In my columns, I like to point out that health care does not equal health. Insurance, access to care and providers and new technology all matter. Yet, despite extraordinary advances in medicine, the gap between health care and health remains stubbornly wide.
If health care isn’t enough, what’s missing?
A recent conversation I had with an energetic octogenarian shed some light. James Karagon is a licensed social worker who has provided in-home mental health counseling for elderly and disabled Detroiters for nearly four decades. Here’s what he sees.
First, trauma is everywhere. The majority of Karagon’s clients struggle with the fallout of adverse childhood experiences. Many never disclose their trauma and quietly struggle with resulting anxiety, depression and even physical pain. These individuals, he says, can be too overwhelmed to implement provider recommendations about things like lowering their blood pressure.
Isolation and loss are also consistent themes. Limited mobility, family issues and transportation challenges create obstacles to the social connection so essential to health and well-being. And loss is ubiquitous — of spouses, siblings, friends, children, physical abilities and independence, and even neighborhoods. Many are also confronting their own mortality. At 82, Karagon says he can talk to patients about death because “we’re in the same boat.”
Finally, people’s health problems are layered. “Rarely is there just one problem,” Karagon says. It’s typical to find some mix of anxiety, depression, pain, diabetes, hypertension, other chronic conditions and mobility challenges — all worsened by financial strain and lack of transportation.
Health care occurs within this messy reality, and to paraphrase Tolstoy, every unhealthy life is unhealthy in its own way. The missing piece in modern health care, in other words, is context.
People’s health care problems are deeply intertwined with their personal and social problems, which only come to light when you see where and how they live. Health policy necessarily operates in generalizations, and the average provider gets only brief glimpses of the complicated story that is each patient’s life. When Karagon enters a home, by contrast, he’s looking at whether the refrigerator is empty, if the person can get to their appointments, and how trauma is shaping their behavior.
Practical support often does more than anything else to facilitate healing. Equally important, it develops trust. “Once I go into the home and a client feels heard and understood,” Karagon says, “they start to trust me.” Only then can work on health begin — and there are no quick transformations.
“We work on small changes, one step at a time, and patients improve through gradual gains over years.”
Since we cannot clone James Karagon, how might policy better reflect his insights? He has a couple of ideas.
First, more caseworkers should be embedded in communities to meet patients where they are.
“It’s the relationship, the relationship, the relationship,” Karagon says. Human connection is an essential ingredient of successful health care. It’s also cost-effective. Keeping people stable and functioning in their daily lives prevents costly downstream medical events. Medicare is taking steps in this direction by starting to reimburse Community Health Integration services.
Any expansion of home- and community-based services must be accompanied by rigorous oversight. In-home care has been vulnerable to fraud and abuse, a problem Congress and federal regulators continue to address.
A second and related policy imperative is local primary care expansion to improve prevention. The primary care setting is the place where the context of patients’ lives has the best chance of coming to light. This will entail addressing the country’s primary care provider (PCP) shortage by tackling the educational, training and licensing barriers to expanding this workforce. And policymakers will need to find ways to incentivize PCPs to open up shop in high-poverty areas.
Policy designers often lament the impacts of “information asymmetry” in health care: providers have expertise that puts laypeople at a disadvantage in making health decisions. Karagon’s work suggests this asymmetry goes both ways. Providers have the expert medical knowledge patients need to get better, but only patients grasp the life circumstances that are every bit as important for their long-term health.
The gap between health care and health will only start to close once we find better ways to get this information flowing smoothly in both directions. Until then, health care will continue to fall short because it cannot fully account for the context in which health is actually lived.
Kelly Rogers Victor, Ph.D., MPH, MPP is a writer and consultant on nutrition, health policy and public health. Her columns appear regularly in The Detroit News. Reach her at Kelly@upstreamhealthconsulting.com.
This article originally appeared on The Detroit News: To improve health, we must look beyond the doctor’s office | Rogers Victor
Reporting by Kelly Rogers Victor / The Detroit News
USA TODAY Network via Reuters Connect
By Kelly Rogers Victor | USA TODAY Network
