“A crisis should never be allowed to go to waste,” said Winston Churchill. Is it time to fix health care in the US? From recent estimates, 18% of our GDP is spent on health care and yet we do not rank in the top ten countries in terms of medical outcomes. There is much waste, administrative costs are uncontrolled and cost of care, including drugs, surgery, and investigations are unconscionably high.
Our health care has been tweaked for years but now some common-sense measures are urgently needed so that we can get out of this morass we find ourselves in. To my mind, some fundamentals should be addressed and can be done with bipartisan support. These would be:
- Reduce waste by improving quality: Barwick and Nolan, et.al., have shown that we can do so on a large scale. What is needed is clarity of vision. The new approach towards the fee for value, accountable care, bundled payments care initiatives, measurement of outcomes, and customer engagement are all steps in the right direction but these initiatives need to be energized.
- Evidence-based medicine: Following the standard of care needs to be emphasized. Palliative care for end-stage diseases and dignity of life should be an integral part of medicine. Heroic measures at the end of life need to be avoided and doctors and loved ones should be able to make decisions that are appropriate and beneficial for the patient and community.
- Align incentives: Doctors and facilities are paid more for doing more. This is perverse and drives up costs unnecessarily whether the patient needs expensive and drastic procedures or not. Pharmaceutical entities and makers of implants, instruments, equipment, and appliances peddle the most expensive products and spend millions on advertising to lure patients and providers into unscientific treatments and interventions. The new approach of incentivizing physicians for better outcomes, quality, patient satisfaction, and safety and compliance are all steps in the right direction.
- Cap costs and negotiate contracts: Negotiations on a large scale with drug-makers should be opened just like the Department of Veterans Affairs does. The cost of drugs is going up 10-15% every year on average and this is unsustainable. Every Medicare Advantage Insurer should be mandated to have the same number of commercial patients. This will increase competition and reduce the burden on patients, small businesses, and the government. A simple solution like this would have reduced the burden on the Accountable Care Act but for that to happen the decision-makers need to be free of the pressure brought upon them by vested interests.
- Integrate Health Care: Right now our health care delivery is fragmented. The continuity of care is poor. The hospitalists and providers going to Skilled Nursing Facilities (SNFists) do not get medical records on time. Medication reconciliation is poor along with communication. Interoperability is minimal among the various facilities and modules and electronic medical records. Teamwork is thus compromised along with patient education and readmissions are unnecessarily increased, resulting in higher mortality and morbidity. Universal health care platforms need to be encouraged and communication between providers at various facilities mandated along with proper handing over of patient care from one facility to another. Data is not just the new oil; it is our life-blood. Analytics, artificial intelligence, and augmented reality can and must be leveraged to eliminate waste and diagnose diseases early and prevent them.
- Remove politics from health care: Panels that are bipartisan and involve physicians who are working in the trenches along with patients are needed and the influence of lobbyists and vested interests curtailed if not entirely removed. A physician may not get even a pen from a drug-manufacturer. How is it then that politicians and lawyers not only get paid but get a referral fee and commissions in matters of health care which are legitimate?
- Remove commercialization from health care: Health care should not become a blind profit-making field. Health and education need to be freed up of financial interests as the sole or primary arbiter in decision-making. Anti-Trust relationships are investigated by the regulatory authorities to reduce bid-rigging and restraint of trade; these need to be vigorously pursued and providers need to be educated on Stark and Anti-Kickback issues. Stark needs to be made simpler and more practicable. Simple interventions and alternative approaches like good nutrition, habits, hygiene, exercise, and personal care are ignored in favor of costly pills; personal responsibility is avoided and patients and providers have no skin in the burgeoning costs of unnecessary care even though the whole society pays for it in the end. I have had patients get electric scooters from Medicare to hang clothes on them. Such leakage must end.
- Malpractice and trial lawyers: Fear-based medicine is inordinately expensive and a lot of providers do things just to placate patients and families even when there is no medical necessity. The cost of care has increased along with the cost of malpractice insurance and this needs to be addressed on an emergent basis. Protection of patients along with proper education and improving patient safety needs to be institutionalized in every health care entity, and malpractice reform is urgently needed.
- Graduate Medical Education: It is extremely expensive to become a doctor, pay for medical school, and survive residency and fellowship on a limited or minimal income. Most doctors have several hundred thousand dollars of loans that they have to start paying when they graduate and in most cases, it takes 5-7 years to pay them off. In some cases that I know the providers have not been able to pay them off after 30 years of practicing medicine. This is unhealthy and adds to the stress on physicians and providers incentivizing them to practice medicine for commercial reasons and not as their vocation.
- Administrative overhead: The US has the largest operational cost of health care. This can and must be reduced with the use of technology, outsourcing, creating virtuous cycles of cost optimization, and not rewarding inefficiencies.
We have seen what the health care system and providers can accomplish when everyone comes together to handle a public emergency. The wastefulness of our health care system is another such emergency and needs to be addressed expeditiously. More patients are dying every day due to the inefficiency and ineffectiveness of our health care than COVID. We need as much focus and resolve to address the debilitating flaws in our health care system and fix it as if it were in the ICU. It is.