by John Kaegi
We all complain about the cost of health care and health insurance. Ours is by far the most expensive health care system in the world. And for the money, our health isn’t so hot either. On the world stage, the U.S. ranks 37th in health care efficiency (a measure of health outcomes such as infant mortality, incidence of chronic disease, etc.) as reported by the World Health Organization. America ranks behind virtually every EU country and Canada. What can we do about it? Ration health care? Control doctors?
The answer begins with that which we want to retain. Most Americans enjoy unlimited access to health care. And despite the world rankings, it is generally accepted that the quality of American health care is unsurpassed. Let’s not throw the baby out with the bath water, right? But, if we are going to continue to enjoy our access and quality, then we need more than information and empowerment. We also need a little push.
As in most things, health has interconnected, but contrary forces — its “yin and yang.” Could it be that wide access to quality care after we get sick may be the culprit creating growing indifference to the consequences of poor health behaviors? It is so easy to rationalize super-sizing our cheeseburger and fries when we have Lipitor, liposuction and a litany of care providers watching our backs. As important as it is that we have convenient and transparent health cost and outcomes information to control health care costs when we need it, I assert that it is equally critical that we avoid poor health in the first place as the ultimate means to reducing the cost of health care.
The crux of the problem is found in our attitudes and values toward health. To reverse high health cost inflation will require us to reverse our attitudes and values first. Incentives as well as information can play a role. Many large employers now provide their employees (and often their spouses) with on-site health management clinics, staffed primarily by nurse practitioners who are generally better trained than doctors to engage patients in health management dialogs. Coordinated with these clinics are health risk assessments in order to identify potential health issues so that individual health management plans can be created. They often include wellness programs and incentives to make behavior changes. Some even include disincentives to motivate participants to change, such as increased deductibles for those who persist in smoking or over-eating.
Driving these employers is sensitivity to the root causes of high health care costs. We hear a lot about the aging of the population, about the contribution to cost by new technologies and drugs, and of course, about defensive medicine and malpractice costs. However, those are just the symptoms. The root causes of high health costs are:
- poor health behaviors,
- misaligned provider incentives, and
- disconnected health information.
Poor health behaviors accounts for about one-half of the $3-trillion we spend on health care annually. Three years ago, in 2008, every annual health insurance premium included an additional $1,405 to compensate for smokers, $1,280 to compensate for lack of exercise and obesity and $1,070 for uncontrolled hypertension and cholesterol. Three years of uncontrolled inflation makes it even worse now.
It would be helpful if doctors took the time while we see them to explore the root causes of our illnesses, to counsel with us about our health behavior choices, to create health management plans and to follow-up with us on our progress. But, don’t count on that in the fee-for-service reimbursement system. Because the FFS system pays for procedures delivered, it incentivizes physicians to overutilize medical services. It is extraordinarily inflationary as it seemingly justifies overutilization in order to avoid malpractice litigation. It creates an assembly-line culture among providers that results in an average of 7 minute appointments, clearly not enough time to engage in wellness counseling.
Wellness counseling will only occur when providers are incented to do so. But to add more financial incentives on top of FFS is not the answer – it only exasperates the problem. Rather, a system of salaried providers combined with liberal bonuses for improving the health of their patient panels is the ideal solution to refocus practitioners on taking the time to know their patients, to engage them in wellness and to follow-up. Most employer clinics use salaried providers and often feature average appointments of over 25 minutes.
Finally, even those providers who are wellness focused are still ineffective without data, information and health history. Yet, only 20% of hospitals and about 10% of doctors use electronic medical records in their everyday practices. Less than 1% of doctors are interconnected with one another, sharing information about common patients. That leads to errors, misdiagnoses and even deaths. Over 90,000 patients die unnecessarily in hospitals every year according to the Department of Health and Human Services.
As we fight for greater transparency of information, we should also fight for a change from an illness to a wellness model; from FFS to outcomes-based reimbursement; from intuitive medicine to data-based care plans. With that, we also need that push to do better; incentives (and poor health behaviors disincentives) to engage in wellness as vigorously in the future as we do now in poor health behaviors.
John Kaegi is Chief Strategist, Healthstat Inc.
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