Healthcare is one of the more confounding aspects of American life. We host some of the finest technology and talent in the world. We have state of the art facilities. But when we compare the overall quality to other countries we land somewhere around 42nd in the world. Our costs are out of control, we spend a disproportionate amount on the last 6 months of life – we only delay death, often without adding to the quality of life for the person.
So what problem do we need to solve with healthcare? The Republicans, under the guise of protecting employers, want to de-certify the Affordable Care Act (ACA.) The Democrats are calling to expand it. Some pundits are calling for a single payer system. We can debate the details. Suffice to say for most of us, we have had little experience of large systems, when taken over by the government, getting better.
What is the pressure in the system that makes people act as they do?
The complexity of healthcare system, as it currently exist, became evident during a recent experience I had with my primary care physician – commonly known as my PCP. We recently changed insurance plans when we started our new company. As anyone who has changed plans knows, you have to sign up for the new services with your new company. My PCP’s office wanted me to know I would have to come for an exam before they could sign me up for my prescription – even though such an exam would not check the condition for which I have received the meds for the last 15 years. This is a really good example of a “systemic pressure.” In my PCP’s world, his revenue model is driven by the number of people he can get to his office and the number of procedures he can order for each patient. It is no accident that many PCP’s like mine, service a large number of older people (look around the waiting room next time you’re in.) Granted, as older humans they may have more needs. The real reason they are there is the services they get are provided for and paid for by the government program at the heart of the ACA. What was designed to assure access, has created the “systemic effect” by rewarding the PCP for seeing as many as he or she can on a daily basis thus driving up the cost without affecting the outcome in any way we can measure as “better.” When I was going to the doctor with my late father, it struck me that nearly everything wrong with him was due to his age – and they haven’t got anything in the PCP bag of tricks to cure that. It seems like the ambulatory version of the aforementioned “delaying death” strategy. Seems like a vicious cycle – we keep feeding the expensive system with more government funding (that’s our money remember) and the best outcome we can garner is to delay death. No wonder we’re 42nd!
“Every system is perfectly aligned to get the results it currently gets.”
Some of you may remember the Clinton’s ill-fated run at healthcare reform during his first presidency. Everyone agreed it was a huge problem but no one wanted to give up anything to change it. The desire to change the system got blown away by the collective commitment to avoid loss (hospitals, doctors, nurses, patients, advocates alike.) On a personal level – seeing our loved ones in distress can pressure us to advocate for “whatever they can do.” This is the heart of the healthcare reform problem – our own relationship with loss. It is often said people don’t like change. People are happy to change – if they think it will be good for them! (Just ask the Florida couple who recently revealed they won a portion of the $1.5 billion lottery.) What people really don’t like, in fact will do anything to avoid, is loss. Everyone wants good change – nobody wants to lose anything. The insurance companies want to provide coverage at a profit (as do their shareholders.) The hospitals need to stay in business (some are making money – many are viable but not profitable and are swallowing up other hospitals or being swallowed up to achieve scale.) They struggle with paying doctors, whose leverage, and in some cases ownership, has given them a negotiating advantage over nurses who are clinging to archaic leave and compensation models in a desperate attempt to remain relevant in the strategic conversation about the future. For the consumer it all seems ridiculously expensive – though most of our outrage is based on sticker-shock and not any insight into the technology, talent and risk calculous that goes into determining healthcare costs. We declined fixing my father’s broken hip because $200,000 to spend on a man who was 90 and would probably never walk again seemed ridiculous. We never imagined days later when faced with life bedridden and diapered, he would choose to stop living – and was gone in three days!
But if no one gives up anything – how do we ever get better at this? Some changes are coming. Pity my poor PCP – he has no chance of remaining viable when the reimbursement scheme changes from the frequency of care to the quality of the experience. He has the wrong staff, the wrong business model and the wrong relationship with his patients. It looks like ugly days ahead for the frontline providers. Some large healthcare systems are trying to get ahead of the curve by integrating preventative medicine into their primary care model. Even those efforts are running into headwinds as the finance people cry for more frequency-based fees to be generated, reinforcing a system that is perfectly designed to get the results it’s getting.
Adaptation is not easy!
I imagine the real test will come for us when we least expect it. I can imagine standing at my 91 year old mom’s bedside, facing the choice of keeping her alive or letting her go. In that moment it will be interesting to see what I am willing to do on behalf of a “better” healthcare system. We’ll see.