Can politicians fix our health care system? Sure, but they and everyone else trying will have to realize what our political leaders have voiced, but not seen that the system is complex and the truth behind Einstein’s statement that we cannot fix a broken system using the same thinking that created it. The lack of those elements is why we are still stuck. Rather than repeating the arguments of the past to see how our health care marketplace needs to be regulated, let’s just skip to how it should be treated as the complex and adaptive system that it is.
Don Berwick, writing in JAMA (April 5, 2016) proposes an Era 3 he calls the Moral Era. In it, he says: “Without a new moral ethos, there will be no winners.” Era 3 needs nine changes: 1. Reduce mandatory measurement; 2. Stop complex individual incentives; 3. Shift the business strategy from revenue to quality; 4. Give up professional prerogative when it hurts the whole; 5. Use improvement science; 6. Ensure complete transparency; 7. Protect civility; 8. Hear the voices of the people served, and; 9. Reject greed.
Dr. Berwick is on the right track, but his nine areas indicate he still thinks in mechanical, rather than complex terms. Thinking in complex terms is not that difficult. We are adaptable. We make choices based on the information we have and how it is processed in our brains. If the information is perceived as threatening it goes to our midbrain for a rapid, possibly life-saving, response — mostly in the form of fight, flight or freeze. If it is not threatening, our responses can be slower and more deliberate. Those are the responses we should promote in all areas of health care. So how do we do that?
The function of a health care system is to promote the health of the populace. Salutogenesis — literally the origins of health — is a concept that addresses this subject. It originated in the late 1970s from studies done by Aaron Antonovsky in this country and Israel looking at people who were healthy despite conditions that would drive others to the doctor’s office. The critical element he saw in his healthy population was a sense of coherence, made up of a sense of control, a sense comprehension and a sense of meaning. But all of these have much more to do with adaptive humans and were foreign to those thinking in linear mechanical terms. We ignored them.
The question is can we, with wise public policy, nudge people in these areas? And the answer is — absolutely.
- Dean Ornish developed a plan to reverse coronary artery disease and wrote a book about it. His success was based on three parts: diet, exercise and group therapy. The public focused on the mechanical parts —diet and exercise. Those in his program credited the group sessions where they could break down the walls of their heart.
- Tom Insel led the National Institutes of Mental Health for 13 years, until an audience member at a conference where he was explaining his research, interrupted him to say that the country was dealing with a fire and the chemistry of the paint made little difference. So he went to work for Google and began putting people together in online support groups based on their psychiatric problems. Groups, like Ornish’s and Insel’s, provide both the sense of comprehension and a sense of meaning, which is overwhelmingly found in working with others in cooperative ways. These groups work and can be multiplied by an empowered public health service. What about control?
No sense of control comes from outside help, like when some outside agent decides and pays for what is needed as in our current Medicaid. But if our Medicaid program was shifted to an HSA that is set up for and controlled by the individual a sense of control comes with it.
There is no doubt that the best way to deal with a complex system is a transparent marketplace, but in our current “market-based system” the purchasers of care are the organizations of insurers and the government — not the individual. Empowering the individual by shifting the insurance money to an HSA empowers the patient. A study by Linda Gorman at the Wisconsin Policy Research Institute showed that putting the patient in charge decreased health care costs by 10-30 percent with no adverse health outcomes.
In the past, HSAs have not worked because people did not have the time to build equity. In cases of need, the government does have a role. HSAs would also be more appealing to all ages if they could be patterned after Singapore’s Unified Fund, which can be used for other socially desirable things like housing, education and even, as we suggest, incorporating SNAP. And their Unified Fund can be shared within families, an institution that all agree needs strengthening.
Seeing our system in this way opens many doors, just as any new paradigm does. And such shifts universally open many new doors for progress. We need this shift.
Lon Jones is a family physician and can be reached at Common Sense Medicine.
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