25
AN OCCUPATIONAL HEALTH PERS PECTIVE* G. H. COLLINGS, JR., M.D. General Medical Director New York Telephone Co. New York, N.Y.
C ONCEPTUALLY, total health care can be divided into sequential segments: 1) autocare, 2) health education, 3) preventive measures, 4) early diagnosis, 5) ambulatory treatment, 6) hospitalization, and 7) rehabilitation and after-care. In such a system, to the extent that autocare is successful there will be less need for health education; to the extent that health education and preventive measures are successful there will be less disease to treat; to the extent that early treatment is successful there will be fewer patients to hospitalize, etc. Thus, this system can be said to be sequentially and cumulatively dependent. Although it is apparent that the term "primary care" means somewhat different things to different people, it is clear that it falls somewhere in the first stages of the health-care system as depicted here, and should encompass part but not necessarily all of the first four items: health education, preventive medicine, early diagnosis, and ambulatory care. We in occupational or industrial medicine are involved with and to some degree responsible for the health of large populations. In addition, our companies pay hundreds of millions of dollars annually to protect workers against adverse health effects on the job and to purchase medical care for them and their families. Therefore, we are likely to visualize health care in its broadest connotations as it affects such populations. But at the same time we see individual employees on an intimate patient-doctor basis and empathize with the individual as regards his view of personal health and health services. From this dichotomous vantage point we have been concerned for many years that the existing system of medical care was devoted almost exclusively to crisis or episodic care, was interested increasingly in the disease rather than the patient, and inadvertantly seemed to discourage early entry of the patient into the system. In times gone by we labeled these shortcomings as in* Presented in a panel, What is Primary Care? as part of the 1976 Annual Health Conference of the New York Academy of Medicine, Issues in Primary Care, held April 22 and 23, 1976
Vol. 53, No. 1, January-February 1977
26
G.H. COLLINGS, JR.
26G.H.
COLLINGS,
JR.
adequacies of primary care and tried to compensate for them by supplementing primary care through the provision of health education for employees, early diagnosis in the form of periodic health inventories or multiphasic screening programs, and by encouraging employees to consult their industrial medical departments at the first sign of illness. Unfortunately, until recently we did not realize fully that the inadequacy was not limited to primary care, but resulted from a more basic shortcoming, namely, inadequate management of the entire system. The present system is not a health-care system at all, but a disease-care system, and the real issue is how to transform it into a comprehensive health-care system. In the process of this metamorphosis I do not wish to minimize the need for improving the elements of primary care which are provided. We certainly need to add to the existing system large doses of some more effective (and as yet undeveloped) form of health education, better and more universal early detection of disease, and better ambulatory care; we also need to recoup some losses in the quality of the personal relations with patients. But even if we were to be 100% successful in adding these components, we could fail to achieve an effective health-care system, simply because we had failed to provide effective management. It is one thing to provide all the essential services. If these services are disorganized and fragmented, it is quite another matter to use them at the right time, to the right degree, and in a manner that will guarantee maximum effectiveness. The most critical ingredient for a system's effectiveness is management of the system, and this, unfortunately, is the ingredient in shortest supply at present. I shall explore briefly what is meant by management of the health system and, by noting the areas in which some degree of management already exists, illustrate what needs to be done in these and in other areas in order for the whole system to be managed more adequately. From the viewpoint of industrial medicine, management of the health-care system can be divided naturally into three conceptually and operationally distinct levels. Level I is the management of a single episode of disease, e.g., in a gallbladder attack, pneumonia, a cerebrovascular accident, etc. In industry for many years we at first hand have had occasion to observe the management of such disease episodes as provided under widely varying circumstances in all kinds of communities. From this experience we are satisfied that from the standpoint of getting the patient well management at Level I is usually good. The principal exceptions are in those cases in which diagnosis is difficult and
Bull. N.Y. Acad. Med.
AN OCCUPATIONAL HEALTH PERSPECTIVE
27
in which there may be poor coordination of the fragmented specialties. From the standpoint of cost-effectiveness, however, much remains to be done at Level I. As a result of the relative clinical success at Level I, there are those who claim that the whole medical system already is well managed because they mistake the management of an illness at Level I for management of the over-all health of the individual. Obviously, this is where confusion of episodic care with comprehensive care occurs; in fact, it is because of its almost exclusive devotion to Level I management that the present system of medical care fails to become a good, comprehensive health-care system. At-Level 2 there is management of the over-all health of the individual. This is not the same as treating the whole patient during one episode of illness. Level 2 management includes long-term responsibility for the health of the individual in its entirety, beginning with adequate assessment of the influence of inheritance and past environments, of the present state of health or ill health, and of known or predicted future influences such as the environment and life style of the individual. With the possible exception of pediatric practice, medical practice today virtually ignores Level 2 management; as a consequence, the individual has been left to his own devices to provide this essential ingredient, i.e., he must manage his own health-a job for which usually he is poorly prepared. Such information as he has usually is contradictory and confusing; he has little contact or influence with the resources he needs; and present economic conditions seem to conspire to prevent his access to help until he becomes sufficiently ill to require episodic care. Obviously, there is great opportunity for providers of care to develop better answers to the problem of Level 2 management. Level 3 management is concerned with planning and coordination for groups of individuals or populations. Activity at this level is concerned with organizing components of health-delivery systems, monitoring and constraining costs, assessments of quality, measurement of productivity, etc; all of these areas have been receiving increasing attention of late, but there are more questions than answers and even fundamental principles are still in the developmental stages. Obviously, opportunities abound and the influence of activity at this level will increase significantly in the future. Now I shall return to the subject of this panel: "What is primary care?" in the light of the foregoing discussion. Primary care has to do with what is offered by providers at the point of primary contact with the patient. What occurs at this initial interface between patient and system, however, will vary Vol. 53, No. 1, January-February 1977
28
28
G.H. COLLINGS, JR. COLLINGS,
considerably, depending on the comprehensiveness of the health care offered to the patient and on the time of entry by the patient. If the health-care system is limited to episodic care or if the patient's entry is late (the typical situation today), primary care constitutes the first phase of episodic care. If the patient's entry is earlier (and considerable expansion of existing concepts and systems will be necessary to accommodate this), primary care would embrace more of the first stages of the comprehensive system of health-care delivery and would require much more sophisticated management at Level 2. To improve the entire health-care system significantly we must develop the first stages of the system by providing earlier entry by the patient, continuing contact between patient and system, and, above all, better management of both the patient and the system at each of the three levels.
Bull. N.Y. Acad. Med.
AN OCCUPATIONAL HEALTH PERS PECTIVE* G. H. COLLINGS, JR., M.D. General Medical Director New York Telephone Co. New York, N.Y.
C ONCEPTUALLY, total health care can be divided into sequential segments: 1) autocare, 2) health education, 3) preventive measures, 4) early diagnosis, 5) ambulatory treatment, 6) hospitalization, and 7) rehabilitation and after-care. In such a system, to the extent that autocare is successful there will be less need for health education; to the extent that health education and preventive measures are successful there will be less disease to treat; to the extent that early treatment is successful there will be fewer patients to hospitalize, etc. Thus, this system can be said to be sequentially and cumulatively dependent. Although it is apparent that the term "primary care" means somewhat different things to different people, it is clear that it falls somewhere in the first stages of the health-care system as depicted here, and should encompass part but not necessarily all of the first four items: health education, preventive medicine, early diagnosis, and ambulatory care. We in occupational or industrial medicine are involved with and to some degree responsible for the health of large populations. In addition, our companies pay hundreds of millions of dollars annually to protect workers against adverse health effects on the job and to purchase medical care for them and their families. Therefore, we are likely to visualize health care in its broadest connotations as it affects such populations. But at the same time we see individual employees on an intimate patient-doctor basis and empathize with the individual as regards his view of personal health and health services. From this dichotomous vantage point we have been concerned for many years that the existing system of medical care was devoted almost exclusively to crisis or episodic care, was interested increasingly in the disease rather than the patient, and inadvertantly seemed to discourage early entry of the patient into the system. In times gone by we labeled these shortcomings as in* Presented in a panel, What is Primary Care? as part of the 1976 Annual Health Conference of the New York Academy of Medicine, Issues in Primary Care, held April 22 and 23, 1976
Vol. 53, No. 1, January-February 1977
26
G.H. COLLINGS, JR.
26G.H.
COLLINGS,
JR.
adequacies of primary care and tried to compensate for them by supplementing primary care through the provision of health education for employees, early diagnosis in the form of periodic health inventories or multiphasic screening programs, and by encouraging employees to consult their industrial medical departments at the first sign of illness. Unfortunately, until recently we did not realize fully that the inadequacy was not limited to primary care, but resulted from a more basic shortcoming, namely, inadequate management of the entire system. The present system is not a health-care system at all, but a disease-care system, and the real issue is how to transform it into a comprehensive health-care system. In the process of this metamorphosis I do not wish to minimize the need for improving the elements of primary care which are provided. We certainly need to add to the existing system large doses of some more effective (and as yet undeveloped) form of health education, better and more universal early detection of disease, and better ambulatory care; we also need to recoup some losses in the quality of the personal relations with patients. But even if we were to be 100% successful in adding these components, we could fail to achieve an effective health-care system, simply because we had failed to provide effective management. It is one thing to provide all the essential services. If these services are disorganized and fragmented, it is quite another matter to use them at the right time, to the right degree, and in a manner that will guarantee maximum effectiveness. The most critical ingredient for a system's effectiveness is management of the system, and this, unfortunately, is the ingredient in shortest supply at present. I shall explore briefly what is meant by management of the health system and, by noting the areas in which some degree of management already exists, illustrate what needs to be done in these and in other areas in order for the whole system to be managed more adequately. From the viewpoint of industrial medicine, management of the health-care system can be divided naturally into three conceptually and operationally distinct levels. Level I is the management of a single episode of disease, e.g., in a gallbladder attack, pneumonia, a cerebrovascular accident, etc. In industry for many years we at first hand have had occasion to observe the management of such disease episodes as provided under widely varying circumstances in all kinds of communities. From this experience we are satisfied that from the standpoint of getting the patient well management at Level I is usually good. The principal exceptions are in those cases in which diagnosis is difficult and
Bull. N.Y. Acad. Med.
AN OCCUPATIONAL HEALTH PERSPECTIVE
27
in which there may be poor coordination of the fragmented specialties. From the standpoint of cost-effectiveness, however, much remains to be done at Level I. As a result of the relative clinical success at Level I, there are those who claim that the whole medical system already is well managed because they mistake the management of an illness at Level I for management of the over-all health of the individual. Obviously, this is where confusion of episodic care with comprehensive care occurs; in fact, it is because of its almost exclusive devotion to Level I management that the present system of medical care fails to become a good, comprehensive health-care system. At-Level 2 there is management of the over-all health of the individual. This is not the same as treating the whole patient during one episode of illness. Level 2 management includes long-term responsibility for the health of the individual in its entirety, beginning with adequate assessment of the influence of inheritance and past environments, of the present state of health or ill health, and of known or predicted future influences such as the environment and life style of the individual. With the possible exception of pediatric practice, medical practice today virtually ignores Level 2 management; as a consequence, the individual has been left to his own devices to provide this essential ingredient, i.e., he must manage his own health-a job for which usually he is poorly prepared. Such information as he has usually is contradictory and confusing; he has little contact or influence with the resources he needs; and present economic conditions seem to conspire to prevent his access to help until he becomes sufficiently ill to require episodic care. Obviously, there is great opportunity for providers of care to develop better answers to the problem of Level 2 management. Level 3 management is concerned with planning and coordination for groups of individuals or populations. Activity at this level is concerned with organizing components of health-delivery systems, monitoring and constraining costs, assessments of quality, measurement of productivity, etc; all of these areas have been receiving increasing attention of late, but there are more questions than answers and even fundamental principles are still in the developmental stages. Obviously, opportunities abound and the influence of activity at this level will increase significantly in the future. Now I shall return to the subject of this panel: "What is primary care?" in the light of the foregoing discussion. Primary care has to do with what is offered by providers at the point of primary contact with the patient. What occurs at this initial interface between patient and system, however, will vary Vol. 53, No. 1, January-February 1977
28
28
G.H. COLLINGS, JR. COLLINGS,
considerably, depending on the comprehensiveness of the health care offered to the patient and on the time of entry by the patient. If the health-care system is limited to episodic care or if the patient's entry is late (the typical situation today), primary care constitutes the first phase of episodic care. If the patient's entry is earlier (and considerable expansion of existing concepts and systems will be necessary to accommodate this), primary care would embrace more of the first stages of the comprehensive system of health-care delivery and would require much more sophisticated management at Level 2. To improve the entire health-care system significantly we must develop the first stages of the system by providing earlier entry by the patient, continuing contact between patient and system, and, above all, better management of both the patient and the system at each of the three levels.
Bull. N.Y. Acad. Med.
