Experts generally agree that certain screening tests improve the overall health of the population; blood pressure testing is one example. But there's controversy over the value of other tests. Screening can, paradoxically, "make the population less healthy because it leads to so many more diagnoses and to overtreatment," says H. Gilbert Welch, a professor of medicine at Dartmouth Medical School and author of Should I Be Tested for Cancer?: Maybe Not and Here's Why. He cites prostate cancer screening as an example. Since the prostate specific antigen test was introduced in the late 1980s, over a million men have been diagnosed with prostate cancer who otherwise would not have been, Welch says, and up to half suffer serious treatment-related side effects like impotence and incontinence. Prostate cancer deaths have declined since the introduction of the PSA test, but factors other than more aggressive diagnosis—improved treatments, for example—might be responsible for the decline. "We still don't know whether this test helps reduce prostate cancer mortality," Welch says.
An oft-cited reason for people not getting timely screenings and for poor management of chronic conditions is that the healthcare many people receive is fragmented. In recent years, policy experts and clinicians alike have embraced a "medical home" model of primary care that takes a back-to-the-future approach in which patients' primary-care doctors are responsible for managing their healthcare, not just the particular issues that arise in a brief office visit. Medical home practices often employ a team approach to managing care and keep close tabs on their patients with high-tech information technology.
Medical homes also strive to enhance access to care, and patients can often communicate with their doctors by E-mail or make same-day appointments. The American Academy of Family Physicians sponsored 36 medical home practices as part of its TransforMED demonstration project; other professional groups are also experimenting with the model. Geisinger Health System in Pennsylvania reduced hospital admissions by 20 percent and trimmed medical spending by 7 percent by using a medical home model of care, according to a study in the September/October 2008 issue of the journal Health Affairs. But such practices are still rare, and it's too soon to know how they might affect healthcare delivery or costs overall.
At Harbor of Health, a primary-care practice in Memphis that is one of the TransforMED demonstration sites, there are only four chairs in the waiting room. Everybody gets same-day appointments, and patients are whisked into the exam room within five minutes, according to Susan Nelson, one of the physicians there. Even though she spends more time one-on-one with her patients now, they are in and out of the office in just 45 minutes, compared with nearly an hour before. "It's labor-intensive, because you have to be a health coach, and people don't want to exercise or diet," says Nelson.
Homegrown. How we organize our communities and even our own homes may have as great an impact on our health as the way our healthcare system is structured. Communities without sidewalks or bike paths offer little encouragement for people to rely less on their cars. School cafeterias that serve french fries and sugary sodas tempt kids with unhealthful lunch choices.