Health Policy

A Change in Tactics

By ROBERT PRETZLAFF MD, MBA

Those that advocate for change in healthcare most often make their case based on the unsustainable cost or poor quality care that is sadly the norm. A 2018 article in Bloomberg highlights this fact by reporting on global healthcare efficiency, a composite marker of cost and life expectancy. Not remarkably, the United States ranks 54th globally, down four spots from 2017 and sandwiched neatly between Azerbaijan and Bulgaria. Unarguably, the US is a leader in medical education, technology, and research. Sadly, our leadership in these areas only makes our failure to provide cost-effective, quality care that much more shameful. For the well-off, the prospect of excellent accessible care is bright, but, as the Bloomberg article points out, as a nation our rank is rank. Anecdotally, I can report that as a physician I am called upon with some regularity to intervene on the behalf of family and friends to get a timely appointment or explain a test or study that their doctor was too busy to explain, and so even for the relatively well-off, care can be difficult and deficient.

The cost of care frequently takes center stage in arguments advocating change. The recognition that health care costs are driving unsupportable deficits and limiting expenditures in other vital areas is very compelling. Therefore, lowering the cost of care would seem to be an area in which there would be swift consensus. However, solutions to rein in costs fail to address the essential truth that most of us define cost subjectively. Arguments about the cost of care divide rather than unify as the discussion becomes more about cost shifting than controlling overall cost. Further, dollars spent on healthcare are spent somewhere, and there are many who profit handsomely from the system as it is and work aggressively sowing division to maintain the status quo.

Poor quality and access are additional lines of argument employed to win support for change. These arguments fail due to a lack of a commonly accepted definitions of quality and access to care. Remedies addressing quality and access issues are frequently presented as population level solutions. Unfortunately, these proposals do not engage a populace that cares first and foremost about their access to their doctor. The forces opposed to change readily employ counterarguments to population-based solutions by applying often false, but effective, narratives that population-based solutions are an infringement on a person’s fundamental freedoms. In that counterargument is the key to improving healthcare.

It is time to acknowledge that creating change by arguing from an economic or quality perspective has been unsuccessful. The truths of these arguments are a fact; however, the power of these arguments to affect change has failed and should be abandoned.  A fundamentally different approach is needed.

As the Preamble to the Declaration of Independence demonstrates, our country was founded by leaders that understood that creating societal change was best accomplished by framing arguments that appeal to the rights and principles of citizens. The Civil War, a war fought to secure the freedom of an enslaved populace, was ultimately fought based on arguments that appealed to the principles of freedom and opportunity. The tale of President Lincoln’s greeting Harriet Beecher Stowe by saying, ‘So you’re the little woman who wrote the book that made this great war!’ highlights that it is the social conscience of the country that ultimately generates great change.

The Social Security Act of 1935 created a right to a pension in old age and insurance against unemployment. The Civil Rights Act of 1964 outlawed discrimination based on race, color, religion, sex, or national origin, and was followed by the Voting Rights Act of1965. These historic advances in advancing the rights of citizens were resisted as avidly then as changes to healthcare are fought now. The interests that would be negatively impacted by change resisted just as vigorously then as they do today. Nevertheless, these hard-fought victories against entrenched forces were ultimately successful by appealing to the “the better angels of our nature.” Despite living in a country founded on the recognition and protection of the rights of citizens, healthcare is not considered a basic civil right.

This article is not the first to suggest health care as a basic human right. It is recognized as such by developed nations across the globe, but we fail to recognize the tactical value in viewing healthcare as a right. In the US, health care is viewed as a transactional exercise. The economic foundation of health care in this country, the fee for service model, reinforces the concept of healthcare as transactional. When conceived in this way, arguments to improve healthcare are provided in the language of commerce. We argue about cost. We argue about quality. Efforts to improve care become arguments about what changes are needed, but fail to capture what is fundamental and therefore lack appeal to the imagination and passion of the nation. Fundamental change requires arguments about fundamental issues. Healthcare is a fundamental issue.

The country has made progress toward viewing healthcare as a right and enshrining those rights into law. EMTALA, Medicare and Medicaid are examples of recognizing healthcare as a right granted to specific populations.  Providing Medicare For All is a strategy to establish this right for everyone. Unfortunately, I predict this attempt will fail if the right to healthcare is not first established in the hearts and minds of the nation.

A system that benefits the very few and yet does harm to the majority is prima facie evidence of a violation of a people’s civil rights. Those that will lead the charge against healthcare as a right will appeal to the prejudice of many that rights are but privileges given to the undeserving. A counterargument to this perception is that the most basic of our civil rights, the freedom of speech, is not a license to say anything one wishes. Rather, the right of free speech comes with the responsibility not to liable or defame another, and that the exercise of this freedom does not permit the speaker to endanger others. The right to healthcare will come with responsibilities as well. In a transactional model such implied or explicit responsibility does not exist. In short, you get what you pay for.  Hence, a right creates an obligation on both sides – where a transactional model creates no such obligation.

The goal of this article has been to suggest a tactical shift in the pursuit of affordable, quality care by turning away from divisive debate about cost and quality measures. Rather, by looking to history as a guide, a revolution will require that healthcare is first established as a right in the minds and hearts of the citizenry. Only in this way can the popular will succeed in overcoming the interests arrayed against it. For those convinced of the need for change and comfortable with the direction this may take, my suggestion will appear as a step backward. However, our failure to make any real progress demands a reevaluation of our approach to accomplish what many see as obvious. Solutions that center on quality and cost by their nature perpetuate the idea of healthcare as a transactional process. This is the fundamental flaw of this approach, because so conceived, our solutions focus on fixing that which is broken and will never be fixed due the ability of those that profit from the current system to sow division. The language of rights differs from the language of the marketplace and creating the recognition that these rights exist should be the primary goal and principal tactic for creating change.

Robert Pretzlaff is a Pediatric Critical Care physician and physician executive working for Evolent Health to advance value-based care.
 

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  1. Health spending for our nation’s HEALTH can be most easily understood by its population distribution that mimics a power law distribution curve. If you rank-order each of our citizens by each person’s total health spending during a year from highest to the lowest, 20% of these citizens would use 70% of health spending, 35% of citizens would use 25% of health spending, and 50% of our citizens would account for 5% of national health spending. As a basis for decreasing health spending for the high users, we will methodically need to increase health spending for half of our citizens with stable health.

    Without a means to offer enhanced Primary Healthcare to each citizen, community by community, that is equitably available, ecologically accessible, justly efficient and reliably effective, neither the cost or quality of our nation’s healthcare will improve. I offer a new concept as a means to understand the Paradigm paralysis afflicting our nation’s healthcare. “The Capability Trap: Prevalence in Human Systems” is the title of a proceedings presentation (2017) by Erik Landry and John Sterman (both at MIT).

    https://systemdynamics.org/assets/conferences/2017/proceed/papers/P1325.pdf

    As a strategy to for implementation, community by community, I offer a reference based on the research of Nobel Prize winner (2009), Elinor Ostrom: “Generalizing the core principles for the efficacy of groups.” (2012)

    http://dx.doi.org/10.1016/j.jebo.2012.12.010
    NOTE: Its easier to access by doing a google scholar search for David Sloan Wilson, Elinor Ostrom & Michael E. Cox in the Journal of Economic Behavior & Organization.

  2. Dr. Pretzlaff,

    You are quite right when you point out that in the U.S. much of the population “cares first and foremost about Their access to Their doctor.”
    In other words, they think in terms of what would be good for “me and my family.”

    This can be traced to a strong emphasis on the rights of the individual in our history and culture.

    By contrast, Europeans are more likely to think
    collectively–in terms of “we.”
    A friend who lived in France for a number of years
    once told me that French healthcare is so good, because the French feel that “nothing is too good for another Frenchman.”

    Unfortunately, many Americans do not feel that way about each other. But because the French do think in terms of “us” they are willing to pay relatively high taxes to ensure everyone in the country has access to high quality care.

    In the U.S. we don’t think collectively, as you say, “forces opposed to change readily employ counterarguments to population-based solutions by applying often false, but effective, narratives that population-based solutions are an infringement on a [individual] person’s fundamental freedoms.”

    But those arguments are as you suggest, “false.”
    We all would be better off living in a nation where the population as a whole has access to high quality care.

    If the poor don’t have access to good care they
    are more likely to suffer from mental illness, alcoholism and drug addiction, which in turn, leads to
    higher rates of crime, not to mention car accidents.
    If they don’t receive good preventive care, they are more likely to spread contagious diseases. Finally, if they don’t have access to healthcare, they are more likely to be unable to work and contribute to the economy. Instead they become wards of the state, and the rest of us must support them, even if at a very low standard of living.

    Can we learn to think collectively?
    We did when we finally approved Social Security,
    and later when we supported Medicare and Medicaid.

    You’re right that those who profit from our for-profit healthcare system will resist reforms that make
    healthcare more affordable for all.
    The AMA stood in fierce opposition to Medicare.
    But the AMA lost that battle.

    Some who profit from healthcare resisted The
    Affordable Care Act. But they, too, lost. (Some pretended to co-operate with passage of Obamacare because they thought Obama could never be re-elected. But they were wrong, and by the time the GOP took over the government, the program was too popular to be repealed.)

    As a result, today, a significant chunk of the population that was uninsured now has access to comprehensive care that covers all essential benefits. That care is subsidized on a sliding scale,and insurers cannot charge patients more if they suffer from a pre-existing condition. If someone loses their job, along with their job-based insurance, they can buy insurance in their state’s Obamacare Exchange, even if the enrolllment period has ended. These are important victories.

    Meanwhile, now that we have seen what Obamacare can do, it is far more popular with the public than it was when the legislation first passed.

    There is no question that we need to improve Obamacare by extending subsidies to a larger share of the population, including more of the upper-middle-class. At the same time, we need to regulate what providers, drug-companies and device-makers can charge, just as most industrialized nations contain cost, while insisting on high quality, evidence-based medicine.
    In the U.S. most reformers believe that we should do this by paying doctors, hospitals and drugmakers
    more for better outcomes and significantly less for
    procedures and products that cannot show evidence that the treatment will help a patient who fits a
    particular medical profile.

    Without such evidence, we are simply exposing patients to unnecessary risks without benefit. (Everything in medicine–even a test–carries a risk. When it comes to testing, the risk is that a false positive will lead to an unncessary procedure.)

    Virtually every nation that suppports universal care
    insists that providers practice “evidence-based medicine.” In the U.S., thanks in part to our emphasis on the individual, we let many doctors practice according to “doctors’ druthers”–doing what an individual doctor thinks is best, even if it’s just because this is just the way he has always done it, since graduating from med school 25 years ago.

    Or even it means using a new, over-priced not fully-tested artificial hip because a company rep “sold him on it” and now it’s more convenient to keep on using the same device. This happens even when reserach shows that the device leads to more complications than another, older and less expensive hips.
    (For this reason, some of our best hospitals are now
    insisting that all surgeons use one of 2 or 3 fully tested artificial knees & hips with the best track record.)

    Are Americans just too selish to think collectively?
    I don’t think so. Look at Medicare, Social Security, and the growing support for Obamcare.

  3. We have to try running it as an experiment with convertible, refundable vouchers.
    The providers need to feel that the patients are shopping. The patients need to feel that they should conserve
    vouchers if they can.
    The government needs to be able to help the poor.
    We can’t use money because we can’t reliably keep its use within the health care sector.

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