And not redesigning it sometimes literally results in us dying.
Let's start with a clean slate. I'm not as ambitious as Ideo, in terms of the breadth or number of topics, but here are 11 things about heath care that I'm dying to redesign:
- Assure affordability: We don't expect that everyone can buy a Mercedes, or even a car, but we do have federal programs that try to ensure poor people can get food (SNAP) and housing (Section 8 and other programs). When it comes to health care, though, we're wildly uneven, both in terms of who gets help and what that help looks like. That is not the mark of a civilized country.
- Share high costs broadly: It is well known that a small percentage of the population accounts for a majority of health care spending. Unfortunately, while some of those people fall under broad social programs like Medicare or the VA, most do not. They may be covered by an employer plan or a small health plan, and their cost can be catastrophic to that plan and the other people covered by it. The highest cost patients should be a broadly spread social burden.
- Count: Sadly, we don't know the actual effectiveness of many things we do in health care. Even for the ones we do, we know many don't work for many, if not most, of people they're done to, although we don't know which people or why. We know there is more unnecessary care and more medical mistakes than there should be, although, again, not which care, done to which people by which providers. Even counting mistakes is frowned upon, due to malpractice fears. Health care is not voodoo, and $3 trillion is too much to pay for art. It should be more of a science, and that requires not just better data but better use of it.
- Health, not medical: We don't have a health care system. We have a medical care system, and it shows. We need to treat health habits and social determinants of health at least as importantly, if not more, as we do medical care.
- Recognize who "we" are: We talk about "our" health, but it is becoming increasingly aware that our health is heavily dependent on the health of our microbiome. We don't fully understand how it impacts us, but we know there are more of "them" than "us," and treatments that impact our microbiome impacts us. We need it to be healthy for us to be healthy.
- Reinvent health insurance: Insurance is supposed to protect us against unexpected and catastrophic expenses. Somehow it now also is used to encourage preventive care, pay for budgetable expenses, subsidize lower income members, negotiate payment rates with providers, dictate our choice of providers, and try to manage our health. Plus, we've decided to treat dental, vision, and most long term care separately, not to mention health portions of auto insurance or workers compensation. None of this makes sense; time to start over.
- Get rid of the mystique: Medical care is complicated. It has lots of codes, lots of jargon, and uses highly trained professionals to dispense it. This is not a system designed for us to understand, and so we put our health in the hands of the people who have helped it be so complicated. We defer to the degree and the white coat. We each should be the best expert about our own health, and others in the health care system should help us achieve that.
- Encourage responsibility: Few of us are maximizing our heath. We don't eat right, we don't exercise enough, we're under too much stress, we weigh too much, we drive too distracted. Then we delegate taking care of the consequences of our behavior to our various health care professionals. We're not responsible for everything that happens to our health, but we should take responsibility for much more of it than we do now.
- Move health back home: Too much of our care happens outside the home -- in a doctor's office or outpatient facility, or, if we're more unlucky, in a hospital or long term care facility. Indeed, hospitals now own increasing portions of the delivery system. This is backwards. We want to be at home, with our families and living our lives. We should recognize that as the locus of our health, deliver more care there, and see a stay in a facility not only as last resort but as a failure.
- Remember whose health it is: The health care system is not oriented around us. It is designed around health care providers, and oriented around their views of and interactions with us. As a result, our data is siloed, incomplete, and often incomprehensible to us. No one who has had to wait hours for an appointment or a procedure can think it is about them. It should be about us.
- Better, not just more: Health care is like the defense industry, where technological advances get progressively more expensive without necessarily having the corresponding effectiveness. New drugs add minor health improvements but cost tens of thousands more. Technology should drive costs down and productivity up, and make our experience better. Where is the iPhone of health care -- delighting consumers at a price they are more than willing to pay?
These are not little asks. These would not be small changes. They are, indeed, suggesting that we basically rethink everything about health care. They may not be possible.
We're spending almost 20% of GDP, for mediocre results, and with neither patients nor health care professionals happy about the system we've built, or, at least, allowed to develop. It's only going to get worse, unless we drastically change the course we are on.
This is not a time for tweaks.
Maybe your dying-to-redesign list for health care would include things like better hospital gowns or slicker apps, but I'd prefer to think bigger.