The janitor approached my office manager with a very worried expression. "Uh, Brenda..." he said, hesitantly.
"Yes?" she replied, wondering what janitorial emergency was looming in her near future.
"Uh...well...I was cleaning Dr. Lamberts' office yesterday and I noticed on his computer...." He cleared his throat nervously, "Uh...his computer had something on it."
"Something on his computer? You mean on top of the computer, or on the screen?" she asked, growing more curious.
"On the screen. It said something about an 'illegal operation.' I was worried that he had done something illegal and thought you should know," he finished rapidly, seeming grateful that this huge weight lifted.
Relieved, Brenda laughed out loud, reassuring him that this "illegal operation" was not the kind of thing that would warrant police intervention.
Unfortunately for me, these "illegal operation" errors weren't without consequence. It turned out that our system had something wrong at its core, eventually causing our entire computer network to crash, giving us no access to patient records for several days.
The reality of computer errors is that the deeper the error is -- the closer it is to the core of the operating system -- the wider the consequences when it causes trouble. That's when the "blue screen of death" or (on a mac) the "beach ball of death" show up on our screens. That's when the "illegal operation" progresses to a "fatal error."
The Fatal Error in Health Care
We have such an error in our health care system. It's absolutely central to nearly all care that is given, at the very heart of the operating system. It's a problem that increased access to care won't fix, that repealing the SGR, or forestalling ICD-10 won't help. It's a problem with something that is starts at the very beginning of health care itself.
The health care system is not about health.
Yes, the first word, "health" is inaccurate. Our system is built to address the opposite of health, sickness, exchanging money for addressing illness. The clinician is paid for matching diagnosis with procedure (ICD for CPT, in code). Economically, more (or more serious) diagnoses and more (or more complex) procedures result in more pay. Last I checked, more/more serious diagnoses and more/more complex procedures are not in the definition of "health."
So is this just a case of bad nomenclature, or not wanting to use the term "sick care system" for PR reasons? What does it matter what it's called? The problem is that health is what the patient wants (although it's hard to call someone a "patient" if they are healthy), but the system does nothing to help people each this goal. In fact, our system (as constructed) seems to be designed to discouraging providers from helping people toward the goal of health. After all, the system itself becomes unnecessary in the presence of health.
Getting What we Pay For
So what do you get from such a backward system, one that rewards the outcomes people are supposed to avoid? You get what you pay for:
- A premium is placed on making diagnoses, since they are rewarded.
- Unnecessary tests are done to "fish" for problems to treat. I got my vitamin D level drawn at my last doctor's visit, but was not displaying any symptoms/signs of a deficiency and know of no evidence that treating it in someone like me would do any good. To what end do I have this diagnosis? I am not sure.
- New diseases are created to promote intervention. "Low T" syndrome is a perfect example of this, not only rewarding the provider by adding complexity for the visit and the lab for the test run to make the diagnosis, but also the drug company who brought the "disease" to the public consciousness.
- The likelihood of a person being considered "healthy" is much less.
- Obesity, depression, poor attention at school, social maladjustment - things that used to be considered different points along the range of normal human existence - are now classified as diseases. Risk factors, such as high cholesterol, are made in diseases to be treated. The end result is a diagnosis for everyone.
- Overdiagnosis leads to overtreatment with medications that themselves can cause problems (which is rewarded by increased pay for doctors, hospitals, drug companies, etc).
- Little effort is made to do things that would lead to health.
- Spending more time/resources on people to educate them about their health is bad business, as it decreases the number of diagnoses and procedures a clinician can do in the course of the day.
- Since there is no motivation to prevent little problems from becoming big ones, they tend to be neglected. Patients often report the need to be "sick enough" to go to the doctor's office, and seem embarrassed when their concerns are found to be "nothing serious."
Why Payors Won't Change
So why don't payors just stop paying for unnecessary medications, tests, and procedures for invented diagnoses? The did once, actually. Back in the early days of HMO's, when most doctors and patients were used to getting any medication, test, and procedure without question, the payors changed: they stopped paying for everything. "No, sir, you don't need an MRI scan for back pain." "No, ma'am, you don't need the brand name drug that costs 20 times more."
This attempt to control cost was not met with praise, but instead by the demonization of payors by both doctors and patients. Insurance companies quickly became public enemy #1, said to be denying care to those in need. In reality, they were not denying care; they were simply refusing to pay for it. Patients could get the MRI or brand medicine if they wanted, they'd just have to pay for it themselves. But that wasn't in the discussion.
In the end, they did what every God-fearing person does with a problem they don't want: they passed the buck. Instead of refusing to pay for unnecessary procedures, they did two things:
- Required authorization by providers - this meant that the denial was because of the provider's inability to justify it, not the payor's unwillingness to pay for it.
- Started penalizing/reporting "bad" providers - this started with the use of "pay for performance," and has come to full fruition recently by the "transparency" movement, where doctors' and hospitals' utilization are publicly reported.
The analogy I've used in the past is that of an alcoholic who blames their spouse for their inability to control their drinking. "If only those damn doctors would stop ordering those unnecessary tests and prescribing those unnecessary drugs, I wouldn't have the need to irresponsibly pay for them."
The root financial arrangement in the health care system is to promote more: more diagnosis, more disease, more tests, more interventions, and more medications, with each of these being rewarded with more revenue. It seems the obvious cause of our out-of-control spending - spending which does not yield better health.
Attempts to reform the system have ignored this root problem, instead focusing on other things:
- Improving access to care (a la the ACA) - which addresses the real problem of uninsured/underinsured people, but ignores the fact that care became inaccessible for a reason: it costs too much.
- Measuring the care of providers and hospitals, attempting to manipulate them into reducing the cost of their care. The HITECH act (and our old pal "meaningful use") does this via computerizing and capturing the data of clinicians, as do the ACO's (accountable care organizations) for hospital systems. While there is a small shift of financial incentives in these arrangements, they greatly increase the complexity of the system, creating huge areas of spending that did not previously exist (yes, I am talking about the EMR companies, with Epic at their head).
- Changing who is in charge - either by privatizing Medicare and Medicaid or by going to a single-payor system. If a ship is sinking, the priority is to fix the hole, not to change captains.
Warning! This is where I get on my soap box.
For any solution to have a real effect, this core problem must be addressed. The basic incentive has to change from sickness to health. Doctors need to be rewarded for preventing disease and treating it early. Rewards for unnecessary tests, procedures, and medications need to be minimized or eliminated. This can only happen if it is financially beneficial to doctors for their patients to be healthy.
What a coincidence! That's what my new practice does! Who'd have thought it? The healthier my patients are, the less of me they need and the larger my patient panel can get. I am motivated to keep problems small, to avoid complexity, and to think in terms of true prevention rather than the invention of diseases.
Obviously, the system still must address the inevitable/unpreventable medical problems that arise despite my best efforts to prevent them. This is where the high-deductible plans come in: covering problems that the patient cannot afford. Yet my job will aways be to prevent patients from spending that deductible, wherever possible, avoiding unnecessary tests, medications, or ER visits. Why? Because in doing so I justify the monthly payment. It turns out that this is not very hard. This is a win/win/win, as patients are healthier, I make more money, and insurance companies don't have to pay for nearly as much.
The Bottom Line
Any significant change, whatever the means, won't happen until there is an even more basic shift, a shift in the very center of health care: we must focus again on people. The patient (or the person trying to avoid becoming a patient) has moved from the center of the health care transaction and has become the raw-materials for what we call "health care." The doctor/hospital needs the patient to generate the codes necessary to be paid by the payor, which is the bottom-line reason for our problems. A system that has incentives to create disease and procedures, will be satisfied (and even happy) with a lack of health. But a system which rewards health will be radically different.
Changing the focus of care to this is more than just emotional idealism, it is good business. Care should not be about codes, procedures, medications, tests, or interventions, but instead about helping people live their lives with as few problems as possible. We need an economy that thrives when the patient costs the system less.
Any attempt to reform without this change will ultimately fail.