Tuesday, January 29, 2013
Where is the health care crisis?
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 health care 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 health care reform, takes some steps toward patching this problem, but not solving it. Health care 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 and 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 health care, especially public health and cost.
When capital for innovation comes largely from health care 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 long-term, 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 health care 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 health care 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.
Peter A. Lipson, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. After graduating from Rush Medical College in Chicago, he completed his internal medicine residency at Northwestern Memorial Hospital. This post first appeared at his blog, White Coat Underground. The blog, which has been around in various forms since 2007, offers "musings on the intersection of science, medicine, and culture." His writing focuses on the difference between science-based medicine and "everything else," but also speaks to the day-to-day practice of medicine, fatherhood, and whatever else migrates from his head to his keyboard.
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Suneel Dhand, MD, ACP Member
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