[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. http://healthaffairs.org/blog/2014/03/17/nine-questions-about-my-new-medical-home/
[3]
Collins J. How the might fall: and why some companies never give in.
Collins Business Essentials. New York. 2009.