Let’s solve our most pressing healthcare problems first

“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.

“PalMD” is an internal medicine physician who blogs at White Coat Underground.

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  • Suzi Q 38

    I looked up the numbers as far as surgeries for a specific one that I needed.

    I was able to obtain data for 8 months for any given hospital in our area.

    I looked up 4 major teaching hospitals within 30 minutes of each other.

    For laminectomies: Hospital X had 24 in an 8 month period.

    Hospital Y had 200, and hospital Z had 199. The most famous hospital C had the record number: 1,198 laminectomies recorded for the same 8 month period. I understood hospital X, because it was a cancer teaching hospital.

    My question is this: Why is there such a discrepancy of the number of certain surgeries so huge between the other 3 hospitals?? They are all general teaching hospitals. They are all geographically close to each other.

    How can the patient population at hospital C be so different than hospitals Y and Z???

    I decided not to go to hospital C for my surgery because I surmised that virtually anyone that walked in with back pain probably went out with a scheduled surgery.

    That is crazy.

    I am sure all of the patients had insurance.

    No wonder our system is not sustainable.

    Think of all the additional CT scans, MRI’s, blood tests, physician exams, PT, respiratory care, EKG’s and other tests.

    Times 1,198.

    This is just for 8 months of laminectomies.
    What about all of the other surgeries?

  • jsmith

    Wait one cotton-pickin’ minute! As a Family doc of 23 years, I am convinced that the whole point of the HC system in the US is to maximize the profits of those that have a piece of it.. It is doing exactly what is it designed to do. Any health benefits that might accrue to the population are purely incidental.

  • http://www.facebook.com/people/John-Thomas-Gregg/709666621 John Thomas Gregg

    Interesting paradox: a big chunk of the problems you note are issues created in response to insurance and CMS incentives – many of the latter influenced by the former. Yet you postulate the need for more centralized control to fix the current problems. One would hope that the experiment of the past 30 years of federal mamagement should have disabused you of that fantasy.

  • StephenModesto

    Thanks for sharing the post. You make well written and well thought out good points which would seem to be self-evident. I am reminded by your article of Hans Christian Anderson’s story of the `Emperor’s New Clothes’. You are pointing out the parading of a regal elegance in the nakedness of its own pendulous omentum.