The high cost, low quality, and systemic inequities of the U.S. health care system have prompted its redesign. The current health care system is now controlled by consolidated health care institutions, insurance companies, pharmaceutical companies, and health information technology companies (CHIPHIT complex). The CHIPHIT complex, along with the federal government, will shape the future health care system. However, independent health care policy experts, independent health care providers, and members of the general public are ominously absent from this list.
Historical evidence has shown that the CHIPHIT complex is incapable of creating the health care system we need. Therefore, if we hope to build a low-cost, high-quality, and egalitarian health care system, physicians and their professional organizations must take a strong stand against the CHIPHIT complex.
Consolidated health care institutions
There are numerous mandates that make it difficult to run a small medical practice. As a result, many younger physicians no longer try to start a new medical practice, and existing profitable practices that want to offload their regulatory burdens are being acquired by large health care institutions and private equity firms.
While these consolidated health care institutions claim to want to improve our health care system, they often impose a uniformity on the practice environment that ignores the reality of patient care; there is no “best” practice model, nor are there information technology tools that work well for all physicians. This imposed uniformity stifles physician innovation, which is essential for improving our health care system.
If consolidated health care institutions want to maximize the chances of improving our health care system, they should encourage their physicians to innovate, they must stop pushing for practice uniformity, and they must defer all practice-related decisions, including the selection and design of information technology tools, to the professional judgment of relevant health care providers.
Insurance companies inform their patients which primary care physicians and specialists they are allowed to see. For many patients, this means they are unable to see the same doctors throughout their lifetime, which can be a source of anxiety for elderly and chronically ill patients. Insurance companies also dictate which tests and medications doctors are permitted to prescribe. As a result, doctors may be required to use an “approved” medication even if they believe a different, non-formulary option would be better for the patient. While it is possible to request an exception, many doctors have been denied so frequently and arbitrarily that they have altered their practice patterns against their own professional judgment.
Several years ago, I needed to order an emergency head CT scan for a patient with “the worst headache of my life.” The CT required prior approval, so I called the insurance company and was told the scan was “not indicated.” I explained to the insurance representative (who lacked the clinical training to make this decision) that if the insurance company did not approve the CT scan, I would send the patient to the emergency room, where the insurance company would have to pay for both the ER visit and the emergent head CT scan. The representative eventually agreed to approve the CT scan, but only if it turned out to be abnormal. After experiencing events like this multiple times, it becomes disillusioning and one may become hesitant to interact with insurance companies.
Many people have suspected that some health insurance companies prioritize their own financial interests over the health care needs and fiduciary obligations to their patients. This illegal business model was exposed in Judge Spero’s ruling in Wit v. United Behavioral Health.
Pharmaceutical companies and pharmacy benefit managers
Pharmaceutical companies and pharmacy benefit managers (PBMs) also contribute to the high cost of health care. Pharmaceutical companies extend the expiration of patents on brand-name medications, delaying the creation of cheaper generic options. They also use legal loopholes to acquire inexpensive generic medications and turn them into non-generics, allowing them to significantly increase the price. For example, URL Pharma transformed colchicine into a non-generic medication and then raised the price by over 5,000%.
PBMs negotiate drug prices on behalf of multiple insurance companies, giving them bargaining power to (theoretically) lower drug prices. However, the cost of medications continues to rise faster than the rate of inflation, and health care policy experts have begun to identify PBMs as a contributing factor to the high cost of pharmaceuticals. For instance, the price of a vial of Lantus insulin has increased 300% in the last decade, even though it is the same medicine in the same container.
Health information technology companies
The electronic health record (EHR) vendors have inserted themselves in the middle of the exam room and now have an inappropriate amount of influence on the interaction between a patient and their physician. In the exam room, physicians have to “click” on clinically irrelevant buttons in the EHR. The poor design of EHRs forces physicians to spend two hours entering data into the EHR, much of it clinically irrelevant, for every hour of face-to-face patient care, a massively inappropriate use of a physician’s skill set. While there have been successful EHR implementations, sadly, that is not universally the case. EHRs do have an important role in our health care system, but they are not the panacea that the EHR vendors claim. They are simply one tool of many that can help physicians, if properly designed, to provide care to their patients.
As a result of my decades-long experience creating an EHR, I am certain that EHRs would be far more useful to physicians if the person who has the ultimate authority over all EHR design/implementation decisions:
- Is required to use the EHR on a daily basis
- Has deep knowledge about clinical medicine
- Has some experience in computer programming
- Has an in-depth understanding of information technology
- Is committed to evidence-based medicine while acknowledging its limitations
Physician burnout is the accumulation of the aforementioned assaults on the physician’s professional judgement. It is characterized by depersonalization, including cynical or negative attitudes towards patients, emotional exhaustion, a feeling of decreased personal achievement, and a lack of empathy for patients. It is a prime cause of physicians prematurely ending their clinical careers, reduces the quality of health care provided, and increases patient mortality. I know several physicians who had previously committed large amounts of time trying to improve their health care system, but have since withdrawn their involvement because “nothing ever changes.”
Dangers of the CHIPHIT complex
The CHIPHIT complex, in conjunction with the federal government, have created a health care system that undervalues direct patient care and overvalues clinically irrelevant documentation. They institute roadblocks that thwart physician innovation and adversely impact our ability to provide health care. They are the cause of physician burnout and the reason many physicians, nurses, pharmacists, and CMOs (personal anecdote) are frustrated with the current design of our health care system.
In President Eisenhower’s farewell address, he said, “We must guard against the acquisition of unwarranted influence … by the military-industrial complex…” The U.S. health care system rivals the size of the military-industrial complex, and the CHIPHIT complex already has an inappropriate amount of influence over our health care system. If we choose to ignore this precedent, our health care system will continue to be dominated by the CHIPHIT complex for many decades into the future, and that will prevent us from obtaining the health care system we need.
The primary goal of the CHIPHIT complex is to maximize their revenue, as it should be in a free market economy. If we want their primary goal to be the optimization of our health care system, then the laws that govern the CHIPHIT complex must be changed – an unlikely outcome in today’s political climate.
As the CHIPHIT complex is incapable of building the health care system we need, we must look beyond the CHIPHIT complex for a mechanism to repair our defective health care system.
A potential (partial) solution
Fortunately, there is objective data that shows us how to address some of the failures in our health care system. As the 2014 Robert Wood Johnson Foundation report “Time to Act: Investing in the Health of Our Children and Communities” discusses, “the key to better health does not lie primarily in more effective health care.” We need to move health care out of hospitals and into the communities that need it. We should invest in youth and those who are educationally, socially, and economically disadvantaged. By doing so, we can reduce the prevalence of unhealthy behaviors such as obesity and cigarette use, as well as societal inequities that disproportionately affect certain segments of our society and drive up health care and other avoidable social expenditures. This model has already been implemented in other countries and has been shown to be more effective than our current health care system.
If we want to have the health care system we need, society must redirect resources away from the CHIPHIT complex and into the hands of those who prioritize a holistic, high-quality, low-cost, and egalitarian health care system.
Hayward Zwerling is an endocrinologist who blogs at I Have an Idea.