people be as forthcoming?  Would patients and families worry about their privacy?

But the more I think about it, the more it seems worth trying.  I recognize that my practice is exactly that, my practice.  I’ve heard enough from enough other providers that for at least some providers or specialties, the burdens of the EHR are real.  As for having that extra person, I’ve had experience where there was a scribe for my provider, and I have to be honest, it was hard to even remember there was someone else there.  And I’ve not noticed any reticence on the part of patients when I have students or others shadowing me.

The real question is, is it worth it?  Scribes cost money.  Will any efficiencies and provider satisfaction we gain justify that cost?  What’s the value proposition?   The early evidence, albeit anecdotal, suggests it very well might be worth it.

In last week’s posting, I pointed out that people come to the ER, or for health care in general, for all kinds of reasons, not always obvious at first glance.  In fact, it may be difficult to discern unless one asks very specific questions.  And those needs may appear not to be “medical” at all.

But non-medical factors are a more important determinant of health than the care we provide.  The best estimates are that medical care accounts for no more than 10% of an individual’s health status, while behavior accounts for 40% and social/environmental factors, 20% (the remaining 30% belong to genetic predispositions).  One could argue that we’d get far better results focusing on behavior and environment than on medications.

As is so often the case, the Canadians are far ahead of us on this.  A Toronto family physician is pushing for incorporating poverty screening into routine health care, an approach being promoted by the Ontario Medical Association as well.  Dr. Bloch points out that poverty is the second leading cause of lost life in Canada after cancer.  (I wonder how the US would compare?)  He has developed a screening question – “Do you ever have difficulty making ends meet at the end of the month?” – that has 98% sensitivity and 64% specificity for predicting economic need.  (That performs better than a CBC in predicting infection, something we do all the time at $71.50 a pop.)

Identifying people under economic stress has several benefits.  First, unrecognized poverty may mean that people will be unable to obtain prescribed medications or have recommended follow up.   It may also cause or exacerbate a variety of conditions.  One example: a new study in Health Affairs showed that lack of money for food at the end of the month leads to increases in admissions for hypoglycemia in people with diabetes.  Moreover, in early childhood, chronic stress such as that associated with poverty has a long-lasting, and in many cases heritable, biological impact via changes in the developing brain and epigenome.  Early recognition and intervention may be helpful, and is an area of focus for the American Academy of Pediatrics.

Children’s Hospital of Wisconsin has a vision that the children of Wisconsin will be the healthiest in the nation.  The care we provide will only accomplish 10% of that.  We must therefore pay attention to all of the factors that affect the health of the kids we serve.  Identifying economic needs and working to end poverty will accomplish even more.