Health Care - A Wicked Problem
What is health care and how do you access it?
How do you find a primary care provider when physicians are not accepting new patients? How do you get referrals to specialists when you do not have a primary care provider? How do you find a primary care provider or a specialist when they do not accept Medicare or Medicaid? How do you achieve wellness when the clinic person you see is not trained in your area of need and is a different person every visit? How do you access care when the clinic schedule is on a first-come, first-serve lottery system on Monday and Wednesday from 7:30am to 11? If you have a primary care provider, what do you do when appointments are scheduled out three or four months? When referrals to specialists are scheduled out from your primary care appointment another three or four months?
“The Joint Task Force on Universal Care issued an in-depth report in September outlining a vision for Oregon health care that includes no premiums, copays, or deductibles, generous benefits to what public employees enjoy and no medical debt.”
Is health care in Oregon in violation of constitutional human rights?
The vision for Oregon health care represented by the Joint Task Force addresses one aspect of health care – paying for it. The vision does not address Oregon’s capacity for providing health care. Currently, Oregon’s health care infrastructure falls short of providing access to health care for Oregon’s residents. US News and World Report lists Oregon as 22nd in overall health care with access to health care at 32nd, quality of health care at 8th, and public health care at 17th. Looking at specifics, however, tells a more pressing story about what is needed to meet the mandate created by Measure 111 that makes health care a constitutional human right in Oregon.
How does health care in Oregon measure up nationally?
A 2020 report from Mental Health America ranks Oregon worst in the nation for the prevalence of mental illness and 50th for access to care. The National Survey on Drug Use and Health ranks Oregon first in the nation for illicit drug use disorder, 5th for alcohol addiction, and 50th for access to treatment. Becker’s Hospital Review of 2020 listed Oregon 14th in the number of active physicians per capita or 1 active physician per 311 people; however, the category of active physicians is defined as physicians working more than 20 hours per week in direct patient care, administration, medical teaching, research, and other nonpatient care activities.
Does your county have enough physicians?
The assessment of the Oregon healthcare workforce needs mandated by the 2017 House Bill 3261, identified active physicians working in direct patient care (primary care provider) as physician, physician assistant, or nurse practitioner. The statewide ratio is one primary care physician to 850 residents, however, by county, the ratio ranges from 600 to 1,500 with 24 of the 36 counties having a higher population-to-provider ratio than the statewide ratio. The 2018 report, Examining the Health Care Workforce Needs for Communities and Patients in Oregon, provided an additional breakdown of the numbers: 70 percent of Oregon primary care providers are physicians, 10 percent are physician assistants, and 20 percent are nurse practitioners. Further analysis determined that in 27 of the 36 counties, physicians make up less than 70 percent and in 16 counties nurse practitioners and physician assistants account for more than 40 percent of the primary care providers.
Ratios created to sugarcoat stats
Reviewing data associated with all categories of providers (MD, DO, PA, RN, dental, occupational therapy, physical therapy, pharmacy, and dietitians), 13 of 36 Oregon counties have higher population-to-provider ratios than the statewide ratio in each provider category. Looking at the various specialties within the provider category complicates interpretation of the data about the distribution of health care providers. Specifically, providers other than specialists in gynecological, pediatric, and geriatric health care may be serving women, children, and the elderly. Use of ratios as a measurement of health care provision in Oregon is only a partial view of the system’s capacity to give residents access to health care services. Considerations not captured by ratios include whether providers participate in specific insurance plans, the specific services provided, the number of patients served, the effect distance has on care access, the health care needs of each community, the diversity of the residents, and the certification and registration of traditional health workers.
The Health Care Workforce Needs report concluded:
There is insufficient primary care capacity across the spectrum.
Our health care workforce continues to lack needed diversity in many areas.
Additional dental care capacity is needed in much of the state.
Behavioral health workforce needs are a growing focus.
Data to determine both workforce supply and demand are improving, but further improvements
are needed.
Who pays for health care is more complicated than who pays the premiums
Health care costs involve administrative and financial oversite of provider contracts that reimburse enough to provide operating costs for the providers; a provision for primary care, specialist care, and prescriptions; an operating budget based on return on investments, estimated costs, a reserve fund, and purchase of reinsurance; a process for claims adjudication and payment. Who provides health care is influenced by the cost of education, the length of training programs, the availability and location of positions that pay enough to cover educational costs, professional expenses, and cost of living, and the effectiveness of delivery systems – hospitals, clinics, individual practices, and agencies. Who gets health care is by far the most complex as a fully inclusive and accessible system of care covers the health needs of every person whether indigent or wealthy, newborn or elderly, healthy or chronically ill, gender specific or gender nonbinding, located by a health node or a health desert, insured or noninsured - an endless list of fragmenting factors.
Health care - who pays for it, who provides it, and who gets it – is a wicked problem.
A wicked problem is a social or cultural problem that’s difficult or impossible to solve because of its complex and interconnected nature. But at some point, problems where vulnerable populations collide with broken systems becomes more costly to ignore than to solve. Rosanne Haggerty, a successful social entrepreneur for ending homelessness and founder of Community Solutions, believes system design, performance, and accountability at the community integration level is key to addressing seemingly intractable problems. Communities need to understand the whole system and change the way problems are solved and the way organizations work together. They need to understand the problem, how it is moving and changing, and everyone must be on the same page. They must build an operating system to align activities and resources and understand what they need to do.
The State of Oregon has a health care problem that is now more costly to ignore than to solve, however, addressing each of the component parts of the problem separately and in siloed fashion is a costly nonsolution. The Health Care Workforce Needs report noted: “The specific health care needs of communities can vary significantly, limiting the use of one-size-fits-all ratio recommendations, and making them potentially problematic” (pg 19). Perhaps it is time to work from the community level up instead of the legislative level down. Such work could model an inclusive process to reflect the end goal of inclusive health care.
Starting at the community level provides each community with a custom process to find agreement about why health care for all is important, what health care is, what providing health care requires and who is involved, and how to create systems and funding to meet the why and what. A custom process allows engagement in out-of-the-box thinking to explore what if options based on local needs and resources.
Taking a page from Community Solutions successful playbook, this process includes the following components:
Who is at the table – Instead of operating in silos, everyone who touches the problem – providers, for profits, nonprofits, and agencies – needs to work together.
How the leaders define success – Success must be defined by whether the overall number of people who access quality health care is going up, not by whether individual programs are succeeding.
How communities understand the problem – Solutions must be guided by real-time, person-specific data, not by annual anonymized snapshots from statewide and national data sources.
How resources are spent – Investments must be data-driven, targeted, and measurable in their impact.
And, most importantly, what we believe is possible – Healthcare for all is a solvable not an intractable problem.
Creating a legislated funding mechanism to pay for healthcare without updating the services and delivery system to meet identified needs is a continuation of broken systems that divert funds and result in minimal benefit and change. Complex problem solutions require long-term and committed work at the level closest to implementation and accountability.
Let the Oregon Legislature partner with the community-based, reiterative process to actualize health care as a human right.
