Most of them are Medicare ACOs, which are measured under 33 quality measures including how well a doctor communicates, influenza and pneumococcal vaccinations, depression and obesity screenings, and shared decision-making between the patient and provider. Many of the performance measures revolve around preventive and chronic disease care. They are eligible for bonuses if they run efficiently and can keep overall costs down. Since 2012, under the Affordable Care Act, more than 500 accountable care organizations, or ACOs-networks of doctors and hospitals-have been delivering coordinated care. That is, trying to get the United States back on the trend line that links health care spending and life expectancy. Measuring the health of health care is about ensuring that patients are treated well, with trust, and with less money. Health care is a constellation of providers-nurses, doctors, hospitals, insurance agents, administrative staff-who work to treat a patient. To make these savings real and visible, an alternate approach would be one in which health care completely reorients around outcome, not service.
The money doesn’t come back to the mobile clinic. A $17 return on investment is a whopping return, but these are hypothetical dollars, saved by the health care system in general. In a later survey across more than 670 clinics, the estimated returns were about $17 for every dollar spent on the clinics. The researchers came up with a return on investment figure for the Family Van: Every dollar invested brought a return of $36. The researchers estimated a dollar value of preventive care services based on data from the National Commission on Prevention Priorities.
How do you explain the costs of setting up a mobile clinic that may offer free diabetes screenings that eventually lead to months of regulated diet and exercise? And by that yardstick, mobile clinics don’t have much going for them. Health is a long-term endeavor, but it’s being measured against short-term profit goals and narrow performance indicators. The system rarely factors in the effects of preventive screenings in reducing future hospitalizations, for instance. Whether it’s a screening, consultation, or surgery, the costs are siloed under each service, without explicit connections. Everywhere you look, health care today is largely a fee-per-service industry. They are mostly run by five big players-CVS, Walgreens, Kroger, Walmart, and Target-with CVS alone accounting for more than 800 MinuteClinics. More than 1,700 retail clinics have popped up across the country, with projections to go up to 2,800 to 3,000. There are, of course, others who have eyed the market for health care services. Something isn’t right when Americans pay more for less, and die of preventable conditions.
Chronic diseases-what the Centers for Disease Control and Prevention calls “the most common, costly, and preventable of all health problems”-accounted for seven of the top 10 causes of death in 2010. Our $8,500 per capita spending is more than twice the amount for France and the United Kingdom, both places where people live longer than Americans. On average, Americans have the same life expectancy as Chileans (78.7 and 78.3 years, respectively), but Americans spend five times more. They fell on a trend line that broadly showed that the more a country spends on its people’s health, the longer its people live. Most of the results across its 34 member countries seemed predictable. Last year the Organisation for Economic Co-operation and Development took a stab at assessing health care efficiency by plotting a country’s life expectancy against that country’s health spending per person. By that metric, things don’t look great for the United States. But broadly, it has to do with helping people live healthier and longer lives, affordably and sustainably.
It’s a little difficult to define health care. Residents can get immunizations, emergency contraception, blood pressure and blood sugar screenings, tuberculosis tests, and general advice on health care. It’s a walk-in clinic, no appointment necessary. The mobile clinic sees about 10 to 25 patients a day at various locations near community centers, adding up to 3,400 patient visits last year. I was reminded of this when I recently visited the San Mateo County mobile health clinic parked behind a neighborhood library in Redwood City, California.