What Shall We Do With Healthcare?

Imagine you are a doctor walking down the street. You come upon a woman lying on the sidewalk possibly unconscious. Surrounding this woman are four people each loudly suggesting a different way to help. One is urging a candy bar, while another is promoting his unique, patented guaranteed cure for today only: $19.95 plus tax. A third is trying to resuscitate the woman, and the fourth is threatening her with a charge of public drunkenness.

This scene looks like something straight out of The Three Stooges. You approach the self-styled helpers and ask if they know what the woman's problem is. They all start speaking at once, suggesting diabetes, low self-esteem, a heart attack, and vagrancy. No one has examined the woman or even tried to talk to her. You shake your head, wondering how anyone could even think of treating a patient without first understanding why the person is sick. As a doctor you know that treating symptoms never cures anything, it just masks the problem.

The woman down on the sidewalk is Healthcare. Those offering to help - in essence doctors-without-licenses - are legislators, insurance executives, expert consultants, and regulators. You are the doctor - the person responsible for making the patient (healthcare) better. What should you do?

This blog is devoted to answering to that question. One message will be repeated over and over. The Lone Ranger had silver bullets. Harry Potter has magic potions. In our real world, these do not exist. Anyone who offers you a simple, quick, painless solution to a complex issue like healthcare, that person is selling snake oil. If the Public demands a simple solution, someone will sell us one - for money or votes. It just won't work.

Among the myriad problems in healthcare, one is relatively simple: semantic confusion. Words such as cost and quality have different or ambiguous meanings in healthcare versus general conversation. For instance: healthcare or health care? The answer is both. Health care (two words) refers to what a patient receives and what nurses and doctors offer. It is a service. Healthcare (one word) refers to a process or system for providing health care services.

Making good decisions is part of "practicing good medicine," for both doctor and patient. A key element in any decision-making process is evidence. In order to avoid a charge of saying one thing but doing another, I will defend myself in advance. While everything I write is by definition opinion, the assertions are based on hard evidence, not just personal bias. I will gladly share the references with any interested reader.

To start the discussion, consider what "practicing good medicine" means. How would you - the doctor - care for a sick individual? First, you take a history and do a physical exam. Then you do various tests. You study the results and review the literature to compare your patient to previous reported experience. Eventually, you figure out WHY the patient is having the symptoms: what doctors call the etiologic (or causal) diagnosis.

If the patient is obese; goes to the bathroom frequently; has a high blood glucose as well as foot ulcers; and experiences chest pains, this might point to an etiologic diagnosis of diabetes. If confirmed, the doctor and patient then understand that the body is not handling sugar properly. A medical and dietary regimen will aim at restoring proper control of sugar metabolism by treating the cause - insulin production - of illness.

Is that how we treat healthcare? (That was a rhetorical question.) The answer is an emphatic no! The Public experiences and loudly complains about certain symptoms. Rising costs; errors and bad outcomes: not always the same; insufficient access; and shortages of nurses or doctors: these are four of the most obvious. How do we handle these? Do we discuss and uncover WHY they occur? That was another rhetorical question.

What we actually do is the following. For rising costs, the treatment is to reduce payments. For errors and bad outcomes, we punish the perp. For limited access, the government mandates that care must be provided. For nursing shortages, we offer signing bonuses. All these "treatments" are symptomatic. As we all know, none has worked: the problems - symptoms as well as causes - remain and the patient is no better.

What we need to do is uncover, discuss and agree on the reasons for healthcare dysfunction. The "we" in that sentence is the general populace, not leaving it to the self-styled experts, our political leaders, or hospital administrators. Before we can cure healthcare, we must first understand the WHY of healthcare sickness, and then develop a consensus of what we want healthcare to accomplish. Neither answer is simple or easy (I told you I would write that several times) but here online, is where we can make a good start. We need to discuss: Price-based costing; Casting stones; the Dangers of risk-free medicine; and Cost reduction that does not reduce costs. Topics to consider include: Bad apples; Name, blame and shame; Efficiency kills; and our Continuing, never-ending healthcare crisis.

Comments are not just welcome: they are eagerly sought. Let the discussions begin!

Comments

[odyssey]

Another solution is the provision of practical, hands-on disease prevention programs and the coaches to disseminate them. This means understanding that one of the symptoms of Healthcare illness is the lack of knowledge on what it takes to be healthy. Wellness education includes addressing surface issues like "stop smoking " or " 10K a day" programs, and addressing health from an internalized relational point of view, then encouraging implementation through a behavior change model. Understanding the demographic, and connecting in a personal way, will go a lot farther to build success than the programs currently available through health provider "experts." With all due respect to those public health educators in the field, this is a marketing issue - the message isn't getting out there. It's tIme for a new model. The model must make it personal.

Americans feel entitled, but don't understand true cost. If less healthcare resources were consumed, these saved resources could be re-allocated to programs for those same 47 million currently uninsured, thus cutting into the need for revenue increases and/or program cuts, both public and private sector. In the end, citizen health promotion and wellness programs go deep into the American social strata and have the potential to affect change for all - providers, corporations, agencies and individual consumers. These programs, along with letting doctors be doctors, are just two pieces of a solution to the much larger healthcare problem facing the country today.

[systemMD]

Of course Odyssey is right that not knowing what it takes to be healthy is a symptom of our sick system. However, the big obvious things " diet; exercise; and not putting harmful substances into our bodies like drugs and cigarette smoke " are known and this symptom persists. Part of the Cause of this symptom is our reluctance to accept who is responsible for our health. It is not the doctor or the government and certainly not the insurance company. It is us. I am responsible for me as you are responsible for you.
Odyssey, you are also right again saying we do not know true cost, especially in health care. We do not know the actual cost of a hernia repair or open heart surgery. We only know the charge and what Medicare pays. No one knows or even tries to calculate the avoided cost of staying well. THAT was the theoretical foundation of all HMOs: that it was cheaper in the long run to prevent (and stay healthy) than to pay for sickness care. That principle got lost in the financial game I call Healthcare Money Madness. If we want and as you say (I agree), we need a "new model," it should have positive incentives to reward outcomes we want, like staying well, which means personal responsibility and prevention programs.

[odyssey]

For some Americans, the cost of a premium or co-payment is a stretch. For others, there is a dread of the pharmacy. For 47 million of us, healthcare is out of reach all-together.

While there are other players, let's start with the one we can control, us. We dictate as much as the physicians and provider organizations what kind of treatment we want. For every treatment turned down, there are many more tests now used which are perhaps unnecessary, given the information already available, to provide a diagnosis and course of treatment.
What does this mean in, in practical terms? When a doctor is able to diagnose an underlying issue from the symptoms already available, a battery of tests, costing hundreds, perhaps thousands of dollars, may be redundant. Ask. Will there be mistakes? Yes. Are there mistakes made now? Yes again. We must allow the doctor to doctor and not depending on every technology tool available to support the diagnosis. There are many tools in the chest; doctors should use only the ones necessary to supplement their own expertise, not do the job for them. If we want to help with a solution, start with actively taking responsibility, by getting the doctors to do just this very thing.

[systemMD]

We need to be clear. Tens of millions are without health insurance and while this is a huge problem, it is a financial issue. Such individuals DO receive care. Hospitals cannot turn them away (though some try). The problem is that without insurance, someone will hemorrhage [$$$]: patient, providers (hospital and doctor), or both.
The issue of mistakes and allowing doctors to be doctors is a highly sensitive one. The first step is to recognize that doctors and nurses are human and therefore imperfect. The second step is to recognize that medical science is equally imperfect and primitive in comparison to the natural sciences. The result is that, despite the well-intentioned efforts of providers, bad things sometimes happen to patients. As long as the medical negligence tort system holds providers to a standard of perfection and assumes (wrongly) that individual medical outcomes are predictable and guaranteed, we will have defensive medicine, injured patients who get no assistance, and learning will be suppressed. We need a whole new medical negligence system.

[Dohiyi]

I agree with the basic concept of Medicare for all. I am sure there are myriad complications in implementing such a plan, but if we can all agree on the means of providing universal health care in this country, we can work out the details as we go.

[systemMD]

May I suggest you read my forthcoming post titled "Universal Health Care Is None Of The Above?" Then we can talk about Medicare For All.
Bottom line: the "means of providing universal health care" [not universal health insurance] involves much, much more than money. And while we can work out details later, we must first be clear on what we want healthcare to do " what the desired outcomes are from the system. Without a consensus on that, everything else is bandaids and snake oil.

[Henry]

Medicare for all. It is the single payer system that breeds efficiency. The sum total of corporations in this country spend 100s of billions in health care for families. They need not do this. However, those 100s of billions can be extracted (sum neutral) in the form of taxes on profits (of only the profitable) to pay into the single payer health care system. Those uninsured now will be included and the cost "increase" would effectively be at the margin. Not a gigantic a problem as the not christian right believes. The ugliness of cost shifting and treatment by emergency ward would be eliminated.

[systemMD]

With respect, monopolies such as a single payer system, tend to breed INefficiency. As a general rule, government monopolies are much, much more wasteful, slow and inflexible compared to market-driven competition.
What can produce efficiency (and better effectiveness) is simplification. There is an official medical coding book that is nothing but codes to bill medical services and supplies. It is over 500 pages long and is updated at least twice per year. A colleague once studied how a large, prestigious medical system (in southern California) handling billing. Between the doctor seeing the patient and the bill being sent, the system had 57 (!) steps. You do not need to be an expert in Operations to know how inefficient that is, not to mention how much potential there is for error and therefore the need for reconciliation. Bottom line: simplification will save billions but there is no assurance that a single-payer system will be simpler and every reason to fear it will not.
Watch for a post titled "Who Benefits From Billing?"

[hopeless277]

Medicare for all. No ifs, ands, or buts. Too bad Hillary is lying about her plan, Obama is lying about his plan and McCain's plan is no plan at all. Trust me, not one of the lying, criminal candidates gives a flying fig about anyone but themselves. Isn't it funny that to be a politican you have to be insanely narcissistic, the exact wrong qualification to be a representative of other?

[Deane Waldman - Huffpost Blogger]

See Deane Waldman's Profile

Have you seen the movie The Contender? It is worth your time. At the end, the President played by Jef Bridges offers an interesting quote reputedly from Napolean (Buonaparte). Paraphrased, he said: "To get power you need absolute pettiness. To exercise power, you need true greatness. Such attributes are rarely found in the same person." Makes you wonder about politics in general and politicians in specific. I take some comfort from one of my favorite politicians, a man who could never get elected in today's world: Winston Churchill. He quipped, "If you do not like politics, consider the alternative. It is called...war."