Anticipating Challenging Changes, Principles must be the Backbone of our Approach

Introduction

Today we are bowled over by the combination of political divisions and headlines regarding a healthcare crisis. Workforce shortages, long waits for essential services - and even basic services, inability to access needed materials and pharmaceuticals, seemingly purposeful dissemination of mistruths and half-truths, all point to a need for critical interventions. One of the dangers we face is getting so involved in critical individual issues and political struggles we miss the opportunity to look at real issues we need to face to make a difference on a community or societal level. Don’t mistake my thinking; we need to address the individual issues and each of those aspects of healthcare I mention above where we are currently challenged. My point is we need to address them based on science, facts, and a principled approach with a meaningful dialogue.

When considering these issues, I’ve been overwhelmed with the enormity of the issues that require both public policy and individual attention, as well as the many and varied obstacles we face, not the least of which is the growing presence of misinformation. I was then reminded of a lesson I learned early in my career; every problem brings with it an opportunity. When I think of these important thoughts through the lens of Beauchamp and Childress [1, 2] and look closely at the issues at hand thinking about Autonomy (informed decision making for ourselves); Beneficence (intention for good); non-maleficence (avoidance of harm); and Justice (requiring fairness for all), the issues before us have more clarity and opportunity for improvement.

As I’ve raised before in these pages, we must commit ourselves to those ideas and principles we hold dear. Ideas in the US like “all people are created equal”, and we have some basic responsibilities to one another as we live in community (“it takes a village” as my wife (a nurse) reminds me). These basic responsibilities have been defined over time as society and science have evolved and include things like public education, public health, public utilities, and criminal justice. To the degree that access to healthcare is one of these ideas we need to get back to basics and remember the quotes above. Now I’ll share some thoughts on how we might move in that direction.

Some of the critical issues we see today are symptomatic of more basic underlying structural problems that must be addressed if more permanent solutions are to be developed. For example, in instances where there are labor disputes, long delays and impediments to access needed care we need to ask some critical questions:

• Is there an adequate workforce?
• Are there professional education opportunities and incentives adequate to continuously build the workforce needed to operate the complex system of healthcare we require?
• Are public entities investing adequately in the workforce (nationally, in states, in communities)?
• Do payors (private and public) adequately reimburse care at levels that support this workforce?
• Are there hidden profits consumed by some players in the system dragging us down? These questions need open discussion under the light of the principles mentioned.

On the question of adequate supply, in one example we heard and saw comparisons of recently is insulin pricing internationally [3]. The average US price for a unit in the referenced report was $98.70, the non-US average was $8.81. This has since been addressed for some limiting the US out of pocket cost in Medicare to $35.00, still multiples of the international average [4]. These discrepancies point to one of the roots of issues. While clear, this is a minor example of the type of violation of fairness and justice impacting our systems. We must ensure that public funds are invested wisely, and that people have access to critical medications, services and supplies.

When we apply the lens I mention we must also ask difficult questions about basic access to care. We know that uninsured people are less healthy, more likely to incur ongoing costs (from chronic conditions), and more likely to incur significant costs for emergent care – much of which is preventable. Population wide currently chronic conditions account for over 86% of healthcare costs, much of which is preventable [5]. Another set of critical questions comes to mind:

• Is our current system of funding healthcare (a mix of public and private “insurance”) really the best way to proceed?
• Should we find ways to offer preventive care to all to reduce the financial and human burden of preventable chronic and emergency care?
• Should we invest in raising awareness throughout the population on ways we can all improve our health and reduce risk of serious chronic conditions (including Alzheimer’s disease and mental health [6, 7, 8].
• Would additional access to prevention and primary care reduce chronic and emergent care needs broadly?
• If so, how can we achieve these goals while maintaining high quality standards of care?

Additional Related Issues Recently Raised

A recent Commonwealth Fund Report offers additional information [1]. First, we can look at the percentage of GDP spent on health, the US at 17.8% while the international comparison group averages 9.6% [1]. The rest of the sample offers 100% of the population health insurance compared to the US with 62% Voluntary Insurance and only 38% with Government Insurance. At the same time the US life expectancy at birth is three years lower that the average and US rate of avoidable death is 336 per 100k population compared to the average of 225 per 100k. Other key factors include the US Obesity rate almost double the average and the US leads the group in adults with multiple chronic conditions. The US is also significantly below the average for practicing physicians per 1,000 population and has among the lowest number of hospital beds by population.

Conclusion

This data, and the fact we’re facing another period for policy change offer us an opportunity to catch up to other nations while building a healthier population and health systems that respects the individual and community. We need to stick with science, we have evidence of what works, and we need to call out misinformation for the danger it is to all of us [9, 10]. We need to realize the value of investment in prevention and public health and the future workforce across health and public health. We need to recognize the value of all the professions focused on health and wellness working together with similar goals and collaborative approaches. This will all be a smoother and more efficient process if we share basic principles to motivate us. All this we need to approach respecting the values of our founders like “All are created Equal” and the principles referenced above including [2]:

• Autonomy (fully informed decision making for ourselves and those we serve);
• Beneficence (always begin with intention for good);
• Non-maleficence (avoidance of harm, “first do no harm”);
• Justice (requiring fairness for all).

This involves all the professions mentioned above, many of which already profess to adopt these or similar principles. Additionally, if we are to be successful, we need to encourage the same standards and approach for our communities and society by calling on media and press, public officials, our faith and corporate partners to adopt and live out these or similar principles.

This is the point when I address these principles in person where audience members say, “but what can I do?” My advice is this: if you work in public health, clinical care, healthcare financing, educating healthcare professionals, or related areas - tell your story. Talk about cases that illustrate your points, share data with people who can benefit from having facts like policymakers and leadership, offer to speak to groups in your community so the facts become the conventional wisdom, we’ll all be better off for your hard work and sharing your story. This approach will take time and effort, but if we’re serious about our priorities and principles we have good reason to hope together for a better future.