vision

I'd been meaning to publish this post for a while. It was inspired by election day (yep, definitely a while). I tried to move beyond the sense of hope and imminent change that much of the country was wrapped up in, and begin to pulling the bits of pieces of thoughts I've had over the past several years on how the American health care system can best move forward. It's quite a change from the research-heavy type of writing I've done in the academic sphere of Stanford, where your every word must be backed up by 5 peer-reviewed papers or else it doesn't count. So pardon the oozing optimism, my lack of citations, and please bear with me.

Tuesday, Nov. 4, 2008

As I watched this new era unfold and thought about my part I was to play in it, I felt that it’s appropriate that I should begin putting down thoughts of a coherent vision for the future of health care, both in the US and internationally. Overall, the keywords are integration and multidiscipline. We need to realize that the future of medicine doesn’t only lie in more advanced drugs, devices, and procedures, but also in maximizing the efficient utilization and equality of access to existing medicines. This paradigm shift will reduce costs in the developed world as well as bring about more impact in developing regions. Innovation does not only need to occur in the sciences, but also in health care management and policy.

Unique in that it’s driven by a strong sense of ethical purpose, the health care industry also needs to realize that it’s part of the business sector. The tough job is to balance its moral obligations to patients with adopting more cost-cutting and quality-raising business processes. The beauty, however, is that if incorporated correctly, these two commitments are complimentary. This mindset will shift current perverse incentives of overspending, patient appeasement, and isolationist physician practices towards evidence-based, low-cost practices that improve patient outcomes.

On the other end, patients need to be both given greater access to accurate information as well as learn to compromise, so that they have more tools at their disposal to cooperate with their physicians. These changes require both a change in psychology as well as information infrastructure. For better or for worse, the latter has already begun to take shape – direct advertising of drugs to consumers, the burgeoning health 2.0 movement (websites like WebMD and CDC). There is no isolating patients who want information from those who are more than willing to provide it, so there had better have a planned approach to developing these infrastructures and monitoring their quality. The former, however, might be more difficult to bring about. Traditionally, physicians have been the benevolent patriarch, dispensing tokens of pure truth to their patients who then follow it to the word. Armed with direct access to information and choice, however, patients have begun a backlash of sorts; they now demand certain procedures or brand-name drugs even when the effectiveness has not been proven. And physicians often have no choice but to appease patients for fear of losing business, which then gives patients a bad taste of the health care industry only tending the bottom line, making them even more likely to be on the defensive and demanding unreasonable care. This speaks to an underlying imbalance and inaccuracy of information, of patients and physicians being out of touch with each other and failing to realize that they are working towards a common goal. Physicians need to be taught how to deal with their patients’ demands and insecurities, and patients need to learn to trust their doctors again. With the recession rolling in, perhaps here’s a sliver of a silver lining – as a new sense of economic insecurity sets in, perhaps both patients and physicians can be more easily persuaded to back cost-saving measures that might curtail some of out society’s appetite for the newest and most expensive technologies.

Of course, there is the perennial problem of health insurance coverage. Studies that establish the negative consequences of having no or inadequate health coverage are numerous and indisputable, as well as research that shows how factors such as race and ethnicity compound these consequences, so I won’t spend time on this here. The bottom line is that universal health coverage should absolutely be a goal that policy makers strive for. Obama and McCain both have important elements of what I believe to be the correct solution. McCain’s idea that empowering individuals to make their own coverage decisions derives from both the Republican ideal of self-determination and an economics model of free market competition. Both have proven to be effective in other situations to improve quality of the product, which is in this case not only more efficient health insurance plans, but also improved medicine. Patients will only pay for the best insurance packages, which in turn cut costs and increase their competitive edge by paying only for the most effective medical practices. But he falters on at least two important points. First, he underestimates how heavily health insurance is essentially being subsidized by employers. By taking away the tax benefit of employer-based insurance, McCain would be uprooting a bothersome but deeply entrenched wisdom tooth without the precaution of anesthesia or stitches. There would only be pain and chaos. His proposed credit would not only be inadequate to cover health plans for those who will lose their employer-sponsored insurance, it also won’t do a single thing for the working poor who most need the coverage. It’s been shown that when the poor receive cash, they will choose to spend it on necessary goods such as food and clothing; health insurance will be the last thing on their minds. Secondly, even if he were to give families enough money to buy insurance from the market, he would never pass a mandate. But without such, the majority of this cash return will only get lost in the general economy.

Obama is willing to pass a mandate, but even he only goes as far as proposing it for children, along with raising the income limit for SCHIP to enroll more kids, to avoid tanking his candidacy (because, after all, who would take away health insurance for kids, right? Oh wait…George W. Bush). But to me, the most insightful one of his proposals is the creation of a government-financed basic insurance package. Obama might still be fuzzy about the details of this plan, and in the end it might be too much for a conservative America to swallow, but I’ve long suspected that when absolute equality can’t be achieved, at least we can strive for guaranteeing a basic level of care for all. Let’s face it, for all the talk of equality we have here in America, what we believe in is not absolute equality, but equal opportunity. We don’t think everyone should be allocated the same amount of resources; instead, we think that people should be given the same chances to achieve their dreams, and be rewarded differentially based on how hard they chase after their dreams. And gosh darn it, we should certainly be able to use our hard-earned money to buy superior health care. By nature, we balk at a Canada- or EU-style pseudo-socialist health system that is heavily subsidized and/or entirely run by the government and offers no special treatment based on economic status. Instead of ignoring this fundamentally American trait, we might want to acknowledge it, and more importantly, focus on the fact that it stems from the belief that one has the fundamental right to pursue one’s dreams. There are several precursors to this pursuit such as education, public safety, and health. (Interestingly, the former two are largely recognized as responsibilities of the government without anyone raising a whimper, but talk of a publicly financed health care system would put most Americans on edge.) Right now, we have a baseline of service -- emergency care. Yet when a patient walks into an ER with advanced stage breast cancer or diabetes-related complications, they are many times more likely to have poor outcomes, and are tens of thousands of dollars more expensive than they would be if these conditions were caught early and managed properly. This means that they would need access to regular primary care. They need to have health insurance. Hence, it makes sense, both from a cost savings and a health outcomes perspective, for all people to have a basic level of health insurance that ensures them access to yearly check-ups, prenatal care, mammograms, prostate exams, dental work, etc.

The next question is – how does this happen? Nearly half of all ER care is uncompensated by either public or private funding. Therefore, hospitals need to shift this cost to their paying patients, driving up health care costs and making health insurance more expensive for all. This relationship potentially produces a cycle in which more people are squeezed out of the insurance market due to high costs, which makes them more likely to end up in the ER for care. If an entity was willing to step in and ensure better primary care for those who seek care in an ER, it would stop this cycle, drive down the overall price of insurance, and ensure a healthier, more productive society. Sounds like some good incentives for a large public body (if only Obama can use his silver tongue to convince the middle class that spreading the cost will ultimately be worth the sacrifice).

Now we’re getting down to the nitty gritty – what’s the best mechanism? How do we combine the ideas of encouraging individual choice, establishing a mandate to ensure coverage, and fostering health competition in both the insurance and medical care markets? Some point to the Massachusetts system as a model of a potential solution. This system, the initial success of which was recently validated by a JAMA study, operates on a pay-or-play model – employers are either required to offer their employees affordable insurance options or pay into a common pool that is used to alleviate the burden of uncompensated ER care. But they forget that Massachusetts was operating with a huge surplus that was supporting the cash pool. Also, no pool would be large enough to cover ER services for the 46 million uninsured in the US today. Again, the solution lies in early and regular care, not supporting the existing safety net that’s bursting at the seams. Rather, a solution that would incorporate all these principles would be a health insurance voucher. This can be offered, as Obama suggests, as one of the options offered by one’s employer, and it can also be obtained directly by those who are unemployed, self-employed, or for some reason don’t have employer-based options. Note that this only affects how health care is financed, not how it’s operated. The way that care is delivered will change very little; there will still be large non-profit hospitals, private physician groups, and plenty of specialist care. It also doesn’t drive out private insurance companies; those wealthy or sickly enough, of whom there are plenty in America, can still choose to purchase additional coverage on top of this basic package or skip it altogether. This solution simply guarantees that the money allocated will be spent only on health care, and it also encourages competition – in the insurance market for the most cost-effective plans (they’ll have to compete with the government option), in physician services for the most high quality, evidence-based practices (patients gets a much wider choice of physicians and hospitals), and in the PMP market for low-cost generics (they must compete for government business). These principles are similar to how Medicare effectively integrated hospitals in the 60’s by refusing to pay racially segregated hospitals, as well as how it leverages its position as the biggest buyer of pharmaceuticals to set prices.