We are in strange days, and they
are only going to get stranger as COVID-19 works its way further through our
society. It makes me think of Benjamin Franklin’s response when asked
what kind of nation the U.S. was going to be: “A Republic, if you
can keep it.”
The versions of that response that COVID-19 have me wondering about are: “A federal system, if we can keep it,” and, more specifically, “a healthcare system, if we can keep it.” I’ll talk about each of those in the context of the pandemic.
In times of national emergencies — think 9/11, think World Wars — we usually look to the federal government to lead. The COVID-19 pandemic has been declared a national emergency, but we’re still looking for strong federal leadership. We have the Centers for Disease Control, infectious disease experts like Dr. Anthony Fauci, and a White House coronavirus task force. But real national leadership is lacking.
Healthcare today, in the broadest sense, is not a benevolent giant that wraps its powerful arms around the sick and vulnerable. It is a world of opposing forces such as Government public health ambitions and more or less unfettered market ambitions by hospitals and downright profiteering by some of the middlemen who stand between doctors and patients, such as insurers, Pharmacy Benefits Managers, EMR vendors and other technology companies.
Within healthcare there is also a growing, more or less money-focused sector of paramedicine, promoting “alternative” belief systems, some of which may be right on and showing the future direction for us all and some of which are pure quackery.
I stand by my conviction that physicians must embrace the role of guide for their patients. If we see ourselves only as instruments or tools in the service of the Government, the insurance companies or our healthcare organizations, patients are likely to mistrust our motives when we make diagnoses or recommend treatments.
The term “moral
injury” is a term originally applied to soldiers as a way to help explain
PTSD and, more recently, to physicians as a way to help explain physician burnout.
The concept is that moral injury is what can happen to people when “perpetrating,
failing to prevent, or bearing witness to acts that transgress deeply held
moral beliefs and expectations.”
I think healthcare
generally has a bad case of moral injury.
Melissa Bailey, writing for Kaiser Health News, looked at moral injury from the standpoint of emergency room physicians. One physician decried how “the real priority is speed and money and not our patients’ care.” Another made a broader charge: “The health system is not set up to help patients. It’s set up to make money.” He urged that physicians seek to understand “how decisions made at the systems level impact how we care about patients” — so they can “stand up for what’s right.”
Picture, if you will, a healthcare sector that costs less, whose share of the national economy is more like it is in other advanced economies—let’s imagine 9% or 10% rather than 18% or 19%.
A big part of this drop is a vast reduction in overtreatment because non-fee-for-service payment systems are far less likely to pay for things that don’t help the patient. Another part of this drop is the greater efficiency of every procedure and process as providers get better at knowing their true costs and cutting out waste. The third major factor is that new payment systems and business models actually drive toward true value for the buyers and healthcare consumers. This includes giving a return on the investment for prevention, population health management, and building healthier communities. This incentive would reduce the large percentage of healthcare costs due to preventable and manageable diseases, trauma, and addictions.
Picture, if you
will, a healthcare sector in which prices are real, known, and reliable.
Price outliers that today may be two, three, five times the industry median
have rapidly disappeared. Prices for comparable procedures have normalized in a
narrower range well below today’s median prices. Most prices are bundled, a
single price for an entire procedure or process, in ways that can be compared
across the entire industry. Prices are guaranteed. There are no circumstances
under which a healthcare provider can decide after the fact how much to charge,
or a health insurer can decide after the fact that the procedure was not
covered, or that the unconscious heart attack victim should have been taken to
a different emergency department farther away.
well-informed, savvy healthcare consumer, with active support and incentives
from their employers and payors, who is far more willing and eager to find out what their choices are and exercise that
choice. They want the same level of service, quality, and financial choices
they get from almost every other industry. And as their financial burden
increases, so do their demands.
Picture a reversing
of consolidation, ending a providers’ ability to demand full-network
contracting with opaque price agreements—and encouraging new market entrants
capable of facilitating a yeasty market for competition. Picture growing
disintermediation and decentralization of healthcare, with buyers increasingly
able to act like real customers, picking and choosing particular services based
on price and quality.
industry whose processes are as revolutionized by new technologies
as the news industry has been, or gaming, or energy. Picture a healthcare
industry in which you simply cannot compete using yesterday’s technologies—not
just clinical technologies but data, communications, and transaction
As is customary for every administration in recent history, the Trump administration chose to impale itself on the national spear known as health care in America. The consequences so far are precisely as I expected, but one intriguing phenomenon is surprisingly beginning to emerge. People are starting to talk about single-payer. People who are not avowed socialists, people who benefit handsomely from the health care status quo seem to feel a need to address this four hundred pound gorilla, sitting patiently in a corner of our health care situation room. Why?
The all too public spectacle of a Republican party at war with itself over repealing and replacing Obamacare is teaching us one certain thing. There are no good solutions to health care within the acceptable realm of incremental, compromise driven, modern American solutions to everything, solutions that have been crippling the country and its people since the mid-seventies, which is when America lost its mojo. To fix health care, we have to go back to times when America was truly great, times when the wealthy Roosevelts of New York lived in the White House, times when graduating from Harvard or Yale were not cookie cutter prerequisites to becoming President, times when the President of the United States conducted meetings while sitting on the toilet with the door open and nobody cared. Rings a bell?
Single-payer health care is one such bold solution. Listening to the back and forth banter on social media, one may be tempted to disagree. We don’t have enough money for single-payer. Both Vermont and California tried and quit because of astronomic costs. Hundreds of thousands of people working for insurance companies will become unemployed. Hospitals will close. Entire towns will be wiped out. Doctors will become lazy inefficient government employees and you’ll have to wait months before seeing a doctor. And of course, there will be formal and informal death panels. Did I miss anything? I’m pretty sure I did, so let’s enumerate.
[Note to the reader: Anything that is in italics and square brackets (such as this note) is addressed to you, personally. Yes, you. Try it on, see if it fits.]
Healthcare has, right now, the greatest opportunity we have seen in our lifetimes to make a big change, to rebuild itself in a hundred ways to become better for everyone, and cheaper—to get cheaper by getting better. We’re not talking “bending the cost curve,” cutting a few points off the inflation chart. We’re not talking a little cheaper, a little less per capita, a few percentage points off the cut of GDP that healthcare sucks up. We’re talking way cheaper. Half the cost. You know, like in normal countries.
We’re not talking a little better, skipping a few unnecessary tests, cutting the percentage of surgical infections a few points. No. Don’t even think about it. We’re talking way better. Save the children, help the people who should know better, nobody dies before their time, no unnecessary suffering. Seriously.
I don’t know how high you want to aim, but personally, I think we should aim at least as high as the cutting-edge programs and facilities that are already out there, in the system as it exists today, cutting real healthcare expenses of real people, even “frequent fliers,” by 10, 20, even 30 percent, while making them healthier, much healthier. At least. To me, that’s a wimpy goal, just doing as well as some other people are already doing. Because these programs are just getting off the ground. They’re in the first few iterations. The stretch goal, the goal we can take seriously, is to cut real costs by 50 percent, by making people healthier. There is at least that much potential out there.Continue reading…