A Practicing Doctor’s Prescription for Health Care Reform

Our national healthcare system needs a ‘step-change’, not incremental change. We are facing a vast and complex problem. Let’s use it as an opportunity; rather than blaming our nation’s health problems solely on corporations, providers, insurers, or the government, let’s also think constructively about individual behavior and incentives.

Why do we stop at a red light? Why do we pay our grocery bill when we check out? Why are we compelled to ‘service’ our car when the red indicator light starts to flash? The simple answer is that if we don’t we know we will incur a penalty. Either we have to pay to get things fixed later, or we pay extra financial fees, or we get nasty looks from our neighbors.

A behavioral sociologist would offer a more complex answer: such contracts form the heart of a civic society. We behave in accordance with laws and a sense of civic duty (we abide traffic signals) because we understand that preserving the community is ultimately self-preserving. We act in ways consistent with financial incentives, or disincentives (we service our cars) because it is immediately self-preserving.

Small, homogeneous countries like Denmark and Switzerland have a common historical thread — the shame of the town square. That is, the personal accountability borne out of responsibility when using your fellow countryman’s resources for you own good. Furthermore, citizens of these countries are inculcated at a young age to adhere to societal rules for the good and longevity of society.

The current US health care debate is starting to define itself by two rhetorical threads: finance reform and utilization/outcomes. The politico’s wax and the physicians holler. Many cite the recent New Yorker article by Atul Gawande, “The Cost Conundrum”, as the harbinger of the current crisis: procedure-oriented doctors as opposed to outcomes oriented doctors. There is plenty of mud being slung at the ‘greedy’ insurance companies, big pharma and the army of salesmen hawking questionably relevant middle-ware.

Nowhere in this debate is the patient, the consumer, and the citizen: the American! We lack accountability, responsibility and civic sensibility. It is Joe Diabetic that snacks on ice cream, misses appointments and doesn’t take his insulin that increases the cost of health care. This diabetic will be admitted to your local ER with diabetic ketoacidosis and have many subsequent hospital admissions at our (read: your) expense, not his. This is a fundamental collective action problem.

Our town square is so big that we can get away with malfeasance to our village (and our country) with no shame. Yet, the forces of economics do not defy gravity and the cost of health care is now affecting all of us. Those of us that are untethered from the reality of cost are driving our health care ‘car’ into the ground.

Unless we get real foundational reform in health care, we will need to start a meaningful discussion of the “R” word as elegantly stated by Peter Singer, in his July 16th article in the New York Times, “Why We Must Ration Health Care.” We are not a country used to contemplating rationing as an option. We’re too great, we’re too rich, and we’re too smart. The reality is, if we don’t get ‘real’ and individually ‘responsible’ in this great debate, we are really just too arrogant.

The only difference between our car and our body is that we don’t have a flashing ‘service’ light — and, more importantly, there is no consequence if we miss all our service checks. We can dismiss every doctor recommendation, ignore every ‘annual appointment’ and patently thumb our noses at our neighbors who watch us eat and not exercise. What’s up with this? What happened to the ethos of World War I and World War II — when we looked at our fellow citizens and made efforts to unload their burden? Now, the pendulum has swung wildly in the other direction — numb, careless and self-centered. Civic duty is drowned out — why? What happened?

I started thinking, where is the flashing ‘service’ light in our health care system. Where are the age-related, disease related or genetic reminders that could help us prevent illness, or at least, catch it early. The government has no problem regulating Wall Street, nuclear energy, the health care system and the legal system. Where are the regulations for maintaining personal health?

It is a privilege to drive a motor vehicle. We need to pass a test, show our competence and revisit this test at a government-determined frequency. If we get too many tickets, we lose our right to drive. Why can’t we find the analogue for auditing personal responsibility in health care? The current system is basically like going shopping with someone else’s credit card — no limit, no penalty, no shame.

My solution is simple: match personal behavior with benefits. You either get with the health program or you don’t get the benefits. Every patient should have the opportunity to meet with a physician which lays out a cogent, fair and meaningful plan for health. For example, if Joe Diabetic was given a road map of appointments (online) that meet the standard of care for diabetics, and he actually showed up, without fail, to the doctor, the podiatrist, the nutritionist and followed their subsequent recommendations, he would not need an ER visit and we would not shoulder his cost. If he misses these critical steps in his care, he pays, not us. Sure, there will be exceptions for missing appointments, but there must be the rule.

When the flashing ‘service’ light goes off, you must take care of the issue. If you don’t, you risk being relegated to the “ration pool”. We could have centers for nutrition, psychology and exercise that would award ‘points’ commensurate with your commitment to your health. Without fair and appropriate carrots and sticks, health care will become our Waterloo. Let’s pick ourselves up, look ourselves in the mirror and pay attention to our individual health. Ultimately, our individual health is the best proxy for our nation’s health — it will save trillions of dollars over time. This plan will cost less than providing blanket insurance for all, and will provide tangible incentives to the millions of Americans committed to living healthy lives. If we don’t, we’ll just continue our slow decline from Pax Americana to Lax Americana.

Dr. Jordan Shlain is a practicing Internal medicine doctor in San Francisco and the founder of Current Health Medical Group, a Health 2.0 medical practice where doctors, patients and technology peacefully coexist in the spirit of better patient care and outcomes management.  He has recently been listed as a health care innovator in the HealthSpottr Top 100 list and lectures at UC Berkeley on medical economics. Dr. Shlain spends most of time treating patients and thinking about the future of our health care system. He received his medical degree from Georgetown after spending a year in Kenya with Harvard’s Center for International Development.  Jordan is also a contributor on The Huffington Post, where this blog first appeared.  He lives in Northern California with his lovely wife and three happy children.