Our body is a machine for living. It is organized for that, it is its nature. Let life go on in it unhindered and let it defend itself, it will do more than if you paralyze it bey encumbering it with remedies. — Leo Tolstoy
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No matter how optimistic and hopeful you might be by nature, it’s difficult to approach the issue of health care in the United States without a sense of foreboding. And confusion. And frustration. And maybe a little anger.
The issue of affordable, reasonable, pragmatic health care is the defining issue of our times. In the U. S. in 1969, we spent about 5.0% of GDP on healthcare; today that number is closer to 18.0%. We spend at least half again as much per capita on health care as any other developed country, yet our health outcomes lag significantly behind those countries that spend less. Medical advances have allowed us to extend life, to treat illnesses that a generation ago would have been fatal, to keep the seriously ill alive longer. But the result of that is that 50.0% of the population now accounts for 97.0% of health care spending, while the other half accounts for 3.0%. We spend nearly $3.0 trillion a year on health care, with the vast majority of that spending – as would seem obvious on reflection – going to treat the chronically ill, the elderly, the frail. Meanwhile, the young and healthy balk at paying into a system that benefits them disproportionately less. Our under-performing, too-expensive health care system is the penalty we pay for deep, extensive fragmentation, and a stunning, remarkable absence of organizational strategy.
It’s little wonder that such a complex and deeply personal issue brings out the best and worst in us as a society. We have both practitioner heroes and grandstanding ideologues; hardworking, dedicated research innovators and quacks; informed, mindful healthcare consumers, and fad-obsessed spendthrifts. Our public dialogue about healthcare resembles a 10th-grade debate society, with the exception being that the 10th-grade debate society is likely more focused and disciplined. We seem unable or unwilling to separate fact from fiction, science from politics. We constantly conflate expense with spending, payment systems with payees. We cannot engage in any conversation concerning health care that is not ideological. As messy, complex and fragmented as our health care system is, our conversation about it is worse.
The challenge of income inequality is mirrored — in reverse – in the healthcare system itself, with the bulk of medical expense concentrated in one age demographic. We spend nearly ¼ of all medicare dollars in the last year of life and about 30% of that in the last month of life. The vast majority of those dollars go to hospital care, when it is very likely that the patient would be better off at home. Leading up to this end-of-life stage, we avoid spending on preventative care, then bemoan the expense of treating illnesses that might have been easily prevented.
Of course, we see the world of healthcare through the lens of our individual experiences. Doctors see the world of medicine through the eyes of a practitioner, patients through the eyes of illness. Researchers see a science problem, while insurers see actuarial tables. The politicians see an opportunity. And the average taxpayer sees a train wreck.
Our fragmented model of healthcare places extraordinary burdens on those who are ill and suffering and oftentimes even greater burdens on their families. It’s not enough to simply be sick; there is also the labyrinthine world of the payment system, the simple challenge of managing an illness through multiple channels, multiple providers, multiple business models. It is as if we should require an MBA for anyone to be seriously ill. Being ill is not for the sick.
We live today in a world of remarkable advances in medicine. We have tools and treatments and science that bedazzle us, that defy our imaginations. There is so much we can do that the issue is no longer can we treat an illness, but do we we choose to treat an illness. And then there’s the harsh reality of whether or not we can afford to treat every illness and condition we have the ability to treat.
How is that we have allowed the system of healthcare to grow so byzantine, so bizarre, so difficult to manage, while at the same time we continue to develop remarkable technologies, devices, medications and treatment strategies? How could a system that has caused so much good in the world, create so much bad experience, so much angst and argument and divisiveness? How could we be so good at medicine and so bad at management?
The answer might be found today in pockets of health care leadership, expertise and innovative thinking. There are individuals and groups and organizations and companies that are out there, working to do better at delivering quality health care, approaching this enormous challenge with integrity and thoughtfulness. You can find them, if you look hard enough. In the next few weeks, I’ll share some conversations I’ve had with leaders in health care, to see what kinds of innovative thinking are emerging. To start off, next week I’ll talk with Dr. Brad Stuart, a leader in the field of advanced illness management and a pioneer in organizational strategies aimed at reducing costs and improving patient experiences. I invite your comments and input and your active participation in this conversation.