What makes a good health care experience?

With the fast appointment, and equally sudden withdrawal of Tom Daschle as Secretary of Health and Human Services, what had been growing momentum behind long overdue health care reform was derailed, and we hope only temporarily sidetracked. Daschle, a veteran of Congress and one who had experienced many attempts at health care reform, was viewed as a very solid and informed choice for the post. Those who have read his book, know that he is an advocate for practical and doable change, recognizing that what many see as the ultimate destination, a single payer system, may require some interim steps. His plan would amalgamate existing government care programs, require that everyone be covered with affordable insurance for a basic level of health care services, and remove politics from decision making by creating a federal health board with confirmed appointees (like the Federal Reserve Board) to oversee the system.

Personally, while some of Daschle's plan characteristics have merit, I am a proponent of going for the whole enchilada now and proposing a single payer system to get rid of greedy profit motivated health insurance companies now. Why allow profit at the expense of health and life? And why spend even one more penny on marketing, advertising or competition when the money can and should go to delivering care and prevention?

Let's do what we have to do now to make the system affordable, accessible, fair, accountable, universal, portable, and responsible. By responsible, I mean a system that devotes resources to health promotion and prevention, a system that aims to promote well-being rather than just ameliorate disease after it has occurred, and a system that recognizes that responsible lifestyle change is more than half the battle in keeping people well. Health is related to happiness and happiness is related, inextricably, to doing what makes life worth living, with those we love, and in supportive communities. Beyond these basic philosophical changes, why not pay providers more for keeping their patients healthy? Rewarding them for listening to and counseling their patients about lifestyle (not just exercise and nutrition) might also be a nice addition.

Think about your idea of a good healthcare experience. I have had primary care delivered by angels and by robots. By people who listened and believed I knew my own body, and those who were so focused on arriving at a diagnosis, (or getting to their next appointment) that they cared little about my experience of illness. Incredibly, the Washington Post had an article recently about an Ethiopian-born physician who is also a novelist (Abraham Verghese) who proposes that medical schools teach their students about the importance of the life stories of their patients. This advice is, on the one hand, good news— and on the other, incredible in its acknowledgment that medical curricula are woefully out of touch. I doubt it is coincidental that my favorite primary care practitioners are physicians who were first trained as nurses, pharmacists or therapists. In fairness to medical schools, (not that any is really warranted) it is incredibly difficult to change the curriculum in a medical school, even a smidgeon.

So, what characteristics do you think make for a good health care encounter? Share them here, and perhaps a medical educator or two who believes in the importance of the humanities will stop by and take note.

Cost Does Not Equal Value

This is not a post about the economic stimulus package in the United States.

Rather, it is about thinking clearly about the distinction between cost and value in all areas of our lives. When the current crisis is behind us (and it will be sooner or later), thoughts will turn to other items on the national agenda. The most pressing of these from the standpoint of both cost and value is the health care "system" in the United States.

In many ways, health care, and the sad state of the non-system we have, mirrors the economic system. We have, as a nation, refused to make the hard choices in the moments where integrity was needed. Much like the hungry traveler who opts for the big mac when the salad might be the better choice, we have chosen the hamburger again and again.

Soon, during the discussions about health care reform, we will have the choice again. This time, we will have the opportunity to invest in a health care system that not only provides more value for cost, but does so in a way where public health programs focus on lifestyle change. The big mac is sold as part of a value meal, but here the relationship between cost and value are mistaken. The value of choosing prevention and health promotion programs is unmistakable. We must insist on value in the choices we make for our new system.

Health Care Reform and Well Being

Were it not for the constraints of time, this could be a longer post. The topic of health care reform in the United States prompts many passionate reactions from citizens. Abroad, people must wonder how we have tolerated the system we have for this long anyway? In the midst of economic chaos in the United States, the issue has been temporarily put on the back burner. Yet, President Obama knows very well that the costs of inaction, in human terms and in dollars saved, are greater than the cost of reform—and growing every day.

The irony is that attempts at national reform in the United States have been tried several times during the past century. For example, most people don't appreciate that President Harry Truman tried valiantly to reform the system, without success. Then there are the better known efforts of President Kennedy (leading to the compromise that became Medicare and Medicaid), and the failed Clinton effort. In each case, the complexity of the issue, special interest groups protecting their "rice bowls", and an effective disinformation campaign by the health insurance companies linking a national approach to "socialism" or socialized medicine, were able to derail the efforts. Meanwhile, like a patient in critical condition, the system is in need of urgent life support and getting worse.

So, what does this have to do with "Doing Life Well"? It's simple, really. Important requirements for doing life well include being informed about issues, making wise choices, and advocating for conditions in our communities that support our ability to participate in activities that contribute to our health. Former HHS Secretary nominee Tom Daschle has advocated for a compromise solution that would create a Federal Health Board and unify both private and public systems, requiring everyone to have insurance. Personally, I think the best system is a single payer system that enables choice and limits profits that are based on human illness or suffering. Why profit from services that people have no choice but to accept? Isn't that a grand perversion of monopoly? But, the important thing is to make progress in reforming the system. Whatever we do, however, we must have as a principle of reform that lifestyle-related prevention and health promotion initiatives and funding are part of the solution. The value of such efforts is unmistakable, and can save millions (not to mention the advantages of helping people feel better about themselves and making them happier and more productive). Most people would rather live their lives well and be active and engaged than to have health care money spent on keeping them "alive" at the end of life, hooked to tubes and merely surviving rather than flourishing.

Albert Einstein, a wise and learned man, once observed that not everything that can be measured counts, and not everything that counts can be measured. The dialogue about health care must include a discussion of issues not easily measured, like value. There is a wide difference between the meanings of cost and value. We must ask the question: How is the system to support efforts that address people's quality of life?