Healthcare Stewardship

Copyright © 2008 by Dale J. Block

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ISBN: 978-0-595-51032-0 (sc)

ISBN: 978-0-595-50223-3 (dj)

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Library of Congress Control Number: 2009922168

iUniverse rev. date: 1/14/09

Contents

Dedication

Preface

1.0 Introduction to Stewardship

1.1 The Roots of Stewardship

1.2 A Plea for Stewardship in Health Care

1.3 Concepts and Critical issues of Health Care Stewardship

1.4 Good Stewardship

1.5 Conceptual Issues of Stewardship

1.6 The Domains of Stewardship

1.7 Monitoring Stewardship

1.8 The Potential for Health Care Stewardship

1.9 Conclusion

2.0 Ethical Considerations for Health Care Stewardship

2.1 Introduction to Medical Ethics

2.2 Equity, Justice, and Health Care Stewardship

2.3 Equity and Ethical Theories

2.4 Equity, Need, and Health Care Stewardship

2.5 Assessing Equity: A Practical Approach

3.0. The Medical Commons

3.1 The Tragedy of the Commons

3.2 Protecting the Medical Commons

3.3 Managing Medical Resources in the Twenty-First Century

3.4 Looking at the Health Care Marketplace More Closely

3.5 Health Care Market Forces in the Twenty-First Century

3.6 Conclusion

4.0 Health Care Stewardship and the U.S. Health Care Delivery System

4.1 Introduction

4.2 Current U.S. Health Care Market Forces

4.3 Characteristics of the U.S. Health Care System

4.4 Characteristics of Free Markets in Health Care Delivery

4.5 The Distribution of Health Care Resources in the U.S.

5.0 Cost, Quality, Access, and Health Care Stewardship within the U.S. Health Care Delivery System

5.1 Introduction

5.2 What Is the Cost of Health Care?

5.3 Reasons for High Health Care Costs

5.4 Controlling Health Care Costs

5.5 The Problem of Access to Health Care Resources

5.6 What Are the Reasons for Unequal Access to Health Care Resources?

5.7 Quality of Care

5.8 Conclusion

6.0 The Biopsychosocial Approach to Health Care Delivery

6.1 The Biopsychosocial Approach to Clinical Medicine

6.2 Clinical Practice and the Biopsychosocial Approach

6.3 Integrating Biological, Psychological, Social, and Environmental Domains

6.4 Understanding the Clinician

6.5 Focusing on the Biopsychosocial Approach for Clinical Practice

6.6 The Future of Clinical Biopsychosocial Practice

6.7 Conclusion

7.0 Transforming the U.S. Health Care Delivery System to the Medical Home

7.1 A Proposal for Transformation

7.2 A New Direction for Primary Care Medicine

7.3 A New Model for Medical Care

7.4 Primary Versus Specialty Medical Care—A Difference?

7.5 A Primary Care Home for Americans

7.6 The Future of the Primary Medical Home

7.7 Conclusion

8.0 Public Health—Health care Stewardship for Populations

8.1 Introduction

8.2 Determinants of Health and Disease

8.3 Promotion, Protection, Preservation, and Restoration of Health

8.4 Health Promotion and Disease Prevention

8.5 Essential Public Health Functions

8.6 The United States Public Health Service

8.7 The Social Capital Imperative

8.8 The Changing United States Public Health System

8.9 The Future of Public Health in the United States

8.10 Conclusion

9.0 Public Health Law and Health Care Stewardship

9.1 Introduction

9.2 Public Health Law and Government Responsibility

9.3 Population-based Health Care

9.4 The Relationship between the State and the Community

9.5 The Public Health System in the United States Revisited

9.6 Role of Coercion in Public Health

9.7 Public Health Powers and Limits

9.8. Systematic Evaluation of Public Health Regulation

9.9 The Process of Evaluating Public Health Regulation

9.10 Conclusion

10.0 Environmental and Ecological Medicine

10.1 Introduction

10.2 Ecosystems and Population Health

10.3 Environmental Health Management

10.4 Systems Model for Environmental Change

10.5 Hazard Versus Risk

10.6 Environmental Health Risk Assessment

10.7 Risk Management

10.8 Ecological Medicine

10.9 The Basics of Ecological Medicine

10.10 Ecological Medicine: A Call for Inquiry and Action

11.0. Conservation Medicine: A Transdisciplinary Approach to Health Care Stewardship

11.1 Introduction

11.2 Defining Conservation Medicine

11.3 Conservation Medicine: A Crisis Discipline

11.4 Conservation Medicine: A Discipline of Health Care Stewardship

11.5 Ecosystem Health

11.6 Conclusion

12.0 Patient-Centered Care

12.1 Introduction

12.2 Defining Patient-Centered Care

12.3 Models of Patient-centered Care

12.4 Factors Contributing to Patient-Centered Care

12.5 Strategies for Leveraging Change

12.6 Patient-centered Primary Care Practice

12.7 What Is Needed to Get to Patient-Centered Care?

12.8 A Systems Approach to Patient-centered Care

12.9 Conclusion

13.0 Measuring Health System Performance

13.1 Introduction

13.2 An Operational Framework for Measurement

13.3 Major Intrinsic Goals for a Health System

13.4 Performance of the Health System

13.5 Factors that Explain Health System Performance

13.6 Health System Performance—Putting It All Together

13.7 Conclusion

14.0 Measuring Individual Health and Well-Being

14.1 Introduction

14.2 What Is Health?

14.3 Health Versus Well-Being

14.4 Conceptualizing the Quantification of Health

14.5 Boundaries of Health

14.6 Measurement Issues of Health

14.7 Conclusion

15.0 Disruptive Innovation: A New Prescription for Health Care Delivery

15.1 Introduction to Innovation in Health Care

15.2 Diffusion of Innovation in Health Care

15.3 Disruptive Innovation in Health Care

15.4 Complexity and Innovation in Health Care

15.5 Model for Innovation in Health care Delivery Systems

Dedication

I dedicate this book to the memory of my daughter, Julie Ann Block, taken from our midst without having the opportunity to live a full and productive life on this earth. I also dedicate this book to my wife, Ellen, and my three sons, Aaron, Jeremy, and Stuart, who have encouraged me to share my thoughts and opinions with others about health care delivery in this great country of ours, the United States of America.

Preface

The health and well-being of Americans are steadily disintegrating at an alarming rate. However, Americans are living longer. The increase in life span is not due to healthy living. It is because of technology that can identify and then replace worn-out organs. It is because of the pharmaceuticals that can get every last little bit of physiological and biochemical essence out of the human cell to keep people alive. Health care has become a game of increasing the quantity of life and not the quality of life! How did we as a nation allow this to happen? How did we as individuals lose our way along the healthy continuum of life?

The answers to these simple questions are complex. However, the solution is rather straightforward. Health care stewardship, a concept with religious roots dating back to biblical times, needs to become the guiding force for the American health care delivery system. Adopting the principles and practices of stewardship will allow individuals, populations of individuals, and our nation as a whole to change the direction of health care delivery for years to come.

I have been a practicing family physician for the past twenty years. Being involved in all facets of the health care delivery system—academia, clinical practice, research, administration, corporate America, and the insurance industry—I have observed a common theme that has woven its way throughout all of these areas of health care delivery. It is the inability of patients, clinicians, and administrators to practice disciplined stewardship related to our limited health care resources. My ongoing frustration with the health care system’s policies and procedures leading to unbelievable levels of inefficiency, duplicity, and waste has served as my motivation to write Health Care Stewardship. A change is required, and the time is now!

Practicing stewardship is really quite simple. The limited health care resources that are available for Americans must be managed in a manner that is clinically and socially responsible for those in need of health care services today (and for the generations of Americans that follow). Unfortunately, simplicity in the United States is far from being easily achieved. The United States of America has the most complex and ineffective health care delivery system in the world. The vision behind writing a book on health care stewardship is to help Americans get back on track to being healthy, happy, and functional human beings. We, as individuals and as a nation, have forgotten that without our individual health and well-being, nothing else matters. Stewardship, as it relates to health, is a concept to teach at all levels along life’s continuum—from cradle to grave. A commitment to make all of us healthy and wise consumers of our precious health care resources is required in order to achieve stewardship in the American health care delivery system.

In my previous book, Healthcare Outcomes Management: Strategies for Planning and Evaluation (2006), I identified many stakeholders in the American health care delivery system (Table 1). The diversity among these stakeholders should have allowed interested parties to come to some reasonable agreement on how to manage the U.S. health care resources. Unfortunately, that has not been the case. I have often said, If you take care of people, the financials take care of themselves. American health care delivery has not focused on the patient for some time. Profit margins and profitability have changed the focus of American health care delivery away from the ethical obligations once followed as a guiding force in caring for the health and well-being of all patients. The more powerful stakeholders have exercised their brute strength in the last fifty years to change how the United States cares for its people. Rising health care inflation, the highest per capita costs per patient in the world, and dismally poor health care outcomes demonstrate a national crisis in need of immediate attention and correction. The very survival of our country is at stake. Responsible management of our nation’s limited health care resources needs to be implemented now in order to avert this crisis. It will require a significant paradigm shift in our current American health care delivery system.

No measure, no manage

No manage, no margin

No margin, no mission

This is concisely what our national health care mantra needs to become. First, a thorough understanding of how to make the patient-consumer the center of the health care delivery system needs to become a priority. Those in charge of the U.S. health care delivery system need to understand the determinants of health within a more focused and comprehensive approach to health care delivery. Shifting the focus of health care delivery back to the patient-consumer requires a willingness to think outside of traditional models regarding health care delivery. The magnitude of the carbon footprint that health care delivery is leaving behind must and should be brought out into the consciousness of all Americans if we are to succeed in becoming successful health care stewards.

This book will trace the evolution of stewardship from its religious beginnings to its current place in health care delivery. A significant portion of the book is devoted to making a business case for health care stewardship focusing on the issues of health care inflation, cost, accountability, quality, and outcomes. The book also discusses influencing stakeholders ethically and morally to become informed health care fiduciaries and responsible managers of health care resources.

Other areas of discussion include exploring the present state and future of our nation’s public health system as it applies to health care stewardship. I will identify environmental issues in health care to help us improve our health care carbon footprint for future generations of Americans. I will present a discourse on measuring health system performance and individual health and well-being as a means to allocating precious health care resources. I will introduce the new discipline of conservation medicine. Finally, I will discuss the concept of disruptive innovation as a mechanism to get the stakeholders of the U.S. health care delivery system to approach health care production and delivery in a different light.

The main goal of health care stewardship is to improve the ability of our nation to increase positive health care outcomes for all Americans. I am writing this book to stimulate discussion among all stakeholders of the U.S. health care delivery system in order to get us to meet this achievable goal.

Dale J. Block, MD, CPE

July 2008

Table 1. Stakeholders in Health Care Delivery

Consumers/Patients

Family and friends of patients

Community at large

Clinical providers of health care

Government

Health system administrators

Pharmaceutical companies

Pharmaceutical benefit management companies

Technology companies

Health plans

Private payers

Employers

Media representatives

Health services researchers

Academia

References

Block, D. J. 2006. Healthcare outcomes management: Strategies for planning and evaluation. Sudbury, Massachusetts: Jones and Bartlett Publishers, 5.

1.0 Introduction to Stewardship

1.1 The Roots of Stewardship

Stewardship has its roots in biblical times. According to Saltman and Ferroussier-Davis (2000), the Old Testament presents the following references to stewardship:

• In Genesis, men and women were created in the image of God, given a privileged place among creatures, and commanded by God to exercise stewardship over the earth.

• Also in Genesis, Jacob’s son, Joseph, when sold into slavery by his brothers becomes Potiphar’s then Pharaoh’s steward, and exhibits the following qualities of stewardship:

™ He becomes a selfless servant of his masters.

™ He manages his master’s assets without owning any of them.

™ He anticipates the future trends and devises grand plans for the use of his master’s assets.

In the New Testament, Jesus tells the parable of the talents, whereby a master divides his goods between his three servants. The story emphasizes that when one is entrusted with something of value by others, one has an obligation ethically and morally to improve the value of what they are managing. The notion of stewardship as an ethically driven responsibility for protecting and developing one’s resources lies at the heart of both the Christian and Jewish faiths.

Saltman and Ferroussier-Davis (2000) describe the very first reference to health care stewardship based in religious teachings. The Islamic faith and the institution of Hisba organized public administrative functions in both the moral/normative and administrative/technical dimensions. The head of Al Hisba, the first Muhtasib, was appointed in Medina in the ninth century. The functions of the Muhtasib in precolonial Arab societies included the regulation of medical practice and pharmaceuticals and overseeing the requirements regarding the equitable provision of services and the public interest.

Religion also serves as the basis for the environmental and ecological stewardship that has emerged in Europe and North America within the past decade (Saltman and Ferroussier-Davis 2000). Originally, it started out as accountability to God in the Judeo-Christian doctrine. Responsibility to God has been replaced within the ecological and environmental movement with intergenerational responsibility. Saltman and Ferroussier-Davis (2000) interpret the lack of control over the degradation of the environment over centuries as humans’ misinterpretation of God’s mandate to be earth’s steward as a license to dominate, exploit, and destroy the environment. Others argue that damage to the environment has occurred because of people disregarding God’s recommendations to appropriately manage the earth’s precious resources.

1.2 A Plea for Stewardship in Health Care

In Oslo, Norway, on March 8, 2002, then director-general of the World Health Organization, Dr. Gro Harlem Brundtland, addressed the Seminar on Stewardship of Health Systems at the Board of Health. Dr. Brundtland noted that good health systems enable populations in which they serve to be healthier. These good health systems ethically and financially respond to the expectations of the populations they serve. Some health systems perform well, while others perform poorly. According to Dr. Brundtland (2002), the differences between health systems that operate well and those that operate poorly are a result of factors other than differences in income or expenditure. The factors that make a difference in the performance of the health system encompass all actions whose primary intent is to improve the health and well-being of the population served.

The ultimate responsibility for a country’s health system performance lies with the government. The government has the continuing responsibility for ensuring the health and well-being of its people as a national priority. The responsible management of a health system promoting the health and well-being of its constituents is the very essence of good government. Many governments fail to use their health system funds efficiently. This results in large numbers of preventable deaths and increased impairment and disability. The poor bear the impact of this inefficiency more than others do in the population.

Health systems must put in place procedures that address the financial health of the populations they serve. This is necessary in order to reduce catastrophic health care expenditures that can ruin the lives of people who experience major health events that may become chronic in the long run and therefore very costly. Market failure can be a direct result of health systems focusing exclusively on either the public or private sector. In order to achieve better health system performance with respect to quality, access, and cost, health systems must take on a global perspective while addressing the health and well-being of the entire population, not just smaller segments that may benefit the financial health of the system.

Based on identification of the factors that may make a difference in the health and well-being of populations through addressing health system performance, Dr. Brundtland (2002) stated that there were four elements that need immediate attention:

1. Delivery of essential health goods and services

2. The human and physical resources needed to make the essential health goods and services available

3. The procurement of funds necessary to pay for the essential health goods and services

4. Establishment of how the health system affects all the stakeholders in the delivery of the essential health goods and services to the population and achievement of appropriate outcomes.

It is this last point that speaks to the definition of health care stewardship. Brundtland (2002) articulated in her speech to the Board of Health that stewardship is not just about ensuring the health and well-being of the population served by the health system; stewardship requires the careful and responsible management of resources that promote people’s well-being.

From a practical perspective, Dr. Brundtland articulated that a steward must provide the necessary leadership to establish the rules by which all the stakeholders behave in ways that reflect the interests of both public and private sectors. Stewards must ensure corrective action when behavior by the stakeholders becomes aberrant and potentially harmful to the population served by the health system. Brundtland (2002) notes, Good stewardship is based on clear standards, applied well within the local context, in ways that are as effective and efficient as possible.

Dr. Brundtland, at the end of the address to the board, stated the following:

High quality stewardship is critical if a modern health system is to perform at its best. This means management that empowers, supports, reviews and communicates; that encourages participation while sanctioning those who undermine, and that offers incentives for better performance. Within the WHO, we are committed to promoting health stewardship for all, and to seeing its benefits reflected in greater equity in global health.

1.3 Concepts and Critical issues of Health Care Stewardship

According to The World Health Report 2000 (World Health Organization 2000), there are four core functions that all health systems, public and private, must possess to carry out their health care mission: financing, resource generation, service delivery, and stewardship. Understanding the function of stewardship allows health systems to attain appropriate and measurable outcomes and cost efficiency. How is stewardship defined within this context?

The report broadly defined stewardship as the careful and responsible management of the well-being of the population … the very essence of good government. Stewardship is the responsibility of the government through an appropriate governmental agency. Different aspects of stewardship may be divided among the stakeholders of the health system; however, according to Travis et al. (2002), a country’s government acting through its health ministry remains the steward of stewards for the health system. This allows a central responsibility, both administratively and normatively, to ensure that all the stakeholders in the health system collectively provide effective stewardship for the well-being of the population.

The report also identified three tasks of health system stewardship: provide vision and direction for the health system, collect and use intelligence, and exert influence through regulation and other means. The governmental execution of its stewardship role in health care can influence the quality, cost, and outcomes within the health system.

Stewardship has similarities to public governance, but the WHO definition is more specifically focused on how government takes responsibility for the health and well-being of the population and guiding the health system as a whole. This ultimately influences the ways that other health system functions (i.e., finance, resource generation, service delivery) are undertaken, embedding the health system into a wider society (World Health Organization 2002).

A significant amount of research is needed to establish a methodology for understanding, assessing, and improving the tasks of health care stewardship. A practical format is required to assess how stewardship fits into the goals and objectives of a health system. The key to this assessment is developing a measurable format that takes into consideration both the administrative and normative issues that affect stewardship activity within complex health systems. Remembering that the ultimate goal of stewardship is the careful and responsible management of the well-being of the population should align all the stakeholders in achieving what is best for the people served by the health system.

1.4 Good Stewardship

Good stewardship is essential in order to influence the behavior of all the stakeholders involved in the delivery of health care. What constitutes good stewardship?

According to Travis et al. (2002), there is little structured evidence in the literature as to the essential things that health care stewards should be doing. Good stewardship activities develop through the convergence of functions defined in the field of public health and work done on general governance within health care systems.

In 2001, a meeting of experts was convened in Geneva, Switzerland, by the World Health Organization to discuss what constituted good stewardship function in health systems (World Health Organization 2001). The meeting was held as a follow-up to the World Health Report 2000, which proposed a comprehensive framework for health systems’ performance assessment that identified the goals of health systems and the four main functions that contribute to their attainment: finance, resource generation, service delivery, and stewardship. With respect to stewardship, the report claimed it to be the most important of the four health system functions; however, an operational definition of stewardship that identifies how countries might strengthen stewardship and thus improve health system performance has long been elusive. Finally, the report identified three principal components of stewardship: formulating health policy, exerting influence, and collecting and using intelligence.

The consultation provided by the meeting of experts had two major objectives due to issues generated by the report: first, obtain the opinions of a group of recognized international experts on refining the WHR 2000’s definition of stewardship and decomposing stewardship to more tangible elements for better assessment of stewardship in a particular country; second, obtain the advice of the experts for a WHO program in the area of stewardship to provide support and advice to member countries.

The experts agreed that stewardship incorporates much of what is inherent to public governance. Stewardship does differ from governance operationally by combining three elements related to its WHO definition: 1) hold all the elements of a health system together; 2) keep the health system operationally moving smoothly, and 3) give the health system its ethical direction and momentum to meet its mission and vision.

The experts also see stewardship as the function that embeds the health system in wider society in addition to its ethical content and relationship to governance. Internalizing and reflecting the cultural and political context and broader societal norms, stewardship must reach out to address the interactions between the health system and other aspects of society as a whole. The scope of effective stewardship, according to the experts, needs to extend beyond the boundaries of the health sector and its limited stakeholders in order to be operational and successful in managing the limited resources available for delivery of health care goods and services.

Stewardship must foster a culture of self-determination and self-direction among individuals and organizations in the health system within an overall framework of agreed-upon norms and values.

The experts at the conference agreed that some form of descriptive classification of approaches to stewardship would be helpful to understanding the elements of stewardship. A three-part classification established a list of tasks that might be included as these elements of functionality: formulating health policy, exerting influence, and collecting intelligence.

Formulating health policy would include such tasks as policy analysis, policy formulation, national health plan development, health system mission and vision development, resource allocation decisions, investment strategies, value statement development, and policy evaluation and correction. Exerting influence would include such tasks as consensus building with stakeholders, strategic planning, regulation and enforcement, national health plan implementation, health system mission and vision implementation, value statement implementation, incentive alignment, consumer education, establishing health system transparency, and health public policy development. Collecting and using intelligence would include such tasks as intelligence gathering, public health monitoring and evaluation, communication strategies, and stakeholder relations. The experts also considered an additional classification that bears resemblance to the above classification by developing domains of function, which included the following: stewardship of health system functions, strategic management of the health system, and stewardship of factors in the broader social, political, and economic environment.

The experts believed that effective stewardship should have a broad focus and a long-term view and be ethically driven and diverse. Stewardship should be broad in its focus in order to engage all of the stakeholders to bring about positive changes in the delivery of health care goods and services. Stewardship needs a long-term view because it must not be limited to managing the challenges of health care delivery today, but it must also seek to develop lasting solutions for the health system problems of tomorrow with continuous improvement. Stewardship needs to be ethically driven because it requires that the interests of patients be placed above those of the people who are administratively and clinically providing for those patients of the health system. Finally, stewardship is diverse since it