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Deconstructing Healthcare in America – a Modest Proposal
Posted By Mark Sisson On August 1, 2007 @ 1:26 pm In Health | 67 Comments
I’ve been giving a great deal of thought to our system of healthcare lately. Frankly, I am disgusted not only by the perverse waste of money (we will spend  2 trillion dollars – that’s 17% of our GDP – next year on health related expenses), but also by the obscene lack of success our current system has in helping people achieve, maintain or regain good health. We are getting sicker and sicker as we continue to spend more  on healthcare.
While we rank number 1 worldwide in health-related spending, we rank  37th in overall health performance. Sure, Americans live longer now on average than we did 20 or 30 years ago. But the truth is we are only surviving longer, because we are most certainly not thriving longer. Drug companies are keeping us alive just so they can pump more meds down our throats while they pump up their own bottom line. And we are now told  that the generation in grade school today may be the first – in centuries – not to outlive their parents. Something drastic has to be done soon. This current system is beyond repair. But if you are one of the 45 million uninsured Americans, for whom the thought of getting sick is, well, sickening, you already know that.
As I’ve been reading all the pre-election political proposals  to fix our current “healthcare” system, I am struck by the fact that they are trying to fix something so badly broken  that it simply can’t be repaired. Even Michael Moore ’s new film “Sicko” doesn’t get to the heart of the problem. The assumptions upon which the current system are built are outdated, obsolete, and illogical. The system requires a wholesale reevaluation and rebuilding from the bottom up, including our rights, our responsibilities – and our reasonable expectations. If virtually every other developed nation (and several underdeveloped) can take care of their sick, we certainly ought to be given the chance.
With that in mind, I would like to offer a “modest proposal” to overhaul the U.S. healthcare system into one that, in my opinion, would do a much better job of caring for its sick and making sure the rest of us stay healthy. I realize that what I’ll be suggesting is a radical change and one that may irritate more than a few professionals who currently operate within our existing healthcare system. Nevertheless, this discussion is vital and I can no longer sit back and watch the system and its patients self-destruct. We gotta talk.
While the problems with today’s healthcare system are many, I have chosen a few to illustrate why we need a massive intervention:
1) Let’s start with the patients. Americans have lost all sense of personal responsibility. We want to blame anyone or anything but ourselves for our illness or condition. Furthermore, we have ceded all control of our health to the people in the white coats. We tend do whatever they say because we hold them in such high esteem. But doctors (like lawyers and accountants) do not have answers. All they really can offer are opinions and advice – only slightly more educated than our own and often biased by Big Pharma, medical supply companies or the fear of being sued. As a result, we way spend too much money on unnecessary visits, drugs, tests and procedures.
2) There aren’t enough doctors in the U.S. One report  suggests that as baby boomers start needing even more care, there will be a shortage of close to 200,000 doctors as early as 2010. One of the reasons for this shortage is simply because it takes far too long (usually 7-10 year) and costs far too much to train doctors. Furthermore, most doctors have to pay for this training themselves, often incurring huge student loan debt. It’s not unusual for kids these days to incur six figures in debt simply to get through a regular four-year degree – you can see the problem for the youngsters who desire to go on to medical school. As a result, and to compensate for all this, doctors have to charge too much money for too little service, and then hope that some day they will be reimbursed by the for-profit insurance companies. This doctor shortage is also why when you really need to see one today, the earliest available appointment isn’t until two weeks from Thursday. It would be funny if it weren’t so tragic.
3) The current system depends on private insurance companies to reimburse all costs. This profit-driven insurance-based medical reimbursement system is fatally flawed on several levels – and always has been. The basic business model of any insurance company is to do everything possible to collect premiums and then do everything possible to deny coverage. Therefore, people who need medical attention are frequently denied expensive (but often the most effective) treatment or, alternatively, people with pre-existing conditions can’t get insurance coverage in the first place – when they are the ones who need it most. As a result, insurance companies often dictate the most critical medical decisions more than the physicians. It’s just so wrong.
4) The majority of conditions for which people seek treatment can be better treated (and in most cases cured) with lifestyle intervention and education, yet our system of medicine would rather treat symptoms with drugs and/or surgery. Obesity, diabetes, heart disease, osteoporosis, arthritis, digestive problems, asthma and a wide range of other conditions often respond far better to diet and exercise or environmental changes than to even the best “state-of-the-art” pharmaceutical interventions. But doctors are under the gun to meet payroll, pay the rent and pay off the student loan, so they limit office visits to eight minutes and move on to the next patient. Under these circumstances they are far more inclined to prescribe meds than they are to spend 45 minutes or an hour to fully “describe” a lifestyle change that could cure the condition. Of course, they are even less inclined to follow up on any educational visit. What’s the incentive?
5) Pharmaceutical companies, medical equipment providers, hospitals and even a few doctors have a vested interest in keeping their patients ill. You’d think that a successfully “cured” patient should represent a major victory in strict medical accounting terms, yet a cured patient generates no income and no profit. Type 2 diabetics are a good example. Drug companies view a diabetic as the perfect patient – a 20, 30 or 40 year income stream generating $500 to $1,000 a month. The longer they live with the disease, the more additional drugs they’ll need and the more profit the company will make. In fact, the drug company has zero interest in the patient altering his or her lifestyle (and as I have said here often, type 2 diabetes is an entirely preventable and curable condition). They just need to keep them alive.
Moreover, when the market on one disease is tapped out, our friends in pharmacology manufacture new ones : “restless leg syndrome”, “social shyness”, “erectile dysfunction” and “PMDD” are not diseases, but they represent huge profit centers for doctors and pharmaceutical companies who see a lifetime stream of income from patients taking their prescription meds month after month, year after year.
6) The fear of lawsuits causes many physicians to assume a “cover your ass” approach to avoid any potential implication of liability, however remote. Medical malpractice has become a huge industry  as personal injury lawyers seek outrageous settlements for even minor mistakes or misdiagnoses. Many physicians leave the business because they can’t afford the malpractice premiums, and they fear the one multi-million dollar mistake that could ruin them. As a result, doctors resort to generalized “standard of care” methods even when those standards have been proven ineffective. For example, there is no good evidence that statin drugs lower the risk of death from cardiac events when cholesterol is between 200 and 250, while there is compelling evidence that diet and exercise interventions dramatically reduce deaths in that same group.
Nevertheless, most physicians prescribe statins and spend minimal time aggressively outlining lifestyle changes because statins are the “standard of care” for high cholesterol cases and because there’s safety in knowing that’s what most other physicians are doing. A physician who does not prescribe statins might be subject to a lawsuit if his patient died of heart problems because, shunning statins, he had tried but failed to get the patient to follow his diet and exercise advice. Fear of lawsuits is also why your doctor will sometimes run hundreds or thousands of dollars worth of diagnostic tests “just to be on the safe side.” You might think your insurance company pays for it all. But those costs are passed on directly to you and everyone else via annual insurance premium increases. God forbid the insurance companies should have an unprofitable year.
These are just a few of the problems with the current system. There are many more. These problems will not go away with the kinds of compromise proposals offered by politicians today. Forcing business to cover the costs of employee healthcare is ludicrous. Other than worker’s comp coverage, by what logic is it the obligation of business to pay for the bad luck, unfortunate genetics or unhealthy lifestyle choices of its workers? The single-payer system that has been often proposed has many merits, but is continuously shut down by Congress. Government guaranteeing the profits of private insurance companies using taxpayer funds is viewed as a misuse of taxpayer money. Yet there is a strong argument that perhaps the time has come for government to step in and do something drastic to fix this mess.
When it comes to business and economic models, I’m one of the biggest Freidman free-market proponents you will ever meet, but sometimes the basic needs of the people require that the government get involved. You could even argue that in the 21st century, given the health tools science has provided us, access to quality healthcare has become a constitutional right (provided you are willing to take personal responsibility for it). It has become my opinion that access to basic healthcare for all, like defense, fire departments and interstate highways, should be viewed as a public good, not as for-profit business with corporations’ profits favored over the health of our poorest citizens.
Yes, I’m advocating a federally funded and federally driven program that would allow anyone of any means access to basic healthcare at little or no cost. Now before you get all Republican on me, let me explain that I am also in favor of keeping parts of the current system for people who prefer and can afford a private medical system. After all, cosmetic surgery, Botox, stomach stapling and Viagra still need to be made available to those willing to spring for it.
It’s not often you’ll hear me suggest that government could do a better job than for-profit industry, but there are so many players in the current healthcare system that require a profit at the expense of the sick – and who have so shamelessly lobbied Congress to allow them to continue this charade – that the concept of “free-market forces” left the building with Elvis decades ago. For example, according to a 2003 study  we spent almost $300 billion on “administrative costs” associated with medical experiences in one recent calendar year. From the patient point-of-view, that’s $300 billion of your hard-earned dollars completely wasted.
My proposal is a two-tiered healthcare system which offers government-sponsored healthcare to everyone (we’ll call it “public healthcare”), yet still allows for private medical practice as we know it today to be available to those who prefer and can afford it (“private healthcare”). Anyone of any means could access the public healthcare system with minimal co-payments (which could be reimbursed via tax credits for low-income patients). There would be no private insurance involved in the public system at all because taxes would cover almost all expenses, but the private system would still largely depend on private insurance reimbursements. For those who wonder how or why a two-tiered system could work in this country, look no further than the US system of retirement planning which offers social security to everyone (and mandates taxes to insure it), yet allows those who prefer and who have the means to set up additional private retirement accounts (IRAs, 401ks, defined benefit plans, etc) with tax benefits and almost unlimited upside.
The public system would work much the same way that the armed forces work today. In fact, it could be its own branch of service. Prospective medical students who elected to go through the public system would enlist and would be trained within that system. Their entire training, as well as room and board would be free (paid for with tax dollars), and in exchange for the training, they would guarantee to provide at least eight years of service within the public health sector compensated at a reasonable rate of pay (let’s say $80,000 a year, comparable to a public defender). After eight years of service, they could elect to remain in the system (with an increase in pay) or they could go into the private healthcare system and hang out a shingle (remember how most commercial airline pilots came out of the military?). Nurses, physicians’ assistants, exercise and diet coaches, even administrators could all be trained within this same system. All this could even take place within today’s current armed forces structure with added pay incentives for actual combat-readiness training, but might be more effective as a stand-alone service branch.
With regards to the growing shortage of trained doctors, my system would fix that in relatively short order. This does require a major re-evaluation of what it takes to be a doctor. Bottom line: it shouldn’t take eight years to train a competent specialist like it has up until now. Aside from general practitioners and Emergency Room docs, almost all medicine is specialized today (just tell an orthopedist you have a GI problem and see how fast she runs the other way). I would argue that you can train a smart pre-med college grad 90% of a chosen medical specialty in under two years and have him or her be perfectly competent to begin supervised practice on real patients. After all, most diagnoses theses days are done by computer modeling anyway – not by the actual physician. I don’t wanna say a monkey could do it, but let’s get real.
If a condition is not immediately obvious to attending physician today blood, urine, stool and saliva samples are sent to labs and returned with nice distribution curves and all the relevant data with which to make a cogent diagnosis. CAT scans, X-rays, MRIs and other imaging techniques allow almost anyone to spot a problem and begin treatment.
Even surgical techniques no longer require years of practice with a supervisor looking over your shoulder. Surgeons today can be quickly trained using computer simulators. Ironically, most new surgeries these days are taught to older surgeons by 30-year old medical sales reps (who most definitely are NOT doctors) shilling the latest stents, shunts, implants and titanium joints. The idea is to train more doctors quicker and pay them less. Pure and simple. Those doctors who wish to charge more for special services could either train and operate within the current system or enter that system after their years of public service. But as we have seen in the private system, most of our healthcare money goes to greedy middlemen (insurance companies, pharmaceutical companies, bureaucracy-laden hospitals, student loan collectors) or to wickedly non-productive overhead (office rent, administrative staff, malpractice insurance). As a result not much of our health dollar flows through to provide patient services. That would change radically under my system.
The public system would rely on generic drugs wherever possible and would negotiate very favorable pricing on brand-name meds when those are absolutely necessary. Drugs would only be prescribed when truly medically necessary (sorry, no Viagra or recreational Oxycontin) and elective surgeries would usually be discouraged. Experimental drugs would be allowed if they were the only recourse in critical cases, but only with patient permission and waiver, adequate supervision, and oversight from a restructured FDA. The more expensive drugs would be used on a “pay-for-performance” basis, where the drug company would supply them, but would only be paid if they worked within acceptable parameters.
Education would be a major focus of the public health system. The current for-profit system is based on maximizing treatment as opposed to maximizing prevention. Under the system as it is, we will never make progress preventing or curing the lifestyle diseases that threaten us the most: diabetes, obesity, heart disease, stroke, arthritis, even some cancers. In most cases these respond very favorably to lifestyle interventions, but no one is willing to spend the time or energy to educate. Under my proposal, doctors would be paid for their treatments, but would also incentivized for successfully weaning their patients off meds and for having their patients achieve medical milestone numbers such as losing a certain percentage of weight or bringing fasting blood glucose to under 100 for two successive visits.
These goals can only be achieved when the patient is educated, understands the mechanisms and then takes responsibility for her health. Under my proposal, specialized health educators (maybe those who didn’t fully qualify for the medical training, but who exhibited the interest and the intellect) could be trained within the system and then deployed to schools or assigned to work with physician groups to do hands-on small-group diet, exercise and stress-management coaching. The success private clients currently enjoy working with personal trainers could then be made available to those who currently have no hope of ever gaining access to the true secrets of health and wellness.
Within the public system malpractice and medical “mistakes” would not be subject to the same litigation system we see in private medicine today. Instead, a 3-person panel of experts would hear cases and, upon finding gross or willful negligence, could choose to award reasonable costs according to a set schedule. This would ensure that any patient harmed by the system would be looked after, but would not be awarded lottery-like sums from aggressive tort-lawyers impressing overly sympathetic juries.
In the best of all possible worlds access to a public health system would bring the realization that there are no more excuses. We must each take responsibility for our health and realize that if we don’t make the lifestyle changes necessary to heal, we give up our right to complain or blame “the system” for leaving us behind or for not taking care of us. As we’ve seen with the current system, there’s only so much modern medicine can do at any price.
There, I’ve said it. Give it some thought and let me know what you think. In my opinion, without serious dialogue and outrageous ideas like this, our health will continue to deteriorate until we are a bankrupt, obese, diabetic, arthritic and Alzheimer’s-ridden nation with no good prospects for the future – and no good memories of the past.
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