Many have pointed to the poor outcomes of the US health care system over the last few years as an indictment of various things–how we pay for services,the services we pay for,how care is managed,who manages the care,and so on.
Among those critics have been a few observers who have quietly noted that the system itself was not simply ‘broken’but closer to actual collapse. Various factors have been on a collision course:the uncontrolled upward spiral of health care expenses that have employers on the brink of pulling out of a sponsorship role,a shift in service utilization to higher and higher fees and technology-based solutions,economic models that only marginally engage and reward consumers,and more. Add all that to an aging cohort of ‘Boomer’adults whose health care needs are expanding in scope and volume well ahead of the ability of the system to adequately address them,and any sense that we have a system whose functioning begins to look more and like a fiction that we are collectively agreeing is fact. In terms of outcomes,the target is being moved. And the system’s ability to stay focused on it is not keeping up.
This issue was highlighted by publication of a study on Medscape. Under the heading US Gets Less For Its Healthcare Buck Than Other Nations,a report detailed a study by Colin Pritchard and Mark S. Wallace. In Comparing the US,UK and 17 Western countries’efficiency and effectiveness in reducing mortality (J R Soc Med Sh Rep 2011;2:60. DOI 10.1258/shorts.2011.011076),the authors looked at data that indicate that the US is losing ground in its attempts to achieve cost-effective outcomes. In fact,they show,we are paying more and more and actually getting less and less. Compared to its cohort of developed countries,the US is losing ground,actually getting less efficient in relation to its peers. While improvements have certainly been made in morbidity and mortality since the Institute of Medicine’s landmark 2001 study Crossing the Quality Chasm,the US is falling behind its peers. Steadily and in embarrassing ways. Other countries are improving;in relation to them,we are not.
In my mind,this is beginning to beg the question:how much longer can we keep up the charade of our own fiction that we have a viable system? By almost any performance evaluation metric,those who are running our health care system should be fired. We have normalized a toxic system dynamic that handsomely rewards those in a middle-man position who retain near-total control over the system’s transactions. Proportionate value does not accrue to those who use the system,nor to most of those who supply the services.
That we tolerate this as a society only makes sense when we see what else we tolerate in our political system and in the loss of civil discourse across all society. We have grown used to holding our noses and acting as if nothing is actually rotten. The emperor is not only wearing no clothes;he is not bathing,either.
While American health care reform efforts may seem to many to be disruptive in their scope and influence,in fact they are disruptive only to those who have benefited the most from the system’s dysfunction:those largely inured from economic ‘harm’by their position in the supply and management chain of the US health system. Any company seeking to revise its ability to serve its customers that did as badly as the supposedly ‘market-driven,’innovation-oriented system we’ve developed here in the US would be put out of business very quickly by normally unforgiving market forces. The fact that we tolerate the fiction that we have a market-driven system is all we need to know about our own standards:the only market we have in the US health care arena is a market of convenience for a limited number of large-scale players,where they genially agree that the rules are the rules,and nothing really upsetting should be permitted to participate. So it does not.
It must be asked at this point whether the system can fix itself. It must be asked at this point whether any of the fundamental aspects of the system should survive health care reform.
There are probably five or so basic areas these fundamental flaws fall into.
Maintaining health is the goal of our system. It is not;the American system is set up to control disease. That inversion of a health promotion paradigm is fundamentally flawed:you don’t promote health by controlling disease. That disease emerges enough to be controlled is a metric of a failing system.
Medical doctors are the appropriate cultural authorities. Being on the ‘alternative’medicine side as a doctor of chiropractic (now out of practice for fifteen years) may make it seem like this is an assertion borne out of a sense of injustice and envy,but in fact it’s not. MDs have been granted a degree of cultural authority that they have not earned and do not deserve. There are too many problems with the levels of evidence that insufficiently support community medical practices,too many culturally-incestuous relationships and rewards,and too little cultural authority enjoyed by other professions who have a meaningful contribution to make. MDs are important members of what ought to be teams of diverse provider skill sets,clinical competencies and paradigms of health.
Health care plans are the best source of innovation. As someone who worked in a very large health plan for some time,this presumed competency simply does not exist. What innovation does exist is driven by market opportunity but based on the wrong paradigm of health. American health care is not likely to ever truly reform itself until the economic power of health plans is fundamentally revised and they are restricted to their main competency:being the expert managers of transactions that they actually are.
Consumers shouldn’t be held accountable for their own health. It is hard to imagine any path out of the problems of our health care system’s economic woes without a dramatically different role and degree of accountability for consumers and our individual health and lifestyle practices. There are a number of influences truly beyond certain individuals’control,but when more than 3/4 of health care expenses are attributable to individuals’practices,we know where the buck should–literally–stop.
And finally,that the system can fix itself. No broken system can repair its own fundamental flaws. There are good reasons in business why external consultants or subject matter experts are brought in to rectify fundamental problems in a business’culture,practices and procedures. There are good reasons why external medical intervention is needed when body systems break down. And there is no evidence in hand that our own health care system is capable of honestly identifying its own faults,let alone repairing them.
Next:a simple blueprint for systemic health….
I am moved to re-start this blog;I have found myself exercised and upset over a news item in a way that I have rarely experienced. The news item Sunday 7/10 that there is a new ‘medication adherence score’being launched by FICO,the folks who brought credit scoring to our lives reports that we will soon be subject to an analysis of our compliance with filling prescriptions that physicians write for us in the course of medical care.
This sounds somewhat benign. Physicians only write prescriptions for what we absolutely need,don’t they? It would be helpful if those in the system had their medical records flagged so that they could receive ‘extra counseling,followup and phonecalls,’right?
Not so much. Statistics from 2006 indicated that 2.2 million people were hospitalized due to harmful prescriptions. Cited in the report source for those figures were 1992 data from a national pharmacy database that found a total of 429,827 errors from over 1,000 US hospitals. Medication errors were found for one in twenty patients,leading to the mathematical conclusion that more than 90,000 patients annually were harmed by medication errors in the country as a whole. This was one of the more startling revelations in the Institute of Medicine’s 2001 seminal work on health system change agency,Crossing the Quality Chasm.
But that’s not what has me so concerned–beyond my normal state of frustration and anger over the carelessness and inadvertent damage being done by medicine,and the lack of accountability for this. What has me most incensed over this new ‘product’is that our personal health information has been monetized again–without our participation,active consent or knowledge.
In its report Crossing the Quality Chasm,the Institute of Medicine listed a set of design principles for improving the health care system of the 21st century. Among them are assertions that the system needs to see the patient as the source of control. This is not simply a false level of reverence being applied to individuals who are supposedly at the center of ‘patient centered care.’This is in fact an acknowledgement that the entire dynamic of control,power,decision-making,permissions,and information flows needs to not simply loop the patient/individual/consumer in when the system is expanded to include them,but to be fundamentally redesigned into a new hub-and-spoke model. Another requisite design element is listed as being shared knowledge and decision-making,while yet another is the need for transparency. How are we doing with all that,by the way?
FICO can certainly claim that they are only following one additional design principle in the IOM report,anticipation of needs. But here’s the problem:medical and pharmacy records do not have any provision for accounting why an individual has not filled a prescription.
Many of the reasons are,in fact,potentially serious and need to be addressed:the elderly in particular are often unable to fulfill prescriptions because of financial barriers,memory issues,and so on. Not obtaining many of those prescriptions can be life-threatening. But that’s not the whole story,and the underlying dynamic is what has me most incensed over this.
The reality is that we (consumers) do not command any of the information regarding our behaviors in the marketplace,nor online. We have no idea how much data is actually being collected about us,and the degree to which we can be individually identified through electronic vectors from our web and purchasing histories should give all of us pause–or heartburn. But medical records are supposedly one area where we supposedly should have some semblance of comfort that our privacy is protected,right? Hope you’re sitting down.
Again,the reality is that our privacy is NOT protected. When we sign in to a doctor’s visit and we periodically sign that little form that has the title ‘HIPAA’on it,we commonly sign away our ability to restrict access to our medical information. Medical records are commonly ‘mined’for information on the frequency,outcomes,and application of different kinds of medical treatments,medication usage,and so on. In fact,many doctors’offices and health systems make a good chunk of change from allowing access to your records and this ‘data mining.’One thing about this effort,though:it is normally anonymous. So our names and other information that could be used to personally identify us are not included. (I say,‘normally.’Data breaches are increasingly common;according to the National Healthcare Anti Fraud Association,80% of healthcare organizations have reported one or more data breaches that involve the loss of health information.)
From another angle,the information that is not listed in most medical records is extremely relevant here,and through FICO‘s product will be codified as fact with no ability for consumers to rebut its falseness. The reality is that many consumer/patients do not fill prescriptions because they are using other healthcare providers for clinically- and cost-effective care,and the prescriptions are simply unneeded or a secondary priority and choice at the time. And most physicians do not ask whether their patients are using other providers or types of care,especially when they involve complementary and alternative healthcare. So if I have a bad back and I consult with my medical physician and get prescriptions for pain relief and muscle spasms,but end up getting care from a doctor of chiropractic,acupuncturist or massage therapist (or a potential host of other options) that is effective for me,and my medical doctor doesn’t know about it,I will be listed as ‘non compliant’in my medical record–and accumulate a black mark towards my FICO ‘medical adherence score.’And anyone who thinks that FICO is not going to find some way to link medical adherence and credit scoring together in their databases is dreaming. Buckle up.
The level of offense in the ability of FICO to mine our medical and pharmacy records as a way of measuring our ‘compliance’is,in my view,extremely severe. I intend to revise every HIPAA permission slip I’ve signed with my doctors and health systems,and I will explicitly forbid them to grant access to my information to any other entity without my explicit permission.
I have no expectation,nor any illusions,that this issue will be raised to the extent it should be. But it is more than an additional degree of erosion in personal information rights. It’s an entire section of personal territory sliding off into the sea. We should all be very,very aware,concerned,and moved to action.
The New York Times had a piece October 25th on the stunning cost increases being put before many small businesses in the US this year:an average of 15%,double that of the previous year. Few small businesses can absorb these increases,which means that their employees are being asked to take more on,further reducing their economic position and stability in our economy.
This begs the question:do insurance companies add to our costs,or save us money through their functions in our marketplace? The short answer is that there is no good answer. Insurers provide some oversight on health expenses,but their ability to control them is actually rather limited. Providers have had discounts imposed on them for years,and there frankly isn’t much left there to get in terms of efficiencies. Hospitals are in the same boat,and their ability to cost-shift service ‘loss leaders’to ‘profit centers’is eroding quickly. Highly paid specialists are doing better than most even with imposed contractual discounts,largely because the valuation put on their services is higher than general practitioners. Cost increase-drivers such as new technologies and drugs without generic equivalents are large portions of the problem.
But what about profits? “Profits”is a broad category,for while portions of actual profits are available to stockholders of ‘for profit’insurers,non-profit insurers are required by state laws to maintain cash reserves that create a type of ‘profit float’that,while not being rebated to stockholders,represent excess revenues and investment returns that in essence take money out of the system over and above health care expenses.
Health care ‘costs’that end-user purchasers (businesses) see are a product of expenses,profits (excess revenues or investments) and the insurers’operating costs themselves–which can be substantial and are largely self-regulated without external oversight or control.
Viewing this in the context of insurers’business environment can be tricky. An AP news item October 26th reviews the profits of US insurers and finds that they are not great,especially when compared to other retail brands and companies. But the claims of low profitability by insurers leaves many questions unanswered,including the value their own infrastructure adds to health care service delivery.
Collectively,these latest news items point more painfully to the fact that our system is not breaking down–it has already broken,and these ‘jagged pieces’are going to wound many people if we don’t start asking the right questions and exhibit some societal courage in tackling new solutions.
One of the polarizing aspects of the debate in America over health insurance is whether it’s a ‘right’or a ‘privilege.’People tend to come down on polarized political lines when the question is framed in these terms.
It’s my view that this is the wrong way to look at this. It seems to me that the health of its citizens is a collective societal responsibility,not an issue of individual right or privilege.
The lack of that perspective seems to be at the root of why we can’t solve this problem:we’re asking the wrong question. Instead of asking whether an individual has rights or responsibilities–which have to be inferred,because the Constitution does not address ‘health’directly–we should be asking this:Do we,as a society,feel a responsibility for the health of our members?
If we don’t,then free market dynamics rule,because we cannot delegate that responsibility. We must collectively assume it,and resource decisions then orient themselves around that position. If,on the other hand,we do see ourselves as collectively responsible,then very different decisions get made.
I see us as a culture coming up to this question,and stopping short. I personally believe that we are stopping short of addressing this issue of responsibility,at least in part,because we can’t come to grips with what the implications are for our members.
If I’m a member of a society that feels collectively responsible for my health and well-being,I don’t get a ‘free ride’with my behaviors in that society. As a citizen of that society,I have responsibilities. Those responsibilities are the ‘price I pay’for being a member of a society that cares about its individual members. It’s my individual responsibility to be part of the collective social response.
What does ‘health care citizenship’entail? In the largest sense,that as an individual I have a responsibility to share a portion of the collective effort required to maintain,achieve,or recover health. In this context,if I eat fast food five or six days a week,my health is going to suffer,and my contribution to societal health is not a positive one.
On the other hand,if I work to achieve,recover and maintain my health and wellness to the best of my ability (influences beyond my control notwithstanding) I am fulfilling my responsibilities as a citizen.
It would be interesting to see things in the health care reform debate framed in these terms. But I am not going to hold my breath:there are no “citizenship special interests.”
Others who have commented on health care citizenship:
Candace Johnson Redden. Partial article can be found here.