In researching our new book on American health and health care, we met with more than a hundred smart front-line providers. One meeting in particular, with Pat Manocchia, longtime owner and director of a hybrid medical-fitness center called La Palestra in New York City, proved particularly prescient. We spoke about the ongoing health care reform efforts and his efforts to grow an organization that was refused to abide by the many perverse incentive structures in which more care was supposed to lead to better health. After the close of our time together, Pat said plainly: “The pain is never the problem.” He was referring to physical pain, the kind of which often brings his clients in complaining that they believe themselves to need surgery on this body part or another. Little did he know that the phrase would become a mantra for us in our broader investigations of the American health care sector.
For more than thirty years, the cost of health care has been draining the wallets of citizens and the government alike. Disheartening statistics have flooded the media to suggest the system is broken in any number of ways: primary care doctors are overworked, insurance premiums are high, and medical errors are common. Particularly in the past month, the vitriol hurled back and forth over the implementation of Obamacare is enough to make most sane people want to tune out. But the fundamental point is uncontested: we spend nearly twice what other industrialized countries spend on health care, and we are not any healthier for it. That’s the real pain.
Although most people typically see health care providers as people who relieve the body of pain, the team at La Palestra takes a decidedly different approach. For them, pain is often the body’s way of signaling that something at the systems level is not working. As a result, intervening solely at the site of pain through traditional medical means is unlikely to resolve larger anatomical and biological issues. In fact, they remind us, medicine is dangerously capable of masking underlying issues, thereby setting a patient up for further damage in the future.
When we think about recent efforts to improve health care in the United States, the same perspective provides new insight. Similar to those of Pat’s clients who expect surgery to resolve an aching back, the United States has repeatedly reformed its health care system—long ago with the advent of Medicare and Medicaid, more recently with a push towards health maintenance organizations, and now with the ACA—with the expectation that these reforms will mitigate runaway costs and improve outcomes. Nevertheless, the impact of these efforts has been limited, leading us to believe, as Pat does, that the pain is not the problem. The financial pain that health care creates is the system’s way of telling us something larger is not working.
Strategically analyzing problems at the systems level can reveal surprising results. In counseling and rehabilitating their clients, La Palestra staff advocate a more integrative understanding of how to heal. Often, they find that clients have allowed key muscle systems to weaken—musculature patients may not even know they have—and have relied instead on isolated joints, bones, muscles, or tendons to accomplish necessary tasks. This over-reliance is what causes the damage and ultimately the pain. Your knee hurts? Let’s consider the way your feet strike the ground as you run. Shoulder problems? Let’s retool the way you transfer your weight while serving a tennis ball. Re-engineering and strengthening supporting systems in this way has allowed his clients to avoid any number of costly medical procedures, which are only marginally effective and may delay action on the real issue.
Health care reform could benefit from a similarly strategic approach. Repeated efforts to create a healthy population through redesign of the health care system have largely failed to alleviate the financial pain. So perhaps it is time to ask—what other part of the body politic might be ailing? Are there other areas of American life that may be creating undue strain on the health care system?
Over several years of research, we found the answer to this question to be unequivocally “yes.” Social services in this country are often under resourced (even more so now thanks to recent cuts in food stamps), and health care bears the brunt of these weakened social supports and resulting burden. Front-line hospital staff in particular expressed to us a sense of frustration, suggesting they were being asked to be all things to all people, when in fact they simply want to practice medicine. Many feel stressed and unable to deliver the optimum care the wish to. In one recent survey by the Robert Wood Johnson Foundation, surveyed physicians reported that if they could write prescriptions to address social needs these would represent 1 out of every 7 prescriptions they write.
Taking a broader look at the root causes of our health care challenges unearths weaknesses in key social service systems. Adequate housing, nutritious food and reliable transportation are fundamental to health, and yet rarely enter into our current debate. This oversight continues despite considerable scientific evidence that health is created overwhelmingly by social, behavioral and environmental conditions (rather than medical care) and that investments in these arenas generate impressive financial returns to the health care sector.
Of course, working at the systems level to alleviate a troubling pain is never easy. Pat joked with us that one day perhaps the United States would learn that “Advil is not a cure for a hangover. Not drinking forty beers is a cure for a hangover.” Real reform to the health care sector may have to reach well beyond the boundaries of health care alone, and will almost assuredly require a level of personal and cultural discipline about the way we use medicine. The first challenge, however, is to accept that the real source of our health care pains may not be health care at all.