Saturday, July 9, 2016

Is the US health system about "health" or "profit"?

There are two forces at work in the system of health care delivery in the US which are essentially incompatible. One, which might be called the “health” approach, is focused on improving the health of the people. This could, should, and does include efforts to control costs, because this makes it possible to maximize the number of people who can benefit. This approach, which is codified in almost all international and most national health goals, seeks to use whatever resources exist (financial, structural, institutional, and human) to have the greatest health benefit for the most people. The World Health Organization (WHO) defines health as “…a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. A cornerstone of this is understanding that public health measures, which benefits populations, are generally of greater urgency and wider benefit than individual medical interventions.

While the need for a public health approach is perhaps more obvious for poor countries which lack, for example, clean water, it is no less important for wealthy nations such as the US; we just don’t usually think of the fact that we usually have clean water as a “health benefit”. As with many things, we are less likely to notice things that are good than those that are problems, and we relegate them to the background of our consciousness. We don’t wake up each morning saying “I’m glad I don’t have cholera because I have access to clean water!” Indeed, it is only when we travel abroad and have to use only bottled water, or when a crisis like the lead pollution of the water supply in Flint, MI grabs our attention, that we give this any thought at all. The result is that public health efforts pay the price; less than 6% of our US health expenditures are on public health, with the bulk spent on direct individual medical care, and the profit that insurers, providers and middlemen skim. In addition, our country spends much less, proportionally, on efforts that impact upon the social determinants of health, those characteristics of people’s lives (housing, food, safety, education) that affect people’s lives much more than health care.

Still, when we – or those we love – are sick and in need of medical care we are grateful that it is there. But for many or most of us, it is often hard to pay for it. When we cannot, when the incredible amount of money we have to pay for medical care (often even when we are insured) threatens our families’ well-being, our ability to pay for shelter, food, education, it is a different story. And we know that access to and use of such individual medical care is neither randomly distributed among the American people nor allocated based on the greatest need; no one is shocked to discover that rich people get more medical services. (What may be shocking to learn, however, is that this does not always lead to better health. Services are often delivered -- to those who can pay -- whether they are really necessary or not, and sometimes this leads to complications and worse health!)

It is in this context that a new study in the journal Health Affairs by Dickman, et al., “Health spending for low-, middle-, and high-income Americans, 1963–2012[1] is very revealing. The authors provide data on both the amount health spending among the American people over that 50 years, and how it has been distributed by quintiles of income. To summarize the findings: in 1963, before Medicare and Medicaid, spending was heavily skewed toward wealthier populations, but after those programs were implemented spending became more equal among the quintiles (although, adjusted for disease burden, which is higher in low-income populations, it was still not equitable). Then, over the last decade studied, the spending gaps returned, with much more being spent on the upper than lower quintiles (despite the generally better hea
lth of those who are better off), for the population under 65 (presumably because those over 65 all have Medicare). The authors state that “The rising income-based disparity in spending suggests a shift from allocation of health care according to need to allocation by willingness (and ability) to pay,” and it clearly does. They add that “It is unclear whether this shift arises from the underuse of needed care among the poor or overuse of unnecessary care by the wealthy,” but I am going to go out on a limb and suggest that it is both.

The reason for this is the prominence of the second force at work in health care systems (you were wondering if I would ever get to this!), which I will call the “profit” approach. This approach looks at health care as a commodity to be purchased and marketed. Unsurprisingly, those taking this approach choose to preferentially market both certain services over others (those for which the reimbursement is much higher than the cost of providing them, called even in non-profit institutions the “profit margin”), and market them to certain populations over others (those with money or insurance, and relatively good health so there are less likely to be costly complications). While this approach tends to favor the wealthy, leading to the data presented by Dickman et al., it also favors the less sick. Since older people tend to be sicker than younger (and are covered by Medicare, which pays less well than private insurance), this may in part explain why the quintile-of-income differences are less for the elderly. In summary, health care providers (mainly hospitals and physicians, but also others), want to market the services on which they can make the most money to the people who, arguably, need them the least. You can have greater difficulty accessing care because you are the wrong person (too poor, too sick) or have the wrong condition (one for which treatment has a low profit margin).

Dickman and colleagues present their data fairly dispassionately, without hammering home the obvious conclusion that it reflects a society more driven by the “profit” than the “health” approach to health care delivery. Essentially, it is a story of half-hearted (called “practical” by its advocates) efforts to introduce greater equity into our health care system being overcome by the tactics that smart and well-paid insurers and providers employ to “game the system”. In his regularly outstanding “Quote of the Day” commentary on the Dickman article, titled “Redistribution of health care from the poor to the wealthy”, Dr. Don McCanne takes the discussion a little farther, noting that a single-payer health care system, in which everyone had the same coverage and which could regulate the marketplace, decreasing the profit incentive, would improve the population’s health.

When I wrote to Dr. McCanne that the effort to find ways to preferentially deliver high-profit care to well-insured high-income folks rather than those who needed it most upset me (OK, I said it made me want to puke), he wisely responded that it “seems like our health care system has excelled at creating ‘work arounds’ for those measures that health care justice advocates keep attempting to advance.” Usually when people use the term “work arounds” they are referring to finding ways to do what needs to be done in the face of bureaucracy or inefficiency. In this case, however, it means propagating inequity in order to make money.

The two different approaches, putting “health” or “profit” as the primary impetus to our health care system, get different results. Personally, I favor “health”. Sadly, though, the other is often more prominent.

[1] Dickman SL, Woolhandler S, Bor J, McCormick D, Bor DH, Himmelstein DU, “Health Spending For Low-, Middle-, And High-Income Americans, 1963–2012”, Health Affairs 35(7):1189

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