Where is the healthcare crisis?

"He's dead, Jim."

“He’s dead, Jim.”

So here’s my beef. At the recent Forbes Healthcare Summit  there was a lot of focus on speakers and vendors offering very cool new tech, from future “Tricorders” that can diagnose multiple diseases, is non-invasive, and hand-held; personal genomics, where data from your own genome is cheap and easy to get and can be integrated with clinical knowledge to produce better care; targeted therapies for various diseases, using the specific biology of a patient and her disease to design a treatment.

All of these are awesome, but really have little impact on our most pressing healthcare problems.

In the U.S., we manage to deliver a triple-whammy: health care that is less effective than in other nations, is only available to limited numbers of people, and costs a ton. There are a number of factors that go into this, most of which are historico-cultural.

Since the end of World War II, we have insured people largely through employers, setting up a system where those who can least afford it to find insurance on the open market. Obamacare, which is largely insurance reform rather than healthcare reform, takes some steps toward patching this problem, but not solving it. Healthcare exchanges will probably make privately-purchased insurance more affordable, but when you’re not making money, the price difference isn’t significant.

We have social safety nets developed during the Depression and the late 60s-early 70s. These are supposed to protect our most vulnerable, and do to a degree. Medicare—government insurance for the elderly—has been wildly successful. It’s relatively easy to work with, but from a doctor’s and patient’s perspective. But it does cost a ton, of which more later.  Medicaid—public insurance for the poor—has had some hits and misses. It has managed to largely protect mothers and children, but generally leaves out any other poor people. It’s also poorly-funded, something that Obamacare will try to rectify, but there will be barriers, more of which later.

We talk up prevention but we largely don’t mean it. Many insurance companies and employers are starting to discover the cost-savings of prevention programs, but prevention is still less favored than treatment, and in the long run, treatment is more expensive, both in dollars and lives.

The key to many of these problems is to improve access and delivery of primary care, and to set up at least minimal care guidelines (that is, rationing). Like much of American industry, health care has been driven by capital and innovation, and has produced what earlier generations would call miracles. But these successes are outweighed by the failure to focus on the social aspects of healthcare, especially public health and cost. When capital for innovation comes largely from healthcare costs paid for by employees and insurers, the cart has driven the horse. Innovative care gets paid for after-the-fact, without significant evaluation as to cost-effectiveness and efficacy. A new heart procedure, for example, may be found help individual patients for a brief time, but if studied longterm, may be found to be too expensive and lead to flat or poor outcomes. But we learn that after it has been implemented. The immediate results seem great, the bills get paid, and no one’s the wiser. Except that we can’t afford it, and patients suffer for it.

This same trend drives the urgency of doctors to specialize. Specialists get to use the new toys, the ones that make the money. There is no systematic way in the U.S. to evaluate treatments for their medical and social utility, their cost-effectiveness. The ability has existed for decades, the will has not.

Many Americans tend to be fiercely independent and suspicious of government intervention in their lives. But the only way to have real healthcare reform is cooperation, and probably some top-down structure.

It’s true that individual insurance companies have economic incentive to cut costs. On the ground this gets very messy. Each insurance company behaves differently. If I want to get a test for a patient, the hoops I need for approval require completely different processes for each company. In the office, this leads to untenable waste, undoable work. It creates a dis-incentive for doctors to order tests, although I don’t know how that plays out in real life. Limitations on care should be on the basis of evidence, not inconvenience.

Electronic health records, seen as a critical step in improving communication, prevention, and cost of care don’t even communicate with each other. Rather than make data sharing easier, EHRs often create enormous, wasteful, useless records designed so that every entry meets the requirements of every insurer. Hospital discharge reports and letters from specialists have become useless and unreadable.

We have what is probably the most technology-intensive healthcare system in the world, and it has produced overall lousy results. Our focus should turn toward providing better, evidence-based and cost-effective care to more people. I really want a Tricorder, but I’m willing to hold off for a few decades to get our house in order first.

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  1. Julie Stahlhut

     /  December 29, 2012

    The spouse and I are in a metastable employment situation because of research budget cuts, and have to buy our own insurance for awhile after repatriating to the US from Canada. We calculated the cost of several plans, and the best will cost us between $12K and $14K in premiums and deductibles. No choice but to go for it — the consequences of a serious health issue sans insurance are too great. We’re fortunate enough to (a) have savings, (b) be reasonably healthy, (c) not have to support children, a mortgage,or consumer debt, and (d) be old enough to join the AARP. I don’t know how a family with children and a bout of unemployment can do it. Our taxes were higher in Canada, but we’re talking three figures, not five. This is completely insane.

  2. stefanid

     /  December 29, 2012

    The elephant in the room is the payment methodology for physicians. They are incentivized to do more, order more, spend more. No incentive for preventive medicine or the use of evidence based protocols.

  3. Elissa

     /  December 29, 2012

    As an outsider (in Australia), I see the insurance-though-the-employer thing as a large part of the problem in the US health care system. Individuals and families are not able to choose the insurance that suits them – they are (afaik) locked in to the insurer their company uses. There’s no incentive to the insurers to serve people better, because the people have no real option to take their business elsewhere.

    Of course, the hugest part of the problem is the distrust of government that permeates so many areas of life in the US. Even Obamacare perpetuates this insurance-based paradigm, because the idea of the government just providing healthcare is so unthinkable to USians.

    Sure, government funded health care has it’s downsides – it can be slow and patients can have limited choice in providers, and some things aren’t funded – but it’s so much better than a fully profit driven system. A nice balance between public and private gives the best of both worlds. You can’t get cost-effective health care where /everone’s/ goal is to make money out of patients. There’s profit being taken out of the system, there’s commercial pressure on treatment choices, pressure to get more people through the door for more $$, commercial limitations on treatment development (eg- using antibiotic eye ointment on newborns because the cheaper non-antibiotic treatment is not worth the $$ to get approved (leaving aside the issue that routine treatment is not supported by the evidence – whole ‘nother story)).

  4. As for preventative care, I’m not even really sure that it’s preventative care in the sense of establishing a care relationship with a primary care physician. It seems to me that many are giving lip service to preventative care by making employees jump through hoops with points programs, health care coaching, and profiling administered by TPAs. The employee gets a number that is supposed to indicate how healthy they are in a “standardized test, fill in the bubbles” sort of way and then given advice by nurses they’ve never met beyond a short phone call. Employees are told that it’s up to them to share the information with their physician, but none of that seems to me to be the same thing as preventative care.

  5. Barbarella

     /  December 30, 2012

    You being a primary-care provider, I am very interested in learning your view of preventative care which can be distributed to your patients, but isn’t. I have a strong suspicion that I am in an elite group, someone who works part-time in a public interest job with no insurance (a librarian), but I am covered by my husband’s insurance. I am creeping into old age (50+) and suffer from no illnesses which have been diagnosed, aside from arthritis and bipolar illness. (I have reached half of my lifetime cap on coverage for mental illness, although have been actively treated for less than two and a half years, not continuous.)

    Who is eligible for care, in a world where we test by procedures which are successful? If one is fifteen pounds overweight, are you dropped from your healthcare, as a risk existing outside the accepted norm?

    I don’t have a problem with government-issued or overseen healthcare. I would much rather pay for universal healthcare than some other expenditures, expensive defense implements, etc. But as a layperson, with little medical knowledge aside from what I read in magazines and studies, I have to rely on my primary care doctor to keep me informed about what health procedures are appropriate for me. The last time I was in her office, I was allotted approximately five minutes before she had to rush to the next patient. I was left with several questions which I wrote down and filed for my next appointment. I feel as if I am doing something wrong. Questions–I may have them, but where I can turn to ask them, has been left open in the current system.

    • Depending on the care environment (but largely everywhere) PCPs don’t have enough time. I rarely leave a room until I (and hopefully the patient) think we’re done, but this is costly. Reimbursement for prevention/primary care is relatively small compared to specialty care, and there’s a shortage of PCPs. As more people become insured, we’ll probably make more use of physician assistants and nurse practioners, since we can’t turn out enough doctors interested in primary care. It’s not that we PCPs are starving…most of us have steady, good-paying jobs, but the debt burden is so high that the income for the first decade disappears quickly, and since it only takes a few more years to specialize and be able to pay the bills easier, well…

      As far as “penalizing” patients, it’s a horrid idea, but incentives are not a terrible idea. Many insurers will lower rates for patients who are in good health or at least try to achieve certain health standards (for example, joining a smokers program or weight watchers). If the patients don’t come see me and have me fill out the forms, their rates go up. Usually, if they see me and, say, their cholesterol is high, we just have to say that we’re working on it together to keep the rates down.

      Writing down questions saves time. It annoys some doctors (tough shit) and others find it useful.

      The resources for knowing what preventative care you need are out there but not well-publicized. See, for example, http://www.ahrq.gov/ppip/women50.htm

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