Incremental change will not cure our health care system

Earlier this year I discussed (The denominator matters: we only have a quality health care system if everyone can access it!, February 16, 2020) an article from the New York Times by Elisabeth Rosenthal, the editor of the Kaiser Health News and an emergency physician, called “Where the frauds are all legal.” One of those “frauds” I focused on was “surprise” medical bills. “Even though you went to a hospital that was in your insurance network and saw a surgeon who was in your network,” I wrote, “it turns out that the ER group or the anesthesiology group contracted by the hospital, or the assistant surgeon your surgeon picked, is not in network. Boom! $10,000, $100,000 bills! No one is “satisfied” by this.”

In fact, this is not entirely correct. Yes, your insurance company is not happy about this if they have to pay the bill. Yes, you, the patient, are certainly not happy about it if the insurance company doesn’t pay the bill, or only pays a part of it, and you are stuck with the rest. Very likely, the hospital itself doesn’t like this if they themselves are indeed in your network, because it makes them look bad, and they know that you, and your insurance company, are going to hold them in large part responsible. So who likes it? Well, as you might guess, those doctors who are getting the big payments. In fact, probably even if the hospital tried to hire its own, say, anesthesiologists or emergency physicians, they’d have a hard time paying as much as those independent groups do.

But the other stakeholders who are happy with this arrangement are the owners of these physician practices, who are not always the physicians themselves but increasingly private equity funds, which have been buying out physician groups for a few years (‘Specialty physician groups attracting private equity investment’, Modern Healthcare, August 31, 2019). Expanding upon a “research letter” published in JAMA, JM Zhu from the Leonard Davis Institute of Health Economics at the University of Pennsylvania writes:

Of approximately 18,000 group medical practices, we found 355 physician practice acquisitions across a number of specialties, most commonly anesthesiology (19.4%), multi-specialty (19.4%), emergency medicine (12.1%), family practice (11.1%), and dermatology (9.9%). From 2015 to 2016, there was also an increase in the number of acquired cardiology, ophthalmology, radiology, and obstetrics/gynecology practices. Acquired practices had an average of 16.3 physicians, 4 sites, and 6.2 physicians affiliated with each site. About 44% of acquired practices were in the South. (‘Private Equity Investment in Physician Practices’, February 18, 2020).

Of course, it doesn’t take great acumen to realize that the reason that private equity investors are attracted to buy these practices is exactly the opportunity to profit handsomely from this “loophole”, by what Rosenthal calls “legal fraud”.  In essentially all areas, the whole strategy of private equity funds is exactly this sort of “gaming the system”, finding the margin where the income far exceeds the cost because of some loophole in the law.

This demonstrates several flaws in our current healthcare “system”. The most obvious is the specific problem created by “surprise” bills, one that has been even recognized (although not addressed) by Congress. For example, HR 3502, “Protecting people from surprise medical bills”, introduced in this congress by Rep. Raul Ruiz (D-CA). It could pass the House, and if both the Senate and White House flip, it could even become law. Of course, it would have considerable opposition from the very equity firms that are making money from the current situation. This is the second flaw – legislation to regulate the system often fails because those who make big money from the very problems such regulation is intended to correct have – big money. They can give contributions to legislators.

Every inequity in health care, every exploitation of the system, results in (and usually from) someone making money, and those “someones” are very interested in preventing the issue from being corrected. This holds true, as I have previously discussed, for hospitals (“health systems”), long term care companies, pharmaceutical and device companies, and insurance companies, as well as equity-owned physician groups. Kansas Congressman and GOP Senate candidate Roger Marshall, according to a recent article in the Kansas City Star by Shorman and Lowry, pushed for aid to physician-owned hospitals (ones not yet bought up by for-profit equity companies) while his wife, as a partner in real estate ventures that owned the land that they were on, profited greatly! In this case it didn’t even require contributions to politicians; the politician was in it for himself.  You can be sure that if there is a buck to be made, someone will be making it. You can just be certain that it isn’t you, the patient, particularly if you are uninsured, poorly insured, or poor. Of course, if you are, you’ve probably figured out by now that the system overall is not designed for you!

The design of the capitalist US, particularly so in this age of corporate “gangster” capitalism is to make money for the wealthiest and everyone else be damned. The only question that might still be open to discussion is whether people’s health, and health care, should be subjected to the same rules of that system as consumer goods. After all, it is your health, your life! Your family’s health and life! The same could, and should, be said for other basic necessities such as food, shelter, and education, but health has special resonance such that every survey of the American people finds overwhelming support for the idea that everyone should be able to get adequate healthcare, and agreement that profiteers such as insurance companies and pharmaceutical companies are bad guys (there is less awareness of the role of hospital systems, still less of the private-equity-owned physician groups discussed here).

The third key aspect (I keep wanting to say “flaw” until I realize there are strong advocates for these policies) that this illustrates is the fatuousness of trying to solve the problems of our health care system and its exploitation by profiteers one issue at a time. Each scam that has been exposed and addressed by regulations or legislation (more rarely) has generated another; each loophole that is supposedly “closed” contains exceptions. The problem isn’t “bad apples” (although there are many), it is the whole system and the powerful forces that wish to continue it.

While Republicans policies are often targeted at eliminating any regulation, and indeed encouraging overt corruption and exploitation, “mainstream” Democratic policies are about putting in occasional patches, and then saying “there!” until another scam pops up. The Democratic Party, like the GOP, is beholden to rich donors, and a high percentage of theirs are financiers. Their mantra, clearly articulated by Joe Biden, is that we need to keep the private (read: profit-making) sector, and not change everything. Unfortunately, if the goal is actual to make the health system more equitable and increase the nation’s health, it cannot work.  It certainly cannot contain costs; the very profit that these companies make IS the cost!

The only solution is a comprehensive change to our entire health system, one that eliminates the incentive for profit-making altogether. This will work, is a good idea, and is what we should do, starting with Medicare for All.

Government programs should reward hospitals for reducing inequities

Systemic racism is ubiquitous in the United States, despite the denial of its existence by Vice President Mike Pence in the vice-presidential debate. It is different from individual racism, the kind people most often talk about (frequently in the context of the phrase “I’m not a racist, but…”, generally indicating that they are). While it comes from the same roots, a belief that people of non-White races are not equal (and maybe not even people), it has then led to a structure, or set of structures, that continue to disadvantage people of color even when there is no current intent to do so; this is its insidious nature.

Structural racism has a big impact on health care, as this blog has often discussed. The health care system in the US has evolved within a racist structure, and as its inequities create victims, people of color are disproportionately affected. Ironically, often attempts to “solve” problems – of cost and quality in particular – exacerbate the situation and increase the inequities. The reason for this is that they are not comprehensive solutions, but rather compromises that have been arrived at, often after lobbying by hospitals and healthcare corporations, which continue to allow “gaming” of the system in a way that creates losers, and the losers are almost always the poor. And, as a result of structural racism, members of minority groups are overrepresented in the ranks of the poor.

This is not to say that there is never malicious or evil intent. There is, and, as usual, its roots are in money, the desire of institutions involved in health care to maximize their income and profit, and their influence on the policy-making process to allow them to pursue those goals. This is discussed in detail in a recent NY Times Op-Ed by Navathe and Schmidt, “Why a hospital may shun a Black patient” (October 6, 2020). The article identifies a number of ways that programs intended to address existing problems, have a negative impact on the poor and on minorities. The underlying structure is one in which doctors, and more important the health systems in which they work, are oriented to doing procedures that generate the most money in profit. This of course tends to discriminate against the poorly insured and uninsured, as I recently discussed (Hospitals compete for money, not the people's health. We need to stop this, August 31, 2020).

Navathe and Schmidt note several programs aimed at improving quality and lowering cost, all of which have the (presumably) unintended consequence of making hospitals and doctors less interested in providing care for higher-risk, poor, and minority patients. These include programs that pay for “quality” without taking into account the populations the hospital cares for; people who are healthier (and less poor) to start with have better outcomes. Other programs “rank” – and more important pay -- doctors and hospitals based upon their outcomes for surgical procedures; this provides strong motivation to not care for high risk patients. And

consider the Hospital Readmissions Reduction Program, which penalizes hospitals for excessive re-hospitalization. Again, the intention is noble: to discourage hospitals from skimping on care in a patients’ initial hospitalization such that the patient returns to the hospital soon after being discharged. But since people with worse living and working conditions are readmitted more frequently, hospitals that serve more worse-off racial and ethnic minorities were more frequently penalized.

The results are in. Those hospitals (especially public hospitals) that provide care for a much higher percent of poor and complex patients do much worse on these “quality” rankings, and thus get less money from these programs. Not only do richer patients get better care, but rich hospitals get more “bonus” money.

The COVID-19 pandemic has further exacerbated these inequities, creating a syndemic (Freeman J, “Something Old, Something New: The Syndemic of Racism and COVID-19 and ItsImplications for Medical Education”, Fam Med. 2020;52(9):623-5) that penalizes both poor and minority patients, who are more likely to get infected and get sicker, and the hospitals that care for them. Hospitals tend to serve the communities in which they are located, and the neighborhoods with higher concentrations of poor and minority people have been far worse hit, as documented by Feldman and Bassett in an article which looked at neighborhood poverty and mortality from COVID-19 in Cook County, IL (“The relationship between neighborhood poverty and COVID-19 mortality within racial/ethnic groups,” medRxiv preprint doi: https://doi.org/10.1101/2020.10.04.20206318, posted October 6, 2020). This is the first study looking at mortality among minority (Black and Latinx people) and neighborhoods relative to income. They looked at 3 kinds of difference: age (<65 vs >65), race/ethnicity, and income level (divided into 4 quartiles by neighborhood). For the younger (<65) population, the most important determinant of mortality was income, with those in the lowest income group having a mortality rate of 13.5 times that of the highest, but there was not a significant difference in mortality by race in this lowest income group. For the older group (>65), however race was an enormous predictor, with minorities having 3x the death rate of Whites, and  Whites in the lowest-income group having a lower mortality rate than minorities in the highest income group.

This table summarized age-and-gender adjusted mortality per 100,000 people:

The two articles tie together. The worst disparity in mortality is in the over-65 group, which has Medicare and are thus not uninsured; however, they have the accumulated deficit of a lifetime of negative social determinants of health (SDH) with a much higher rate of pre-existing chronic disease. They also access hospitals that are overburdened with low income people which have, as described above, benefited less from “quality” and “value” payments. This, then, exacerbates the existing inequities of the system.

 

What to do? Navathe and Schmidt have a number of suggestions, focused on making reducing disparities a criteria for any “quality” or “value” based payments. They specifically suggest that this be an explicit goal for any program, that all such programs be subject to “disparity impact monitoring”, and that “we need a complete and detailed picture of the full extent to which payment reforms are conduits, or barriers, in reducing health disparities and structural racism.” These are good ideas, in fact are necessary to prevent unintended consequences from hospitals “gaming” the system.

 

But there is more that we can, and should, do. Navathe and Schmidt note that one relative success has been in programs that provided fixed funding to hospitals for all the services that they provide, rather than paying per patient or per procedure. This should eliminate any incentive to pick patients with better insurance or “better” (i.e, more profitable) diseases.  The example that they use is the Pennsylvania Rural Health Model, a collaborative effort by Medicare, Medicaid and private health insurers. Because these are rural hospitals which presumably provide care to everyone in the area, it can work. In an urban area, however, fixed funding can be susceptible to a third kind of “gaming”: selecting (by marketing to) people who are less sick and thus cost less to care for (“Oh, you have this [high cost] disease? Why don’t you try St. Elsewhere? They do a great job with patients like you!”) What we need is a system that combines strategies to prevent all three forms of gaming, by providing a fixed budget to hospitals that is not dependent upon the individual services they provide, but does take into account the cost of taking care of the population that they do, and is re-negotiated annually.

There actually is a system nearby that does this. In Canada. That is how hospitals are reimbursed under their single-payer Medicare system. That is what we need here too.

Doctors need to care: It's about the patients, not about you

 

 Recently, a friend of a friend had an accident and fell in her driveway. After two days of pain that did not improve, she went to an urgent care center where an x-ray was taken and the PA told her that there was no rib fracture and her lung had not collapsed, so she went home. The next day the urgent care center called back and said “whoops, there is a rib fracture and you do have a collapsed lung”. They said they’d call her primary care doctor, but didn’t. The patient tried to, but the doctor was on vacation. The covering physician refused to see her. So our mutual friend, who is a physician and surgeon who lives 1000 miles away, called someone who lived in the patient’s town to take her to the emergency room. There, they re-x-rayed her, and admitted her to the hospital, telling her that they would need to insert a small tube to remove the air (called a pneumothorax) from around her lung. The doctors said she refused the procedure, although she says she just asked some questions about it. She was admitted for “observation”, and given oxygen. In the morning, since the x-ray was no better, they said that they would have to keep her in the hospital, but this later was reversed on a visit from the resident on the hospitalist service, who said she could go home.

 Our mutual friend called the resident, asked about it, was told that it was OK to discharge her (quoting the “resident’s best friend”, the medical information website UpToDate®) and would not put the friend in touch with the attending physician. However, the patient was terrified about going home, especially given her accident, that she lived alone, that she had had her bad experience with the urgent care center, and that her physician was out of town. I suggested that our mutual friend might try to contact a hospital administrator to see if the attending physician could be reached. Then I got a message that there was a new hospitalist over the weekend, who happened to be a family physician, and who tried a novel approach: she talked to the patient, examined her, and reviewed the chest x-rays. After this, she decided to call a pulmonary specialist, and it was decided to insert a chest tube. The patient, with the proper treatment, improved and should get better.

 So probably the story will have a happy ending, at least from the point of view of ultimately getting the right treatment. The woman who was the patient may recover physically, but is unlikely to recover a lot of faith in what is amusingly called our health care “system”. The number of things done wrong were many, and most could be blamed on the individuals; the PA in urgent care who mistakenly thought that they could accurately read the chest x-ray, the provider in the emergency department who was apparently in too much of a rush to answer her questions and decided the fact that she had them meant she was refusing the recommended treatment, the hospitalist service who changed their mind about her need for hospitalization without explanation, the resident who would not contact the attending physician, and the attending physician who apparently did not want to be contacted.

 But to blame just the individuals would be incorrect, although we can be very enthusiastic in lauding the weekend hospitalist who decided to actually care for the patient. The system is critical here. I do not know that hospital, but I imagine the doctors in both the emergency department and on the hospital floors are stressed an overworked, and that the way they responded to the patient in question, while unjustifiable, was probably caused in part by that overwork and stress. The resident may have been the “point person” in contact with the patient, but the service attending was ultimately the one making the decision. Poor role modeling by attending physicians and senior residents is common and leads to poor behaviors by residents, who are often more concerned with their own workload or pleasing their bosses than providing proper patient care. In such busy situations, patients are often assessed quickly, and judgements are made not just regarding their medical problem, but their personality. Are they going to be a “good patient” – meaning that they will quickly accede to doing what I am recommending -- or are they going to cause me “trouble” and cost me time? That trouble can be real if the patient is aggressive, intoxicated with alcohol or other substances, or has a serious mental health diagnosis, but it is sadly true that the label “troublesome” patient can even be applied to someone who asks perfectly appropriate and reasonable questions about the treatment being proposed for them.

 Racism provides us with a bit of a metaphor, in the sense that there is both an individual and a structural (or institutional) component. Yes, behavior by individuals can be inappropriate and wrong and blameworthy. But if we leave it at that, if we do not understand the overall structure that encourages or facilitates such individual behavior, we will never solve the problem. We will never decrease or end racist behavior, and we will never ensure that patients get treated with the respect and concern that they should. Racism affects the medical system and medical education as it does the rest of society, but disrespect and self-centeredness can inhibit appropriate medical care even when race is not involved. Indeed, in this case the patient was a 70-ish middle-class white woman. One can imagine with what frequency, and to what degree, people are treated with disrespect – and poor medical care – when they are members of minority groups, poor, homeless, have a psychiatric diagnosis, are not clean and nice-smelling, are not coherent, are under the influence of a substance, etc. Of course, if one is a health care worker, one need not imagine it; one sees it all the time.

 As a family doctor, I would like to take pride in the fact that the “hero” of our story also was one. In fact, I will. I actually believe that the training of family physicians, and the emphasis on caring for the patient rather than a particular problem, makes a difference, and enhances the caring characteristics of the individuals who choose to enter this specialty. That is, I think it is more than a coincidence. However, of course there are wonderful caring physicians, including resident physicians, in every other specialty, as well as family physicians who are jerks. I just think that it is a smaller percent.

 Should there be any jerks in medicine? I have heard it argued that in some specialties, it is not necessary to have good “people skills”. In pathology, or diagnostic radiology, or even anesthesiology, where the doctor spends little or no time with living patients. Or in surgical and other procedural specialties, where technical skill, not “bedside manner”, is what matters. Sometimes I have acknowledged that this made some sense. Until I thought about the colleagues I have had in every specialty. And in every case the good ones cared about the patients they were involved with, whether or not they met them face-to-face.

 The pathologist or radiologist knows it is also their patient, and the use of their skills in the performance of their jobs may make the difference in a person’s life, or death. They care. Caring may not be the same as “people skills”; we recognize that some people have greater difficulty connecting directly with others, and are certainly not trying to create a profession full of hucksters and snake-oil salesman with false charm. But we do want one whose practitioners can convey concern, and caring, and at the minimum not disparage the people who are in their care.

 So, yes, I think that everyone admitted to medical school should care about people. And, yes, I think that we need to ensure that our medical education does not beat or role-model it out of them. Our residents need to have schedules and lives that are reasonable enough that, when they are tired or frustrated, they don’t act out. Our attending physicians need to be available.

 Even when you are tired or overworked, it is not ok to be cruel or insensitive any more than to be racist or sexist. After all, there is a reason that this profession exists, and it is not to provide a good life for the practitioners. It is to try to maximize the health of the people for whom it cares.

"If the only tool you have is a hammer..."

 “If the only tool you have is a hammer, everything looks like a nail”.

 This old adage has been applied in many contexts, and sometimes appropriately to the work of medical specialists, particularly those who do procedures. It is something that family physicians and other primary care doctors are only too well aware of; before referring a patient to a specialist equipped with their hammer, we like to do our best to make sure that this is the right tool for the job. Perhaps, metaphorically, the family physician has the full range of tools on their belt and can thus address most medical problems, but sometimes the complexity of the treatment that a patient needs requires someone with great expertise. Pushing the metaphor, a general contractor might think that a particular job needs a skilled electrician.

Sometimes, really a lot of the time, subspecialists are consulted for their opinion of a problem, because it is an area in which they have in-depth knowledge. This is not a bad thing at all, as long as that opinion is guided by the evidence that exists and not by the doctor having limited their knowledge to the extent that they know only one approach, or, worse yet, are guided by the potential to make money doing a procedure. This happens, but, thankfully, less often than it could. Most commonly, the issue is not lack of knowledge on the part of the specialist, or even greed, but rather a sense of what others expect of them.

If you present to a primary care doctor with chest pain that sounds like acid reflux, they’ll probably prescribe treatment for acid reflux, with caution about changes in the character or frequency of the pain. If the pain sounds a little more suspicious for cardiac angina, they might refer you to a cardiologist. After examination, history and physical, the cardiologist might think it is probably acid reflux. But – and it is a big but – because they are a cardiologist there is a good chance that they will maybe do more tests, expensive and possibly invasive, because, since they are a cardiologist, missing a potential cardiac diagnosis would look worse. Plus, even if the cardiologist is not greedy (or is even on salary, not paid per procedure) the organization they work for might want them to run profitable tests.

For the society, this means a lot of extra tests are done, and this is costly. For the individual, especially if they are uninsured or poorly insured with a big deductible or co-payment, it can be particularly costly. Plus, for the individual, it can be risky – few procedures have no risk of harm, and the more extensive and invasive the greater the risk. That said, they can also be beneficial or even life-saving. The key is to do them when they are necessary, or the evidence suggests that the probability of benefit outweighs the risk of harm, and not otherwise. Of course, we ourselves, patients (or, to use the English word, people) often demand an “answer”, even if the answer is not going to be clear and/or the methods for obtaining it not without risk. When I tell people that the results of their tests to rule out potentially dangerous causes of their symptoms are normal (I try to not use “negative”, which sounds, unsurprisingly, negative!) they often respond “But what is it?” I have to tell them that I still don’t know, but I have discovered it is not something that is really bad. That is always a good thing. Finding out that the cause of your symptoms is not cancer, for example, doesn’t tell you what it is, but it is  lot better than finding out that it is cancer!

Of course, this whole incentive to intervene, to do more sophisticated, high-tech, complex, invasive, and expensive tests or treatments, applies only to that segment of the population that is well-insured or rich. It is an incredible source of inequity, because a different set of decision rules is applied to different groups of people depending on their ability to pay rather than the medical need (or lack thereof). Yes, people with good coverage may get too many tests, which not only cost a lot and have some risk of harm in themselves, but also can snowball into needing to repeat tests or do more complicated ones if there is a suggestion of abnormality in the first set. [Think of the math in terms of something as “simple” as panels of laboratory tests. “Normal” is usually based on 2 standard deviations from the mean value in that lab, 95%, so 5% of normal people might have an “abnormal” test result. But if 20 tests are done – and their results are independent of each other – the probability that someone’s results are “normal” on all 20 might be .95^20 or about 35%!] This can result in harm to people with money.

However, it is still more common for people without money or good insurance to suffer harms because they do not get the testing and treatment needed. And, unsurprisingly in the US, racism enters into the mix; Black Americans are less likely to get recommended diagnostic and treatment interventions for heart disease than White, even when they are insured!

What can be done? Changing medical education to teach that interventions should be done based on the overall evidence, not evidence selected to lead in a particular direction, could help. This has actually improved; when I was in medical school most of the surgical literature, for example, was case series (“We did this procedure on X people, and this many got better and that many died or got worse”) without control groups or controlling for how sick people were. (A famous study in my medical youth compared surgical intervention for coronary artery disease with medical treatment. Surgical was better. Of course, all the people with other diseases that made them at higher risk for surgery were allocated to the medical treatment group!)

Another very big thing would be to make sure EVERYONE is adequately insured. Not more people, but everyone. And, best, with the same insurance, so there is no gaming the system to get the folks whose insurance pays the most. If everyone has the same insurance – most simply, improved and expanded Medicare for All, there is no financial reason to do, or not do, tests or treatments on anyone (this would not,of course, cure racism).

Also, more primary care doctors would be great. As research presented by Etz and Stange at the recent Society of Teachers of Family Medicine (STFM) conference, and published in the Annals of Family Medicine has shown, currently primary care sees 50% of all physician visits (500,000,000) with only 30% of the workforce and <7% of the dollars (and, for the academic researchers, 0.2% of NIH funding).  More primary care physicians, which would almost certainly result from (and probably require) a lot larger portion of the money spent on health care to be directed to primary care, would almost certainly lead to more equitable and higher quality care for everyone.

A highly-placed non-medical health care executive once asked me (a family doctor) why he would go to me with a prostate problem instead of a well-known urologist. Skipping over “how do you know it’s a prostate problem?” I said “I guess it depends upon whether you want surgery or not.” Oversimplistic, perhaps, since urologist might provide other options, but not entirely unrealistic. The urologist’s job may be, in part, to care for prostate problems, but their training is to operate. 

By the way, the executive had no follow up questions.

Hospitals compete for money, not the people's health. We need to stop this.

For decades, Santa Fe, NM, had only one hospital. St. Vincent’s was founded 155 years ago by the Sisters of Charity, but was taken over by the national Catholic corporation CHRISTUS in 2008. It’s a pretty good hospital with about 200 beds, for a small city of 85,000. A couple of years ago, the largest health system in New Mexico, Presbyterian, opened another hospital. It is a big building, but has only 30 beds, so its additional contribution is not primarily general inpatient care. Interestingly, while the hospital is on the far southwest side of Santa Fe, its main medical center building is directly across the street from St. Vincent’s. This is obviously not a coincidence, as it is now firmly in the center of the area in which people are accustomed to coming for medical care, establishing itself, at least for outpatient care, as a competitor.

The point that I want to talk about is not hospitals in Santa Fe specifically but rather competition among hospitals in general. This is not a problem in rural areas and small towns where the struggle is, rather, to hang on to their hospitals at all (often with just a very few inpatient beds, and almost invariably losing money). It may not be a big issue for mid-size cities like Santa Fe. It is a huge issue in the major metropolitan areas where most hospitals and doctors are, and where there are the greatest concentrations of patients (the medical term for what in English we call “people”).

In these areas, you will find that almost every big hospital (or “medical center” or “health system”) has a Cancer Center. And a Heart Center. Centers for Orthopedic Surgery and Sports Medicine are also big. And in the last decade Neuroscience centers have joined the ranks of “must-haves” for each of these centers. Of course, if they deliver babies, they certainly will have a Neonatal Intensive Care Unit. What is wrong with this? Are these not important, serious diseases that can and do kill a lot of people and need treatment? Am I advocating against treating, say, cancer?

Not at all. But while there are a lot of people with cancer, it is a finite number. Was the new Cancer Center just opened to a lot of hoopla at St. Elsewhere necessary because there were many cancer patients for whom there was not room in the Cancer Center at Downtown General, opened a few years ago, and now would have an opportunity to receive treatment? Or, just perhaps, is St. E’s hoping to attract many of the patients, and perhaps the doctors, who currently use DG to instead use their new, glitzy, state-of-the-art facility? Is it a simple matter of competition for a limited market?

If we had a medical care system that was based on the health care needs of the population, we wouldn’t have such redundancy of facilities; we would have enough for all the people who need care and not unnecessarily duplicate services. Downtown General might have centers of excellence in cancer and orthopedic sports medicine, while St. Elsewhere might be great for heart and neonatal care. And, since we are fantasizing about a system in which the driving force is the health of the people, let’s throw in primary care and mental health. But that doesn’t happen. And, in our hypothetical city, even with both cancer centers (and perhaps yet another at Doctors Medical Center), there will still be bunch of people who cannot receive care because they have no insurance or their insurance is poor (i.e., they are “underinsured”).

So, in addition to creating excess capacity, which creates major excess cost, competition in medical care services doesn’t meet the needs of all the people. The true driver of the health system, making money, creates at least three major sources of inequity:

1. The services are only for the well-insured. Entire groups of poorly-insured people are excluded. The services offered by these special centers may be highly-profitable, but only if they get paid. They don’t make money providing care to poor or uninsured or underinsured people. 
2. The services offered are those that are highly profitable, and most often this is for particular procedures. Yes, cancer is bad. So is heart disease. But the real reason for these centers is that these conditions are very well reimbursed by insurers, so the hospitals (and doctors) make a lot of money (provided the patients meet criterion #1, of course). For example, while chemotherapy drugs are ridiculously expensive, of course, making money for the pharmaceutical industry, the hospital makes money on the “administration fees” which are far in excess of the actual cost of administration. In addition, the creation of new “centers” are often driven by a single procedure. No one had big “Neuroscience” centers until the procedure for inserting a catheter into a brain artery to pull out a clot was developed. THAT is reimbursed incredibly well! All of a sudden every big hospital needed a “Stroke Center” and started competing (and paying a lot of money for) “stroke doctors” (who might be neurologists, neurosurgeons, or invasive radiologists) who could do this procedure. But poorly reimbursed services? No matter how much the people need them, don’t expect lots of new centers for primary care. Or mental health. Or even general surgery. Essentially, we discriminate not only against those who are poor or uninsured, we discriminate against those who are unlucky enough to have poorly-reimbursed diseases!
3. The third great inequity is obviously geographic. If you live in a major metropolitan area, and are well-insured, you can have your choice of which hospital is the best for your problem. You consult US News, ask your friends, read the ads. But if you are in a small town or rural area far from such a city, it’s a long trip. And not worth making if you don’t have the money.

What can and should we do? In the long term, we need to eliminate the motivation of hospitals to compete for profitable services by putting them on a global budget, which is what is done in Canada as part of their single-payer health care system, called (interestingly) Medicare. And, of course, we need to cover everyone so there are no people left out because they are poor and uninsured, a universal health insurance system, not “cover more” but “cover everybody”. And by long term, I mean as soon as possible.

In the mid-term, we must change policies to much less dramatically favor certain procedures at the expense of others. Pay more for mental health and primary care. Pay less for cancer drug administration and sucking clots out of brain arteries. Stop making it so much more profitable to do knee surgery than gall bladder surgery. The availability for any kind of procedure should be based on the need for it, not how well it is highly reimbursed. That is a totally backward motivation, and dangerous to our health. This can actually be done by federal policy simply by changing how (US) Medicare values and pays for services. Because Medicare is the largest payer, it sets the market rate. Private insurers may pay more, but it is always “multiples of Medicare”; the ratio of what is paid for one medical service relative to another is set by the federal government.

And while we’re at it, let’s eliminate the universal tax-breaks “non-profit” hospitals get for anything that they do, which are mostly things that will make them money! As evil in many other ways as for-profit hospitals are, they are at least required to pay taxes, and go to the capital markets for capital expansion. No donations to a hospital should be tax-deductible if they are going to be used for a money-making scheme. Again, in Canada capital budgets are separate from operating costs. A hospital is not motivated to increase its operating profit so it can expand and build, to better compete with others. It must apply for additional capital funds, which will only be available if they serve a health need.

In fact, this is something we can do in the near term. As citizens and donors, we can demand that the next opulent fund-raising gala for our local hospital is not for the purpose of expanding money-making services, but rather to expand those services to those who cannot currently access them. The money raised should be earmarked only for, say, providing cancer care at our great cancer center to uninsured people. That would be something for which tax-deductibility is justified.

It is outrageous that our health system in the US is structured to maximize money-making and not health. But as in so much else in our society, those making the money have a lot of it to use to exert their clout. It is going to take a massive national effort by the people to make the changes that we need to have.