Thursday, March 27, 2014

Perception of problems in the health care system: will the mighty fall or is there a chance to save it for all of us?

[This is a particularly long post, but I haven't posted for some time. I have been working on a book, and if it ever comes together, this will be part of it.]

There are a lot of problems with our health care system in the US. Undoubtedly, there are problems with all health care systems, but ours has the distinction of being – by far – the most expensive in the world, and yielding health outcomes that are shocking low, especially for the cost. Our outcomes are much worse than those in comparable advanced capitalist democracies, and often follow behind other generally less wealthy countries. There are those who persist in saying “the US has the best healthcare in the world” but to the extent that they are not completely ignorant, or, worse, purposely dissembling for political reasons, they are talking about a narrow portion of health care. First of all, medical care. Second of all, medical care that is accessible, and therefore only for some individuals. Thirdly, mostly rescue care – high intensity, highly-specialized, high-tech, high-cost interventions for individuals with some conditions.

Even within these parameters, the claim is not entirely true. Many of the interventions that are available do not actually prolong life or the quality of life. They exist as goods which can be purchased by those with sufficient resources and sufficient motivation (presumably, ill health that is not responding to other treatment) but do not always (or even most of the time) create benefit that is “patient-important” – elimination of unnecessary death, or increased quality of life. For overall health care, even those with money, access, and insurance do not always get higher quality care; frequently, they have things done to them both diagnostically and therapeutically which they are led to believe may be of benefit to them, but often is not. In fact, these interventions can lead to further interventions, at greater cost in both dollars and discomfort or morbidity to the person, as abnormalities that turn out to be unimportant are chased down. Sometimes, these interventions, available mostly to the best off of us, are actually harmful. The costs are so high, we are seeing a new enterprise, “medical tourism”, in which Americans who need or want more-or-less elective surgery travel to other parts of the world, where the outcomes are as good and the cost is often (even with airfare and hotel!) less than the deductible would be in this country.

When we look at population health, rather than the individual health issues of people in the middle and upper class, the problems are even starker. By virtually every measure, health status in the US lags beyond other wealthy countries, and many less wealthy, in markers such as infant mortality, years of life lost to treatable conditions, disability adjusted life years, and even age of death. Our “between groups” contrasts are very stark in the US, mirroring those of many developing economies, not other “first world” countries. The fortunate among us may get the “best” care for some conditions at the expense (both financial and personal) of over-intervention, but many of us get what is frankly poor care or no care at all.

Finally, most of the negative determinants of health are outside of and before interaction with the medical care, or even any aspect of the health care, system. They are the social determinants of health, the economic status of your family (and of your family of origin; wealthy people born poor, while admirable “Horatio Alger” role models, have worse health status as a group than wealthy people born rich). They include housing, food, education, warmth, discrimination, environmental pollution (much worse in poor communities than in wealthier) and a host of other negative impacts that, in Dr. Camara Jones’ analogy[1], put you closer to the cliff face, more likely to fall off and then be at the mercy of whatever the medical care system does or does not provide.

However, even when people acknowledge that these disparities, inequalities and inequities exist, and that our health system is sorely lacking, there is not agreement on what the most important problems actually are. Even when we eliminate overtly political posturing and consider only the honestly conceived beliefs of different players in the system, there is lack of consensus because there are many different perspectives from which to view the elephant of health care. In addition to the differences in perspective, there are differences in incentives, in the fact that what may be good for some part of the system is bad for others. Physicians and other individual providers, hospitals and health systems, politicians, policy makers and pundit – and of course patients – have different perspectives. And, certainly, there is plenty of blame to go around, and no shortage of others that any of us can point fingers at as the “real” problem.

For a physician who is interested in caring for patients, the regulatory burdens can be the real problem. Days are spent with less and less time providing care to patients, and more and more completing the record (and the evidence is that, whatever the benefits, electronic health records take more time to complete), filling out forms, complying with regulations. Increasingly employed by hospitals and health systems, they are driven to “be productive”, which in a fee-for-service system translates into “see more patients and spend less time with each”.  The number of people who need care is increasing, not just from the one-time bolus of people getting health coverage under ACA, but more from the increase and aging of the population. There are exceptions, systems where care is capitated, where physicians and other providers (especially those in primary care) are organized into teams and paid on the basis of providing comprehensive care for populations rather than for face-to-face encounters, but these are far from the norm. From the perspective of these providers, most of the efforts to increase access have increased their workload, decreased their job satisfaction, and, possibly most important, decreased their sense that they are providing quality health care to their patients.

For hospitals and health systems, which have built enormous physical plants and infrastructures based upon “product lines” that are highly reimbursed (and, more important, have a high return on investment, or high reimbursement-to-cost-of-providing-the-service ratio), the challenge is also regulation, but in a different way, and of changing what is reimbursed. Like physicians, hospitals would like the public to think that they are in the business of delivering quality health care, but the emphasis, whether for-profit or non-profit, is often on the business part. Hospitals and health systems are sometimes run by physicians or other health providers (often with MBA degrees) but are frequently run by accountants. They may do well by their metrics, making (or not losing) money, but this may be a result of providing a particular market segment, or product line, or service to a particular (insured) patient population, rather than providing the most-need healthcare to those who need it most. If policy changes begin to financially reward doing something different than the hospitals have been doing (for example, keeping people out of the hospital) they can restructure, acquire ambulatory practices, fight it and hope it will go away, or go bankrupt. They can adopt collaborative arrangements with their physicians, and sometimes restrict referrals to keep them within the system. Changes in policies and regulations are very challenging, because there is such an enormous capital investment.

Policy makers, politicians, and pundits have different challenges. Politicians want to be re-elected, and so need to satisfy voters, or at least likely voters, or at least those with the most money who will finance their campaigns. Pundits have few restrictions other than their beliefs. Policy makers, who may be politicians or work for them, or may have been or later become pundits, have to implement goals. But sometimes the goals are in conflict. To restrict the potentially inappropriate admission of patients by hospitals in order to collect more money from Medicare, puts policies and practices into place which encourage classifying patients as outpatients (“observation” status). But this then does not eliminate the cost; it both decreases the reimbursement of the hospital and increases the amount that the patient, the Medicare beneficiary, has to pay out of pocket.

Of course, there is the patient, who is ostensibly the focus of all the attention, for whom the entire health system exists, but who is usually the least powerful player in the entire equation. More important, there is not a patient, there are many people with different sets of needs and preferences. Yes, most would like to stay healthy if they are, or get healthy if they can. They may be willing to put a lot of work into it or may have a more passive approach, wanting to be made healthy. They may have very different understandings of health, and different degrees of belief in and trust in physicians or other providers, and indeed in science. Even if they want to trust science and medicine, they are very likely to be confused by the complex way in which new medical knowledge is developed and found to be accurate, scarcely in a linear “this is good for everyone, this is bad for everyone” manner. Their lives may be very busy and have little time to spend at the doctor, or they may see visits to the doctor as one of the more positive and fulfilling experiences that they have. They may “know” what is wrong and what is to be done, and find the doctor to be just a particularly uncooperative store clerk who will not provide them with it, even when the doctor believes that it would be of little or no use, unnecessary and expensive, or even dangerous. They may have the sense of invulnerability that often accompanies youth, or the frailty and fear of old age. They may have cultural beliefs that make it difficult or impossible to understand or accept medical recommendations, and lead to frustration in interactions with the medical system. Even positive developments, such as the “Patient-centered Medical Home” (PCMH), are challenged by the fact that not all patients are the same, and what makes one comfortable, at ease, and feel healed may be a negative for another.

In his sensitive and thoughtful essay on the Health Affairs blog, Matthew Anderson provides us with 9 questions that he has about the PCMH, in the form in which he finds himself working and in the projections for the future.[2] He is certainly not opposed to a conversion of practice to being more patient-centered and less provider-centered, but raises questions about the degree to which the processes that have been put in place in the name of PCMH have actually done this, and whether they have increased or decreased not just his satisfaction as a provider but the quality of care that is provided to patients. Dr. Anderson is neither a Luddite nor a malcontent, but rather is trying to raise his eyes above instrument panel at which he is working to see if the direction in which the ship is sailing is the one we want to go in. He is, above all, focused on the values that we are trying to achieve, and concerned that our over-emphasis on the process, on the plan we have put in place rather than the goal, will not get us where we want to go.

In his book “How the Mighty Fall”[3] business professor Jim Collins puts forward 5 stages of decline in once-great companies. Stage 1 is “Hubris born of success”, Stage 2 is “Undisciplined pursuit of more”, Stage 3 is “Denial of Risk and Peril, Stage 4 is “Grasping for Salvation”, and Stage 5 is “Capitulation to irrelevance or death”. Which stage is your organization in?

Luckily, Collins’ work suggests that turnarounds can happen even in Stage 4. The key is staying true to the key principles and practices of our work. Dr. Anderson’s 9 questions can be a start to guiding us.

[1] Jones CJ, et al., “Addressing the social determinants of children’s health: a cliff analogy”, J Health Care Poor Underserved. 2009;20(4 Suppl):1-12. doi: 10.1353/hpu.0.0228.
[2] Anderson, M, “Nine questions about my new medical home”, Health Affairs blog, March 17 , 2014.
[3] Collins J. How the might fall: and why some companies never give in. Collins Business Essentials. New York. 2009.

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