To Your Health
For centuries we’ve toasted to each other’s health with lifted glass. Not the most sophisticated form of healthcare, but for most of our history that’s all we had. The last century, however, has seen an explosion of scientific advances, gifting us incredible opportunities to truly affect each other’s health beyond good wishes and a pint of ale. Yet, while some countries have chosen to share this good fortune with all their residents, we in the United States seem willing to leave those among us who are insufficiently insured to the “Good Luck” ethic of Cheers!
As a surgeon for kids, for the last quarter of a century, I’ve had a front row seat to the consequences of this unfunded good will, working in a healthcare system that ranges from the kindest compassion to the most callous indifference. A system that was never engineered or designed, it grew organically. We know we need to clean it up, but never quite find the time.
It’s easy to ask why we would share. Why should the healthy man pay for the bad luck of another or worse, his bad choices? Our uncomfortable truth is that we all share the same story arc. Birth, life, with all its unforeseeable problems, and death.
In our lives, the need for healthcare is never a matter of if; it’s a matter of when. We’ve been stumbling through the political muck for decades in search of a reasonable, equitable system, small shoots of progress always cut down like weeds. If, one day, we do gather the political will to rebuild our system from the bottom up, to design it for health rather than money, I’d suggest we keep the following in mind: Incentives, Wellness, and Compassion For All.
The best place to start is to alter the incentives. Our current system has created some very odd behaviors in both patients and doctors. The following is one example:
“We just met our yearly deductible, so we’d like to move ahead with “Annie’s” surgery. Before January 1st, of course.” Another message from another patient’s mom, the fifth family to reach out to me between Thanksgiving and Cyber Monday. The calendar had come around to another Deductible December, medical management on a monetary timeline.
The balance of time and money on the healthcare scale drives day to day decisions that would be better left between doctor and patient. For doctors and other healthcare providers, the balance hangs over the elusive sweet spot of how many people to see in a day. One complicated patient can take an hour in a twenty-minute appointment schedule. The same problems arise when a procedure takes longer than anticipated in surgery. For me, time isn’t just money; it’s good medicine. In some cases it is important to slow down and understand that “Annie,” who’d come to talk about her chronic pain and who’d already had three surgeries by three different surgeons, didn’t need another unhelpful procedure; she just needed someone to listen to her.
However currently, taking time with patients doesn’t win the carrot and often draws the stick. Not by design but in response to these time constraints, concierge practices, where patients pay an annual fee for more time with their doctor, have popped up like mushrooms. Membership has its privileges but healthcare isn’t a country club.
A growing number of physicians believe that U.S. Healthcare is ailing. For decades our system has been self-medicating with money, more each year, while at the same time we tell ourselves we have “The best healthcare in the world.” We’re addicted to the status quo. Admitting to a problem is halfway to recovery. We’re not quite there yet. Unsurprisingly, neither patients nor providers feel better.
My own career has seen two acts, and two kinds of incentives, those before and after I joined the staff of a health maintenance organization (HMO). I moved from the high productivity, fee for service practice to a practice that incentivized wellness.
Treatment plans in a fee for service practice are often influenced by conditions imposed by unseen insurance folks, tucked inside company cubicles, armed with algorithms and headsets. Maybe they weren’t the feared government bureaucrats of the Affordable Care Act debate, but certainly they are the people who stand between patients and their doctors.
“Provisionally approved,” “Coding mismatch,” “Denied!” are among the many insurance company letters received by confused and frustrated families with sick or injured kids. Parents cobble together decisions based on a tangled web of medical advice, high deductibles and whatever they can afford. Too often, the sum of the variables adds up to, “We can’t spare that, right now.”
When a physician’s income is directly dependent upon reimbursement for services provided, it can be difficult to remain objective and ethically clean. To offer opinions based on training and experience, not fiscal issues, is an insidiously difficult task in a nuanced medical world. Physicians have student loans, bills and an office staff to pay.
Taking all-comers, including the uninsured and Medicaid kids, never helps at a quarterly revenue review. I remember my own practice manager always flashing a frustrated smile before launching into her “Altruism isn’t cheap” speech.
A completely different model is where the patients’ pooled premiums are divided amongst the physicians tasked with keeping them healthy and well. Simple as that. Income is no longer based on a more surgery means more income for the surgeon. Incentive shifts dramatically when a physician holds a salaried position in a health maintenance organization. Wellness provides a foundation for restructuring a medical system. It turns out to be a surprisingly less complicated and less restrictive way to care for patients. I was relieved to find the corporate second-guessers and treatment denials were mostly gone, and patients had lower out-of-pocket expenses. “Keep the patients well and be a good steward of their healthcare dollars,” was the mandate from the HMO. With fewer patients on the schedule and more time to listen, physicians can be less stressed and therefore better doctors.
But recently, the HMO systems have begun to change. Washington’s constant drumbeat against what’s left of the Affordable Care Act without a visible fix has unsettled the insurance market. In the competitive race to match the lower premiums of hollowed out medical plans, HMOs have begun to offer the high deductible plans. Those with means can afford plans with a lower deductible leaving cheaper “catastrophic coverage” plans with large out of pocket deductibles to hard working, low-income families. Higher out of pocket costs for lower income families discourage even routine visits to the doctor. How many of these families are one illness or accident away from a ten thousand, deductible-dollar catastrophe?
The argument for these high deductible insurance plans goes as follows: “Patients need to share the risk, have skin in the game, to drive down health costs.” Co-pays and personal health savings accounts make sense up to the point where people can afford them, but shelled out coverage, complete with bankruptcy-sized bills, won’t steer U.S. medicine anywhere but off a cliff.
There is a fallacy in thinking that Market Based Medicine will fix U.S. healthcare, that the profit motive will do the trick. It’s been brought to you by the same market forces that have brought us ongoing shortages of injectable drugs. Everything from anesthetic drugs to IV saline has made the FDA shortage bulletins, mostly because they are not profitable to manufacture. For the cost of pennies a bag, saline (sterile saltwater) can prevent death from dehydration, the second leading killer of young children worldwide. But at that price point it’s not nearly as financially rewarding as a patented niche drug that brings in thousands of dollars per dose. At last count, there were over a hundred drugs on the critical shortage list in the U.S. Research and innovation are crucial and their costs must be covered, but at what point must we as a society forgo drugs that can save hundreds of people over those that can save hundreds of thousands?
Compassion is the road map to a reasonable healthcare system, compassion for the person in front of us and compassion for the many we’ll never meet. People argue that socialized medicine is callous. Perhaps, but is it any more heartless or arbitrary than health insurance tied to a place of employment? Why would we turn the good luck of beating cancer into the bad luck of a job shackling, pre-existing condition? Or worse, getting dropped from coverage because of a lost job. Employer related health benefits, a leftover from the post World War II wage freeze era, makes as much sense as basing health insurance on the type of shoes we wear or the car we drive. This system was never designed for our health; it was a benefit to entice good workers during a brief time of fixed wages.
It would take compassion and political will to invest some of our tax dollars in each other’s health. But if we did, maybe we could unleash the economy by untethering ourselves from the daily fear of a bankrupting accident or malady. Health care would be portable. Instead, we tout small businessmen and women, but then clobber them with high cost insurance policies when they choose to provide some level of insurance for their employees. Only the bravest entrepreneur can afford to leave the nine-to-five job and perhaps invent that next solar cell that could save the planet.
In the span of a career, medical business has more and more often financed show business, with an endless parade of ads that encourage the purchase of medicines and treatments but not necessarily health. Our televisions tell us that we need more tonics, laxatives and the most expensive drugs. And despite our more is better model, we don’t top the world’s life expectancy charts. We don’t even break the top forty.
As the Trump administration demonstrates anything but compassion they seek to push us back to a time when “America was greater,” a time when we relied on charities, gifts and a good roll of the dice to pay for Mama’s operation. Wellness only for the well-off.
To what end? As friends, neighbors, and complete strangers, we’re all exposed to the tree root that grabs our shoe. Is it economically beneficial to financially ruin our neighbors due to an unbidden accident or illness? How many times can we give thanks that we’ve not tripped before we take a real fall?
From the beginning of life to the end, from the beginning of one year to the next, treatment for all of us should start on a level field. Disease and bad luck care nothing for our finances and follow no calendar. Why then do we?
Ron Turker is a staff pediatric orthopedic surgeon for Northwest Permanente and Assistant Clinical Professor of Orthopedics, Oregon Health and Science University
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