Monday, May 19, 2008

If we REALLY wanted to fix healthcare, we'd put the patients in charge, not the government!

Healthcare costs continue to outpace inflation as they have for as many decades as I can remember. Pity that the rate of technological progress has not kept up. If I were paying more for commensurately better care, I'd be more apt to shut up and pay. As it is, paying is a foregone in any case, but I do it with a moan. Insurance companies are moaning too, as are doctors and nurses. Drug companies moan, and hospitals threaten to cut back or shut down. Employers moan and cut back on coverage. The media moans via exposes on special case after special case. Politicians ... well, we all know what they do. Nobody works toward even identifying and communicating the problems, much less agreeing on and implementing solutions. We all moan in our special way and continue to pay.


Issue #1: Risk aversion. Research and technological change are artificially limited by our prevailing attitude that change is risky ... and there's no room for risk in medicine. Other countries take the lead in key areas while we frequently take a decade to approve new treatments. This is government-enforced, but it is not out of sync with popular opinion. The FDA is efficiently converting public opinion into public policy. The other, more powerful mechanism we, the people, use for the same purpose is issue #2...

Issue #2: Litigation. Coulda Woulda Shoulda - Folks on the front line earn their living by making life-or-death decisions in a matter of seconds. We all pretend it's scientific (see Issue #3) but there's plenty of arts and crafts involved. Legal precedent makes it clear that one false move and the professional is sued out of existence, along with his hospital, his staff, his dog, and the guy who fixes his boat. Lawyers may be willing to play dirty to win, but they can't do so without a client. True, they market themselves aggressively ("Have you been INJURED??? Call Now!!!") but if we really didn't want them, they'd have gone the way of the Dodo and the Flowbee. No, we need them to debate the dollar value of unquantifiable notions like mental anguish or pain and suffering. When looked at in the first person, I agree. I want that doctor to think twice and three times about pumping some new drug into me. If he fucks me up permanently, I want compensation. However, the tremendous cost of the suit, the pay-out, and the newly-minted preventative measures must come from somewhere. No doctor or hospital dares operate without mega-million dollar liability insurance policies. No insurer will issue such a policy cheaply. In the end, every penny spent on suits is distributed back to you and me via increased insurance rates to doctors and hospitals, who in turn charge us more. What, then, is the proper balance between justly compensating an innocent person for negligence and collectively degrading the cost/benefit for the entire population? It's the type of choice humans are poor at making. We want to save ourselves and our loved ones at all costs. So the healthcare industry obliges.

Issue #3: Stone age science. In the last 500 years, physics has gone from a philosophy to a science so robust that we can successfully alight a nuclear-powered, computer-controlled satellite into orbit around a distant planet and beam back data. It has matured to a level of self-propagation based on sound underpinnings. Over the same period, medicine has failed to find a cure for the common cold, a way to prevent our most frequent killer (heart disease), or even a way to fix back problems so people can return to productive life. True, via trial-and-error we've stumbled onto some pretty cool stuff such as penicillin and the gamma knife, but a collegiate astrophysicist can tell you EXACTLY where Hale-Bopp will be in 2112. Contrarily, doctors who have a half century of education and experience under their belts are as surprised as you and I when a baby pops out with autism or routine surgery goes horribly wrong. There is a wide tolerance for mis- or no-diagnosis. The effect of treatments is often left to "wait and see." Granted we have made impressive gains in the last 100 years. Granted biology and medicine are bafflingly complicated. Behavior appears to be unpredictable, so we can't draw nice neat cause-and-effect conclusions and thus are robbed of the type of universal laws which underpin the successes of other sciences. I use the term "appears" because I would argue we just haven't yet gotten to the root cause. Current state of the art in medical treatment deals largely reactively, and largely anecdotally. As a consequence, doctors are turned into artists, treatments into crafts, hypotheses into hopes. If we can ever move beyond that, medicine will experience the type of quantum leap that computing saw in the 20th century.

Issue #4: Stone age technology. Okay, so we haven't decoded the human genome yet and thus can't nip issues like cancer or multiple sclerosis in the true bud. Does that somehow justify the fact that a doctor still has to write his prescription on a piece of paper which you have to tote to a pharmacy, who must in turn have a human count out pills one-by-one with a butter knife? Usually to get from from feeling cruddy to swallowing a pill takes multiple days. Shit, I can get an exact book sent to an exact address by an exact day at an exact price all by myself. In cities, I can get that book same-day. Where's Amazon for pills?? Why, when I move across the country, do I have to start over with essentially a blank page. Why, when my neighbor passes out in his backyard do the ambulance EMTs show up completely uninformed about his health conditions? Far worse, when he arrives at the hospital 45 minutes later, the doctors and nurses are no more informed. Why does it take hours or days to arrange a test, five minutes to perform it, and then more hours or days to get the results? Why can't I see and quality check my own damn medical records? Every piece of junk email I ever sent or received from my Gmail box and every website I ever visited scoured by artificial intelligence agents for any useful piece of marketing data and likely saved for all eternity somewhere. Would that my doctor could implant a little agent in me to monitor my every bite, beat, and breath so he could really figure out what's wrong with me.

Issue #5: Ambiguous economics. Does the aforementioned genetic puzzle somehow justify the fact that over half of Americans pick a doctor based on convenience (proximity and availability) because they have no way to measure skill or success? I know exactly which camera is better than the others, and which wine tastes a certain way, and even which hairstylist is tops. How? Price. Due to the astounding costs of unlikely events such as cancer, we all have or desperately want to lock in the price of our medical care. Most of us do that via health insurance (which re-distributes the cost of the insured evenly among the insured ... and often their employer). Others by showing up at hospitals sick and broke. Others by not seeking treatment at all. Others (abroad) by socializing medicine so that the aggregate cost of caring for the citizens is distributed to every taxpayer. The consequence of this is that there is no efficient market for the product. There is no measure of supply and demand driving the rates of top doctors up, and warning me against going to cheap-o ones. Insurance companies (and Medicare) engage in collective bargaining to drive rates down for some, but it's like squeezing a balloon - the air just moves around inside - there's no net savings. Horrifying though it may be for you to think of being sick and having to bid on some Medical eBay for a spot at the best hospital, this would drive overall costs DOWN by rooting out inefficiency, inappropriate risk, statistically unsuccessful procedures, and bad eggs. It would provide a whole new incentive system which would align the interests and thus the efforts of patients, hospitals, insurers, scientists, technologists, businesspeople, investors and doctors alike.

Issue #6: Reactiveness. Some studies prove one thing, others prove the opposite, but I'm willing to bet my bottom dollar that the old adage is true: an ounce of prevention is worth a pound of cure. This doesn't stop insurers from declining to pay for the vast majority of what marketers have labelled "well care" or preventative medicine. Pregnant mothers get a whole host of pro-active care. I guess that's based on the inevitability of the event. Strange, then, that we don't have the same reaction with something as nearly certain as obesity leading to diabetes and heard disease and joint breakdown. They'll pay for a heart replacement but not a gym membership and a dietitian. They'll let you see your doctor for a cough, but not for a regular (I'm talking weekly) program of health counselling sessions. They'll pay for the Ambulance ride and the ER visit if you have a crashing headache, but won't pay for a nurse to visit your home and hand you a prescription migraine pill. They'll pay for a wheelchair but not rehab.

Issue #7: Mutated Morality. The success of the sci-fi genre of literature probably owes itself to the same basic human tendency as issue #7. The truly original sci-fi novels, comics, and flicks invariably reprised just a couple of themes: scientific discovery gone awry, especially when it comes to changing humans or animals ... always with evil consequences. Think Frankenstein. Think Neuromancer. If it wasn't human mutation, it was the invention of robots who went nasty and tried to take over the human race. This time think Terminator or War Games. The last theme is of science, itself run amok. More precisely, it is of people who are not mature enough for the technology they've developed. Think Star Wars. Think 1984. Those same 3 fears, plus an overly literal interpretation of religious texts causes us to hold ourselves back from some of the most logical and promising developments in medical science such as stem cell research, genetic testing/profiling, and organ harvesting.

In closing, before I get accused of trying to sell everyone's health and well-being to "the man" on the cheap, let me be clear: I'm talking about implementing some basic economics (and common sense) here. I'm talking about re-using strategies that have succeeded in other industries. I am NOT talking about putting a corporation in charge of deciding which treatments are most cost-effective or profitable. Rather, I'm refraining one of my favorite topics: individuals need to be responsible for their own lives and choices. My gripe with the healthcare industry is that it's structure doesn't allow us the information or flexibility to do that.

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