“This is the third of a series of articles that will be published over the coming days and weeks. The series of articles will define the problems, at a higher level, that we have in what we call our healthcare system, why they are important and how they have conspired to foil our various attempts to “fix” healthcare. Each article will encapsulate one, or more, related issues, describe the problem and its effect today, how it historically developed and describe the framework of the solution(s). The final article will summarize the solutions and describe their intrinsic benefits.
(If you would like a more detailed read you may go directly to the draft Whitepaper titled, HEALTHCARE REFORM 2.0: Beyond the Partisan Divide Lies Pragmatic Solutions currently version 1.1)”
We have a large number of myths that govern our beliefs about our current Healthcare system – or non-system to be more accurate. One of the larger set of myths that drive our perceptions of both the positives and negatives of our healthcare system are our beliefs and expectations as to what we should get from healthcare and the underlying medicine. We believe, that modern medicine has cures for almost anything we face. We believe that the continual research and discovery that has occupied much of the past 164 years has led to a firm and almost complete understanding of the science of disease, injury, and treatment. We believe that there is little difference in cost between the things we need for survival and the things that we want to improve our lives. We believe that the current methods of treatment and the discoveries we have made over the past 80 years are making us a stronger more robust species. We believe that the doctor is typically the best and most qualified person to deliver the care we need. And we believe that in most cases going to the doctor is safe and leads to improvements in our health. These are just a few of the myths and misconceptions we have about the current state of medicine and what we should expect from our healthcare system.
Is Healthcare effective?
Doctors and the practice of medicine have come a long way since my grandfather was born in 1872. In the year of his birth America was only just beginning to understand Lister’s pivotal study on antiseptic practice – lowering significantly the incidence of infection – and the discovery of ether to provide a method for painless surgery. But, through a good portion of his youth and young adulthood America was still dependent, and plagued, by the ills of Patent Medicines, charlatan physicians and quack medical treatments. It was not until he was well into his 50s that the first antibiotic, penicillin, hit the market. Since those days, medical education and licensing has been completely changed, science has expanded and much has been discovered. Many great strides have been taken by medicine and its practitioners. Nothing in the following is meant to call any question into the care, education, skills and abilities of modern practitioners. The information is presented not to show how poorly they do their job; but, to show that we tend to ask way too much of them, in most circumstances, and that it is not their abilities and skill that are in question, it is the state of our misunderstanding of where we really are in our knowledge of our own biology and its interactions with the world and the other species that live in it.
Beauty may be in the eye of the beholder, but good, effective, accountable care is very hard to discern, let alone find, given the myths we hold about the practice of medicine. Let’s start with a few shockers. In January of 2008, Peter Orszag, then Congressional Budget Office director, reported to the Senate Budget Committee that more than $700 billion of the then $2.9 trillion in annual spending that year did nothing to improve a patient’s health and even produced harm. Dr. Elizabeth McGlynn, et. al., reported in 2003 in The New England Journal of Medicine, in an article entitled, “The Quality of Healthcare Delivered to Adults in the United States,” that physicians get the diagnosis wrong about one-half of the time. Dr. Norman Scarborough in his paper, “Medical Misdiagnosis in America 2008: A persistent problem with a promising solution,” that multiple autopsy studies have revealed frequent clinical errors and misdiagnoses with error rates as high as 47 percent. Sanjaya Kumar, MD, MSc, MPH and David Nash, MD, MBA writing in their book Demand Better! Revive our broken healthcare system (2011), found that only about 20 percent of clinical practice treatments that doctors deliver to patients are backed up by solid controlled trial evidence of effectiveness.
The effectiveness of medications do not fare any better, and in many cases they are just becoming worse. The best historical medications, like aspirin, have typically only been able to be metabolized – chemically broken down and used – in about 68 percent of the people that take them. Today many of the medications we are proscribed have significantly less efficacy and many more side effects than those in the past. As time has gone on, it is safe to say that Pharma has picked much of the “low hanging fruit.” The chemistries coming forward today have less effectiveness and many more side effects when proscribed through our current healthcare system. Biotech created medications offer some hope for efficacy and lower side effects but they often have problems with large scale production – unlike traditional Pharma. We are at the advent of the day when soon a pharmacist will require your genotype and phenotype – body chemistry type – to be able to dispense an effective and safe medication. 10 years ago experts in both industries were calling for a focus and development of systems to effectively deliver “personalized” medications to patients – something not supported by the current infrastructure.
So according to the real data 50 percent of the time physicians get the diagnosis wrong; when they proscribe treatment only 20 percent of the treatment actually has an underlying scientific basis in best practice; and, when they proscribe medications, at best, only 68 percent of us can actually chemically use the medication – often it’s much less. Yet, with all of the above statistics in evidence, more than 85 percent of the people who visit a doctor report that they were cured by the treatment or medications provided based on the visit.
Much to our collective dismay, unfortunately, the practice of medicine today is still much more art than science. How can there be such a large disconnect between the statistics of care and our impressions of care? We often confuse the body’s innate ability to heal itself in a given period with a beneficial effect of a visit to the doctor and the provision of their services or medications. We have been trained to believe that the doctor can cure anything and that technology has solved for all but the most deadly of diseases. We have unobtainable expectations of the ability of doctors to cure us of almost anything. Surprisingly, our expectations are not simply to cure us, but to repair us. Not simply a repair to an “as good as new” level, but to a level better than we were before we ever got sick or injured. As a result, we also have evolved to a point where, for many, our expectations far outweigh the reality of care that can be delivered. When the care does not meet our expectations, what do we do? We sue! To combat this rising tide, doctors have evolved to proscribe more diagnostics, treatments and medications – practicing so called defensive medicine. This has both driven costs much higher and increased the very same overuse problem that is also driving the risk of simply seeking healthcare.
Is Healthcare safe?
The Institute of Health Improvement reported in 2007, that about 40,000 times per day there is an incident of medically induced harm – about 15 million cases of medical harm per year. There are a significant number of incidences of Hospital Acquired Infections (HAIs), about 4,600 per day according to the Centers for Disease Control and Prevention (2007). Medication errors are one of the consistently deadly forms of medical error. Another Institute of Medicine report, “Preventing Medication Errors” (2006) showed that medication errors account for about 1.5 million patients harmed each year.
In their book, Internal Bleeding: The truth behind America’s terrifying epidemic of medical mistakes, Robert Wachter, MD, and Kaveh Shojania, MD describe a few of the kinds of problems people face when seeking care:
About 12,000 heart-attack patients are mistakenly discharged from hospital emergency departments each year because a physician failed to diagnose them as having a heart-attack or restricted blood supply.
Twenty percent of hand surgeons operate on the wrong hand or finger at least once in their career.
An estimated one out of 10,000 surgery patients end up with a surgical instrument or sponge left in them
Physician fatigue degrades performance. Staying awake for 24 hours is like being legally drunk with a blood alcohol level of 0.1 percent. And yet, extended-duration work shifts remain common for physicians doing their medical residencies.
Dr. Kumar, and his coauthor, refer to what they call the deadly triad of healthcare delivery: under-use, over-use and misuse, as the core to many of the current problems in effective healthcare. A 2009 report by Consumers Union, “To Err is Human – To Delay is Deadly: Ten years Later, a million lives lost, billions of dollars wasted,” by Kevin Jewell and Lisa McGiffert stated,
“Despite a decade of work, we have no reliable evidence that we are any better off today. More than 100,000 patients still needlessly die every year in U.S. hospitals and healthcare settings – infected because of sloppy compliance with basic cleanliness policies, injured by failure to follow simple checklists for safety – the equivalent of a national disaster every week of every year.”
Patients are no safer outside of the hospital setting. Most specialists report receiving no information from the primary-care physician before specific referral visits, and many primary-care physicians report not having received any information from specialists by four weeks after a specific referral. Two-thirds of the time the Primary-care doctor doesn’t have the discharge summary for a patient returning for the first visit after a hospital stay. When the discharge summary is available, they often lack information such as diagnostic test results – missing up to two-thirds of the time – and test results pending at discharge.
The IOM report, To Err is Human, cited earlier, came to the conclusion that medical error is not a “bad apple” problem and that most medical errors do not result from recklessness or malfeasance. It is also true that many times the person that is front and center in deciding the best mode of treatment, the doctor, is not the best person at all times to affect care. Sometimes they have the least information. Sometimes they have had the least interface with the patient – in some cases never having seen them personally. And sometimes, they do not have the best background for the determination of most appropriate medications to be provided.
In all, the To Err is Human report summed up our current systems this way:
“Imagine arriving at the airport and being invited to board an airplane that is little more than a horse and buggy with jet engines attached. Yet, this is what we ask patients to do every day – put their lives in the hands of a healthcare delivery system built in a nineteenth century for the solo-practice doctor with a black bag and trust it to support teams of doctors and other professionals using twenty-first century technology.”
No wonder seeking healthcare is one of the most dangerous things you can do. Fishermen are considered one of the most dangerous occupations with a death rate of 200 per 100,000 fishermen. Loggers experience the rate of 102 deaths per 100,000. Firefighters suffer 4.4 deaths per 100,000 firefighters. But, if you look at the rate of death from medical errors it dwarfs firefighters, doubles death rates for loggers and beats death rates for commercial fishermen with approximately 265 deaths per 100,000 patients admitted. One could begin to draw the conclusion that seeking healthcare is not one of the safer things you can do! And, one would be correct!
Does more money spent mean better care received?
In June, 2009 The New Yorker ran an article called, “The Cost Conundrum: What a Texas town can teach us about healthcare.” In it, Atul Gawande, MD made this observation:
“Healthcare costs ultimately arise from the accumulation of individual decisions doctors make about which services and treatments to write an order for. The most expensive piece of medical equipment, as the saying goes, is a doctor’s pen.”
The financial incentives in healthcare, even with the advent of the Affordable Care Act, still stimulate the provision of more healthcare services – often, as shown before, with no evidence to justify the additional services. While for a period of time, with the adoption of the so-called “managed care” model, utilization rates and costs did decline from the 1980’s to 1990’s; spending bounced back with a vengeance. America has historically had a visceral reaction when systems are put in place that restrict choice – even if they were only perceived restrictions. One of the main drivers of rising costs is rising utilization. Rising utilization is driven by a few items including, defensive medicine, new more expensive protocols and new more expensive medications – often with little or no gain in efficacies – and the biggest factor is the rising incidence of physicians simply providing more services.
But, more spending is leading to fewer positive results. Over the past 60 years we have trained ourselves as consumers of care to ask for more and, the providers of care have responded by coming up with many new offerings of care. Along the way we have forced our employers to demand more of these wanted types of care to be covered under insurance and, insurers have responded by increasing plan coverage to include the additional items we demanded. We certainly did not expect providers to offer us less care at the same time we were pressuring the people paying for services, employers and insurers, to pay the providers less in order to keep our premiums down. Did we? When Medicare and Medicaid came into law in 1964, there were about 450 diagnostic codes governing what was provided and paid for services. Today we are about to have over 100,000 codes for services and payments. Who sells more products, a boutique store with 25 types of shoes, or a department store with 16,000-30,000 different products to choose from? Healthcare is in many ways no different.
One of the things that distinguishes U.S. healthcare from other countries is the sheer volume of care we consume. As an example, Shannon Brownlee, in her book, Over-treated: Why too much medicine is making us sicker and poorer, (2007) notes that we get three times the number of expensive MRI scans as the OECD average, and compared with other countries, we have many more specialists who often recommend expensive procedures or surgeries. According to Dr. Kumar, in Demand Better, in some cases the tests we spend more on are actually less beneficial. A $20 blood-pressure test turns out to be superior to a $32,973 electroencephalography test, a $24,881 CT scan and a $22,397 cardiac enzymes test. Yet, despite the evidence, there has continued to be an explosive rise in excessive expensive tests. There were 40 million CT scans performed in 2000 and 72 million in 2007.
There is a very dangerous complication to the outcomes focus on reimbursement inherent in the ACA and many of the other current proposals. The same reimbursement system that rewards hospitals to lower readmission also stimulates them to provide more complex acute care on the front end and encourages hospitals, and providers, to get patients out of the hospital quickly. Dr. Kumar, et.al. sum up the lessons we should learn this way:
“Spending more on healthcare delivery does not bring more quality… When you have a hammer, everything looks like a nail. Doctors are paid to keep using the same hammer, doing the specific things they were trained to do. They’re going to set a target income, and they’re never going to stop – at least until the payment (and delivery) system is radically altered. “
Overall more money spent does not equate to better care received. In fact, often the more money that is spent on care is having the opposite result because as noted earlier, the more care you receive, the higher the cost due to error. There is also an almost perverse correlation. The more care you receive – the more money you pay – the more errors you get – the more care you need – stimulating higher cost – more care – more error – more care – more cost…
Does our disconnection between our expectations and what can be delivered increase our costs?
The short answer to this question is obviously, yes! But, the answer itself belies the depth of the problem or the insidiousness on how these myths and misconceptions have conspired to drive up the cost in our system or damage our ability to make fixes to the system. Further, if we do not understand these issues well, then the result will be just what we have had for the past 40 years – a series of fixes, and proposed fixes, focused on the symptoms but not addressing the systemic problems. First, and foremost, our over expectations for services, that our medical healthcare system has under delivered, has driven an ever expanding assumption that we can get any, and all, of the care we need or want, with equal weight through the very same delivery system. We also believe that we should have no increase in cost except as a result of greed, or fraud. We have so held on to the belief that the gains we have made in knowledge and science over the past 100 years have solved all the problems, we now do not recognize why our healthcare system is not working. In continuing our unshakeable faith in the myths that medicine can cure all, we have spent the past 40 years demanding continuously increasing services from our employers who paid the bulk of the bill. Employers, in turn, demanded these increases from insurers. The insurers accommodated the demands and added the increased coverage and raised premium prices to cover the increased costs and additional risks. And who do we blame?
As this transpired over time, and the costs got more, and more, out of control, employers – no longer willing to shoulder all the expense – pushed back on the rising costs to insurers, who passed on part of the expenses back to us in the form of co-pays and deductibles. We have seen significant rise in the scope and breath of items covered. We have seen significant expansion from basic care, to include vision, dental, office visits, physical therapy, advanced medications and numbers of chronic diseases not covered under older insurance plan models. We have also seen a significant increase in the so called “Quality of Life” covered items. We have convinced ourselves as consumers that we can look at the care we need and the care we want with equal weight and entitlement. As a result, as time has gone on, we have expected more care and we have assumed we could get it at the same price. In fact, many today believe that somehow the subsidies that are being paid to eligible people are not real money. I have had more than one person tell me it is really just a group discount that there is no money actually being paid for the subsidies.
So the answer is, yes. And, even more importantly the yes has a number of complications and multiplying effects. It has driven us to believe that the care we get today is much more expensive than the care we got a few years ago; and that the cause is simply because of greed. We now, for the most part, blame insurance companies, pharmaceutical companies, hospitals, doctors and others. We feel they are all getting rich, and somehow this is on the backs of the ability of us to get the care we need. There are instances of greed everywhere, and there are of course bad actors in any system. This is simply not the case in general, and if you review the last article The Plague of Myths: Myth 1 Healthcare Costs Too Much, you will see that even our understanding of the cost of care we receive is highly suspect.
Is our current practice of medicine and its delivery through our healthcare system good for us as a species?
We have a general belief that everything we receive as treatment or medications, particularly antibiotics, is good for us. We routinely gauge the effectiveness of care based on our own personal outcomes, or those of family and people close to us. This is a fine measure in the short run and it is a good measure if we are looking at our own circumstances. It is not necessarily a good measure in the long run and likely a very bad measure when evaluating our future as a competing species on earth.
We get infections that historically would have killed us, or caused significant damage to our ability to survive or reproduce. We get injuries and suffer diseases that just 60 years ago would have left us dead or again severely crippled. Today, we see the rise of many species that prey on us – like bacteria and other microbes – that are now very resistant to the drugs and chemistries that we have to combat them. We have microbes like; Clostridium difficile (c-diff), Carbapenem-resistant Enterobacteriaceae (CRE), Methicillin Resistant Staff Aureus (MRSA), drug-resistant Tuberculosis, and a recent strain of antibiotic-resistant Neisseria gonorrhea. We do not want to forget about viruses. There was a recent discovery of a polio-like eneterovirus in California with no known treatment.
While it is easy to chalk this up to other factors, like the use of antibiotics in feedstock or the overuse of antibiotics in general, one big factor is how we have been treating diseases for the past century. We have effectively removed ourselves from natural selection years ago. As I said in my book, The History and Evolution of Healthcare in America: The untold backstory of where we’ve been, where we are and why healthcare needs more reform!
“The practice of healthcare, after all, is largely a war with other species (bacteria, viruses, and other complex pathogens), a war with our environment (accidents, violence, and pollution), and also a war with ourselves (diet, exercise, work habits, and sleep). From time to time, we can see gains for ourselves in these battles, but our mortality assures us that we will all eventually lose the war. Basic biology and the laws of nature have stacked the deck against us. Innovations in technology, science, and medication have helped many of us delay the day of our ultimate surrender, but these advances have also fostered the false belief that no price is too high to pay for an extra day or week of life.”
Overall, another of the bigger problems is we make decisions for the provision of care weighted almost solely to the needs and wants of the individual. While no one can argue with the heart of this decision, we may be approaching a time when we will need to also look at the effect on us as a species. History has shown that, in some cases, what is good for us individually could very likely become bad for us as a species. There is now ample evidence to show that the mere use of antibiotics – not necessarily overuse – has led to the rise of hype-resistant strains of bacteria. The treatment of other diseases, and conditions that would have limited or prevented reproduction has increased the incidence of the very same disease or condition in the population. These are very thorny and difficult issues that someday soon we will need to address. Some of them may need to be addressed in the decisions we make about the provision of care, and others will be those we will need to address as a society. Who among us wants to make decisions that may be detrimental and damaging to those we love? Yet, we may one day in the not too distant future have to make such decisions.
In the end, the continual trend to extend life for each of us as individuals, and to allocate more of our funds for quality of life care verses basic life care has had a very significant effect – one that we will explore in more detail in our next article.
In order to solve for these problems, we must develop an integrated solution that provides the necessary system architecture and systemic controls to address our needs for care and our want for care separately. We need a system that begins to provide real accountability for the cost and efficacy of care we receive from providers. We need a system that helps inform us as to the real value and results we should expect from the healthcare providers we select. And, we need a system that effectively manages our own choices between the care we need and the care we want and the system needs to work in a totally transparent manner to prevent cost shifting from the needs side to the wants side hiding the real cost.
We need to rethink the delivery of the care we need. We need to establish best practice protocols for as much of the needs based care as we can, but not in a manner that binds doctors from not exercising their own judgment or choice. We need to re-think our healthcare continuum and reallocate roles and responsibilities of care in order to provide the most appropriate resource improving access, efficacy, and cost efficiency. We need to create a representative group or peers from the healthcare continuum including patients, care facilitators, care providers and payers, housed in a national organization but appointed through the various states and territories to make the required decisions and changes to our delivery system.
This type of system can be created incorporating most of the current infrastructure. It will significantly simply many of the practical problems that plague, insurers, providers, patients and third party administrators. It will significantly lower costs, free resources, lower liability, reduce duplication of services, reduce fraud and provide easier access. Finally, it is designed to provide full portability, transparency and price certainty so that America and Americans can make informed and accurate decisions as to the cost and resulting value for the services they receive and to effectively compare cost and performance between services, providers, institutions, methods and other nations.
Article 4 – The Plague of Myths – Myth 3: We can and should be able to live forever!
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