When I was a child I remember my school textbooks and public figures on television referring to the American "citizen". At some point in the 1970's or 80's I stopped hearing the word "citizen" and started hearing the American people referred to as "consumers".

A "consumer" is defined* as "a person or thing that consumes"; "Consume" meaning "to destroy or expend by use; devour; to spend wastefully".

A "citizen" is "an inhabitant or denizen; a native or naturalized member who owes allegiance to its government and is entitled to it's protection"; "citizenship" is a "characteristic of an individual viewed as a member of society".

*Webster's unabridged dictionary c. 1996.

Inhabiting our Health vs. Consuming Health Care

I ask you can we predominantly inhabit our health, rather than be consumers of health care? Inhabiting our health consists of taking personal responsibility for our wellness and being mindful when it comes to utilizing health care services to treat illness.Some features of inhabiting our health may include:

mindful eating habits to maintain ideal weight and avoid obesity
moderate exercise (e.g. yoga, walking) to maintain or increase flexibility, balance, and cardiovascular function
exploring conservative options for managing deteriorating health
acquiring reliable health knowledge with which to empower ourselves (via health care providers, the Internet, health care associations, and other sources)

The American Health Care Money Vacuum: Elective Services and Emergency Room Care

The The McKinsey Global Institute reports illuminating findings about our behavior in relation to health care:

"In 2006, we found that US health spending totaled $2.1 trillion, an increase of $363 billion since 2003, and totaled nearly $6,800 per capita...the United States spent twice as much on health as it did on food--and more than China's citizens consumed altogether. In addition, the increase in US health care spending in the three-year period is more than US consumers spent on oil and gasoline during all of 2006 when energy prices began to reach new highs."

More Money: Diminishing Returns

Although we spend more per capita than our peer nations on health care we have the highest infant mortality rate and some of the lowest life expectancies compared to other developed nations.

When you look at how we allocate our health care dollar outpatient care accounts for over 40% of all health care spending and is 68% above expected per capita for the average health status of our citizens. Outpatient care includes same-day hospital care, use of hospital emergency room services, elective outpatient surgery (e.g. hernia repair, gall-bladder surgery), imaging studies (e.g. CT scan, MRI), office visits to physicians, and dental care.

Outpatient care accounts for >40% of overall health care spending and 68% of spending above expected (outpatient care defined as: same day hospital visits, hospital emergency room services, outpatient surgeries (usually elective), imaging services (CT scans and MRIs), physician office visits. Same-day hospital care is the fastest growing of all outpatient costs, growing at nearly 10% per year compared to 6-7% annually for other health care services (see below).
Inpatient care accounts for 25% of overall health care spending but only 6% of total spending above expected.
Drugs and nondurables account for 12% of overall health care costs and 15% of spending above expected. In the U.S. we use fewer drugs per capita compared to our peer nations, but we pay on average 50% more than other countries for equivalent molecules.
Health Administration and Insurance accounts for 7% of overall health care costs and 14% above expected.
Long-term and home care accounts for 9% of overall health care costs but is 8% or $53 billion less than expected.
Durable Medical Equipment (eyeglasses, hearing aids, wheelchairs, and the like) account for 1% of health care costs and are 3% or $19 billion less than expected.

Putting Theory to Work:

Now we know some of our most expensive utilization of resources consists of modifiable factors such as elective surgery, emergency room services for non-emergent conditions (i.e. admission and discharge in same day), and extreme measures employed in end-of-life care.

Consider elective surgery. I met a Canadian orthopedist who has worked in both the Canadian and U.S. health care systems. He told me in the U.S. we do a lot of surgeries that just wouldn't be done in Canada. For example: knee surgery to treat "cartilage damage". In Canada you have to wait a year for such elective knee surgery. There is no data that shows elective knee surgery provides better long-term outcomes for knee pain compared with conservative measures such as physical therapy (exercises designed to improve joint function and relieve pain by strengthening the muscles around the joint) and anti-inflammatory meds such as ibuprofen.

So while the Canadian is sitting around a year waiting for their knee surgery, they are probably doing physical therapy, taking anti-inflammatory medications, and over the course of that year may have enough relief of symptoms they opt not to proceed with the surgery.

How Would a Waiting Period Affect Surgical Frequency and Outcomes?

To use a gynecologic example, consider surgery for incontinence versus pelvic floor muscle training (Kegels) with or without resistance. Incontinence surgery has a 30% to 60% re-operation rate due to failure of the initial surgery over time. Use of mesh in incontinence repairs has attendant problems of mesh erosion (a range of 5% to up to 30% in some studies) which can lead to chronic infection, fistulas (communications between the bladder and vagina) and bone infections (see The False Promise of Incontinence Surgery)

What if a 6 month waiting period was imposed on patients before scheduling elective incontinence surgery? During this 6 month period the patient does her Kegel exercises, possibly with weights or a pessary, and two thirds of them will find their incontinence completely resolves or is substantially improved. Even if she decides to proceed with the surgery at that point, her surgical outcome will be much better because she will have spent the previous six months conditioning her pelvic floor which strengthens the muscles around the bladder, increases blood flow to the area, and improves neuro-muscular function.

How do you or can you inhabit your health?

Let us count the ways. Feel free to post how you cope with your illnesses in the comments section.

How are you dealing with arthritis? diabetes? depression? being overweight? being over-stressed? and other conditions. Tell us what resources and techniques you've found helpful.

Can We Be "Citizens" — Rather than "Consumers" — of Health Care?