Scott A. Edmonds, OD, FAAO, focuses his blog on the role of the optometrist in health care reform – moving from primary eye care to primary health care. He is the chief medical officer of MARCH Vision Care, the co-director of the Low Vision/Contact Lens Service at Wills Eye Institute in Philadelphia and a member of the Primary Care Optometry News Editorial Board. 

Disclosure: Edmonds is a consultant for March Vision.

BLOG: Rethinking the health of a nation

In spite of the constant media blitz related to health, health care policy, the health care laws and health care reform, little has changed in the day-to-day delivery of health care services.

In observing my friends and relatives who have needed care over the past few years, I have found that you have to be sick or injured to access the system. You have to access diagnostic services through the emergency room (even if not emergent or even urgent), and you have to have a hospital admission to get rehabilitation services. Discussions on preventive care, wellness and health education are largely academic unless self-directed and outside of the system.

In a paper published in the New England Journal of Medicine in September 2007, Dr. Steven Schroder looked at factors that determined health and well-being of America citizens. This work found that 10% was related to health care services, 20% was related to social and environmental factors, 40% was related to the behavior of the individual, and only 30% were genetic factors.

Looking at this data in another way, 70% of the factors that determine a person’s health and well-being are modifiable. This is truly a shocking number, considering we live in a modern affluent society with a robust health care system. Although it has been 10 years since this data was published, today in America we have just accepted obesity, diabetes and hypertension as “facts of life” and are only concerned with how we are going to fund the long-term care of all of our sick citizens.

Never willing to give up, I am looking at ways to affect change in the modifiable risk factors. I have identified three key groups that can serve as the agents of change for improving the health and well-being of our people. These groups are: health care providers, health insurance plans and the communities where we live.

Health plans can affect the health and well-being of their members by redefining primary care services to focus on wellness, prevention and health education rather than acute and subacute discomfort and illness. This can be achieved by diverting distressed members to designated urgent care locations and then credentialing and contracting with a much wider group of providers to render the redefined primary care services. This group would include providers such as optometrists, dentists, podiatrists, chiropractors, psychologists and athletic trainers. The health plans can then create delivery models that require this new and expanded primary care team to commutate and collaborate with the more traditional primary care provider network to assure continuity of ongoing medical care.

The health plans can address the individual behavior of their members by requiring specific management plans for their members at risk and accountability for follow-up and execution of the management plans by the expanded primary care team. The health plans can improve the social and environmental aspect of health by working with communities to support wellness and health education programs for issues related to smoking, physical fitness and diet/nutrition programs.

Communities can affect the health and well-being factors by assuring that citizens have easy access to this host of new primary care provider locations. This can be in the form of urban planning and development for the future and the arrangement of affordable transportation for the present. They can improve individual performance by fostering a culture of community pride through personal accountability. They can affect social and environmental change with providing parks, jogging trails and other community-based programs that promote health and wellness activities, perhaps by sponsoring a half marathon event rather than a “beef and beer” or a pancake breakfast.

Health care providers have perhaps the greatest role as agents of change. For the health care delivery aspect, providers can take a broader approach to the care of their patient. Health care providers need to evaluate beyond their area of specialty and look at the patient’s family history, social history and risk factors for the development of chronic medical problems. The physical examination, whether focused on eye, tooth, foot or back, should always include vital signs in addition to the specialized examination. Communication and collaboration that occurs across the spectrum of all other health providers involved in the care of each patient is essential.

Providers can affect the individual accountably aspect with specific patient education related to risk factors and physical findings and comprehensive management plans with action items and accountability.

They should be a big part of social and environmental programs and can participate by serving as role models and being involved with community-based and health plan-based activities. This can be as a financial sponsor, a volunteer, an organizer or even as an active participant.

Health care providers of all types are the lynch pin to any programs that will change the attitudes and culture of our people. Like the Shaman, healers and community leaders throughout history, we are responsible for the health and well-being of our people. In today’s world, we need to partner with the health insurance industry and our communities to change the direction of a nation.


Schroeder SA. N Engl J Med. 2007;doi:10.1056/NEJMsa073350.