Fight On Healthcare Reform Misses Core Problems

Politicians and policy makers are fighting over new health reform proposals.

This debate misses the core problems in US healthcare.

Look at this graph from the Our World In Data website:

From Our World In Data website

It shows that Americans pay too much for lousy health outcomes.

Fixing the problem on that graph should be the focus of reform.

I am no policy wonk but here are some obvious problems and potential solutions with our delivery system:

I – Profit-driven healthcare must go. As long as health is big business, it will be impossible to control costs.

Fee-for-service (FFS) payment models favor doing more things to people. The more you do, the more you and your employer (usually the hospital) make.

Some might argue new payment models are moving away from FFS and towards value-based compensation. These new payment reforms are a joke. First, quality measures do not reflect real quality. Most doctors who touch patients feel quality measures reduce quality. Second, the new models favor gaming the system. In the past, an AF doctor would document AF as the problem addressed. Now, most AF doctors will list numerous other diagnoses, such as overweight, stress syndrome, high blood sugar, hypertension, sleep apnea etc. Why? Because the new game is to make patients seem complicated.

II – Speak Hard Truths. Someone needs to say that our country cannot afford to keep delivering low-value care. Doctors know what low value care is, but we keep delivering it because we are paid to do so, and because people conflate getting more care with good care.

The VA healthcare system takes a lot criticism but studies show their outcomes are similar to hospitals in the private sector. That’s not surprising because when you have to care for large groups of people with a fixed amount of money, you make choices: the sick get needed care and you burn less money on low-value care.

It’s important here to say that less care is not always the right choice. Sometimes more care is the right call. The problem now is that wasteful care of the haves make it less likely that the have-nots get essential care.

Our lack of courage on making hard choices leads to inequities of health outcomes among the less fortunate. That is an ugly blemish on our country.

III – Take better care of the dying. End of life care in the US is a mess. Cardiologists and cancer doctors could help the situation because so many people die of heart disease and cancer. Atul Gawande wrote that hope (for the tail of the bell curve) is not a plan.

If people knew the reality of their illness and the reality of their therapies, more would choose care that centered on comfort. When people die slowly attached to machines in the hospital or in nursing homes, everyone loses.

We don’t have to deny care to the elderly—just tell them the damn truth. The default should be that death is normal. Yes, we would like to delay it, but this comes with trade-offs.

IV – Slow the growth of non-caregivers. The complexity of our healthcare system drives the need for administrators. Numerous studies have shown that doctors spend increasing chunks of time doing paperwork, billing and non-clinical care duties. That’s a problem because it decreases access to care, distracts the caregivers and adds cost.

If doctors were salaried, and there was no need to game the billing systems, we could use those extra hours talking with patients rather than just ordering tests on them. Healthcare reform measures should decrease complexity so doctors and patients can spend more time together.

JMM

10 comments

  1. Dr. John, Bravo! (again) and thanks for your honesty/integrity. They are rare & disappearing character traits in this money grubbing, corporate controlled, mostly dysfunctional U.S. medical service provider culture (and American society at large, it seems.)
    I am old enough to remember when honesty was a social norm. Now it is unapologetic dishonesty that fuels politics, business, culture, etc. One has to wonder where we are headed when none of our institutions are trustworthy.

  2. I would “ditto” the above on-target comment by Joan Lardin. What you state John is so painfully OBVIOUS that I continue to be amazed at how so many folks (especially those currently driving decision-making) seem to ignore especially your point #1. But then again, isn’t it “all about the money”. Sad that this is our current state of affairs … THANKS for writing this post!

  3. ….and reform health literacy education. If your high school senior graduates without the knowledge of which side his appendix is on or the definition of a normal blood pressure he will cost the system more than he should

  4. In my country we have a free, universal healthcare system.

    It’s by no means perfect. Many people here have private health insurance as well – its nice to be inside a freshly painted hospital instead of one with faded green painted walls, and its nice to be brought a tasty meal in your bed and have a glass of wine instead of getting hospital issue food.

    But ultimately the public system will provide you with basic healthcare for almost any ailment, even if its slower than you would like. So when I read about people in the US being unable to get meds to control their AF because of some “insurance problem”, my heart really goes out to them. I can’t imagine being unable to get Flecainide to control my AF. No-one should ever be unable to get basic meds. Any system that allows its citizens to suffer like that really needs some drastic fixing.

    Ironically, whats bad for America is not so bad for the rest of the world. The money fuelled monster that is Amercian healthcare churns out technological innovations that the rest of the world gets to benefit from.

    But I really hope that one day the US works out a way to provide basic healthcare to all its people.

  5. Your points are valid but perhaps somewhat paradoxical. Yes healthcare is a mess. Yes doctors should spend more time caring for patients and less time with paperwork. But where did it go wrong or more precisely when?
    Patients aren’t made to seem complicated, they are complicated. They are complicated because the system failed them long ago. There is no patient accountability. We don’t teach it we don’t penalize it – at least not directly.
    If misuse or overuse is an issue anywhere it is at the extremes of affordability. Rich people want to buy healthcare believing they are extending the quality and length of their lives. Poor or subsidized healthcare is overused because perceived value exceeds cost. In the middle, people try to save money by skipping insurance altogether believing they are healthy and don’t need it or avoiding the dreaded copays and deductibles. The middle is the answer. We need the populace to recognize healthcare is a commodity. Use it less and costs go down but use it enough to avoid morbidity.
    We need a “do over” at the education level. Healthy habits and the long term impact are often taught in elementary or middle school when mortality or even the idea of adulthood is barely grasped. It may as well be a myth.
    Profit driven healthcare is a misnomer. There is no profit in healthcare – at least not for clinicians and healthcare organizations. With margins as thin as 1-2% no one would consider that a good business model! There is barely room for capital reinvestment. Most organizations make money on investments rather than the fees for services.
    Nearly a century ago the AMA derided any action that would insert a third party into decisions between a physician and his patient. All we have done is continue to insert more barriers. Nearly every action taken has had negative effects on patient centered care while an entire healthcare industry has risen to the second largest economic factor in America after the government.
    Where does the money go?
    How do we get patients to participate in this pyramid scheme?

  6. I heard a commentary on US healthcare, during the debates over ACA, that US results are much better compared with the other OECD countries when we take out gunshot wounds/death and auto crash results from the metrics. I am certainly not in a position to make such an adjustment, but it seems that if our culture is driving the negative health metrics, it’s a separate question from incentives and payment systems.

    That said, as long as we spend 16% or whatever of GDP on health care, the money comes from somewhere.

  7. The following article from 2007 details a statistical confusion. The US has more death from acccidents and murder than its peers, among other causes. US infant mortality is higher primarily due to a strict reporting standard (all births, no matter how premature) and more premature and defective births from aggressive in-vitro fertalization for older mothers.

    Total mortality is a bad measure of medical effectiveness. One might think that such organizations as the World Health Organization wanted the US to look bad. A government pushing ObamaCare might also want the (former?) capitalist health system to look bad.

    http://politicalcalculations.blogspot.com/2007/09/natural-life-expectancy-in-united.html
    Natural Life Expectancy in the United States
    === ===
    [edited] The CDC’s (US Center For Disease Control) life expectancy figures also incorporate non-natural causes of death, such as those resulting from fatal injuries, which include motor vehicle accidents, falls, accidental poisonings, and homicides.

    These factors represent the leading causes of premature death in the United States for all ages up through 44 years old. Premature deaths caused by these non-natural factors result in a lower life expectancy figure for the U.S., which gives a somewhat misleading picture of the general health of U.S. individuals.

    Without accounting for the incidence of fatal injuries, the United States ties for 14th of the 16 nations listed. But once fatal injuries are taken into account, U.S. “natural” life expectancy from birth ranks first among the richest nations of the world.
    === ===

    The WHO (The UN World Health Organization) statistic that the US is 37th in health care efficacy is commonly repeated and is deeply misleading. See support for this is at ( http://easyopinions.blogspot.com/2009/01/usa-healthcare-is-first-infant.html ) “USA health care is First – Infant Mortality is Low”. The WHO offers various rankings. 37th is the most biased and political one, showing the worst result for the US. The WHO rankings are untrustworthy when you look under the surface at their methods, also at the link.

    The following video criticizes Canadian health care. Canada saves money by making patients wait and sometimes die before they can be treated. Sally Pipes understands and lived under Canada’s national health care system. She gives some personal stories and other facts.

    ( http://www.youtube.com/watch?v=9EYmDnFrHCQ&feature=player_embedded ) “The Difference Between Canada and the US Health Care Systems ) (video 7:34) Through the Cato Institute.

Comments are closed.