Would Universal Health Care Be Enough?

At first glance, the answer to the question, “Would universal health care coverage be enough to improve the health of our nation?” seems to be an obvious and emphatic, “Yes!” (notwithstanding the debate about how to pay for it).  However, we in the health care field have known for years that access to health care (via insurance coverage and the availability of providers) does not necessarily lead to the actual use of these services.  All over the country, hospital emergency departments (EDs) and inpatient units are struggling to encourage patients who over-utilize these very expensive services to make use of the less expensive and often more appropriate primary care (outpatient) services – and that’s for patients who have health care insurance.  So, people who have coverage for the correct level of medical service don’t necessarily use it when they should.  Now, add to that, newly insured patients who are less familiar with the health care system given their previous inability to pay for it, and we may compound this problem.  We may end up with that many more people overcrowding our EDs and inpatient units, preventing adequate care for those who actually need it. 

Researchers tell us that there are likely many reasons for this inappropriate use of higher-level medical services, but some of the stand-outs are that 1) patients like the idea of treatment on demand, which is what you get at the hospital, 2) patients are confused by the complexity of our often-fractured service delivery model (You go to your primary care doc, she tells you to get labs somewhere else, to see a specialist at yet another clinic and then to come back to get the results and finally, treatment recommendations), and 3) patients are stymied by multiple logistical issues (e.g., long waits for appointments, geographic inaccessibility of clinics, a shortage of female primary care physicians, etc.).  And in fact, cutting-edge health care providers and researchers have begun to develop and test several bold and ingenious methods of making ED and hospitalized patients more likely to use primary health care services once discharged.  One notable example is Dr. Jeffrey Brenner of the Camden Coalition of Healthcare Providers whose approach to medical care is truly holistic and intensive, and one that brings many different professional and peer influences to the table, often delivering treatment right to the patient’s home and explaining at great length what needs to be done and how to do it (see the recent New Yorker article on this group at http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_gawande). 

While these and similar efforts have begun to show some evidence that they reduce overcrowding of EDs and hospital beds, as well as improve medical outcomes, they may not be enough.  Thirty years of science tells us that when patients resist what to us seem like highly sensible ideas (e.g., see your primary care doctor consistently and you will be less likely to lose a foot to diabetes; you have a drinking problem and need treatment to address it; if you take your medication every day, you will significantly reduce the chances of a heart attack), the resistance cannot only be explained by a lack of understanding or logistical reasons.  Resistance is a highly personal and often emotional issue.  People fail to do what seems sensible because they have their own good reasons for resisting good advice – reasons that we will never be able to counteract by only giving patients our perspectives on what they need to do.  In fact, such an education-only approach has been repeatedly shown to fail with resistant patients.  Where there is resistance, there needs to be a motivational strategy to create breakthroughs in new behavior.  And the only scientifically-proven way of motivating patients to change health-risk behaviors to which they are resistant is something called “Motivational Interviewing,” developed by Drs. William Miller and Stephen Rollnick in the late 80s.  Recent adaptations of this method for use in fast-paced medical settings has been shown to significantly increase the chances of patients following up with their doctor’s recommendations, even if they were initially resistant.  And how does this MI work?  It works by getting patients to voice their own good reasons, especially emotionally-laden ones that “hit home,” for following the advice of their doctor.  All of a sudden, there are two experts in the exam room – the doctor on the diagnosis and treatment, and the patient on her own reasons (motivation) for wanting to do better with her care.  That’s what’s going to make medical treatment (universal or otherwise) finally work.

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