No, I’m not talking about the recent confirmation of the existence
of gravitational waves, as predicted by Albert Einstein almost a hundred
years ago in his General Theory of Relativity.
I’m talking about a quote of Einstein’s that I recently read: “If I had only
one hour to save the world, I would spend fifty-five minutes defining the
problem, and only five minutes finding the solution.”
Somehow, I suspect our many attempts to “reform” the health
care system often may have those proportions backward.
What started me thinking about this was a provocative post
in Forbes from Reenita Das, “Are
the Days of Building Affluent Hospitals Dead?” In it, she talks about “frugal innovation” –
usually an oxymoron in the U.S. healthcare system – particularly as practiced
in emerging markets. She gives the
example of GE’s low cost electrocardiography machine sold in emerging markets,
and spends more time discussing the Indian-based hospital chain Narayana Health -- a low cost, high
quality hospital chain that is both succeeding and expanding.
Narayana Health just
opened a hospital in the Cayman Islands, particularly aiming at the U.S.
medical tourism trade and not interested in being subject to U.S.
regulations. They expect to be able to
start out 30% cheaper than U.S. competition and plan to discount even further
in the future.
Narayana seems to be coming at solutions from a different
angle, and perhaps they see the problem differently.
Sometimes I view our health system as being like the U.S. auto
industry in the early 1970’s: insular, inefficient, split into oligopolies, and
turning out products that are often neither high quality nor what consumers
really want. I worry that our health
care system is working on the equivalent of adding a couple miles to the MPG,
increasing the number of cupholders, and figuring out how to allow hands-free
texting -- while somewhere in the world someone is perfecting a portable
teleporter that will make cars unnecessary altogether.
The science fiction writer William Gibson once famously
said, “the future is already here – it just isn’t evenly distributed.” I think of this particularly in terms of
technology diffusion, with the implication that technologies which will be
omnipresent fifteen or twenty years from now almost certainly already
exist. The trick is figuring out which
ones they are and how to best make use of them.
Again, clarity on the problem is required in order to
develop the right solution.
Formulations of the problems with the U.S. health care
system abound. Of course, the problem
that the Affordable Care Act tried to solve was the shockingly high number of
Americans without health insurance.
After all, most experts seem to agree not having health insurance is bad.
Still, the problem of lack of coverage may be poorly
formed. Evidence of this may be found in
the so-called Oregon Medicaid experiment.
Oregon was forced to randomly choose which residents qualified for an expansion
of their Medicaid program, allowing for a real-life controlled study. The results found
that those who got the new coverage did, in fact, end up using more health
services, including preventive care, but they didn’t find any significant
improvements in measurable health status.
Perhaps lack of coverage isn’t the real problem we should be
addressing.
Well, then, there is the problem of cost. Most would agree that our health care system
costs too much, with spending that is far more than other
countries, whether measured by per capita spending or share of GDP. There’s no mystery why this is, as it has
been fairly established (e.g. “It’s The
Prices Stupid,” by Anderson, et. alia over a decade ago) that we simply pay
health care providers more than comparable providers in other countries. And we just keep doing it.
Then again, we probably also spend more on, for example,
automobiles or computers, than other countries (and we certainly devote more
resources to defense and prisons), and we pay far more to, say, CEOs or
professional athletes too, so perhaps neither the “excess” spending nor the high
incomes are really unique problems of health care in the U.S.
Many think that the problem is that, despite our inflated
spending, we have very mediocre results compared to other developed countries,
such as when looking at life
expectancy. Ipsos Research recently
issued a report
card for patient satisfaction with health care systems in 15 countries, and
the U.S. scored only a gentleman’s B. A Commonwealth
Fund found
that we lag on access to care and affordability of care as well. Whatever we think we’re buying for all that
spending, it’s clearly not better health.
Still, even this is sometimes explained away with references
to underlying cultural differences, like gun ownership, poverty, or traffic
fatalities, that are not the fault of the health care system nor readily
amendable to fixes to it.
Politicians continue to claim we have the best health care
in the world. They might want to temper
that based on the skewering The Daily Show recently gave that claim. The
truth is that, while it is certainly possible to get some of the best care in
the world here in the U.S., that level of care is not uniformly available. Whether you get the best care, average care,
or poor care depends on lots of factors – where you live, insurance
status, and race/ethnicity,
to name a few.
These variations are certainly a problem, but they’re not
really unique to health care either. For
example, it’s often hard to find grocery stores in low-income areas, and if you
have a particularly thorny legal problem you may want a lawyer from New York or
Washington D.C. Very few goods and
services are uniformly distributed in terms of quality or availability.
One of the big problems with our health care system is that
it often seems we don’t quite know what we’re doing. I’ve complained about this
before (e.g., But Which Half?), and it doesn’t
take much effort to find new illustrations of this: despite supposedly having
one of the toughest regulatory processes in the world, FDA recalls of already approved
medical devices doubled
in the last decade; saturated fats don’t
cause heart disease after all; new guidelines
would put 13 million more people on statins; maybe routine mammograms shouldn’t
be.
Honestly, it’s dizzying, and it’s harder and harder not just
for consumers but also health care professionals to figure out what the “right”
choices are. Yet when ACA included the
Independent Payment Review Board to try to rationalize (not ration, mind you)
Medicare spending, it was greeted with accusations
of it being a “death squad.” Evidently
not everyone agrees on this problem either.
One reason people get frustrated with our lack care system
is because care is often so uncoordinated,
even though we know both intuitively and empirically
that coordination should be better for both the patient and for spending. It’s hard to see how we ever even let this
become a problem, since all parties supposedly have the patients’ best
interests in mind, yet we did. ACA did
start the ball rolling on ACOs, which should
improve coordination, but that ball still isn’t rolling very fast, with 60% of
physician practices still reporting
they don’t participate in an ACO, and don’t plan to anytime soon. Care coordination may have to wait too.
Whatever the problem is, we’re just not very happy with our
health care system. A Rasmussen survey found
that only 32% rated our health care system as excellent/good – and 32% rated it
poor. A year ago those figures were
40%/24%, so the needle is moving in the wrong direction. The Commonwealth study
referenced above found far more Americans thought our system needed to be
completely rebuilt than citizens in other countries, with more than twice as
many (27%) such respondents than the next highest country.
One way or another, we need changes, but hopefully ones that
don’t seem like we’re just muddling along one tentative step at a time.
Maybe the future will be recognizable, like Narayana Health,
or maybe it will be something already at least on the horizon, like gene
therapy. Perhaps it will be something even
more unconventional, like nanotechnology, that will make the practice of
medicine obsolete. I don’t know what’s
going to happen, but I’m fairly certain it will take someone radically
redefining the problem, and coming up with a solution we aren’t expecting. Moreover, I’m willing to bet someone is
already working on it.
To use another, more well-known Albert Einstein quote: “we cannot
solve our problems using the same thinking we used when we created them.”
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