Healthcare: like baseball, but no peanuts and crackerjacks

It's a challenge to understand just how broken our healthcare system is. How broken is it? Let me explain. 

Imagine you're in a stadium with thousands of other people watching a (hypothetical) baseball game. Your employer bought your ticket, a third-party purchased the ticket for the family sitting next to you, and the government purchased the ticket for the family sitting behind you. Despite sitting in relatively similar seats with the same view, each ticket costs a different amount, negotiated by whoever purchased the ticket. If you wanted to know the price of any other ticket, good luck trying to find out. There's absolutely no transparency in the pricing. 

Looking out on the field, you see talented, well-trained players. They spent their lives training and physically challenging themselves to be able to play the game of baseball. The players are dressed in their teams' colors, head to toe. Each glove, bat, and uniform was meticulously designed to fit the needs of the players. Millions of dollars and hundreds of hours were spent researching and developing the players' gear. Players develop opinions on different equipment, and might think that one brand or type offers them an edge. However, no matter how much the players love a specific glove or bat, they do not have the power to choose the one they’d like to use. Why? The decision affects too many people, and all of these people have different interests. The player wants the most comfortable glove, but management wants the glove that will bring in the most money. Not to mention, the spectators want the glove that looks nice and attractive. There are too many groups offering opinions for this to be anything but fragmented.

Imagine that management recently enacted a new rule for all their players. Under this new rule, each player on the field is required to run a mile during each inning. Before, players ran at most 3/4 mile each game. Now, they're totaling over nine. Why? Management believes this will make them more fit. This might be true in a general sense – running can improve fitness, and running is part of baseball. But running is not the most important component of baseball. More importantly, running is not the reason that baseball players play baseball. One can assume that if the players simply wanted to run, they would have chosen to be elite runners rather than baseball players. When the management takes such a myopic view of baseball, they not only focus energy on something tangential to success in baseball, they also rob players of the freedom to focus on the aspects of baseball that bring them joy. As a result, they are forced to spend most of their time running, gradually wearing them down. They're spent. They’re burnt out. 

Strangely, the way these players are reimbursed is counter-intuitive. There is no signing of contracts that guarantee a predetermined compensation package. Instead, players are compensated for every play and action they make, whether it's good or bad. The pitcher throws the ball off target? Paid. The batter swings (no matter how off target the pitch is)? Paid. The batter hits the ball, and the outfielder runs to it, but misses it? Paid. The message being sent to the players is that it doesn't matter at all how well they play, only that they pitch the ball and swing at the ball as many times as possible, with no regard for actually making a play. Shouldn't the players be paid for making valuable plays and penalized for errors? 

You're sitting in the stands wondering, what in the world is going on? Why is this such a mess? 

In healthcare, we have the payers. These are the private insurance companies (e.g., UnitedHealthcare, Cigna), government insurance (e.g., Medicaid, Medicare, TRICARE), or self-insured companies (e.g., Walmart). All in all, insurance companies are meant to protect individuals from financial catastrophe when a healthcare crisis occurs. Simply, health insurance "pays" for your “ticket” to receive healthcare services. Because healthcare services are becoming increasingly more expensive, and thus unaffordable, so too are your premiums and deductibles. If for whatever reason you choose to waive healthcare insurance and pay out-of-pocket, it is unfathomably challenging to figure out what you'll pay for certain services. Why? All pricing strategies are secretly negotiated between the healthcare organization and the payers. There's absolutely no transparency in the pricing. Confused? So am I. 

To confuse you more, let me talk about the fragmentation of the system. A plethora of players exist in healthcare, and each player has their own unique interests. Where in baseball we have the spectators, athletes, and management, in healthcare we have the patients, insurance companies, physicians, and executives (just to name a few). Now, let's say I present to Hospital XYZ my new service that focuses on managing and the health of their patient population. I spent years and millions of dollars developing this service with a team of people. Insurers will love my service because I'm maintaining and improving the health of their beneficiaries, consequently keeping them away from a costly hospital or specialized care visit. On the other hand, providers will be apprehensive about adopting such a service because their reimbursement will decrease since they're seeing fewer patients. Likewise, the C-suit may like it because this service may reduce any shortfalls experienced for uncompensated care if a patient is uninsured; however, from a broader perspective, Hospital XYZ won't be making as much revenue since fewer patients are utilizing their (expensive) services. There are too many groups offering opinions for this to be anything but fragmented.

The Affordable Care Act requires that healthcare providers and organizations demonstrate the meaningful use of technology. This "meaningful use" influenced the buying and adoption of electronic health records (EHR), permanently moving from hand-written documents to electronically-written documents. There are certainly benefits of maintaining everything on the computer in one system, just like how there are benefits of running a mile before each inning. However, the buzz in healthcare today is about physician burnout due to excessive documentation and focus around EHR systems. Balancing the delivery of sound, compassionate care with tedious and excessive note-taking has led to emotional stress, depression, and exhaustion in physicians. Nowadays, doctors spend more time looking at the screen than they do at their patients. While documentation is an important part of medicine, it should be facilitating the delivery of compassionate care, not impeding it. Hours of documentation is frustrating and unnecessarily time-consuming for physicians. Like running in baseball, documentation is a necessary component of medicine, but it is unlikely to be the thing that brings physicians a sense of meaning in their work. When they spend more time doing something that feels rote, and less time doing something that brings them joy in their work, physicians feel worn down. They're spent. They’re burnt out. 

As for the reimbursement system, it's antiquated and has been slow to catch up with the current state of medicine. The majority of physicians and healthcare organizations are reimbursed on a fee-for-service (FFS) basis. Simply put, this means that providers and organizations are compensated for their inputs, not outputs (value of care delivered). Imagine how the baseball players were pitching off target, swinging at every pitch, and making errors while getting paid for each action, no matter if a play was made or not. And, the problem with FFS is precisely that. Doctors may purposefully or inadvertently perform unwarranted procedures or treatments (e.g., spine surgery) and order excess tests (e.g., blood work) to increase their returns instead of focusing on delivering the most valuable care (outcomes). Shouldn't the physicians and healthcare organizations be paid for providing the highest quality of care and penalized for errors? 

Unfortunately, a full discussion of what can be done to fix this healthcare system will require subsequent posts to break down the issues even further. What I can say now, however, is that the system needs creative thinkers to draw up innovative — perhaps even disruptive —solutions to fix these problems. Batter up!