Our Workarounds Aren't Working

In yet another headline I wish I'd written, Theresa Brown -- nurse, author, clinical faculty member, Ph.D. -- wrote a provocative op-ed for The New York Times: The American Medical System Is One Giant Workaround.  That's a great description, and one that anyone who has ever touched the healthcare system can easily appreciate.

Never mind the insightful but somewhat inside-baseball examples Dr. Brown mentions; who among us in our healthcare journeys has not seen the sticky notes, been asked to send a fax, gotten stuck in a telephone tree, or had to refill (paper) forms?   Those and countless other examples should make us all realize the creaky platform upon which our actual care depends.

To call it a "system" is to give our healthcare system way too much credit.

Not a healthcare workaround, but a metaphor for them

Let's go through the big workarounds about our system.

Coverage
Dr. Brown noted that "Obamacare, though, was never intended to make sure that all Americans had affordable care; it works around our failure to provide health care to all our citizens."  Indeed, ACA was able to cut the percent of people without health insurance in half, but still left some 8% without coverage.  Even worse, that percentage is now rising again.

The big workaround is that we have such a multiplicity of sources of coverage: about 55% with employment-based coverage,18% each for Medicare and Medicaid, 11% with individual coverage, and 4% for military-related coverage (TRICARE, VA, CHAMPVA).  Some people are covered by more than one source.  

ACA finally put some parameters about what (private) coverage had to include and what kinds of cost-sharing were permissible, but few see different plans as easily comparable, or even understandable.  And if you change jobs, gain or lose income, or become old enough or disabled, you may have to also change your source of coverage/plan of benefits.

No wonder why Medicare-for-All has become a rallying point, although few really understand what that might look like or how it would have to be financed.  

If I would wave a magic wand, I'd say that everyone should automatically be covered --period, full stop -- and that we end employment-based coverage.  

Quality
We talk a lot about quality in our healthcare system, often like to brag about it, but the fact of the matter is that we don't even really know what it means, from an empirical standpoint.  We have a hard time defining it, much less trying to measure it.  It is no surprise, then, that we have what has been described as an "epidemic" of unnecessary or inappropriate care, possibly as much as a third of all care.

Healthcare's workarounds are legion.  We have a variety of licensing, credentialing, and accreditation requirements, more regulations than anyone could count, a malpractice system that manages to miss most actual malpractice, and an ever-growing set of "quality" measures that no one really think really do.  We collect data - lots of it -- but are reluctant to share it, even with the patients it reflects and even if sharing would improve our understanding of it.  We are slowly trying to move to "evidence-based medicine," but most of what healthcare professionals do is not.

There are healthcare professionals who are incompetent or motivated by greed.  There are healthcare institutions from which you should not get at least certain kinds of care.  There are mistakes that are made.  There are treatments that don't really work.  We should know who/what they are, and the good healthcare professionals/institutions would benefit by our knowing.   

If I could wave a magic wand, I'd suggest we treat quality not as a largely implicit, intangible aspect of health care but as an indispensable feature, and make defining and measuring it our top priority. Fix this and other problems become more tractable.

Price
I deliberately am using "price" instead of "cost" because, as was pointed out long ago and repeatedly since, "It's The Prices, Stupid."  Our prices for almost everything healthcare related are widely higher than anywhere else in the world.  Worse than that, those prices vary wildly by type of coverage, location of the service, and the person/institution delivering it.  Our healthcare system seems to spend more time, attention and money maximizing billing than getting patient care right. 

We act outraged at surprise billing, patients being hounded by debt collectors, and the murky role of PBMs in prescription drug pricing, to name a few, but they are almost inevitable outcomes of our workaround that allows such a multiplicity of prices.  No one really seems to know what a price for something "should" be, and no one really seems motivated enough to ensure they aren't excessive.  Everyone simply tries to pass the cost of those prices along -- to the taxpayers, to people paying health insurance premiums.

If I could wave a magic wand, I'd suggest a set of fully disclosed, comprehensible prices that do not depend on source of insurance, with variation allowed only to reflect measurable differences in quality. 

Convenience
The U.S. healthcare system is not, and never has been, centered around the patient.  We make sick people go to physician offices or healthcare facilities.  We warehouse even sicker patients in hospitals or nursing homes -- away from their friends and family, out of their familiar settings -- because it is more convenient for the healthcare professions who work in them.  We spend way too much of our time in the healthcare system waiting for someone to help us, usually never sure when that help will happen. 

Sure, healthcare now gives patients online portals (which don't usually talk to other healthcare portals they might use), allows patients to fill out some forms online (which often doesn't seem to preclude having to subsequently fill out more in person), even offers virtual care options (although probably not with the healthcare professional patients know).  The rest of the world is mobile, real-time, and on-demand, and healthcare is still faxes, far-in-the-future, and in-person. 

If I could wave a magic wand, I'd say that where and when a patient gets care and advice needs to be as important in healthcare as it is for other services consumers use.  

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Unfortunately, I do not have a magic wand.  We live in a world of compromises.  But those compromises have led to our current healthcare system, which we can no longer afford and in which we are not achieving the health outcomes we should expect.  We're paying premium prices for mediocre outcomes. 

Our workarounds have failed.  It is time for real fixes.