Everyone knows the US health care system is in crisis. We spend far more on health care than any other nation—a breathtaking $2.6 trillion annually, according to a 2011 report by the Kaiser Family Foundation. The US Department of Health and Human Services estimates that health care expenditures will be 25 percent of US GDP by 2025, twice what many developed countries currently expend.
The burden of rising health care costs falls
not just on individuals—half of all personal
bankruptcies are at least partly due to medical
expenses—but also on US companies. At
General Motors, health care costs put the company at a $5 billion
disadvantage against Toyota.1 The same is true for federal, state, and
local governments. In Massachusetts, for example, school employees’
health care costs rose $1 billion from 2000 to 2007, crowding out
growth in nearly every other area of the state budget.2
Despite such spending, US health indicators are among the worst
of high-income countries. Since 1960, the United States dropped from
12th to 46th in infant mortality rankings (below Cuba and Slovenia),
and from 16th to 36th in life expectancy (below Cyprus and Chile),
according to the CIA’s World Factbook. In certain neighborhoods
in Baltimore, Chicago, and Los Angeles—and other communities
across the country—life expectancy for subsets of the population
is lower than in Bangladesh.
Such ineffective spending is bad enough. In the coming years,
additional factors will keep our health care system from providing
high-quality care to all those who need it. Two high on the list are
a shortage of primary care doctors and rising poverty.
Primary care doctors are the key to improving value-based care:
By focusing on preventive services, care coordination, and disease
management, they can reduce unnecessary health care costs. In the
1960s, half of the doctors in the United States worked in primary
care. Today, barely 30 percent do. And this trend is deepening: From
2000 to 2005, the percentage of US medical school graduates who
chose to enter primary care dropped from 14 percent to 8 percent,
creating a projected shortfall of up to 150,000 primary care physicians
by 2025.3 More than 56 million Americans—greater than
one-fifth of the US population—already live in areas with too few
primary care physicians, according to the National Association of
Community Health Centers.
There are many reasons doctors eschew primary care. The fee-for-service reimbursement system has incented tertiary care and
episodic crisis management. Primary care providers are thus often
paid less than specialists, with specialization acquiring particular
cachet among medical students and residents. Moreover, for those
who do choose primary care, the job is especially taxing because of
the high demand for services and the absence of sufficient support
to meet patients’ nonmedical needs—access to healthy food or heat
in the winter, for example—which often thrust themselves into the
doctor’s office, especially in a shaky economy. Few physicians have
been trained to confront these social issues that often thwart conventional
medical care. In a recent poll of 1,000 primary care physicians
across the country, 80 percent said they were not confident
in addressing their patients’ social needs, even though those needs
undermined their patients’ health.4
Ironically, health care reform will make the problem worse, not
better. Expanded insurance coverage will increase the number of
patients seeking care, but from the same number of physicians. In
Massachusetts, where universal coverage became law in 2006, there
are critical shortages of primary care doctors—more than half do
not accept new patients, and most report dissatisfaction with the
practice environment, according to a 2011 Massachusetts Medical
Society report.
With 21 million potential Medicaid patients poised to enter the
health care system in 2014, primary care physicians will face a
double burden: caseload constraints coupled with at-risk patients’
substantial social needs. Poverty seeps into emergency rooms and
inpatient wards and pervades the health system. Half of the adults
who will gain insurance eligibility in 2014 are very poor (with incomes
below 50 percent of the federal poverty level), a third have a
diagnosed chronic medical condition, and many are likely to have
long-neglected health care needs due to years without coverage.
The links between poverty and poor health are well known: Foodinsecure
children, now numbering 17 million in the United States,
are 91 percent more likely to be in fair or poor health than their peers
with adequate food, and 31 percent more likely to require hospitalization.5 Children under age 3 who lack adequate heat (another 12
million) are almost one-third more likely to require hospitalization.6
And families with difficulty paying rent and housing-related bills face
increased acute care use and emergency room visits.7
Unfortunately, social workers and case managers—traditional
first responders for patients’ social needs—are overloaded, too. New
York-Presbyterian Washington Heights Family Health Center, for
example, has only two social workers for the clinic’s 46,000 patients.
This is sadly typical. Even if all the United States’ 24,750 licensed
medical and public health social workers in clinic or hospital settings
served only Medicaid patients—and many serve none at all—there would still be just one social worker for every 2,404 patients.
But it doesn’t have to be this way. Models of health care delivery
that improve patient outcomes while cutting costs are cropping
up with increasing frequency. Further, in the last 20 years, public,
private, and philanthropic entities have invested billions of dollars
learning how to build health care systems despite extreme resource
constraints, too few doctors, and overwhelming poverty. Some of
these models have been pioneered in the United States; many come
from other countries. One characteristic they share is a broader
conception of health care. Given the challenges facing the US health
system, policymakers and others advocating health
reform would do well to give a hard look at some
of these alternative models.
Indeed, the innovation we need is right in front
of us. In his 2009 best-seller The Checklist Manifesto,
surgeon and journalist Atul Gawande eloquently
argues that medical “innovation” is less about
discovering new interventions than it is about
properly executing the ones we already have. As
Gawande explains, failure more often stems from
ineptitude (not properly applying what we know
works), rather than ignorance (not knowing what
works). “The knowledge exists,” he writes, “yet we
fail to apply it correctly.” As one example, Gawande
cites a five-point checklist implemented in 2001 in
the intensive care unit at Johns Hopkins Hospital.
Although the checklist merely summarized wellknown
best practices of administering drugs to
a patient’s body through a “central-line” tube, its
consistent use virtually eradicated central-line
infections. A subsequent use of the checklist in
intensive care units in Michigan caused infections
to drop by 66 percent and saved more than 1,500
lives in a year and a half.
We contend that Gawande’s insight about the
benefits that could be reaped by deploying existing innovations extends
beyond the operating room and hospital to the very structure
and orientation of health care itself. The depth and breadth of the
US health care crisis has led some to throw up their hands. Others
imagine grand reconstructions of health care roles, incentives,
and behaviors. Between these extremes are concrete adjustments
that will save lives and dollars—in short order. Drawing on lessons
learned from high-quality health care delivered in resource-poor
settings here and overseas, the US health system can finally shed
the inefficiencies of habit and history.
Broaden Definitions of Product, Place, and Provider
In the developing world, health care providers must adapt to limited
financial resources, scarce health care professionals, underdeveloped
health infrastructure, and widespread poverty—all in settings
with huge burdens of preventable and treatable diseases that too
often go untreated. Some of the lessons that have emerged are well
worth examining. Just as the United States sought advice about
counterterrorism from Israel after 9/11, and about post-disaster
reconstruction from Kosovo after Hurricane Katrina, we should
look beyond US shores for new ideas about health reform.
Although the landscape of health risk and the systems charged
with providing care differ by nation, resource-poor settings face
common problems and have often devised similar solutions. Specifically,
these solutions broaden conceptions of product, place, and
provider in health care.
Product | What is being delivered when we say “health care”?
In the United States, we usually mean medicines, diagnostic tests,
and hospital services. We rarely include basic necessities, such as
food, housing, or heat, even when their absence leads to ill health.
In a 2007 study at Johns Hopkins Medical Center, 98 percent of pediatric
residents said that referring well-child patients for help with
basic needs could improve the children’s health. But how many of
those residents routinely screened their patients for food sufficiency?
Only 11 percent.8
In contrast, in resource-poor settings, health care providers have
no choice but to design programs based on the stubborn relationship
between poverty and ill health, and to start from the premise
that health care must mean more than medicine.
The UN World Food Programme, for example, provides nutritional
supplements alongside HIV drug therapy in recognition that
“Food and nutrition support is essential for keeping people living with
HIV healthy for longer and for improving the effectiveness of treatment.”
A Haitian proverb is perhaps more to the point: “Giving drugs
without food is like washing your hands and drying them in the dirt.”
In Brazil, Associação Saúde Criança (ASC) has operationalized
this concept by routinely sending low-income children home after
hospitalizations with resources for ongoing nutrition, sanitation, and
psychological support. “Children cannot be discharged from hospital
without first ascertaining what conditions await them at home,”
notes ASC in its organizational overview. The idea is not to expand
doctors’ work beyond medicine, but to improve the ability of health
systems to address structural, nonclinical determinants of health,
and therefore reduce recurring hospitalizations and associated costs.
Place | In addition to a broad conception of health care, resource-poor
settings demand a more expansive view of the place in which
care is delivered. Most care, in countries rich and poor, is delivered
outside the formal health system—in homes and communities. In the
words of medical anthropologist Arthur Kleinman, “for all the efforts
of the helping professions, caregiving is for the most part the preserve
of families and intimate friends, and of the afflicted person herself
or himself.”9 Health providers can leverage such local networks of
care by integrating health care into patients’ daily lives, and locating
health resources where (and when) patients are most likely and able
to access them. Moving health resources from clinics—often remote
from patients in distance and culture—into homes and communities,
or alternatively, bringing critical social resources—which are themselves
instrumental to the efficacy of medical care—into hospitals and
clinics, can improve access to and quality of health care.10
Locating health resources in homes and communities as well as
putting them in clinical facilities recognizes the role of environmental
interventions in improving health outcomes. In Nudge: Improving
Decisions About Health, Wealth, and Happiness, Richard Thaler and Cass
Sunstein describe how “altering the choice architecture” can, without
coercion, adjust the placement, sequence, and context in which
people make choices with an eye toward increasing the common good.
A typical example is altering the choice architecture in a cafeteria by
placing healthy snacks at eye level and sugary snacks on the top shelf,
increasing the likelihood that people will choose the healthy ones.
In Haiti’s Central Plateau, the challenge of place is not one of choice
but of necessity: With just one doctor for every 50,000 people, Partners
in Health (PIH), a medical nonprofit that has worked in Haiti for
almost three decades, rejects the notion that the infrastructure gap
makes it impossible to deliver high-quality health care to the poor. PIH
trains patients and other community members to act as health care
liaisons in their homes and communities, observing the ingestion of
pills, responding to patient and family concerns—including structural
barriers to care, such as high transport costs or shoddy housing—and
spotting symptoms of illness or side effects of medication. Just as
they have taken health to the community, PIH brings the community
to the health care facility by, for example, operating farms adjacent
to clinics to integrate anti-malnutrition efforts into medical care.11
Provider | Widening conceptions of product and place demands
also widening the definition of health care provider. Nontraditional
medical workers are critical to health systems, especially those in
resource-constrained environments. They are less encumbered by
competing clinical care priorities, possess firsthand understanding
of patient culture, community, and experience, and are often more
aware of nonmedical local resources that may improve patient care.
Acknowledging that licensed clinicians are not the only health care
providers can help health systems become more efficient, effective,
and equitable.
PIH, for example, relies on doctors and nurses to provide clinic-or
hospital-level care and hires community health workers (CHWs)
to distribute food, deliver medicine to patients in remote rural areas,
and identify undiagnosed illnesses as well as social needs. CHWs can
help health care systems overcome shortages of human and financial
resources by providing high-quality, low-cost services to community
members in their homes and by diagnosing diseases in their early
stages, before they become more dangerous and expensive to treat.
Similarly, in sub-Saharan Africa, Mothers2Mothers trains and
employs new mothers with HIV, who work side by side with doctors
and nurses in health care facilities and are responsible for ensuring
that patients understand and adhere to antiretroviral treatments and
other prescribed interventions. These “Mentor Mothers” are a new
tier of paid, professional, health care providers—drawn from, trained
in, and working for local communities. Evaluations of the program
have found that enrolled mothers are more likely to receive and take
medications and to undergo tests to determine if they are eligible for
antiretroviral treatment and if their babies are infected with HIV.
Broadening the health care workforce enables doctors, nurses,
social workers, and other professionals to “practice at the top of their
license”: They can spend more time doing what they are trained to
do, while leaving critical tasks like coaching patients and connecting
them to community resources to other health care workers. The
World Health Organization summarized the utility of this “task
shifting” in a 2008 report: “The rational redistribution of tasks
among health workforce teams will maximize the efficient use of
health workforce resources.”
US health professionals, in contrast, tend to take one of two
(largely ineffective) approaches. Most often, as noted in the Johns
Hopkins study mentioned earlier, health care providers bracket patients’
social needs, deeming issues like hunger, poor housing, and
indebtedness beyond the scope of short patient-doctor visits. Some
primary care clinicians do try to address patients’ basic social needs.
But they quickly become overloaded, and addressing such needs
crowds out other key modalities of their clinical practice. A June
2011 Health Leads survey at Bellevue Hospital in New York City
discovered that doctors spend an average of 9.2 minutes of each
15-minute patient visit on social needs.
Practicing at the “bottom” of one’s license can be expensive for
taxpayers, is draining (or demoralizing) for clinicians, and causes
patients to wait longer to get timely and effective care. Task shifting—or task sharing, to be more precise—can reduce such inefficiencies.
Although evolving financial incentives in the US health care system,
including increased risk sharing between insurers and medical providers
for patient outcomes, has begun to catalyze increased task
sharing, there is ample room in the health system to broaden our
conception of what it means to be a provider of health services.12
Approaches Already Under Way
In the last two decades, some health care organizations in the
United States have developed delivery models based on more expansive
definitions of product, place, and provider. The results
have been promising.
The Prevention and Access to Care and Treatment (PACT) program,
a domestic arm of PIH, serves the sickest and most marginalized
HIV-positive and chronically ill patients in Greater Boston. Applying
the principles described above—that health care means more than
clinical care, that health-related resources must be located in patients’
communities, and that the health care workforce must leverage
trained nonclinical personnel—PACT has helped raise the standard
of care, while cutting costs in some of the poorest parts of Boston.
Specifically, PACT supplements comprehensive medical care with
“wraparound” antipoverty services. Its model is built on accompaniment:
CHWs are trained and paid to supplement clinical care and
deliver social support services, health promotion, and harm reduction
services within patient homes and communities. This model is an
example of “reverse innovation” from a successful program in rural
Haiti, adapted for use in an American city. By accompanying patients
to important visits and communicating regularly with licensed clinicians,
CHWs ensure that treatment recommendations are patient-centered.
CHWs visit patients’ homes to provide directly observed
therapy, supervising patients while medication is being administered,
and to help them overcome structural and psychosocial hurdles to
wellness. Their tasks range from motivating medication adherence
to surveying patients’ pantries and helping them identify ways to
make healthy, affordable meals. In so doing, CHWs help patients
more effectively self-manage their illnesses.
The program has realized impressive results. Seventy percent of
its AIDS patients show significant clinical improvement, whether
measured by viral load, CD4 count, incident opportunistic infections,
or emergency room visits.13 Costs to Medicaid have dropped
significantly, thanks to a 60 percent decrease in hospitalization
rates among enrolled patients: One analysis of Medicaid claims
from PACT patients showed 16 percent net savings. Similar gains
are being made among patients with multiple chronic diseases and
behavioral health comorbidities. The PACT model is now being replicated
in New York City, Miami, and the Navajo Nation.
Such “reverse innovation” often occurs when providers serving
the poor in affluent countries travel to poorer countries struggling
with access to care for the majority. In 1996, Dr. Rushika
Fernandopulle went on a medical mission to the Dominican Republic.
There he saw promotoras, community health workers who coached
individual patients through medical compliance and recovery. When
Fernandopulle was named to run the Special Care Center (SCC)
in Atlantic City, N.J., which serves the 14,000 union employees of
Atlantic City’s restaurants, hotels, and casinos, he adapted the promotoras
model, expanding the health care product and provider.
Under the guidance of SCC doctors, “health coaches” see patients
at least once every two weeks and regularly communicate by phone
and e-mail, helping them achieve healthier lifestyles and manage
chronic disease. Like PACT’s community health workers, the coaches
are recruited from within the community and speak the patients’
language, often connecting more successfully than doctors might
about patients’ true difficulties and helping them identify realistic
solutions. The doctors, social workers, nurse practitioners, and health
coaches meet as a team every morning to review the medical and
nonmedical issues facing their patients.
A program evaluation found that after 12 months in the program,
patients’ emergency room visits and hospital admissions dropped
by more than 40 percent and surgical procedures fell by 25 percent.
Among 503 patients with high blood pressure, only two were in poor
control of it at the end of the study. Patients with high cholesterol
experienced, on average, a 50-point drop in cholesterol level. And a
remarkable 63 percent of smokers with heart and lung disease quit
smoking, Gawande reported in a Jan. 17, 2011, New Yorker article.
Meanwhile, the cost of care for these patients rose by only 4 percent
per year, compared to 25 percent before they began participating.
Health Leads likewise widens the frame of health care, broadening
the health care product to include connections to basic resources
like food and housing; broadening the health care place by
using hospital waiting rooms to make resource connections; and
broadening the health care provider, by integrating college volunteers
into the health care team.
Located in primary care and prenatal clinics in six US cities,
Health Leads empowers doctors, nurses, and other health care providers
to ask the previously un-askable questions: Are you running
out of food at the end of month? Do you have safe housing? These
providers can then write “prescriptions” for food, housing, heating
assistance, or other basic resources, just as they would for medication.
The patients take their prescriptions to the clinic waiting room,
where Health Leads’ 1,000-member corps of college volunteers works
side by side with them to secure these resources. The volunteers’
assistance is often as straightforward—but critical—as tracking
down an agency phone number, completing a benefits application,
or bridging language barriers.
Health Leads leverages providers’ scarce time, so that they can
focus on activities that demand their training and experience. At
Harlem Hospital Center, for example, an electronic medical record
automatically refers all patients with an elevated body mass index—an indicator of obesity—to Health Leads for help in accessing
healthy food, exercise programs, and other resources. A recent
study at the Dimock Center, a Boston community health center,
found that Health Leads increased the clinic social worker’s ability
to provide reimbursable therapeutic services to children by 169
percent, improving the quality of care while generating additional
revenue for the health center. This is just one example of the several
ways in which the definition of provider might be expanded: promotoras,
community health workers, and college volunteers each
possess different competencies, but all can increase the efficiency
and quality of care delivered to patients.
An Open Window
The United States is poised for a primary health care transformation.
The health care system is in crisis, driven chiefly by escalating
costs, suboptimal health outcomes, scarce primary care resources,
and rising poverty. At the same time, thanks to grassroots innovation—and, in some cases, US-based funding—a growing number
of health providers around the globe have learned to deliver high quality
health care at low cost. Now we need to align our resources
in the United States to bring this knowledge fully to bear in saving
dollars and lives.
And the time is, indeed, now. The dual, market-driven imperatives
to cut costs and improve outcomes—and the inevitable shift
away from fee-for-service reimbursement to shared risk between
payers and providers—create an unprecedented receptiveness to
new approaches in care delivery. The United States has a window
of opportunity to seize this fluidity in the sector to broaden the
health care product, place, and provider and thereby expand access,
improve outcomes, and cut costs. This approach demands,
as Gawande says, that we innovate by properly executing the solutions
we already have—and that the private, philanthropic, and
public sectors invest in these evidence-based models of health
care delivery.
Private Sector Creativity | Recognizing the opportunity for significant
returns in a sector that currently comprises 17.6 percent of
GDP, private sector groups have long invested in some components
of the health care industry. Last year, US venture capital firms invested
$2.38 billion in medical devices and $3.78 billion in biotech.14
Private equity dollars also increasingly are focused on the health
care sector, as restructuring inefficient hospitals can be especially
lucrative. The initial public offering in 2006 of the Hospital Corporation
of America, a for-profit hospital chain backed by KKR & Co.,
Bain Capital, and Bank of America, was the biggest private equity-backed
offering in history, raising $32 billion.15
Deployed strategically, even a fraction of these private sector dollars
could accelerate a broadening of the definition of product, place,
and provider to drive down overall costs and improve outcomes. One
compelling, if unconventional, example is the so-called retail clinic.
An alternative to lengthy waits in the emergency room or the challenge
of getting to the doctor’s office during working hours, retail
clinics typically offer brief visits with an advanced-practice provider
(physician assistant or nurse practitioner) who can provide immunizations
and care for simple illnesses in a retail store, such as CVS
and Wal-Mart. The clinics are open evenings and weekends; they
provide care that is roughly 30 to 40 percent less expensive than
similar care at a doctor’s office and 80 percent less expensive than
the cost of an emergency room visit.16
Retail clinics broaden the health care place from the doctor’s
office to the shopping mall. They are, in a sense, a US analog of
PIH’s accompagnateur-based service delivery model in rural Haiti.
(The financing models, however, are divergent: PIH depends not
on out-of-pocket financing but on philanthropic and public sector
support.) Not surprisingly, 35 percent of patients visiting retail clinics
are underinsured or have no coverage at all—according to Tine
Hansen-Turton, executive director of the Convenient Care Association—and thus would almost certainly be using the emergency
room or not receiving care at all in the absence of this care delivery
model. Yet, as Julie Appleby reports in the Nov. 17, 2011, issue of Kaiser
Health News, “The clinics see a pure business opportunity based
on consumer convenience and cost savings, which they can market
to the public, employers, insurers, and hospitals.”
We have an opportunity to leverage private sector investments
in new care delivery models that generate revenue or cost savings
and address the nonclinical needs of low-income patients, who are
among the most “costly” consumers of health care. If the PACT
model, for example, yields 16 percent savings for Medicaid, why
isn’t it attracting private sector dollars to scale up regionally or
even nationally? If the booming electronic health records market
designed products that captured nonclinical data (such as whether
a patient is living in a shelter or running out of food each month),
health care providers would be far better positioned to negotiate
bundled or capitated payments that reflect the true cost of delivering
care for vulnerable patient populations.17 Given the size of the
health care market—and the dollars spent delivering unnecessary
health care—private sector players could likely sustain profits from
scaling up cost-saving models of comprehensive, community-based
care for the poorest.
Philanthropic Sector Investment | The philanthropic sector
also should recognize the opportunity represented by domestic
health care reform. In 2008, US foundations invested more than
$2.5 billion in global health, according to the Foundation Center.
The Bill & Melinda Gates Foundation alone has committed $15.3
billion to nondomestic global health efforts since 1994—more
than twice as much as it has invested in all US-based programs
combined. These investments have saved countless lives and untold
suffering; they also have yielded critical insights into how to
improve health outcomes amid severe resource constraints—and,
in particular, how to do so by broadening the health care product,
place, and provider.
The philanthropic sector now has the ability to secure the full
return on investment from past grants by adapting lessons learned
to the US context. Global health programs should also be continued,
expanded, and bolstered with insights developed in poor communities
in the United States.
The Center for High Impact Philanthropy, in its January 2012 report
Women’s Health and the World’s Cities, cites the example of the
Nurse-Family Partnership, funded by the Edna McConnell Clark
Foundation and BRAC’s Manoshi Project in Bangladesh. The partnership’s
programs achieved great value by applying shared principles:
reaching women in their homes, providing links to referral systems,
creating partnerships and networks that address the root causes of
ill health, and developing a critical feedback loop to improve performance
and generate data for others seeking to adopt a similar model.
Another example is the Gates Foundation’s $15 million award
to the Last Ten Kilometers (L10K), a project that addresses health
care provider shortages and lack of access to health care in remote
areas of Ethiopia. L10K trains local volunteers to demonstrate
healthy behaviors pertaining to prenatal care and maternal and
child health in their own households, and thus serve as model
families in their communities. But securing adequate prenatal
care is also a significant challenge for low-income women in the
United States, as evidenced by vivid disparities in infant mortality
rates: African-American infants are twice as likely to die in the first
year of life as Caucasian infants; in some cities, the infant mortality
rate for African-American infants is five times higher.18 Basic
prenatal care can significantly reduce infant mortality, but poor
women in the United States often gain access to such care later
in their pregnancies and have fewer prenatal visits.19 The Gates
Foundation could secure the full return on its investment in the
L10K project and accelerate improvements in health outcomes in
the United States by leveraging L10K’s core elements, including
a broader definition of provider (to include community health
workers) and place (to include household- and community-based
modeling of prenatal care).
Public Sector Funding | Philanthropic and private sector investment
cannot by themselves shift the direction of health care
delivery. Government funding streams will always drive decision
making, especially with respect to health care provision to lowincome
people. At long last, policymakers are reevaluating the incentive
structure—often inefficient, sometimes perverse—of the
US health care system. How will their decisions affect providers
and patients? What are the corresponding implications for both
costs and health outcomes?
Although the 2010 Patient Protection and Affordable Care Act
makes significant strides toward expanding insurance coverage
and improving quality of care, it leaves unchanged one of the most
problematic aspects of Medicaid: It does not reimburse the activity
of connecting patients to essential nonclinical resources they need
to be healthy, or to any other services delivered by non-clinicians
that address the underlying causes of poor health outcomes.
To the contrary, the Centers for Medicare & Medicaid Services’
State Medicaid Manual, which advises states on implementing Medicaid
programs, explicitly forbids such reimbursement: “[C]ase management
related to obtaining social services, Food Stamps, energy
assistance, or housing cannot be considered a legitimate Medicaid
administrative expense even though it may produce results which
are in the best interest of the recipient.”20
Nor are such services generally reimbursable as a nonadministrative
expense. States may opt to provide through Medicaid “Targeted
Case Management,” which reimburses efforts to connect patients to
certain social services. But its scope is limited to care management
for chronically ill and complex patients, such as foster youth and
patients with AIDS, mental health conditions, and developmental
disabilities. In short, Medicaid does not support nonclinical services
as a pillar of primary care—even though it could bring substantial
downstream cost savings.
The good news is that there are easy ways for the federal government
to use Medicaid to incentivize health programs with more
expansive conceptions of product, place, and provider: by broadening
eligibility for Targeted Case Management to include patients
whose socioeconomic status puts them at risk for poor health or by
reimbursing community health workers, patient navigators, case
managers, and other lay health care workers for a well-defined set
of activities with documented health benefits. In doing so, Medicaid
could scale up nonclinical services and health care workforces that
have been shown to achieve better health outcomes and increase
health care provider productivity, at minimal cost or with cost savings.
These more expansive health care delivery models are almost
certain to prove the highest standard of care for chronic diseases,
whether in Haiti or in the shadow of Harvard’s teaching hospitals.
Realignment Is Within Our Grasp
It is by no means a new discovery that poverty and poor health are
linked, or that health resources are more likely to be used if they
are offered conveniently to the recipients, or that a goal as complex
and ambitious as “health” can be effectively pursued only with a
multidisciplinary team of workers. The challenge is implementing
these insights effectively and on a large enough scale to reap the
synergies they promise.
But what’s new is this: The US health care system has reached a
tipping point. Reform is in the air across the sector, with primary care
especially positioned for transformation. “Never let a good crisis go
to waste,” said Winston Churchill. The practices of countries that
have improved health despite scarce resources are ready for adoption
and adaptation. And the US health care ecosystem, including
public, private, and philanthropic resources, is ripe to leverage this
crisis to implement solutions that will improve it.
“Health” is a bold, expansive aspiration. Let’s make sure that what
we call “health care” is broad enough to get the job done.