The United States spends more money on healthcare than any other country in the world. So how does Costa Rica outperform the United States in every measure of health of its population?
Costa Rica is healthier because its government spends more money than ours does on prevention and wellness.
In our country, we have left vast segments of the population without affordable care and we do not focus on wellness or chronic disease management. We don’t consistently control the glucose levels in diabetics and, consequently, too many go blind or lose a limb. Too often, hypertension goes untreated until the patient has a stroke or kidney disease. Then, all too often, these individuals go on medical disability with far more societal expense than the cost of the original health management.
Sadly, it has become the American way to leave many chronic diseases untreated until they become emergency situations at exorbitant cost to the U.S. healthcare system. For many patients, this care is too late to prevent life-changing disabilities and an early death.
When people ask me why we started the UC Riverside School of Medicine last year–the first new public medical school on the West Coast in more than four decades–I talk about the need for well-trained doctors here in inland Southern California. But we also wanted to demonstrate that a healthcare system that rewards keeping people healthy is better than one which rewards not treating people until they become terribly ill.
As we build this school, we have a focus on wellness, prevention, chronic disease management, and finding ways to deliver healthcare in the most cost-effective setting, which is what American healthcare needs.
We also teach a team approach to medicine—another necessary direction for our healthcare system. If you have a relatively minor problem, your doctor might refer you to a nurse practitioner or physician assistant for follow-up. This kind of team care makes financial and clinical sense, particularly since we have such a national shortage of primary care doctors. The good news: Even among physicians, the team approach, or medical home model, is gaining ground, with the Affordable Care Act accelerating change.
For all the talk about the lack of health insurance in this country, we don’t often discuss the other side of the problem–the fact that many Americans get more care than they need. You may have heard advertisements that you should have your wife or mother get a total body scan for Mother’s Day, because it will find cancer or heart disease. There is no evidence that this screening is a good idea. But in the U.S., we often encourage people to do things that have no proven benefit, and our churches or community centers sponsor these activities.
For all these reasons, we must shift the focus of healthcare to prevention. Two of the most profitable prescription drugs in the U.S., according to some sources, are those that reduce blood cholesterol and prevent blood clots—both symptoms of coronary heart disease, a largely preventable condition. Shouldn’t we be spending at least as much on prevention as we do on prescriptions? Closely connected to prevention is wellness. So many of our health problems in the United States are self-inflicted, because we smoke, eat too much, and don’t exercise. Doctors need to “prescribe” effective smoking cessation programs, proper diets and exercise as an integral part of care.
One way to accomplish this shift is to teach it to future doctors. At UC Riverside, we are supplementing the traditional medical school curriculum with training in the delivery of preventive care and in outpatient settings. Our approach is three-pronged.
First, we work with local schools and students to increase access to medical school through programs that stimulate an interest in medicine and help disadvantaged students become competitive applicants for admission to medical school or other professional health education programs. These activities start with students at even younger than middle school age, because that is when students begin to formulate ideas about what they want to be when they grow up. We focus on students from Inland Southern California because students who live here now will be among those best equipped to provide medical care to our increasingly diverse patient population. Doctors who share their patients’ cultural and economic backgrounds are better at influencing their health behaviors.
Second, we recruit our medical students specifically with a focus on increasing the number of physicians in Inland Southern California in primary care and short-supply specialties. Our region has just 40 primary care physicians per 100,000 people—far below the 60 to 80 recommended—and a shortage in nearly every kind of medical specialty. Students who have been heavily involved in service such as the Peace Corps, or who are engaged in community-based causes, are more likely to go into primary care specialties and practice in their hometowns.
Then, we teach our medical students an innovative curriculum. For instance, the Longitudinal Ambulatory Care Experience, called LACE for short, replaces the traditional “shadowing” preceptorship, where students follow around different physicians. Instead, our students participate in a three-year continuity-of-care primary care experience that includes a sustained mentor-mentee relationship with a single community-based primary care physician. In this experience, they “follow” a panel of patients and gain an in-depth understanding of the importance of primary care, prevention, and wellness. Our approach also includes community-based research that grounds medical students in public health issues such as the social determinants of health, smoking cessation, early identification of pre-diabetic patients, weight loss management, and the use of mammograms to detect breast cancer.
We try to remove the powerful financial incentive for medical students to choose the highest paying specialties in order to pay off educational loans. We do this with “mission” scholarships that cover tuition in all four years of our medical school. This type of scholarship provides an incentive for students to go into primary care and the shortest-supply specialties and to remain in Inland Southern California for at least five years following medical school education and residency training. If the recipients practice outside of the region or go into another field of practice before the end of those five years, the scholarships become repayable loans.
Third, we are creating new residency training opportunities in our region to capitalize on the strong propensity for physicians to practice in the geographic location where they finish their post-M.D. training. Responding to our region’s most critical shortages, we are concentrating the programs on primary care specialties like family medicine, general internal medicine, and general pediatrics, as well as the short-supply specialties of general surgery, psychiatry, and OB/GYN. We are also developing a loan-repayment program for residents linked to practice in our region.
Ultimately, we hope our ideas for how to change healthcare will succeed and be adopted by others. It might take 30 years, but we believe what we are doing at the UCR School of Medicine will change the face of medical education in the U.S.