America has a disease industry, not a health care system

The decade ahead is one likely to be full of turbulence. How everything will shake out is anybody’s guess.

But we can be sure that technology advancements will slow for no one. The rate of medical technology advancement now is very fast and the speed will only accelerate. One big problem is that technology advances so fast that there is no time for a purchase – say new CT scanner or diagnostic device in a clinical laboratory – to create any return on the investment before a new or upgraded technology becomes available.

The electronic health record is a case in point. Despite years of work and billions spent, we are essentially still in an early generation of the EHR. It will be years and many more billions before the EHR begins to bring the true value of improved care with increased quality, better safety and reduced costs while improving provider productivity.

America does not have a healthcare system; we have a “disease industry.” We focus on disease and pestilence and do a good job of caring for those with acute illnesses and trauma. But we certainly do not address health well and we are not good at caring for chronic illnesses – which are rapidly overtaking acute illnesses as most common and already they consume the bulk of our healthcare dollars.

At some point we must break from our current disease care model and shift to a health promotion and disease prevention model. Until that occurs, the cost of medical care will continue its rapid rise. As a disease industry, the incentives are all based on doing more and more but there is little or no incentive to work on prevention.

Although it is tempting to blame the current problem on the insurers, the device manufacturers, the drug companies or the providers, the truth rests more in the way we have set up our payment systems for care. Insurers pay for doing “something.” This leads to more and more diagnostic and treatment efforts and it encourages the manufacturers to constantly find new approaches. Not bad in and of it self but the incentive is not there to prevent illness and not there to coordinate the care of those with chronic illness. And without this shift in incentives, the cost of care will just keep rising.

Two good steps for the future would be:

Change the Medicare payment code to encourage prevention, coordination, and primary care. With Medicare taking the lead, commercial insurance would likely follow.

Let everyone have a high deductible policy so that each of us will have a real interest in asking about our care and being sure that each and every recommendation for a test, a procedure or a prescription is really the best and really necessary.

Stephen C. Schimpff is a retired CEO of the University of Maryland Medical Center in Baltimore and is the author of The Future of Medicine — Megatrends in Healthcare. He blogs at Medical Megatrends and the Future of Medicine.

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  • Paul Dorio

    Excellent comments from an erudite physician. I would add that I really think it is essential that Americans begin to change their mentalities regarding their own well-being. It is a pervasive mentality that “someone else is responsible.” I think that we need to understand that health starts in the home. If we eat right, increase our physical activity and take responsibility for our actions, our health may improve. As a result of improved personal health, the health care system will be better able to manage minor ailments that arise. Any major ailments that arise will be better managed in an overall healthier person as well.

    I am not making any excuses for the state of the current inefficient health care system. But self-care, i.e. personal responsibility, must be a focus also.

  • Alina

    As I was reading through the article I thought to myself, wow, this is a really good one. But then, I hit the wall once I got to the proposed steps. Often times physicians tend to place the responsibility on anyone else except themselves. Unless we ALL (patients, physicians, hospitals, insurance companies, employers, the government) take some responsibility, nothing will really change. What’s more, the solution is starring us straight in the face! It has to do with prevention as you very well stated. But, to say that the solution is high deductible plans is not only wrong, but it’s also not feasable.

    In any kind of business planning, the goods/service provider has to, first and foremost, consider the customers and their ability and wilingness to pay – without this nothing else matters.

    We will not have any true change unless physicians will also come to the table and accept some responsibility.

    Solution: business planning, primary-care as the corner stone of medicine, prevention plans in place, and competent, caring physicians. Physicians have powerful organizations that can actually lobby for the proposed solution and set corresponding reimbursement set-up. Question is do you want to?

  • Jeff J.

    Changing the Medicare reimbursement code to place increased emphasis on prevention, coordination and primary care would be a good first step.

    I agree with Alina’s suggestion that physician organizations can have an influence in lobbying for proposed changes in our current reimbursement system. Real change within our health care system will need to come from all parties involved.

  • twicker

    Very interesting article.

    As to whether changing Medicare would prompt the commercial insurers to change — well, I’m not so sanguine. Remember that they have very different incentives when it comes to long-term care.

    First, insurers know that, once a person hits 65, that person is no longer their problem; thus, even in the best of circumstances, insurers have no real incentive to fund programs that will help patients be more fit and well during retirement — even if those programs would have large benefits when the patient was 70, or 80, etc. (e.g., early-intervention osteoporosis treatments, Alzheimer’s prevention, some diabetes and cardiovascular prevention routines, etc.).

    If that’s not bad enough, then realize that, because the private insurance marketplace is a marketplace, insurers don’t even expect to keep you around that long. According to a Johnson&Johnson surgical procedure/device presentation I attended, the big pharmas/medical device companies act on the assumption that they have to prove that the medicine/device will have a cost benefit (not health, but cost) within 2 to 3 years — because insurers assume that most of their patients will have changed jobs/insurers (or died) after about 2 to 3 year. Thus, for insurers, they have no incentive to pay for interventions with long-term, but not short-term, payoffs — even when those interventions would lead to much better health and wellness .

    No matter your age, you are likely to be a Medicare consumer — now or in the future. No commercial insurer has that same incentive.

    As for the high-deductible plan: I concur w/Dr. Schimpff — if it’s properly structured. To me, “properly structured” would include:
    a) Allowing everyone to set up an HSA — even if they are not on a high-deductible plan. And allowing these to be separate from any insurance plan (allows for competition in provision of your HSA — given that this is for potentially-immediate healthcare, the tax savings might only go to any portion that’s invested in, say, a regular savings or money market-style account or something; people can invest where they want, but we, as a society, would only provide the tax benefit to the portion that’s immediately available and protected from the whims of the broader market).
    b) Allowing people to accumulate savings in their HSAs over time, so that they can move into higher-deductible plans over time (I’d further support allowing people with HSAs to connect these HSAs with a specific insurance policy, where that policy raises its deductible as a function of the funds within the HSA — allow people to pick a rate of growth, but I’d suggest 2::3 as a good start ($2 of deductible for every $3 of money in the HSA).
    c) Allowing the HSA to roll-over, year-to-year, for as long as you want.

    You would then allow people to build up HSAs for those large medical expenses without removing the option for people to have low-deductible plans; you would further make the expenses more transparent to people, hopefully allowing for better decisions. And you would allow it to be a continual, gradual thing, instead of a large, one-time painful hit.

    But them’s just my opinions.

  • Molly Ciliberti, RN

    You are so right. When we have a complete change of mind and it is a complete change and therefore difficult, we might just provide health to all of our citizens.

  • BobBapaso

    Good opinion twicker. The HSA law of 2008 established most of what you suggested, and the number of accounts is growing. The option will become more attractive as premiums for regular insurance become progressively more outrageous. We all need to promote making HSAs better and prevent the insurance lobby from degrading them.

    We need our disease industry to take care of us when we get sick, and we need fee for service payment. When everyone is paying out of pocket or out of their HSA, costs will be negotiated down.

    Prevention is a crock, nobody knows how to do it, except what we do at home by eating right, exercise and other life style choices. We all get sick. Early detection is a good idea.

  • Mt Doc

    I read articles constantly about how the problem with medical care is that it deals with disease instead of prevention, and it sounds great but I wonder what precisely the authors mean by this. Clearly, the health of Americans would be better if we would exercise, watch our weight, eat our fruits and vegetables, not smoke, not drink to excess, wear seatbelts, etc. BUT, your mother tells you this when you are four years old! You don’t need a doctor for this. Some preventive medicine done in an MD’s office, such as vaccinations, is cheap and cost effective but a lot of it is not. Colonoscopies for colon cancer screening are pricey, and if you’ve been paying any attention to the controversy about mammograms in low risk women under 50, or psa’s in men, you realize that a lot of effort and cost goes into minimal gains. We don’t have effective screening for most cancers. I personally regard managing diabetes, lipids and hypertension as preventive care but it isn’t inexpensive and most people regard this as disease management. You have to treat a lot of people for hypertension to prevent one stroke or heart attack. It’s worth doing but not cheap.
    I wish the authors of the above type of article would detail precisely what they mean by preventive care and spell out how it will save so much money.
    Sick people are not going to go away and the primary function of a doctor is to care for sick people. Everyone eventually gets ill unless you die a sudden traumatic death. Right now we do not know how to prevent inflammatory bowel disease, many forms of cancer, arthritis, degenerative neurologic conditions, and a host of other ailments. In the present time due to the preventive measures of good sanitation, clean drinking water, vaccinations etc for the past 50 years people are living longer and developing multiple chronic diseases. 100 years ago the life expectancy was 30 and infectious disease or obstetrical complications knocked you off early. You didn’t live long enough to get Alzheimer’s or peripheral neuropathy from your diabetes. Part of our current problem in health care costs is due to previous preventive practices. This is a good thing.
    It would probably be most cost effective to have the schools do the nutrition and lifestyle training (if the parents can’t do so), get communities to build parks and playgrounds and bike paths. Probably the best information would be to inform people when they SHOULDN’t see a doctor, such as for colds and minor ailments which will get better without medical intervention.

  • Paul Dorio

    BobBapaso and MtDoc – excellent comments and I think you’re right about preventive medicine being a crock. It will contradict my comments above, seemingly. But you are probably right that people have been told about the “right” things to do, regarding their health, since they “were four.” I still think that people could use some sort of reward or even punitive type of incentive (not money) to improve themselves.

    But MtDoc raises a great point: Perhaps people need to be told that they can’t use the emergency departments for non-emergencies. Two problems: They will anyway and call whatever ails them an emergency, even if there is a punitive system in place to safeguard against that. AND It goes against EMTALA and all of the other comments that will be flung against the wall.

    Perhaps if the health care reform bill actually expands coverage to more people, like we hope it might, then all Americans can be counseled on going to a primary physician and not the ER. Again, it would take a sea change in the mentality of Americans to realize that the ER is not the right place to just saunter into for free care. Now where do we start?

  • Paul Dorio

    MtDoc – One thing I wanted to rebut though: I don’t think I agree with your comment, regarding screenings, that “a lot of effort and cost goes into minimal gains.” At least regarding mammograms, 30% more cancers are detected than would be otherwise if we did not screen women. The mortality statistics also show that screening mammography saves lives. I think that is useful information and improves accuracy of our commentary.

  • Carrie (@LizzPiano)

    I agree with the comments on preventive medicine needing to be clarified, but I think that care coordination with those who have chronic illness should be looked at for reimbursement somehow. This could save costs/time/effort/needless waste for a lot of people. Honestly, it’s one thing about Soc Med in England that I really like. You must go through your primary care doc to do anything. Specialists are exactly that – specialists who then send info back to your primary doc who follows up on the plan. Sure it has its pitfalls, but that way people aren’t having fragmented care. If you ask a primary care doc to coordinate care for those with chronic illness in the US, they might say, “Sure” but then at appointments just tell you, “Well you know when you need to come see me” – making regular follow ups seem silly. After all, what more are you going to discuss with the PCP that you haven’t already discussed with the specialists you see for these particular problems? It doesn’t pay to do a random follow up for care coordination and to “check in” to make sure everything is going as it should…

    Also, re: HSA/high deductible plans – not a fan for them for those who do have chronic illness. There is no way you will ever save anything. It will take forever for costs to actually come down, and in the meantime, those with chronic illness will break their bank in week #1 of these plans. They’re great for healthy people who encounter a limited major illness or mainly healthy people who have perhaps a chronic condition requiring very limited monitoring and expense… However, for those with complex chronic illness requiring multiple specialists, tests, etc on a routine basis, they are currently not practical. It’s not really going to work to ask those with chronic illness to just suck it up for awhile until the system rights itself and the fees drop based on paying out of pocket for things. When in nursing school, I had to pay out of pocket for one month of one medication and it cost nearly $500, then received a bill for home O2 therapy for 2 months that I had used as needed and it came to $800. I sold all my shares of IBM stock that I’d had since birth (granted not much) to make up for medical bills I’d fallen behind on. Then went into significant debt to cover these expenses. I was inadequately covered for only 2 months (by a really bad student HMO plan). Imagine if that had been longer…

  • BlackZack

    It is as you say. But it is not only America that has a disease industry. I think it is an internationally spread curse. Of course, there are countries where the health system promotes health and not healing, but it is still a struggle with the high power owned by the money of pharmaceutical companies and medical equipment industry.

    What government and administration has to do is realize that money is better spent on health promotion and disease prevention. It is usually cheaper than buying so many machines and paying so many technicians. Prevention saves lost work time, lost employees and of course money in treatments, doctors, nurses, and so on.

    The American system, however, is that of private medicine all over the nation. Achieving an acceptable level of health decreases the necessity to heal, so not only medical equipment providers and pharmaceutical companies fall apart, but also the health care system. There are fundamental changes to be done before changing from a disease industry to a real health care system.

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