My Hypotheses

After talking to my girlfriend (who is taking a health policy course) and two of my good friends who are also active webloggers, I decided it would make sense for me to jot down a few hypotheses of mine regarding health care. These have also been on my mind because my current, greatest professional interest is in intensive care, a highly expensive form of care that avid supporters of preventive medicine sometimes believe is incompatible with their mission of improving healthcare for all. I believe they’re wrong on that account. Here’s why:

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Hopefully, there are (or will be) studies out there that support these ideas.

1. Although health care provided for a small percentage of the general population disproportionately accounts for the majority of spending on patients, this small percentage group is not constant and individuals may enter and leave the group through improved health status or death.

Many people will cite a statistic that approximates that health care for 2-5% of the U.S. population accounts for 50-80% of health care expenditures on patient care in a given year. Without looking further, many assumptions are made: that these people are negligent and delinquent about seeking preventive care, that these people are poor and/or uninsured, and that these people are a problem that need to be corrected. If there is truth in any of these assumptions, I suspect that it is only partial. The most expensive parts of patient care are specialized procedures (e.g. surgeries, stent insertions, etc.) and intensive care, typically care that is provided as interventions when someone is very sick and has a very large chance of dying (or having their deaths hastened). However, the majority of people go through these procedures, survive, and often achieve good qualities of life (according to their own post-catastrophic-event perceptions, even though they may have disabilities) for some years more. So, those individuals in the 5% group will then move back into the rest of the 95%, perhaps only needing supportive mediations (e.g. statins, aspirin, fish oil, and others for someone who had and survived a heart attack). Others might die after an expensive effort to save their life (e.g. weeks in the ICU, blood bank resources, etc.). However, those people are the minority, and they are also removed from the equation.

In short, the population is dynamic, so the 5% group is constantly in flux. Putting that 5% on a desert island isn’t going to help anyone. Similarly, focusing entirely on improving preventive care isn’t going to eliminate that 5%. There will always be people dying: that’s one of the few things that all people must do (it’s a free country, right?). Our society values life, and we try our hardest to delay death, which necessitates a significant degree of expenditure on end-of-life care, specifically intensive care. If people are at risk of dying, we’re going to try our best to stop it from happening suddenly and unexpectedly: we want them to have a chance to tie loose ends, enjoy their lasts, and say good-bye to their loved ones. As a profession, we’re now beginning to find better ways of communicating clearly with patients and families at the end of life, particularly when the sick loved one has made the choice to die and would die without life support. For better or worse, these are the steps that our society requires of people to take when they are going to die. And because of our society’s high value on life, we try to preserve life at all costs – and those costs are necessarily expensive.

2. Intensive care is often a profitable venture for hospitals, because third party payers (insurance companies, the government, etc.) reimburse well for its services. This is because people buy insurance with catastrophic health events in mind, not preventive care.

People don’t pay for insurance to help them take care of their diabetes, or heart disease, or cancer, and so on (if they knew they had those diseases before getting insurance, their insurance premiums would be very expensive). They pay for insurance because they believe there is a risk of something bad happening, and that mental image is typically a life-threatening event, such as a heart attack, a stroke, a car accident, etc. If insurance companies did not reimburse physicians and hospitals for these expensive, life-saving treatments and care regimens, then the word would get out, and people would not buy insurance. So, insurance companies don’t mind paying for acute, life-threatening problems, but they don’t like paying for the long-term treatment of chronic diseases or lengthy, less expensive end-of-life care outside of the ICU.

Many people might think that they can simply “move” the money that pays for intensive care to pay for preventive care. That’s not going to happen for at least two reasons: (1) People will still get very sick, and there’s no way in hell that they’re not going to get treatment in a country that demands high quality and values life as much as the U.S, and (2) patients are not (yet) in control of money allocation.

3. In order to institute quality assurance and improve health care outcomes, the authoritative power of payment must be shifted from insurers to patients.

Most people don’t pay for health care. They either receive health insurance from employment or the government (Medicare, Medicaid, SCHIP, etc.), or they may receive free health care for lack of insurance (often from Emergency Departments, compounding the congestion and overuse of EDs). Some people with the financial means pay for their own health insurance, but they aren’t directly paying for health care. Instead, they are paying for a service (i.e. health insurance) that purportedly manages their health by conveniently connecting them with physicians and other health services. Unfortunately, since individual people don’t pay directly for health care, they have no say or control over the quality of services delivered or the prices of services.

Instead, insurers and the government pay for care, and thus, they set the incentives for payment. At this time, the equation is this: High Performance = High Patient Volume. This is not ideal for patients (or doctors) in most cases, except maybe with ICUs (which actually improve patient outcomes when they have higher annual patient numbers). As patients, we would like to spend more time with our primary care doctors, we would like them to have a good patient-doctor rapport, and also be as competent as possible. We would like our surgeons and interventionalists to perform their job in a way that achieves the best possible patient outcomes as much as possible. With the “payer’s authority” in the hands of the insurance companies, there aren’t effective ways of changing priorities throughout the health care system in ways that don’t produce “perverse incentives.” The customer is always right, and in this case, the customers are the third party payers.

Logically, one might follow the line of reasoning to the notion that patients should pay for their health care. Perhaps this is the answer. However, people have many irrational takes on this idea. For example, some believe that raising co-pays on insurance plans will help people be more “cost-conscious” and use fewer resources. This is true: people will be aware that the health insurance is not helping attenuate their health care costs, and they will be using fewer health care resources. But this won’t necessarily help improve health care quality: it will “cut expenditures,” but actually might gut preventive care and funnel more money into intensive care because more people will be getting very sick from lack of use of primary care.

One thing I do think is important is that primary care physicians, in improving preventive care, should help patients develop health care cost consciousness and emphasize spending a little now in order to save a lot later. Everyone should have health insurance (or some other coverage), hopefully insurance coverage that is relatively standardized and not convoluted (as plans are now) so that doctors can actually advise generally. At the same time, insurance companies should move towards a model of funding more preventive care so that they don’t have to spend as much on intensive care. Even if that 5% doesn’t disappear entirely, it might at least be reduced by a couple of percentage points which would represent a much larger benefit with respect to reduced spending. Although I may become a critical care physician someday, it would make me happy not to see patients in the ICU who didn’t have to be there or could have avoided a life-threatening crisis prematurely.

So, to recap, you can’t just magically “move money from intensive care to preventive care”: you need to shift disease incidence from expensive, life-threatening crises to lower-cost, preventable indications for care. Diseases don’t change overnight and may take decades to develop, so rapidly shifting large amounts of reimbursement from intensive care to preventive care will jeopardize the protection of the health of an entire generation: our parents, or ourselves. Instead, the change needs to be more gradual and have measures in place to insure that the preventive care works.

[I’m a big supporter of better health education in the U.S. school system: by helping young people develop good healthy habits early, we can prevent substantial amounts of chronic diseases and also infectious diseases such as AIDS and hepatitis. Additionally, with respect to preventive care, one thing I’d like to see are opt-in courses where people, healthy or sick, can learn about standard preventive health measures. By taking these courses, particularly when people are in their 20s and 30s, these people would be eligible for universal fee deductions for health insurance coverage, so their premiums would become cheaper the more they learn about preventive measures and healthy habits. Even better, it would be ideal if they were tested (as in driver’s education) and their performance was also measured by long-term measures of health, with matching rewards in the form of cheaper premiums or other pro-health incentives. I don’t think this should be mandatory, though, as many people might not want to or might not have the time to do this. However, introducing this program early in life (such as in grade school) might help insure that the program isn’t just for rich people.]

4. Lastly, in order to reset priorities so that higher performance is marked by improved patient health outcomes, patients and physicians need to work together to assign values on services.

I don’t think insurers should have much of a role in this discussion. It should be a focused, in-depth discussion between physicians and patients. While quality ultimately is for the sake of the patient and we would like to think that patients should determine the measures of quality, patients do not know the full extent of quality in the delivery of medicine. To that effect, physicians are the best advocates for patients. Some patients love their doctors, but those doctors may not be competent in medicine. Some patients might not like their doctors very much, but those doctors may be very competent despite their less ideal rapport with their patients. The quality of medical care in the U.S. is better than it is elsewhere in the world; the quality of health care in the U.S. is not. In other words, the expertise and capabilities of physicians in the U.S. are better than anywhere else in the world (which attracts foreign medical graduates to train here, and also to remain here so that they get paid more for their superior training as compared to jobs they might find in their home countries where medicine is not as good or even as valued), but the delivery of health care (including medicine, its main component) is not ideal in the U.S. Many aspects of health care impede the delivery of 100% of the quality of medical care that can be provided by a given physician: shortened visit times, malpractice forcing doctors to practice “defensive medicine” at great financial expense and expense to their potential as physicians (i.e. they don’t reinforce excellent training with excellent practice, because ordering every test when many possibilities can be ruled out with good history-taking and a good physical exam is not good medical practice), general distrust of doctors by patients, poor compliance on the part of patients, and more. At the same time, patients need to assert themselves in a manner that is not threatening to physicians: doctors are not their enemies, but rather, their potential best allies, if the profession is not crippled by politics, malpractice lawsuits, and financial restrictions and disincentives. In order to achieve the best quality of medical and health care possible, physicians and patients must work together to make it happen.

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