I have spent many hours studying different proposals and I've come to the realization that the big issues aren't being discussed, let alone being considered. Both sides seem to be arguing more about minutia rather than what truly matters. To help the process out, here are 6 things that need to change in American healthcare. In conjunction with each point I will ask a probing question that really should be answered.
1. Healthcare should focus on helping patients, not avoiding lawsuits
Billions of dollars are spent every year by the healthcare industry in an attempt to prevent lawsuits. Whether it's striving for a better JCAHO review (a waste of time and money) or simply trying to cover your back by shoving piles of waivers down patient's throats, hospitals, doctors, HMOs and everyone in between often worry about what they have to do to protect themselves rather than to help their patients. Accidents and mistakes should be prevented, but worrying more about preventing a lawsuit rather than delivering quality care. Physicians might be more concerned with an individual patient, but the CEO cares a lot more about a possible tort claim than whether or not Mrs. Jones was pleased with her care.
Question 1: Are malpractice claims intended to help the injured or punish the offender?
2. Efficiency is necessary, even at a cost
The National Highway Safety Traffic Administration estimates that over 40,000 people are killed each year in traffic accidents. That's one out of every 7,500 people in America die every year just from traffic accidents. On top of that, roughly 2.5 million are injured by motor vehicles each year. That's one out every 120 people. How could we reduce these numbers? Simple - we just put a governor at 15 miles per hour on every vehicle in the country. Why won't that happen any time soon? That's also simple - the number of lives we save and injuries we prevent aren't worth the efficiency it costs.
Healthcare is in much the same boat except coming in the other direction. Rather than focusing on ways to make things more efficient and more cost effective, we focus on how to save that one more person. The American Cancer Society estimates that 565,650 people died from cancer in 2008. Of that number, 1/3 of the deaths are attributable to obesity/nutrition (188,500) and 170,000 can be attributable to smoking. Meanwhile, 49,960 deaths are attributable to colorectal cancer. They recommend, though, that after the age of 50 people get a flexible sigmoidoscopy every 5 years and a colonoscopy every 10 years. The average colonoscopy costs $3,081 while the average diagnosis of "obese" or "smoker" is free. Efficiency demands that we first focus on the bigger, more cost-effective diagnoses.
Don't get me wrong, I'm not against regular colonoscopies (there is, after all, a 5.4% chance that everyone will get colorectal cancer in their lifetime). What I'm using this example to illustrate is that we need to be efficient with our resources. Rather than using a new screening method that is 99.9% effective at detecting some rare disease, why not use the much cheaper 97% effective screening method? Will we miss some cases that we otherwise would have found? Yes. Will we save vast amounts of money? Yes. Healthcare shouldn't be confined to 15 mph - we need to make the changes that make us efficient, recognizing that there is a price that we will have to pay.
Question 2: How much risk are we willing to pool as a society?
3. Not all ailments can or should be treated
Americans love stories of underdogs who overcome long odds. While these tales make great stories, they make lousy justification for policy. When a patient spends the last days of their life in the ICU as opposed to at home with family, they may live a few days longer, but they also will pile up huge costs. A 2005 study (based on data gathered in from 2002) estimates the daily cost of a patient on ventilation in an ICU to be $10,794. That means that prolonging life by a few days costs huge amounts of money. I know I value my life, but if someone offered me $10,000 to give up next Tuesday, I'm pretty sure I would take them up on the offer - and that's not even an end of life sick day.
It may seem callous, but we cannot use insurance (cost/risk sharing) to try and work miracles. Hospice/palliative care must be viewed as a viable option. Medicine cannot simply be focused on delaying death but also maximizing life. Two weeks in the ICU compared to one week at home shouldn't be viewed as a tough choice to make by a care provider.
To accomplish this, there needs to be a standard set about what kind of care we are willing to risk share - the debate about what that is can then follow.. Is it that there must be a 50% chance of survival for two weeks and a 10% chance of survival at one year to warrant extraordinary care or is it lower than that? We cannot say that a 1% chance of survival beyond two weeks and a 0% chance survival at one year is worth $10,000 a day for the next week. People can still choose to pay for whatever care they want out of their own pockets, but risk sharing extraordinary care is untenable.
Question 3: What is the dollar value of a day of human life?
4. The federal government cannot make specific decisions about quality of care
Healthcare is a local concern. New Yorkers don't care about how rural doctors are able to get to remote communities any more than Alaskan Inuits care about whether or not a New Yorker has to go all the way from the Bronx to Brooklyn for an MRI (even after a 3 month wait!). The issues affecting each community need to be addressed by that community. Standards of care, expectations and willingness to pay all vary by location, culture and geography. These communities need to make their own decisions about what is expected and what can be afforded. Just as people make decisions about where to live, they also need to make decisions about what they want to pay for. New York offers everything from the arts to Wall Street and every service (including world-class medical care) in between. It also offers crowds, congestion, pollution and crime. Ashley, North Dakota might not have Broadway, but it can offer clean air, open spaces and much cheaper housing. Putting a New York standard of care on Ashley makes as much sense as putting an Ashley pollution requirement on New York.
Whether healthcare is administered via the government or through private insurers, the issue still remains what must be covered. If we have a federally mandated level of care, why should New Yorkers have any say in deciding how many MRI machines are enough for Ashley, ND? In New York, MRI machines per population might be the way to go. In North Dakota, distance might be the more important factor. Additionally, the administration needs to be local. A senator from New England who has never ventured west of the Mississippi has no more business telling North Dakota how to care for their sick than a North Dakota farmer has in telling New York what to do. They come from different backgrounds and are concerned with different things.
If the federal government wants to mandate that everyone is covered to some extent, that's fine, but it CANNOT try to oversee things. Primary care for the implementation of any standards has to be done on a more local level. Whether that is state-wide or smaller can be debated, but the federal government needs to keep its hands to itself.
Question 4: Who should make decision about which risks are shared?
5. People are responsible for their own choices
America is based on a system of rights and responsibilities. I have the right to vote, but I also have the responsibility to get myself to the polling station and make an informed decision. I have the right to choose to have children and I have the responsibility to provide and care for those children.
Healthcare is the same situation. It has been determined (I still wonder who made this decision) that people who need emergency healthcare cannot be turned away. This leads to the underinsured and uninsured flocking to emergency rooms for minor care. The cost of their care then goes to everyone else. Whether the solution is requiring everyone to be insured, creating a national healthcare plan (similar to our school systems where everyone can go) or if it's by somehow really holding people individually responsible for the price of the care they receive is up for debate. What shouldn't be debated, though, is that people need to be held responsible for the decisions they make.
Specifically, we know that certain choices (not genetic disorders) contribute to many diseases. Each year roughly 440,000 die from smoking. Their healthcare costs are a result of the decisions they made over the course of many years. Why should they only contribute the same amount to the risk pool when they are choosing to put themselves more at risk? Because of their choices, they should be contributing to healthcare more than those who aren't making those choices - let the penalty fit the crime. This can easily be implemented by raising taxes on products that are known to cause health problems: alcohol, tobacco, sugary drinks, many fast foods and most candy, just for starters, can be taxed (ideally at a state level) which an then go directly to the healthcare fund. An occasional Big-Mac probably isn't going to hurt you and neither will paying an occasional tax when you buy one. Eating them daily, though, will add up for your health and for your health plan.
Question 5: Should people pay for the benefits they receive?
6. A doctor at a hospital isn't always the best choice
When there is a health emergency, Americans instinctively think about going to the hospital to talk to a doctor. While in many cases this is a good idea, in other cases it really isn't necessary. Why does an MD need to sew up a cut finger or set a broken arm?
A doctor spends many years studying to learn to diagnose. Treatment, often, can be done by anybody with moderate training. While it might take a specialist to decide what drug cocktail is needed to treat a certain ailment, any nurse can administer the IV and any nurse's assistant can hand the patient the right pills. While it is true that certain procedures require specialized training, many (probably most) do not. You can get your eyes checked at Wal-Mart, why not get your stitches there, too? All we need to do is to change the definition of practicing medicine and then allow less-skilled diagnosticians to treat patients for less.
Question: Is a hospital an ideal setting to receive treatment?
