By Rachel Goldwasser (LNH '18), Executive Director,
New England Conference of Public Utilities Commissioners
Defining Health: Access to Medical Care Does Not Necessarily Lead to Good Health. Health care policy can be a divisive issue, and one that has no easy answers. In a diverse group of individuals, it can be challenging to begin a conversation from a place of common ground. Dr. Sally Kraft, LNH ‘18 (the greatest class!), performed this task with great humor and grace – creating the space for common ground and common goals, no matter what perspective one brought to the discussion. Using the hypothetical case of Mrs. Buckley, an elderly patient who receives gold star care from individual providers but whose resulting health is significantly less than stellar, Dr. Kraft was able to raise questions about how society approaches health policy without backing her audience members into their various corners.
Mrs. Buckley is an elderly woman who gets sick and calls her doctor. Her general practitioner’s office tells her to call an ambulance. She is transported to a hospital which does not have access to her electronic records, and her treating physicians address what they see, not what they would have known had they had her records and could quickly learn more about her history. Her adult son, located on the West Coast, is unable to provide full support from that distance. She gets an infection during her hospitalization and ends up needing to be transported to a nursing home rather than back to her residence. The limitations of the medical system – the incentives and institutional systems applied to providers, the necessity for better communication, and the failures of society to provide community support and opportunities for long-term planning – were evident.
How do we learn to value health outcomes over, say, intensity of services? How do we assure that our health care system is supporting the whole person, and not just the brief window that each provider has into a person in any given moment? How do we incentivize investment into communities to increase health, rather than pay for the after-effects of failing to do so? Dr. Kraft provided the perfect entre into these issues, and she avoided drawing class members into the state and national conversations that tend to alienate rather than problem-solve.
We were able to apply Dr. Kraft’s framework throughout the day, across several panels and discussions. Some of the themes we discussed are as follows:
Medical Care is More Effective When it is Designed to Meet the Individual Needs of the Community. We learned about the Manchester Community Health Center approach of using data in new and innovative ways to figure out how to tactically direct resources where they are most needed. The use of data to determine which populations most require which forms of care and education was fascinating to learn about, especially as some of the data might contradict preconceived notions about which populations have the most need, and why. Innovative use of data can help address questions such as: Which populations are healthiest and which are least healthy? What can we do to reduce disparities and increase the health of our entire state?
Incentive Structures are not Always Aligned with Desired Outcomes. From demographics and rising administrative costs to the intractability of the current pay-per-service medical system, there are huge challenges facing the practice of medicine and the provision of healthcare to the New Hampshire population. One major theme identified throughout was the fact that until incentives are aligned with outcomes – or health – we will be pushing a big, heavy ball up a hill.
Normalizing Mental Health & Opioid Crisis Care. The Opioid Crisis has put a spotlight on the lack of access that many New Hampshire citizens have to mental health care and medical treatment. The class heard about the fact that New Hampshire has many fewer mental health beds than it should for its population, which is resulting in holding people in emergency rooms while they wait for access to appropriate care. This issue seems to be compounded by the opioid crisis; we do not have enough access to medically-assisted treatment here in New Hampshire, and the result is that community members are not getting the treatment they need. We learned that while fatalities are down, particularly due to the use of Narcan, overdoses are up from prior years, even as law enforcement and other professionals continue to reimagine how to approach helping addicted members of our community.
Understanding the Federal Process: Formidable and Potentially Intractable. We were lucky to hear from experts in the federal policymaking process regarding action in Washington, DC. The class learned about the roles that the Executive, Legislative, and Judicial Branches play in health care policy, including the budget and administrative processes that are often not highlighted in newspaper headlines. We were reminded that “Every administration since Teddy Roosevelt has tried to do something regarding healthcare” – this is certainly not a new problem. We were also remained that even though it sometimes seems like seismic shifts were made under the Affordable Care Act, the underlying structure of the health care system – one that is mostly employer-based, and in which healthcare is a financial commodity – has continued, with some changes around the edges. Squaring that structure with the problem statement that Dr. Kraft started our day with – how to we encourage health, rather than medical care – is a challenge anytime, but was particularly so at 4:30 in the afternoon after a long day of sessions full of information, which is when we participated in this final panel.
Coalescing around Community Health, but what else? In the concluding session, the class focused discussions about the fundamentals of health, such as access to healthy foods, exercise, and ways of reducing isolation and increasing community engagement. The class leaned away from discussing the larger-scale funding and policy issues, perhaps because those felt too big and challenging so late in the day. It would be interesting to return to some of these questions, including what New Hampshire, as a state, can do to address some of these seemingly intractable issues, now that folks have had a chance to absorb some of the information provided.
A postscript: two books were highly recommended during this final session, and I thought it would be helpful to record them for posterity: The Healing of America by T.R. Reid and An American Sickness: How Healthcare Became Big Business and How You Can Take It Back by Elisabeth Rosenthal.