Untangling the Gordian Knot - US Healthcare 2017

Structural reforms will provide a framework for a healthcare access, delivery and clinical outcomes revolution; do we have the political will?

With the recent failure of the US senate GOP healthcare reform bill, and years of inconclusive data on the benefits of the Affordable Care Act, the sad fact remains that Americans today, and for the longest time, pay too much for their healthcare compared to other developed nations, without any significant improved outcomes, clinical or other (waiting times, procedure access etc.). Let me state that again at the aggregate level. The US as a nation spends approximately 17% of its GDP on healthcare (and estimated to be 20% by 2025 according to the US GAO), more than double the amount spent by most developed nations, yet the ultimate metrics of the efficiency and outcome of that spend are nowhere near ‘double’ that of other nations, in fact, most often worse (see Commonwealth fund reports). Some argue, well, we are the richest nation, spending 1/5th of our economy on healthcare is reasonable, what else would we spend it on? Without giving such a spurious argument credibility, let’s consider, for a moment say; infrastructure and education.

Indeed, many nations provide universal coverage and spend less than the US. And is there ‘rationing’ in those systems, yes – based on clinical need mostly. Here in the US we ration healthcare by coverage, that ought to be morally reprehensible for a nation that often claims the moral high ground. Further, the US insurance-based system is failing large numbers of people, in terms of coverage, linkage to an employer/employment, and a high incidence of bankruptcy with medical bills cited a predominant, if not primary, factor; https://scholar.harvard.edu/files/pgoldsmithpinkham/files/dgy_bankruptcy.pdf

Two pillars that form the very fabric of US culture and society – education and healthcare – both suffering from spiraling costs, access and failure to deliver for many and facing increasing scrutiny. Is the ‘free market’ the best approach in providing these? Is healthcare, in fact, a ‘market’ problem, given that disease strikes randomly and patients (consumers) with a pre-existing condition didn’t make that economic choice. We won’t solve that question here – only to note that almost all western democracies have evolved a system of ‘societal care’ at least at the catastrophic-level, and many of those countries provide full coverage as a national policy of government, think NHS in the UK since 1948.

So, given the complexity of these challenges of healthcare, we shouldn’t expect it to be ‘neat and simple’. Healthcare after all is, life and death, and it lies at the intersection of state and national policies, regulatory and licensing complexities, economics, technology, outcomes, and the complexity of human biology. What then are some of the basic principles that we can tease apart here, and propose a way forward for US healthcare? Problems that we can fix, that would have lasting impact?

1.      The Structural Problem of US healthcare

In the US system, you and I are not ‘consumers’ exerting economic pressure to affect demand, supply and therefore pricing. Indeed, the vast majority of us have no idea what the right price is or should be for healthcare, and the huge variances in medical costs for the same procedure attest to that fact. Your insurance company is the proxy customer, exerting economic pressure and control, negating the ability to patients to participate in a market in an effective way. And therein is a huge part of the problem. The relative power of patients, compared to insurers, hospitals, physicians, employers, government and regulators is the problem, not the solution. Reforms are needed to redress that balance of power, and the transition period between the old regime and a more market-driven heathcare economy is likely going to be ugly, complex and costly. We created this quagmire, we have to find the way of digging ourselves out of it.

 ·      Markets need to be created where consumers unfettered by state, federal, employer and insurance companies can exert economic pressure for the services needed, and for clinicians to be able to meet, or deny, those needs in a market (other than, of course, life-threatening and emergency healthcare – which all clinicians have a moral - not financial - obligation to provide), hence the continued need to set aside monies at state levels for those needs.

·      Medical benefits should not be tied to employment, that’s a clear conflict of interest, and lest I be accused of a political bent in that statement, the same argument comes from The Heritage Foundation. In that manner, patients as consumers can shop in the market for policies (that would through market mechanism adjust to meet that demand), based on their specific circumstances.

·      The Federal government has no business being involved in a system they claim to be ‘market-driven’; let the states and patients/consumers decide.

·      Get healthcare lobbyists in DC out, today. Lobbyists serve the needs of the organizations that employ them. They don’t speak for the people, only vested interests, and they are corrupting our system of needs and priorities as a nation.

 2.      Empower Clinicians to make Clinical Decisions

The US healthcare system has some of the most well qualified, talented, motivated and professional clinical staff anywhere in the world. So, let them create their own clinician-led hospitals and mechanisms of payment, directly at time of service, unfettered by insurance companies meddling. Local jurisdictions are best suited to develop the regulatory frameworks of the who, how, where and when for delivery of medical procedures, they should run the certification processes, and the states can work together for inter-state issues - seemingly much better than any state with the federal government. This brings local accountability to healthcare – it stops at the level of the state, and if you don’t like your state, you are free to move elsewhere. With physicians and other clinical staff making the critical decisions about healthcare – a new dialogue begins. What’s truly best for the patient – and that won’t always be the choice for the most expensive treatment in the last few weeks of life – with a medically-oriented physician engaged directly with the patient and their care team weighing all factors for the patient, including cost as one element, but not the over-riding principle from the outset. At any stage of life or disease, I want that discussion with my doctors and care team, with financial matters clear and easy.

3.      Empower Patients to Make the best Decisions for Themselves and their Families

Third-party payor approaches have failed US healthcare and failed Americans. The interposition between a patient and his or her doctor of a large, for-profit, distant and corporate entity does not serve the best interests of most Americans well. Our antiquated, overly litigious regulations in healthcare are now a hindrance, an obstacle to progress (think about the value of big data and AI across the US patient population if HIPAA can be out of the way) in the emerging world of digital health, mobile health, web-conferencing your clinician, scheduling, billing – the list goes on. Even with insurance, the system is far too complex. What are the out of pocket costs? Where can I get treatment? Is this procedure covered? Is all of this procedure covered? Is the medical annex able to deliver my procedure or does it have to be in the hospital? And then there is the ridiculous, ‘this is not a bill’ letter. I believe we can do so much better by centering our system of delivery, our organizing principle, around the patient. It should not take weeks to obtain medical insurance. It should not take weeks to get an appointment. I should not stand the chance of bankruptcy or non-continuance of coverage if I fall sick, and lose my employment – these are fundamental, societal, ethical issues that other countries have more or less grappled with and found solutions. Let’s learn from others, steal the best practices, we are a young country. I can hail a taxi in minutes from my cell phone pretty much anywhere in the world. I can get millions of products and services delivered to my door overnight. I am sure we as a society, with the political will, can allow innovation, change and a patient-centric approach to win the day.

 4.      Transition to Payment for Wellness, not Disease Treatment

With the lack of a national database of clinical outcomes across the USA, with fragmented systems, policies, the threat of litigation and insurer-led healthcare, we are getting short-changed. The 17% of GDP that we spend for no better outcomes could and should cover every man, woman and child in this great nation – and just to throw it in, we spend that much to cover only a portion of Americans, the number of uninsured Americans vacillates wildly from 20-50M Americans – irrespective of the number, we should be able to cover everyone with the sums we are paying. Maybe illegals too, but that’s a separate argument.

Our system of healthcare is largely predicated on treatment for payment, that’s an asinine approach. ‘Procedure codes’, as the best illustration of this absurd approach, need be replaced by metrics and KPI’s focused on patient health, rehabilitation, quality and quantity of life, recovery, patient satisfaction, reduction in pain etc. Is that going to be harder? Yes, for sure. But it’s about time, and we have the tools now.

Unnecessary procedures that are speculative and marginal at best don’t help anyone – expect of course – the provider, who gets paid, whether you get well or not. There are signs that this is slowing changing with Medicare Advantage plans and procedure-reimbursement limits – that really should be the case, because it encourages hospitals to specialize, and be efficient in delivering care – and US hospitals do deliver some of the best care in the world.

Combined with improved and demonstrable clinical outcomes (below), a patient-centric healthcare delivery system, clinically-focused decision-making and a transition to health monitoring, personalized medicine and precision-treatments all provide hope for a transition in the practice of medicine to be much more proactive and focused on health maintenance, early detection and prevention, than our current status quo.

5.      Clinical Outcomes and Quality of Life Matters

The UK’s NHS isn’t a panacea, nor is Canada’s nationalized system, or likely any other countries. Funding, operations and performance challenges remain. But, would you rather be sick with a chronic or acute disease in the US, or one of those countries? In the US your ongoing healthcare is unclear and unpredictable. Every American, even with insurance, is within one major medical event away from financial ruin – and we all know it (https://www.forbes.com/sites/mikepatton/2016/04/27/americans-top-financial-fears/#720a8cdd5389). So, a comparison of the US system with other developed country healthcare systems can’t be a simply, 'ours works yours doesn’t'. You have waiting list, we don’t. We have so many MRI’s anyone can get a scan for whatever, you only have X number. These are false and mis-leading characterizations and means of comparison of all healthcare systems. The ultimate metric of concern, the only one that really matters at the end of the day is health, wellness, effectiveness of treatment, quality of life, free from pain and suffering and in a reasonably timely manner – and for all of the major diseases, the US system’s clinical outcomes are certainly no better than any other develop countries systems, and more often, much worse – and we spend twice as much, the converse should de facto be true (https://www.theatlantic.com/health/archive/2013/01/new-health-rankings-of-17-nations-us-is-dead-last/267045/).

Despite these challenges before us, I remain highly optimistic that with mounting acceptance of reality, rising political concerns and motivation, a change in political will, and appropriate structural reforms, US healthcare can be fixed and very well. The brightest days for health care and the delivery and practice of medicine are ahead of us. We have deeper understanding of the etiology of diseases, better appreciation for the complexity and heterogeneity of diseases and people, pressure on big pharma to improve pipelines (and a recent spate of very effective immune-oncology drugs), and the rapid emergence of AI, machine learning, big data, digital, mobile, e-health and communications improvements – we are primed for a revolution in healthcare and its delivery for the benefit of all people. So, lobbyists, greedy pharma CEO’s with disproportionate price increases, government and insurers, please either step out of the way, thank you, or direct your efforts deliberately to the biggest improvement in human health that humanity has ever known.

It’s so within our reach if we make that decision.