Healthcare Isn't Working

With the aging demographic, urbanization of whole populations and a globalization of unhealthy lifestyles, health is being profoundly shaped on a massive scale.  As a result of these powerful forces, chronic disease has overtaken infectious diseases as the leading cause of illness, disability and death.  The root cause is multi-factorial, but ‘lifestyle diseases’ are being shaped by our ‘box’ culture; living in a box, travelling to work in a box, eating out a box and watching the box.  

In response to the shifting health climate, we continue to develop new medical technologies and drugs to meet the unprecedented demand.  But they come at a cost.  Healthcare in many countries is approaching the limit, the tipping point where constantly rising costs have become unsustainable.  The GCC healthcare 2025 Report by McKinsey & Co. estimates the demand for hospital beds across the UAE to increase by 160% by 2025, with healthcare spending predicted to surge fivefold from USD12 billion to USD60 billion by 2025.

Not only is the healthcare sector battling external forces, there is a deeper, more concerning conflict within: A fundamental cultural flaw in the health system.  We are operating in a culture of excess: excessive diagnostic tests, excessive interventions and excessive promises that create unrealistic expectations for patients and their families.  The excess culture develops from doctors influenced by a fee-for-service payment structure, defensive medical practices, patient pressures and the biased reporting of industry-sponsored research.

The unaccountability of an insurance-based healthcare system, in the absence of standardized clinical guidelines, leads to unnecessary treatment.  The system has no incentive to restrict doctors’ activity, creating a culture of more is better, where the onus is on doctors to do something at each consultation.  This has led to unbalanced decision-making and patients being offered non-evidenced based treatments that have minimal or no benefit, despite the potential for substantial harm and expense.

Patients are the unfortunate pawn, lost in a depersonalizing healthcare system. Instead of being encouraged to make informed choices, they’re up against the odds, with little ability to determine the quality of service they receive.  Doctors can recommend care of little or no value, because it enhances our incomes, because it is habit and because we genuinely, but incorrectly, believe in it. Invariably, patients will tend to follow our advice. 

Doctors have stopped being doctors and become businessmen, putting profits before patients.  Hospitals and their employees remunerated according to the number of drugs they prescribe, tests they conduct and procedures they perform.  Insurance providers paying for patient contacts and procedures performed, with tariffs for each operation and test, payments become based on amount of activity carried out, rather than patient outcomes.

There are endless examples of ‘no value care’ in the health industry.  CT or MRI scans for uncomplicated lower back pain and simple headaches.  Coronary artery stenting in patients with stable cardiac disease.  In a recent study of more than one million Medicare patients in the US, 14.7% of patients received at least one no value test or treatment in just a single year.

Patients are often oblivious to low-grade examples of abuse happening on a regular basis; unnecessary and often duplicated blood tests, pointless x-rays that have no impact on management, and issuing of medications with no proven benefit.  Most of which won’t, supposedly, cause any harm to the patient, and on an individual basis, are not high cost.  Cumulatively though, the effects are large.  

With all the over-activity, current trends in health-seeking behavior are being reinforced.  We are subconsciously raising the expectations of patients; that such tests are warranted. At the same time, cultivating the attitude that ‘the antibiotics made me better’.  And then there’s the unwarranted health anxiety generated from waiting for test results, which are ultimately of no value.  The least we can do for our patients is alleviate worry, not add to their distress. Doctors should be offering reassurance and guiding patients to appreciate that certain illnesses are self-limiting.  That their chronic disease is treatable with lifestyle modifications, without the need for over-medicalization.

It’s generally, however, quite hard for patients and most doctors to recognize that tests and scans can be harmful.  Given that no one is normal, with sophisticated testing, we are finding more and more abnormalities, particularly when we look closely and often enough.  In the process, we have started meddling in a grey area, shifting a massive amount of resources within health services from the sick to the well, and harming the well in the process.  Often the hardest thing in medicine is to do nothing.  Patients don’t tend to feel much reassurance when “it’s just one of those things” is the best a doctor can come up with.  Neither do doctors for that matter.  A recipe for disaster when coupled with a system which makes it all too easy to leave no stone unturned, and even better, an insurance provider to pick up the bill.  The full cost impact only reveals itself when the patient expects the same over-treatment time and time again.  Or worse still, when they develop a complication as a result of all the unnecessary care.

The problem is further amplified by a health industry focused around secondary care - hospitals, specialists and in-patient beds.  Hospitals only make money when patients are sick.  They are reactive systems dealing with acute medical problems – they lack the focus or expertise in preventing and managing chronic disease.

In any health system which has a startling lack of primary care, there exists an overarching apathy from hospitals to monitor patients and prevent future complications.  Such interventions are of low financial value, and reduce future healthcare costs and hospital profits.   Preventative care is poorly reimbursed by an insurance system which instead rewards more costly reactive hospital-based care.  Private companies shun investment into quality, cost-effective primary care, again putting profits before patients.  In the process, the system avoids taking adequate care of the biggest lifestyle-induced problems that people face – obesity, hypertension, or any number of less technologically intensive or profitable conditions.

We need to think about a different payment incentive for doctors and hospitals with the emphasis on quality of care; reimbursement based on improved patient health outcomes, reimbursement of clinical activity based on standardized evidence-based guidelines, or ‘bundled’ payments on the basis of expected costs for clinically-defined episodes of care.  We need a more thoughtful and measured style of medicine which keeps improving outcomes.

Over-medicalized healthcare cannot be prevented or managed in the absence of a strong primary care infrastructure.  A health system where primary care is the backbone and family doctors are the bedrock delivers the best health outcomes, at the lowest cost and with the greatest user satisfaction. Specialized models of medical care are not the ideal approach to management of aging populations.  Family doctors, who are in the best position to cultivate long-term relationships with patients, are uniquely placed to help people age in good health, stay in their homes as long as possible, remain socially engaged and coordinate the right mix of specialized care when needed.  Of course, health systems must have specialists and hospitals; but they must also have primary care doctors who care about prevention.  They must have doctors who know their patients long enough and well enough to truly manage the totality of health in all its multiple dimensions.  Both doctors and patients need to have open and honest dialogue about the appropriateness of treatment in order to empower patients to make informed decisions about their healthcare.  People should not be treated like a collection of symptoms, who have bits and pieces fixed like a collection of body parts.  Patients want accessible and affordable healthcare in the community that treats them as people, in the context of their social and spiritual lives.

We must build long-term relationships that instill trust, in order to encourage motivation.  Motivated people are the ones most likely to accept personal responsibility for maintaining good health.  We must move away from the de-humanizing ‘sick’ system, and instead, continue to cultivate the human side to medicine.