Creating Health in America, One Person at a Time

A Message for President Trump

“Now is not the time to rail against the election of Trump. Instead, the objective must be to organise, and to use evidence to promote a clear pro-health political agenda for the US, domestically and globally.” The Lancet, November 19, 2016 [1]

Two weeks after the 2016 presidential election a very interesting article appeared in The Economist. Post-election analyses were appearing regularly in the news of course, but this one was decidedly different from discussions of economic disparity, generational ideology, and partisan conflict. Published under the title “Illness as Indicator,” a data team at The Economist set about examining voter patterns using a unique metric: public health. Using publicly available, county-level data compiled by the Institute for Health Metrics and Evaluation, a Seattle-based global health research center at the University of Washington, the authors reported an increased level of support for Republican presidential candidate Donald Trump (relative to votes for candidate Mitt Romney four years prior) in communities with a high prevalence of public health challenges, such as obesity, diabetes, heavy drinking, reduced physical exercise, and lowered life expectancy.[2] This county-by county analysis illustrates a fact that many of us are already aware of: there is a significant public health crisis across much of our nation. This is a challenge President Trump and the whole of our government will need to address as we transition to a new administration.

What positive steps can be taken to improve the health of the nation? Progress made in health care over the past eight years has been associated with increased access to care for previously uninsured individuals, as well as some advancement in providing for preventive medical services.[3] But, as many of us who work in this field recognize, there are still numerous problems within the healthcare system: too much reliance on expensive medical procedures, excessive use of pharmaceuticals to manage chronic disease, and lack of a system to effectively manage complex chronic diseases, which constitute 70% of healthcare expenditures in the US.

Howard K. Koh, MD, MPH, who is affiliated with Harvard University and the T.H. Chan School of Public Health, recently authored an editorial in the Journal of the American Medical Association titled “Improving Health and Health Care in the United States: Toward a State of Complete Well-being.” Dr. Koh points out that the World Health Organization defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” He offers five themes for improving the present health care system that were developed by experts — including himself — who participated in the National Academy of Medicine (NAM) Vital Directions for Health and Health Care initiative:

1. Respect the Social Determinants of Health

2. Advance Wellness and Prevention

3. Strengthening Systems of Care [including coordination and integration of previously fragmented services]

4. Fostering 21st-Century Workforce [this section includes a discussion of tailored treatments based on routine integration of genomic information into health care]

5. Monitor outcomes for Continuous Improvement [4]

These objectives for improving the health of the nation are consistent with founding characteristics of the health care quality movement put forward by Dr. Avedis Donabedian in 1966. His article — “Evaluating the Quality of Medical Care” — was very influential and frequently cited for decades. Dr. Donabedian, a professor of medical care organization at the University of Michigan School of Public Health, proposed using the triad of structure, process and outcome to evaluate the quality of health care. He defined “structure” as the settings and qualifications of providers; “process” as the components of care delivered; and “outcome” as recovery, restoration of function, and survival.[5] Presently, our health care system focuses almost exclusively on the diagnosis and treatment of disease, and lacks effective strategies for recovery, restoration of function, and promotion of wellness. In order to create a value-based health care system that better manages chronic disease, we need to have a restructuring of care to focus on the genomic, lifestyle, environmental, and social determinants of disease in the individual.[6],[7],[8] We are an aging population and our health care system needs to be prepared and fortified to address medical issues associated with this demographic shift by focusing on the prevention of cardiovascular disease, dementia, cancer, autoimmune diseases, and type 2 diabetes.[9]

Dr. J. Michael McGinnis (National Academy of Medicine), Dr. Angela Diaz (Mt Sinai School of Medicine), and Dr. Neal Halfon (University of California-Los Angeles School of Medicine) are participants in the Vital Directions initiative and recently co-authored a viewpoint piece titled “Systems Strategies for Health Throughout the Life Course.” They write: “Based on measures of cost, quality, efficiency, and equity, the US health system is substantially underperforming — a failure unlikely to respond to incremental modifications of the prevailing system.”[10] I agree with this statement but suggest we must reach further. The need to improve health care is about so much more than access and economics. Real change will require a significant perspective shift: from a disease-centric approach to a system based on the concept of scientific wellness. Accomplishing this will require a restructuring effort that will transform how medicine is practiced. The system must be reconfigured from top-down, command-and-control delivery of care to a distributive team approach that utilizes health care extenders who are trained in managing personalized wellness programs.

McGinnis et al. address and explore the idea that resources may currently be misdirected. They pose both a question and an answer: “Why is the US performing so poorly relative to both potential and size of the investment? The answer lies in the fissure between the current reality and understanding that multiple factors interact to determine health status and the long-standing allocation of attention and resources to the acute, the short-term, and the limited treatment of illnesses and injuries that present for care. The persistent and increasing gap between current scientific understanding about the determinants of health and the ability to move beyond fragmented and episodic patterns of care is reinforced by outdated concepts of disease causation and measurement systems that often continue to count what was once thought to be important and easy to measure, but in fact offers scant prospects for health gains.” On behalf of the Vital Directions Initiative, they offer the following suggestions for improvement:

· Shift health care payments to financing that rewards system-wide health improvement

· Initiate multilevel standardized measurement of system performance on core health indices

· Speed development of a universally accessible and interoperable digital health platform

· Foster awareness and action on a community culture of continuous health improvement

The treatment of cancer — due to the emerging nature of research as well as the urgent need for successful therapeutics — is often the area of medicine where we witness the greatest amount of innovation. In recent years, precision medical approaches to cancer therapy that are based on genomic uniqueness have quickly become standard of care. The transformation of this field and the technologies that have led to therapeutic breakthroughs informs us about the power of harnessing genomic information to make more precise and effective health care decisions.[11] Among researchers, it is now recognized that how genes express themselves into the health and disease patterns of the individual are heavily influenced by a person’s lifestyle, diet, and social and physical environment. We now need to translate the concept of precision disease care to that of precision wellness care based upon this emergent understanding. Presently, there is no formalized component within the health care system that delivers this type of care. In order to create positive transformation in health care that will reduce the burden of unnecessary chronic disease and improve the overall health of the nation one person at a time, I suggest the following points need to be supported by President Trump and his healthcare policy team:

1. Health and wellness are defined as a major national priority

2. All people have insurance for crisis care

3. All people have electronic health/medical records that travel with them in the data cloud

4. All people have a primary care provider that is supported by a certified health/wellness coach

5. We have integrated and consistent health objectives and communication among the following: Health and Human Services, Department of Agriculture, National Institutes of Health, Environmental Protection Agency, and the National Academy of Medicine

6. We have a reimbursement system that rewards health outcomes and patient-centered personalized wellness care

7. We create a system for the training and credentialing of health care practitioners to provide personalized health promotion and disease prevention programs that focus on improved function of the individual

8. We support the development of a successful wellness industry that attracts the best and the brightest innovators

Health care is one of the most important issues facing the President and his administration. Policies regarding the health of our nation affect the fitness of the Armed Forces, the productivity of the workforce, the success of children in school, and the availability of services for an aging population. It is clearly obvious that a major overhaul of the system — one that will include strategies for managing the increasing burden of chronic disease — is needed not only to improve the quality of health care but also to increase the financial efficiency of the system.

Calls for modification of the health care system are not new. In 2001, the Institute of Medicine (now called the National Academy of Medicine) published a comprehensive report titled Crossing the Quality Chasm: A New Health System for the 21st Century, which listed challenges and imperatives for improving the health of Americans:

1. Reengineered care processes

2. Effective use of information technologies

3. Knowledge and skills management

4. Development of effective care teams

5. Coordination of care across patient conditions, services, sites of care over time.[12]

We are now 16 years downstream from these recommendations. Since the publication of this report, significant advances have been made in digital health technology, the development of cloud-based health data storage, biometrics, wearable devices, genomics, social media and health affinity groups, and understanding of the role that lifestyle, diet, and environment play in health and disease. These new tools have not yet been successfully integrated into the development of patient-centered health care. Why? I believe it is due to resistance to implementation of significant changes in the disease care system. It is no longer a lack of information or technology that holds us back from improving the effectiveness of our health care system. Rather, the greatest obstacles have proven to be those forces that are holding fast to old economic and disease care models. We must move away from thinking and practices that prevent new concepts — those that would dramatically improve both the health of the individual and the cost effectiveness of health care — from being introduced into our system. It is time to move forward — the next four years are crucial — and introduce the well-accepted concepts described in this article that will materially improve the health of the country.

[1] The Lancet. President Trump. Lancet. 2016 Nov 19;388(10059):2449.

[2] “Illness as indicator.” The Economist. November 19, 2016. Retrieved December 1, 2016. Accessed December 5, 2016.

[3] Obama B. United States Health Care Reform. Progress to Date and Next Steps. JAMA. 2016 Aug 2;316(5):525–32.

[4] Hoh HK. Improving Health and Health Care in the United States: Toward a State of Complete Well-being. JAMA. 2016 Oct 25;316(16):1679–1681.

[5] Ayanian JZ, Markel H. Donabedian’s Lasting Framework for Health Care Quality. N Engl J Med. 2016 Jul 21;375(3):205–7.

[6] Naylor CD. Vital Directions for US Health Care: Big Ideas on Small Signposts with Mixed Signals. JAMA. 2016 Oct 25;316(16):1682–1684.

[7] McClellan MB, Leavitt MO. Competencies and Tools to Shift Payments From Volume to Value. JAMA. 2016 Oct 25;316(16):1655–1656.

[8] Adler NE, Glymour MM, Fielding J. Addressing Social Determinants of Health and Health Inequalities. JAMA. 2016 Oct 25;316(16):1641–1642.

[9] Rowe JW, Fulmer T, Fried L. Preparing for Better Health and Health Care for an Aging Population. JAMA. 2016 Oct 25;316(1):1643–1644.

[10] McGinnis JM, Diaz A, Halfon N. Systems Strategies for Health Throughout the Life Course. JAMA. 2016 Oct 25;316(16):1639–1640.

[11] Dzau VJ, Ginsburg GS. Realizing the Full Potential of Precision Medicine in Health and Health Care. JAMA. 2016 Oct 25;316(16):1659–1660.

[12] Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Retrieved December 8, 2016. Accessed December 8, 2016.