Giberson calls for paradigm shift from health care to health

Rachael Le Goubin | Staff Photographer
Scott Giberson, acting deputy U.S. surgeon general, delivers the morning lecture Wednesday in the Amphitheater.

In taking the Amphitheater stage for his Wednesday morning lecture, Acting Deputy Surgeon General Rear Adm. Scott Giberson said that he had two goals: to “accelerate a paradigm shift to health,” and to “inspire action.”

“You are all consumers of health care,” he said. “You are all making decisions of either healthy behavior or unhealthy behavior every single day.”

Catering mainly to health care professionals, Giberson said that “in order to be leaders in health, to transform health care, to function in a new world, we have to be transformative, collaborative, and we have to be resilient.”

In advising health care providers to be transformative, Giberson said that the paradigm must shift from health care to health. Focusing on health care decisions, he said, is “reactive. That’s too late. Let’s shift that paradigm to health decisions.”

Noting that he has managed 7,000 health care professionals in 11 health disciplines, Giberson stressed the importance of collaboration in interprofessional practice.

“There is no doubt it improves outcomes,” he said. “We have to think about the net outcome. The net outcome is health.”

Giberson’s third quality for health care providers to emulate — resilience — is particularly relevant today, he said.

“In today’s world of fiscal cuts, human resource cuts, scrutiny over performance … you have to be resilient,” he said. “You have to believe in your cause, believe in your innovation and move forward.”

That world is also one of major changes in the health care system, he said.

“We’re at a critical threshold right now in the health care system,” Giberson said. “We have reform, we have the Affordable Care Act, we have change, we have people finding their way in a new system.”

One of the biggest needs in health care today, Giberson said, is addressing the cost of chronic care. Chronic care accounts for 76 percent of all physician visits, 99 percent of Medicare spending, 81 percent of hospital admissions and 91 percent of all prescriptions filled, he said.

“It’s not getting any better,” Giberson said. “It’s getting worse.”

Another need is increased access to care.

“Affordable coverage and access to care are two different things,” he said. “Affordable coverage has put us on a trajectory to improve access to care, but that is still evolving. Sixty million Americans, soon to be 80 million Americans, will lack primary care access.”

Noting that those in urban areas have easier access to doctors than those in rural areas, Giberson discussed inequities in health care access generally.

“We know that there’s disparities in access,” he said. “It’s not based on ethnic background or minority, people of color. It’s based on educational level, economic status and age more so than any other characteristic.”

A provider shortage of 80,000 to 200,000 can be expected in the coming years, Giberson said. “It is challenging to be a physician,” he said. “It is challenging to be a pharmacist. It is challenging to be other health care providers providing care in a new payment system.”

One response to this shortage that Giberson proposed was using every health care provider to his or her full capacity. He recalled the inefficiencies evident during the 2001 anthrax attacks in New York City, when pharmacists were not licensed to administer vaccines, but firefighters were.

“We’ve corrected that. All 50 states, all pharmacists, give immunizations,” he said. “We have to think that same way about providing care. We have to engage every health professional and use them to the maximum of their licensure and capability.”


Q: I want to go back to your balancing model about change, and where we were at a tipping point, and you were talking about it in a professional practice. And I found myself wondering why data technology wasn’t on that fulcrum that you had created. And is it not true that advances in data technology, the ability to share both diagnostic equipment and the ability to share the information therein, is a huge asset of interpersonal practice? Probably also a threat in terms of privacy, but could you comment on that?

A: Absolutely. And one of the reasons that was a carryover slide from my pharmacy talk, where actually we’re challenged in the profession of pharmacy because we don’t have that yet, that piece of I.T. health that we do actually need. So that’s why it’s not on this tipping point just yet. Overall in the health care system, if you think why one of the benefits of a closed system like the Indian health service, or the V.A., or the Department of Defense — it’s just a closed system, and everybody shares information. The dentist, and the pharmacist, and the nurse practitioner, and the nurse, and the physician all see the same information, full medical record. That’s incredible, and that helps you make better decisions, and that helps to expand the access to care. We don’t quite have that yet, and it’s not scaled out yet, and it’s not on the tipping point, but it is one of the variables that will make a difference if we’re going to move forward in inter-professional practice.

Q: Are there other industrialized countries using the inter-professional model that you describe?

A: Absolutely. There are good examples of it: New Zealand, Australia, some places in the U.K., even Canada uses their professionals in a different way, in a slightly more expanded way than we do. And they’ve had a good outcome. So, yes, we do model some of our things after those countries, or look to them to see their successes or failures in those inter-professional practice realms.

Q: In the future, will I see my physician at Walmart?

A: Probably not. You know, Walmart — when we think of the traditional perspective of a pharmacist as, you know, talking about drugs and filling prescriptions behind the counter at Walmart, CVS, Walgreens — it’s true. And that’s still a lot of where students go when they graduate. However, the pharmacy has expanded, the topics have expanded, the Walgreens and Walmarts of the world have developed the clinic within the store, and you can see nurse practitioners, and physician assistants, and now pharmacists as part of that team. Generally speaking, there are not physicians there. Now, can I predict that there won’t ever be? I said no, they probably won’t be, but I can’t say that for sure. I mean, that is a possibility. But the one good thing about that, if that were to happen, is they would have a very close relationship with the pharmacy, because they’re right there, and the nurse practitioners. So, you know, embedding that is a possibility, and it certainly will improve access to care. You think about this: if I said 270 million people visit a pharmacy, that’s — I think, double the three times the people that visit fast food restaurants combined. OK, so that’s access point. We probably don’t have enough physicians to staff that. However, it’s a possibility, I’m sure. Everything’s a possibility right now.

Q: Okay, let’s stay on pharmacies for a second. How do you balance the high-quality mail-order pharmacies — Caremark, OptumRx, etc. — for chronic prescriptions, versus the local pharmacy with a pharmacist that knows you?

A: Yeah. Well, I’m a big proponent of that trust relationship. I’m a big proponent of the person that functions as another primary care provider for the patient and they have to establish a relationship. I know in mail order, the sort of rules are surrounding that they have to have that relationship with a primary care provider and even a pharmacist. Subsequent refills can be done through mail order to increase convenience. But I don’t want convenience to replace the necessary relationship between a patient and any health care provider. We don’t want to lose touch with those people, because it’s very important to us to have that patient-provider relationship.

Q: With the increasing legalization of marijuana, will that lead to a new health issue? And does the Surgeon General have a point of view about the health of marijuana?

A: That’s a good question. Actually, you know, this demonstrates the depth of the questions we get. We can go from pharmacy to Ebola to marijuana to cigarettes, to, you know. But that’s what we do. Marijuana’s an interesting issue. You know, the Surgeon General’s stance on this is one of public health, and solely public health. There is certainly not enough evidence out there — and the study of marijuana has not been broad enough or deep enough for us to comment, to say, ‘It should be legal or illegal.’ That’s not our stance. Our stance is public health. Our stance is the fact that marijuana is a drug, it is an addictive substance, it is an inhaled substance and it affects respiratory illnesses. It also can cause cognitive impairment. We can’t condone the use of it, and we don’t really comment on if it should be legal or not. However, we know that there’s a lot more study that needs to happen in order for us to comment on that more officially. Right now, you know, marijuana is a drug. There are some statistics out there that show if you start to smoke marijuana early, you are more likely to get involved in other illicit drug use. So, as a public health concern, we do not concern the use of marijuana. And that’s not to say if it should be legal or not.

Q: So you talked about the overall proportion that chronic care absorbs in the overall, both the physician costs and others. What’s the role of end of life issues? Is that within chronic care, or is that a separate category? And what’s its proportionality?

A: Another good question. That’s another burden that I sort of haven’t listed up there as a chronic care issue. It is the end stages of chronic care, and long-term care is another thing that’s evolving in our new health care system and our new health care delivery system. I think it’s something that we need to address more, I think it’s something that we should probably research more, but I know there are entities in the U.S. government right now that have many projects and studies and are trying to find better ways to do long-term care. I know long-term care insurance is out there — I have not personally studied that realm, but it’s certainly a decision that everybody has to make at some point. And it is part of chronic care but it is separate in the way we implement that in the health care system.

Q: There’s a trend now of parents not vaccinating their children. What’s being done to educate them about the benefits of vaccination, eliminating misconceptions about this? And how important is that in role of the Surgeon General?

A: Once again, we’re actually seeing a spike in measles; we’re actually seeing more people get measles due to non-vaccination. From a public health perspective, we believe in immunization. We do believe that the person has the right to make the decision if you should be immunized or not. However, immunization is a public health measure that demonstrates public health positive outcome. We do have data that suggests immunizations are safe. We educate the public as to that. The immunization center at Centers for Disease Control has many resources if you aren’t sure about what you want to do. I suggest you go to CDC immunization website, look for yourself, make your informed decision about what your behavior will be.

Q: Who would oppose a movement toward inter-professional health care, and how can we as citizens help influence the dialogue on the future of health care in America? And a follow-up to that: would financial incentives promote inter-professional paradigm change?

A: I hope that we would not need financial incentive to collaborate, to do inter-professional practice. However, I understand that in a society that is capitalistic in nature — we have a democracy, we have a wonderful country — there is always going to be opposition to something different. Inter-professional practice is a little bit different; however, it’s evolving and it’s been successful. I can’t change everybody’s opinion, as I mentioned. There are programs out there that do have some “financial incentive” — and I’ll put it in quotations, because I’d have to qualify it in detail — that encourage and facilitate inter-professional practice. They have not evolved yet to where they should be, but I understand the concerns. If you remember the pictures, the relationships, the predatorial, the competitiveness — you know, that still exists out there. I won’t name who will oppose inter-professional practice, because at first take you might think, oh, physicians oppose inter-professional practice. But we’ve seen support from physicians. Sometimes the people in my own profession oppose inter-professional practice and pharmacy, even though it benefits the patient and the pharmacy. So opposition will come from everywhere, from everyone, and it’s just that we have to educate to the best decision. And if we really think about the net outcome of health and patient outcome, then I think we’ll have to move in that direction anyway.

Q: So the final question: what’s the Surgeon General’s position on the outbreak of Ebola, as a public health issue for this country?

A: I’m glad, actually, you asked about Ebola, because it is in a way historic, because it’s the biggest outbreak ever documented, certainly in Africa, and we’ve never had a case in the United States. It’s also tragic. From a public health perspective, knowing that our mission is both domestic and global, the Surgeon General and his corps — which are all of us — stand ready to respond. We don’t make the decision if there should be a U.S. footprint in Africa. What I can tell you is that if the president says go, we will go. And I know that we have about 30 to 50 officers already there, forward deployed in Africa, helping the health infrastructure, training the people on proper personal protective equipment, educating the people who actually have Ebola and trying to reduce the mortality from the Ebola. We’re in discussions everyday — when I get back to my Blackberry in the green room it will be loaded with emails about Ebola, and Ebola response and the U.S. government’s potential response. Like I say, we don’t make the decision to go, but we stand ready, and I am more than willing to go myself and lead a team there if we have to.

— Transcribed by Cortney Linnecke