The Intervention

1/17/2020

I hope everyone had a good holiday season! I am back to the routine, despite the weather. We had a tiny amount of snow in Seattle, not even half an inch in my neighborhood. Snow causes this city to slow down to a crawl and schools close. This gave me the opportunity to stay indoors and catch up on work and reading.

When I started writing about healthcare, one of my first newsletters addressed “going upstream." One of the up-streamers I read about was Dr. Jeffrey Brenner in Camden, New Jersey. He developed a model of care, almost 20 years ago, that featured a very intensive intervention for the most vulnerable people. Dr. Brenner was highlighted in Atul Gawande’s article for the New Yorker “Hot Spotters” (which is Gawande’s term for up-streamers.)

Dr. Brenner's hypothesis was that this intervention would save the healthcare system money by decreasing hospitalizations and emergency department use. The goal was to improve overall health status while decreasing the use of resources.

However, my reading this week led me to this article:

Reduce Health Costs By Nurturing The Sickest? A Much-Touted Idea Disappoints
By Dan Gorenstein and Leslie Walker - January 8, 2020

As reported in the article, economist Amy Finkelstein began a randomized controlled trial at the Massachusetts Institute of Technology in 2014. Finkelstein wanted to see if Dr. Brenner's intervention was working. The results showed no effect in terms of the rates of hospitalization or money saved. To say this is disappointing would be an understatement. However, it made me think about the goals of the intervention, and what those goals say about our medical system, as well as society in general.

I agree that the cost of care needs to be sustainable, but shouldn’t the primary goal be better health and better life? It seems to me that the type of intervention done by Dr. Brenner, which dealt with evidence-based addiction treatment, housing, and mental health services, takes a few generations to show cost savings. Even twenty years may not be enough to show the effect of addressing everything that contributes to the cycle of poverty, addiction, and poor health.

One way to combat this is by addressing income inequality in our country. Current thought suggests that a guaranteed income would go a long way to solving many poverty-related health problems. Even more importantly, it has a great answer to the question of how we pay for it.

"We are the wealthiest nation in the world. The question isn’t, can we pay for it? But, do we want to? This question is really about who we fundamentally want to be as a nation. Do we want to ensure that everyone has access to the basic human rights that cash can enable? Or do we want to continue to be a country where people are saddled with medical and education debt, working multiple part-time jobs to make ends meet, and living on the street because the rent’s to damn high?"

‘Let’s Give Them Money’: Could Guaranteed Income Be a Solution to Wealth Inequality?

Let's tie together the two issues: how does income inequality affect health equity? You will see that drug addiction and healthcare access are cited as major problems.

“It is simply unacceptable in a country as wealthy as ours that so many people lack sufficient income to pay for health care, housing or even food,” Besser asserted.  “We need to address income inequality if we truly want everyone to have a fair and just opportunity to live the healthiest life possible.”

How Income Inequality Affects Health Equity, Patient Experiences

And finally, there is evidence that increasing the minimum wage has a tremendous health benefit: it results in a decrease in suicide rates. Of course this health benefit comes at a cost. I have no idea if the cost/benefit ratio pencils out, nor do I care. I want fewer people to die by suicide. This is what I mean about realigning our goals and metrics for the healthcare system. Sometimes the right thing costs more money.

"When controlling for changes in a state’s economy and welfare policies, the researchers estimated that a $1 increase in the minimum wage corresponded with a 3.5 percent decrease in the suicide rate for those with a high school education or less. Without some of the controls, the decrease in the suicide rate was 6 percent. The effect was most pronounced during times of high unemployment.”

Minimum Wage Raises Could Lower Suicide Rates, Study Says

Perhaps you'll agree that cost alone is not the measure we should be using. Some of our neighbors will need more help than others. And it benefits all of us when everyone is supported.

I would love to know what you think about this topic. As always, I welcome your comments.