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August 31, 2020

Evidence, Efficacy, and Economics—A Better Path Forward for US Health Care

Author Affiliations
  • 1Division of Geriatrics, Department of Medicine, University of California, San Francisco
JAMA Netw Open. 2020;3(8):e2016118. doi:10.1001/jamanetworkopen.2020.16118

The current crisis transforming the United States has 4 primary contributors: the coronavirus disease 2019 (COVID-19) pandemic, economic collapse, mobilization for racial justice, and historic rates of anxiety, depression, distress, and substance use disorders. The consequent heightened need for mental health care comes at a time when health organizations are fiscally challenged and newly aware of their contributions to creating and perpetuating health inequities. It also enters a medical context of longstanding inadequate recognition of, support for, and investment in mental health, elder care, and health disparities. It is likely not coincidental that older adults and people of color are disproportionately impacted by both the confluent crises and our response to them.

For all those reasons, as well as health care’s current accelerated adoption of telehealth, the article by Choi et al1 could hardly be timelier. The authors demonstrate that brief videoconferenced problem-solving counseling by low-cost lay counselors is comparable to videoconferenced care by licensed professionals for treating depressed, racially diverse, low-income, homebound older adults. Although slightly less effective for depression, lay counseling had similar efficacy in disability, social engagement, and social role satisfaction outcomes. Moreover, as those of us who work in social justice health care are fond of saying, if you can make a difference in the highest-risk populations, chances are you will help all populations, whereas medical history has clearly demonstrated that the reverse is not true.

In the medical literature and elsewhere, the term older adult is typically used to refer to people age 65 years and older, and the word geriatric is generally applied to the oldest and frailest of old people. In their article, Choi et al1 reference geriatric mental health workforce shortages and the Older Americans Act,2 yet their study enrolled homebound participants age 50 years and older and had an average age of just 68 years. It’s worth asking how they could have found so many homebound middle-aged adults. The answer likely comes from the study population’s demographic characteristics. All participants had low income, more than 80% reported being unable to make ends meet or just getting by, approximately 60% were Black or Latinx, and rates of multimorbidity, pain, functional impairment, and polypharmacy were similar to those of truly geriatric populations. These data demonstrate the consequences of the long-described but as yet inadequately addressed phenomenon of accelerated aging in US populations who have systematically received the short end of the socioeconomic stick. Poverty, discrimination, and lack of opportunity create chronic stress, which adversely affects physical and mental health, and depression is not only a consequence but a cause of chronic inflammation and accelerated aging.3

Compared to peer nations, the United States has the highest rates of chronic disease, the greatest number of preventable hospitalizations, the lowest life expectancy, and the highest rates of suicide, obesity, and avoidable deaths.4 These outcomes are produced by a system that costs nearly twice what near peer countries spend and occurs as a result of bureaucratic inefficiencies, overuse of expensive technologies and procedures, and relative underuse of primary care, physician visits, and other cognitive, interpersonal resources. This shameful state of affairs and its nefarious progeny, including structural ageism and race- and income-based health disparities, have been well documented for decades.5 Purported efforts to address the expensive, bias-ridden, self-congratulatory edifice of US health care have largely consisted of moving non–weight-bearing walls and rearranging furniture by the very leaders who built the structure’s flawed foundation and support beams. It’s time for that to change.

What might a new, better US health care system look like? It seems clear that it will include significant amounts of telehealth, but change can’t stop there. The new system must also prioritize and pay for the prevention and care of disorders and populations commensurate with their prevalence and risk. To accomplish this, it will need to become a truly evidence-based health care system, not one that cherry-picks the evidence to support preexisting biases.

Despite the particular demographic and medical foci of their study, the article by Choi et al1 offers insight into some of the significant ways health care might be made less expensive and more inclusive. When the United States pivoted to telehealth in March 2020,6 lower income, rural, elderly, and disabled populations—those groups most likely to live across the digital divide—were placed in acute-on-chronic jeopardy. Already disadvantaged, they were precipitously told that access to medical care required a digital device, internet connectivity, and digital literacy. This meant many would simply not get health care and, worse, would miss the health encounter that is for some older and disabled adults the primary social activity of their week or month.

Paradoxically, these same groups stand to gain considerably from telehealth if its effectiveness is mostly equivalent to in-person care as Choi et al1 and others have found. Telehealth visits are less physically and fiscally costly for frail, disabled, and lower-income patients; they allow those with limited energy to save their reserves for more important activities that may enrich their lives and improve their health. At the same time, the digital divide may be one reason for the social isolation of some older and disabled adults for whom digital devices and capability would provide new access to essential services, social and occupational opportunities, and health promotion activities. Among the notable findings of the study by Choi et al1 unrelated to mental health measures were that many participants preferred the ease and privacy of telehealth. They further found that the costs of a video platform and Wi-Fi connection were significantly less than the costs of sending practitioners on house calls. Thus, for some older patients with multimorbidity and considerable health and social burdens, telehealth is not only possible and cost-effective, it is desirable.

Critically, the US health care system must raze and rebuild its foundational assumptions and structural priorities. It must fund and disseminate interventions that work regardless of who does them (lay counselors vs professionals; social workers, pharmacists, physical therapists, nurses, and all other health professionals vs physicians), how they work (using verbal and relational tools vs technical and pharmacological ones), and who needs them (people who are poor, old, young, disabled, female, black, brown, or gay vs middle- to upper-class, adult to middle-aged, able-bodied, white, heterosexual, Christian or Jewish males). It also needs to respect social proxies and evidence as it already does physical ones; just as we know lowering cholesterol lowers the risk for vascular diseases, so too do we know that improving mood and opportunities improves physical and social function. As Choi et al1 point out, medications only target disease whereas nonpharmacologic treatments, including the ministrations of trained lay people or professionals, can treat disease and also address the social and behavioral contributors to poor health outcomes and high health care costs.

The arrival of COVID-19 demonstrated just how quickly and completely US medical institutions can redirect their priorities and functions. The ascendance of the Black Lives Matter movement has shown just how many people within and beyond health care support fundamental change. This is a pivotal moment for us to reimagine how we prioritize, finance, organize, and deliver health services.

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Article Information

Published: August 31, 2020. doi:10.1001/jamanetworkopen.2020.16118

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Aronson L. JAMA Network Open.

Corresponding Author: Louise Aronson, MD MFA, UCSF Division of Geriatrics, 3333 California Street, Suite 380, San Francisco CA 94118 (louise.aronson@ucsf.edu).

Conflict of Interest Disclosures: None reported.

Choi  NG, Marti  CN, Wilson  NL,  et al.  Effect of telehealth treatment by lay counselors vs by clinicians on depressive symptoms among older adults who are homebound: a randomized clinical trial.   JAMA Netw Open. 2020;3(8):e2015648. doi:10.1001/jamanetworkopen.2020.15648Google Scholar
Administration for Community Living. Older Americans Act: 2020 Reauthorization of the OAA. 2020. Accessed July 3, 2020. https://acl.gov/about-acl/authorizing-statutes/older-americans-act
Squassina  A, Pisanu  C, Vanni  R.  Mood disorders, accelerated aging, and inflammation: is the link hidden in telomeres?   Cells. 2019;8(1):52. doi:10.3390/cells8010052PubMedGoogle ScholarCrossref
Tikkanen R, Abrams. MK. US health care from a global perspective, 2019: higher spending, worse outcomes? Commonwealth Fund. January 2020. Accessed July 3, 2020. https://www.commonwealthfund.org/publications/issue-briefs/2020/jan/us-health-care-global-perspective-2019
Woolf  SH, Braveman  P.  Where health disparities begin: the role of social and economic determinants—and why current policies may make matters worse.   Health Aff (Millwood). 2011;30(10):1852-1859. doi:10.1377/hlthaff.2011.0685PubMedGoogle ScholarCrossref
Shachar  C, Engel  J, Elwyn  G.  Implications for telehealth in a postpandemic future: regulatory and privacy issues.   JAMA. 2020;323(23):2375-2376. doi:10.1001/jama.2020.7943PubMedGoogle ScholarCrossref
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    1 Comment for this article
    Unless EMR become User-Friendly, Inefficiency in Health Care Won't Improve Much
    Edward Volpintesta, MD | general practice (retired)
    The author is right to say that among other things, bureaucratic inefficiencies contribute to the high costs and inefficiency of health care in the U.S.
    Electronic medical records (EMR) are considered by many doctors as the single factor that is most responsible for inefficiency in their work.
    Plucking information onto a keyboard is distracting, time-consuming, and a major cause of physician dissatisfaction and disillusionment with medical practice. Over time it can lead to anxiety, depression, insomnia—and other signs of burnout.
    Worse, by taking physicians’ time and attention away from their interaction with patients, EMR has depersonalized the patient-physician relationship. Office
    visits are often hurried affairs; and patients frequently complain that their physicians seem more interested in their computers than in them.
    Electronic medical records were supposed to improve the quality of care by focusing on the outcomes of physicians’ work and increasing their accountability. But most doctors say that it has added a layer of drudgery that adds noting significant to care. Many consider it a billing machine for insurance companies.
    Although they have been around for at least EMR have retained all of their inefficiencies; and despite doctors’ pleas to make them user-friendly, they remain physicians’ number one “pain point”. 1
    1. Hawkins M. 2018 Survey of America’s Physicians: Practice Patterns & Perspectives. 2018.https://physiciansfoundation.org/wp-content/uploads/2018/09/physicians-survey-results-final-2018.pdf.