By Kevin Barnett, DrPH
As the wealthiest nation on the planet, one committed to the idea of minimally regulated capitalism, we are engaged in a perpetual struggle between two versions of reality. On one hand, we see ourselves through a lens of what some would refer to as a delusion of rugged individualism, where we are the masters of our own destiny, and all who work hard and “play by the rules” will succeed. A more sober analysis leads to the recognition that there are winners and losers in our capitalist enterprise, and there is a need for resources to provide support and create opportunities for those who are less fortunate or capable of providing for themselves. While providing this support is viewed as essential in an advanced society, determining what forms, how much, and when to provide it calls for an assessment of costs and associated returns on investment.
Inadequate investment in what we call the social determinants of health often results in costly negative outcomes. This is so whether we are talking about a lack of investment in disease prevention that yields high acuity and costly inpatient care, or a lack of investment in early childhood education and family support,which contributes to higher costs for special education in the medium term, and higher rates of incarceration in the long term.
In health care, fee-for-service (FFS) reimbursement is the predominant form of payment. FFS rewards the producers of increasingly costly procedures, equipment, pharmaceuticals, and facilities for the treatment of illnesses, many of which are preventable.The capital necessary to finance this medical care juggernauthas beenallocated at the expense of investments toimprove health and well-being, and more broadly, hascontributed to anerosion in the profitability of other economic sectors.The Affordable Care Act (ACA) put into play a series of changes that move us towards “pay for value,” a shift in financial incentives away from conducting procedures and filling beds and towards keeping people healthy and out of clinical care settings.
The challenges faced in the transformation of health care in the U.S. are myriad, but they are centered on moving from a fragmented system of resource allocations for treatment in acute care settings to the financing of a health producing enterprise at the institutional, community, and societal level.In this new world, acute care services are essential elements of a larger system of primary care, preventive services, and strategic investments in a social and physical infrastructure that together comprise the leading causes of life.The accounting for this system sees health systems as “nestled” enterprises that thrive when services, activities and investments are optimally aligned to foster life, liberty, and the pursuit of happiness.
Giving more focus to the social determinants of health and to geographic areas where health inequities are concentrated represents a shift from the question “Who is at greater risk for disease?” to “Why are some people at greater risk of preventable illness, injury and death than others?” The next, even more critical question, however is “What are we going to do about it?”
In the upcoming Authority Health 2016 Population Health Forum, we’ll take a look at the role of health care in this new era of transparency and awareness; where publicly available data on investments and associated outcomes offer the potential to inform a more strategic allocation of institutional and societal resources. In the process, we’ll explore how to build an ethic of shared ownership across sectors for producing health and well-being in our communities; one that challenges us to better align and focus our efforts. The opportunity to make a difference is before us…
Kevin Barnett, DrPH, MCP, is a senior investigator at Public Health Institute,Oakland, California.