Looking at Healthcare in the Mirror of a Pandemic

The COVID-19 pandemic holds up a mirror that shows us what’s lacking and compels us to ask some tough questions.

The U.S. spends more on healthcare than any other country. Yet among wealthy nations, we have the lowest life expectancy. Maybe no healthcare system could have been ready to take on a pandemic, but we were not nearly as prepared as South Korea and Taiwan, which spend far less.

We know from research that 80 percent of the well-being of society has nothing to do with the delivery of medical services. Population health aims to reduce things like income disparity and provide services like maternity leave, housing, good food, and drug-abuse or mental-health counseling. Our healthcare system gives little thought or resources to improving population health by preventing and managing disease. We spend our treasure on health services, not social services, which is upside down and backwards.

Now that we need the public health system to literally save us, we’re challenged by insufficient resources, lack of leadership, and almost no nationally coordinated public health infrastructure.

The healthcare industry is the largest business in America; roughly one out of five dollars goes to it. What do we get for that level of spending? The short answer is, not a lot. It’s not designed to improve health, and it’s certainly not designed to protect health. So what is the business of our nation’s biggest business?

Strange as it seems, we’re not really in the health business. We’re in the business of episodic care of the acutely and chronically ill. The business of American healthcare is to have high-margin diagnoses in heart disease, cancer, orthopedics, and neurosurgery in our in-patient settings. Is that what we should be here for? Or are we here to improve the health of everyone in a city where one out of four people live in poverty? Why should people have to choose between getting a COVID test and feeding their children?

It’s too late now to do more than scramble and do the best we can with what we’ve got. But we can do something about the future, and that starts with education. What can we do in the medical school curriculum today to make sure we don’t find ourselves in this predicament tomorrow?

The answer is that it must embrace the tenets of population health, which align with the Quadruple Aim: enhancing patient experience, improving the health of communities, reducing costs, and reducing caregiver burnout.

Here are the key components of a curriculum designed to do just that:

• Public health. The U.S. was unprepared for COVID-19, despite the fact that national leaders had been briefed about the likelihood of a pandemic. The basic tenets of public health are in our graduate-school curricula right now: monitor and diagnose community health, mobilize partnerships, develop policies and plans, evaluate effectiveness, and research innovative solutions.
• Leadership education. More than ever, we need physicians who can envision and adapt to change, and lead organizational responses. MBA programs excel at teaching the skills and strategies that effective leaders need. Medical and nursing schools can learn from leadership programs, the sooner the better, and incorporate leadership training into their curricula, the earlier the better.
• Population Health Intelligence. AI, big data, and predictive analytics are indispensable tools that assess information in a way no single clinician could. If we mine and analyze large data sets from various sources, we can distill information for making better-informed decisions about patient care, for individuals and communities. These tools also help us identify fraud, waste, and abuse in healthcare systems.
• Performance Improvement. The tools have been around for 30 years: performance and quality improvement, waste or error reduction, and reallocation of wasted resources. Based on the evidence, one-quarter to one-third of healthcare spending, roughly a trillion dollars, is of no value. Imagine if we had been able to harness that waste and reallocate those resources for masks, PPE, and ventilators.
• Social determinants of health. Good health and ill health are more than biomedical conditions: They’re the outcomes of social inequality and the things we do that keep us healthy or make us sick. About half of Americans are one paycheck away from disaster. Research shows that one of the principal predictors of health is poverty and how it constrains choices in how people live. To improve health, we have to improve social services.

Healthcare reform is about creating physicians who can not only implement the curricular change I’ve outlined but teach it, proselytize it, and do what all leaders must, which is train the leaders of tomorrow. If we had more leaders with this expertise and these skills today, we’d be in a much better place.

David B. Nash, MD, MBA, is Founding Dean Emeritus of the Jefferson College of Population Health and Dr. Raymond C. and Doris N. Grandon Professor of Health Policy at Thomas Jefferson University.