Dentzer: Post-acute care key to improving U.S. health system

Katie McLean | Staff Photographer
Susan Dentzer, senior policy adviser for the Robert Wood Johnson Foundation, delivers the final 2013 morning lecture Friday in the Amp.

A projection of Michelangelo’s David stared down at the Amphitheater audience from behind Susan Dentzer as she spoke at Friday’s morning lecture. But this wasn’t quite the perfectly proportioned model of a man that has wowed countless numbers of tourists in Italy. An apparently unhealthy dose of Photoshop had added a massive gut and sagging pectorals to the famed piece of art.

Susan Dentzer, senior health policy adviser for the Robert Wood Johnson Foundation, spoke Friday morning in the Amphitheater in a lecture titled “Rising to Meet America’s Health & Health Care Costs.” She broadly surveyed some of the issues that have plagued the American health care system and spoke about how the Affordable Care Act can work to address these problems.

Dentzer provided some numbers to highlight the behavioral and biological factors that weigh on the state of American health. Sixty-six percent of Americans are overweight or obese, 28 percent physically exert themselves at low enough rates to be considered by one survey to be “inactive,” 23 percent smoke, 36 percent report high levels of stress and 22 percent are at least 55 years old.

Behavioral tendencies contribute quite strongly to overall health, Dentzer said, accounting for 40 percent of premature deaths; genetics are a factor in 30 percent of these deaths.

Geography also plays a substantial role, due to the wide differences in health care throughout the United States.

“Your ZIP code — where you live, what your environment is, how high-income your community is — is going to be as important a driver of your health status as all these other factors, including — and they will outstrip — your genetics,” she said.

Dentzer referenced a Harvard University study that identified “eight different Americas” in terms of life expectancy. She gave a few examples: Women of Asian descent living in New Jersey today have a life expectancy of about 95 years, one of the highest life expectancies for any group of people in the world. But in “another” America, Native Americans living in South Dakota have a life expectancy of about 58 years.

Variations in policy account for some of these differences, she said. In Alabama, for instance, only people whose incomes sit at or below about 80 percent of the federal poverty line can receive Medicaid. In New York, though, Medicaid is available to people with incomes all the way up to 138 percent of the poverty line.

The Affordable Care Act will help this by prompting a Medicaid expansion in several states, Dentzer said, but the Supreme Court ruled that the federal government could not create their own insurance agencies or expand Medicaid. Therefore, broad differences between states will remain for the time being.

“It’s going to come down to where you live, a lot of the time,” she said. “Especially if you’re poor.”

Levels of post-acute care account for three-fourths of the geographic differences, she said. In many places in the U.S., there is no further care after people leave the hospital. Areas with providers who do a better job of monitoring and caring for patients after discharge often have better levels of health.

But technology can help achieve better levels of post-acute care everywhere. Dentzer talked about clinics that are “moving the care out of hospitals.” Patients who doctors visit at home experience the same outcomes as those in hospitals, but they are more satisfied and pay 20 percent less in medical bills.

Telemedicine — treating patients remotely — will continue to rise in the future, she said. “In a decade, most people sitting in this room will have been treated by telemedicine,” she said.

It’s “disruptions” like this of the current system that make her optimistic for the future.

“People say, ‘Are you just throwing everything against the wall and seeing what sticks?’ ” Dentzer said. “Yes, we are.”


Q: As emergency room and urgent care nurses for 30-plus years, my coworkers are frightened with recent trends in 1) hospital closures, 2) decrease in primary care positions, 3) decrease in experienced nurses. Who’s going to take care of the 30 million newly insured, along with the aging boomers?

A: All excellent questions. As I said, care is going to be moving out of the hospital, and that means that certain hospitals will probably close. We do believe we are overbedded, as is said, in many parts of the country, so there will be disruption. But I don’t think that we can think about that in terms of health care disappearing, as health care’s going to move out of the hospital and into the community, and we know some of the best providers of care in the community are nurses, are health aides, are others who are used to meeting people where they are. I think the opportunities for nursing and lots of other professions are going to move more in that direction. I think that one issue that we really need to confront — the other part of the question of who’s going to provide care? We need to invest more in creating a more diverse workforce, where people are working at different levels — physicians with medical degrees, nurses, registered nurses, doctors of nursing practice, home health aides, community health workers. We’re going to need a whole team to tackle the problems, and that is what many states are in the process of doing now.

Q: All week we’ve heard wonderful ideas, but not about how it’s going to be paid for. Can you break down the funding? Is it coming from individuals or taxes or where?

A: We know if we just take the Affordable Care Act, one piece of the funding was essentially, you can think about recycling money in parts of the health care system over to other parts. So the hospitals all agreed to have their Medicare funding not grow as fast as it had been, because they knew that by having more people insured, they were going to get paid by having more people covered. So they agreed to make that trade-off, so some of the money is recycled. We also know, though, that there were taxes. Device manufacturers agreed — not so happily — to pay extra taxes on devices because they know that there are going to be more devices used because people are uninsured. We know that there is going to be an extra tax on very expensive health care plans, now, that essentially will end up being borne by people who have very expensive health plans. Some of them are unions and are not so happy about it. We need to think about this as a series of trade-offs that we agreed to make to move the money around in the system, largely. Of course, we know that a big part of the money is going to go to subsidies to help people buy coverage. The average subsidy available to people buying coverage for the health insurance exchanges will be about $5,000. That’s a big subsidy, and it’s going help a lot of people get coverage.

Q: How much do legal fees contribute to the higher U.S. health care costs?

A: Chris Cassel addressed this question very well yesterday, and just to echo what she said: We know that malpractice — all aspects of malpractice — whether it’s the higher legal fees, whether it’s the estimate of the defensive medicine that physicians provide. The best estimates that we’ve seen put that number at about $60 billion a year, so it’s not nothing. And $60 billion — that’s about three years of the Children’s Health Insurance Program, so it’s not insignificant dollars. I would echo, again, what Chris said yesterday, that there are lots of models out there of different ways of negotiating our way through what we now treat as torts in the tort system in malpractice, and coming up with a different way to basically take that out of the tort system and have negotiations, in essence. because, as I said, we do see plenty of error in the health care system. It does exist; we just have to figure out a much more cost-effective and much fairer way of owning up when those mistakes are made and getting compensation to the people who need it.

Q: Are medical schools to blame when they tell us that things are good when our health outcomes are so poor? Are they partly to blame for not telling us the truth?

A: We’re all prisoners of the system of the past, I think, and many medical schools are trying to change, but they will acknowledge, frequently, that many people who are teaching at medical schools came out of an era when … doctors weren’t necessarily challenged. Frankly, we didn’t have as much evidence as we do now about what works and what doesn’t work in health care, and that’s been true for a long, long time. I mentioned that … study. Another very interesting finding that came out of that study — they looked at two particular procedures in Massachusetts, and they looked within individual medical practices, group practices, and they saw that doctors in the same practice are doing things at wildly different rates — even doctors who are next door to each other. The rates of difference between doctors in one practice were as big as the variations across the whole of the state. So when we show this to doctors (doctors are very intelligent people, typically — learned, very competitive), they say, “Oh my goodness. This guy is doing the same procedure five times less frequently than I am. Maybe I’m doing something wrong.” And then they correct. More and more medical schools, now, are framing all of this for people and telling them, “Look. It’s an occupational hazard.” You tend to do things that you were taught in the past, whether they still make any sense or not, and it’s an occupational hazard that you might be doing things because you think they’re right even if they’re not. Now we can look at the data and correct it, so I think many medical schools, as they move to new ways of teaching people to think about the care they provide, are going to make a very important contribution to this problem.

Q: We’ll close with, why are we reinventing the wheel? Why can’t we adopt one of the plans abroad that we do know works and are effective?

A: I often get asked that question. I will say, as you heard earlier, I travel a great deal. I will say — notwithstanding what you hear about other country’s systems — if you gathered a group of physicians or others in almost every country around the world or health care providers of any sorts or hospital administrators, they would tell you that their systems were less than perfect. And we know that a lot of people still come here to the United States to find out what we’re doing, because they want to evolve in some of the directions we have gone in. I would say, my general conclusion from years of travel is that nobody’s got everything all figured out. What is the case, though, is that, if we look around the world, the countries that spend more on primary care than we do get better health outcomes than we do. That’s one factor … why we’re trying to boost the primary care and particularly the payment for primary care providers, so more people will stay in primary care and provide it. We’re making that investment; we’ve learned that. The other thing that we’ve learned is that if we can strip out the money in the system that’s going for things other than health care, the administrative expenses that don’t buy anybody any extra health, et cetera. I didn’t spend time on this today, but that’s another feature of the Affordable Care Act — pushing down the administrative costs of health insurance in particular and spending more of the money on actual care, especially the part of the care that works, is the other very important takeaway that we’ve had from other countries. I think we’re making progress already, and we can make a lot more.

—Transcribed by Victoria Wolk