Tuesday, January 03, 2006

Roots of US Health Care Crisis ("Etiology")

Assuming you agree the US is in a multidimensional health care crisis- some would say rapid meltdown- let me put forth for your consideration and, please input, the six factors that I believe have led us to this crisis stage. Each will be explored in future postings by yours truly. They are –1) A paternalistic model which attempts to perpetuate an ignorant and infantilized patient population 2) Excesses of reductionism (single cause for single disease) in bio-medicine which for chronic diseases is failing 3) The US love affair with expensive technological solutions for all human problems 4) The US peculiar obsession with only free markets and the private sector to deliver health care 5) The failure to prevent disease and promote health 6) The excesses of the legal profession’s influence on health care delivery(emphasis on the word excesses please)

Now let’s be realistic - $1.8 trillion dollars worth of entrenched vested “industrial” interests are not exactly ready to roll over easily but several dynamics favor change- yesterday. Public opinion polls increasingly demonstrate the political importance of health care and health care costs to American voters. Some say, after the general economy and the war in Iraq it is the number #3 political issue in 2006. Politicians like to get elected and re-elected. They are listening despite obscene funding and relentless lobbying by the “Disease Care” Industry. Secondly we simply cannot as a nation afford to spend close to 15 % of our GNP on health care and significantly more on a per-capita basis per US citizen (@$5300 dollars per person -almost two and a half times the industrialized world’ median of @ $2,200 dollars) than any peer industrialized nation and expect to maintain the US quality of life we have come to enjoy “duh”.Yet, despite these excessive expenditures, quality of health care as measured by a host of objective measurements is declining? What’s wrong with that picture? “double duh” Finally, being a country founded on Judea-Christian ethics, the ethical and moral depravity that the US health care industry now manifests is incompatible with our nation even pretending to exhibit moral leadership as “a beacon to other nations”. The US remains the only nation among nations in the developed world (except for South Africa) that does not provide some level of health care for all its citizens. These three dynamics make change both inevitable and imminent! The question I keep asking myself is do we need a total system meltdown and collapse before a new US health care system arises? Or in other words “I never underestimate the self-destructiveness of institutions entrenched in the status quo”. On this latter observation I sincerely hope I am wrong.


Blogger Cervantes said...

Great post Blake. Alas, even though health care reform offers more than one potential winning issue for Democrats, the party establishment doesn't seem interested. They feel like they got burned over the Clinton plan (which was indeed a monstrosity) and they seem to have no appetite to try again. I.e., they aren't prepared to offer leadership or to take on the powerful corporate interests that fund political campaigns. We need to organize from the ground up.

11:36 AM  
Anonymous Blake said...

yup- right again Cervantes- a pleasure being your partner in helping to make this happen.And it will beacuse of the people's will :)

1:41 PM  
Anonymous Blake said...

Also, Cervantes- Where else do you continuously pay more and get less? And where do you fear obtaining health care out of fear of being harmed? Remember the old joke "Trust me -I'm a Doctor?" Well, I can laugh with the best of them, but trust in physicians and medical science and especially organized medicine has been seriously eroded. I can't quite figure out how it will ever be regained?-hopefully -but over decades!

1:54 PM  
Anonymous C. Corax said...

I'm not certain what you specifically mean when you say: The excesses of the legal profession’s influence on health care delivery. Malpractice lawsuits against doctors? Class action lawsuits against pharmaceutical companies? Just wondering if you can clarify....

4:33 PM  
Blogger Blake said...

c corax- the excesses of the legal profession that I was referring to are the number and types of malpractice suits
against Doctors. Not that Docs should ever be off the hook but there are simply too many lawyers chasing too few dollars$. This excess exacerbates 1) patients believing Doctors are not human= "MDieties" 2)Patients avoiding any responsibilty=remaining infantile 3)higher costs of health care= defensive medicine to avoid being sued.

6:54 PM  
Blogger Cervantes said...

I think we will need to discuss the malpractice issue at some point. It is the case that most cases of actual malpractice don't result in lawsuits, whereas lawsuits often happen where there are bad results, but not malpractice. The problem is that people who are injured by medical errors or just unfortunate iatrogenic events (there are risks associated with all medical interventions) don't have any other way of being compensated. So juries end up giving big awards so that the severely disabled kid or whoever it is will be taken care of.

If we had universal health care, we could also find our way much more readily to a rational system of both malpractice accountability, and compensation for people who are injured -- which ought to be separate issues.

12:02 PM  
Blogger Blake said...

Cervantes-agree with your framing of this malpractice issue. Of course I happen to live in the state of Pennsylvania (the hands down winner of malpractice lawsuit excesses) which has influenced my perceptions.And Cervantes,I definitely agree with some level of federal government sponsored universal health care coverage for all US citizens. Bill and Hill tried but unfortunately mismanaged the process.A few brave and smart pols have to step up right now. WHO/WHERE ARE THEY? The the bottum up grass roots demand has hit critical mass- Be Well :)

5:27 PM  
Anonymous Anonymous said...

A great list, but the most powerful drivers are missing; these are the Perverse Market Forces arising from:
(1) Inadequate intuitive valuation of prevention (immediate trivial needs get too much attention relative to remote but more important needs) produce too little market demand for good prevention.
(2) Poor customer (government and corporate) specifications for health care purchases, which focus mostly on the dollars spent per transaction. There are very few specifications addressing outcomes or quality, fewer than any other major product or service. The medical profession, which has not adequately defined quality and good outcomes, is primarily to blame; medicine cannot expect the customers to define quality for this very complex product.
(3) Subversion of the US Corporate Practice of Medicine Laws allow corporate and “nonprofit” executives who are only focused upon institutional profitability to dictate medical practice to clinicians and patients; community control, which focused also on medical practices that benefit the community, and physician control, which considers the overall good of the individual patients, are being supplanted.

Fortunately, the magic lamp of technology has been rubbed, and a Genie released that can remedy most of these fundamental causes of our Health Care Crisis. Digital Medical Systems, if properly implemented as shared community-owned infrastructure (Regional Health Information Organizations, or RHIOs) that inexpensively (via web-enabled networks) generate an aggregated electronic patient record for all regional encounters, will have a more beneficial impact on national health status than Penicillin.

Work plan for the digital Genie:
(1) Inadequate human intuitive valuation of prevention: incentives, reminders, systems and tools that make prevention needs easily perceived, create immediate benefits for action, and reward both patients and practitioners for successful outcomes; increase costs (e.g. reduce insurance reimbursement) for Rx of trivial, immediate problems.
(2) Low quality customer (government and corporate) specifications for health care purchases: digital quality improvement systems that identify and measure both process errors and successful outcomes on a rational, statistically valid basis that are translated into “dollarized” purchase specifications
(3) Subversion of the US Corporate Practice of Medicine Laws: shared digital infrastructures and systems that allow individual practitioners to enjoy the economies of scale that have advantaged the Corporations; without this competitive advantage, the corporate practice will be easily supplanted by the professional practice
(4) Excesses of reductionism (single cause for single disease): both complex causes and complex solutions are easily organized by the Genie and translated into descriptions and plans that are easily understood and actionable.
(5) Paternalistic model: empowerment of the individual is already a widespread outcome of the Genie’s work in other fields (Google), and will be easily incorporated into the digital transformation of the health care industry.
(6) Expensive technological solutions: more prevention means less disease reaching end stage where the big ticket, invasive alternative is needed; less expensive but equally effective solutions are easily marketed to those with end stage needs.
(7) Failure to prevent disease and promote health: population- based medicine is child’s play for this genie; aligned incentives both for the individual and the health care providers are proven effective and are easily affordable when the Genie keeps track of the details.
(8) Excesses of the legal profession’s influence on health care delivery: the presumed legitimate role for legal malpractice is to deter poor quality practice, but the system has proven in practice to be ineffective; digital quality assurance has proven spectacularly effecitve: aggregated quality data will allow society to supplant the malpractice system with maloccurence insurance (if the trial lawyers can be bested by any rational argument), or at least can supply a great defense for the competent practitoners and institutions.
(9) Obsession with only free markets and the private sector to deliver health care: the Genie cannot help with this one… We poor humans must have the political will to pull together to create shared, community- owned and protected space for the Genie; failure to act promptly to prevent either the legacy commercial interests and / or the newly powerful digital corporations from owning the Genie’s bottle will much diminish the magic.

George Anstadt MD FACPM FACOEM

9:44 AM  
Blogger Blake said...

George-Hi!-Thanks for posting on our blog.I need to carefully digest your post and the merits of your "Genie"-(Digital Medical Systems)in which you obviously have a great deal of confidence. Something tells me that DMS are tools that will enable or enslave us depending on 1)who owns the most powerful computers and hence most info 2) what are the values of these info-owners? If you are saying info is democratized I stand with you. George - I hope you post often-Hope to see you soon to catch-up! :)

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