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What Next: Health Care’s Three Biases (Part 1 of 5)

Over the last few weeks, I’ve been taking stock of where we’ve come from and what we’ve done as a way to understand what we should do next. Typically, that’s the kind of work one does to formulate a strategy and the process is usually behind closed doors. I prefer to do my thinking in public through writing and publishing. Writing helps me find precision amongst the jumble of thoughts in my head and publishing enables me to receive feedback and criticism. Being public also enables me to share the uncertainty of my work, something that can be lost in the polish of a fancy website.

I use the term ‘my work’ intentionally because the shape of it is different in the US and the UK.

In the US, my work has evolved into Bridging Health & Community (BH&C), a Seattle-based nonprofit that we incorporated in October 2016 with my advisors at the time becoming the Board. BH&C has held a national symposium, delivered a lot of talks, and had numerous conversations with entities across the health ecosystem about how the idea of agency (the ability to make purposeful choices) and the 12 Principles (to foster agency and help the health ecosystem change) might be applied to improve health.

In the UK, my work has evolved, with the help of seven colleagues, into Beyond Systems, a project that aims to build a community of practice based on the idea of parity between citizens and the statutory systems that serve them. This requires bi-directional trust and a belief in an equal voice for all (you can subscribe to its blog here). Although the idea of agency and the 12 Principles are relevant to that work, it’s not what we led with because my seven colleagues also have ideas and principles so rather than compete for which is most relevant we organized around the larger vision of parity.

Bias One

All of this work started in late 2012 when I was the Physician Editor of TEDMED. I was plagued by the way in which health care controls the dialog in health so that it’s aligned with its ideology and commercial aims – all while giving the impression of caring for patients and communities.

To be clear, I am not saying that people working in health care do not care for patients and communities. Clearly, they do. However, the health ecosystem does this on the basis of a set of ideas, the most influential of which is that health is a bio-medical construct. This idea is essentially an intellectual bias, and it’s one that goes largely unchecked.

With the health ecosystem biased towards health being a bio-medical construct the research it funds, the data it generates, the information it creates, the knowledge applied to practice, and the wisdom that informs the whole cycle has a bio-medical bias. With that bias firmly in place it is almost impossible to argue against a new technology – whether a drug, a device or approach – if it has been shown to have a positive impact on a bio-medical measure.

Bias Two

The marriage of this ideology with commercial aims has, to my mind, been disastrous for how we invest in health. Any technology shown to have a positive impact has to be procured. Leaving aside the moral dilemma of how you choose which technologies to invest in, and hence which lives to save, the overall impact is that the cost of health care in high-income countries is spiraling out of control.

That, of course, is not news to regular readers. Nor was it what plagued me. What plagued me was our collective inability to have a proper conversation about all of this.

 Sources of Growth in Projected Federal Spending on Medicare and Medicaid, 2007

Sources of Growth in Projected Federal Spending on Medicare and Medicaid, 2007

Although I felt this play out while with TEDMED, the issue had been on my radar for some time. The thing that really brought it home was the graph above, which was produced by the Congressional Budget Office in 2007. I can’t remember how I came across it but I do remember that at the time everyone was talking about aging as the key driver of increased health care costs (many still are). What this graph made me realize was that, while ageing was one driver it was nowhere near as influential as cost growth alone. As the report says:

“Although the aging of the population is frequently cited as a major factor contributing to the large projected increase in federal spending on those two programs, it accounts for a modest fraction of the growth that the Congressional Budget Office (CBO) projects. The main factor is excess cost growth — or the extent to which the increase in health care spending for an average individual exceeds the growth in per capita gross domestic product (GDP).”

In essence, health care is getting more expensive because health care can.

By controlling the dialog in health so that it’s solely a bio-medical construct, the health ecosystem is able to make the case for investment in any new drug, device or approach. Couple that with aging and the growing rates of circumstance-related chronic conditions, and you have a perfect storm of supply-defined growth – and seemingly unstoppable growth at that.

Bias Three

Trying to change the dialog is complicated by the sheer size of the industry. In the US, it accounts for almost 18% of GDP so any discussion as to whether the health ecosystem is fit for purpose inevitably becomes about threatening people’s jobs. Having a proper conversation about health leads to serious existential angst for many working in the industry. Self-interest kicks in; another bias. And it’s one that is rarely acknowledged.

These biases – of health only being bio-medical, of the need to invest in anything that improves a bio-medical measure, and of self-interest – combine to make a formidable force. They have restricted our discourse about the future of health and the role of the health ecosystem. It was for these reasons that I decided to find a new conversation, one that made no assumptions as to what health is.

In part 2 of this five-part series I’ll describe how I went to find a new conversation, and how that led to finding 12 principles to working with communities.

 

Pritpal S Tamber

CEO, Bridging Health & Community