Upside Down: If We Want to Fix Our United States Healthcare System We Have to Change
Updated: Sep 27, 2020
The United States healthcare system is not equipped to deliver affordable, high-value medical care. In fact, our system is completely upside down. It is literally incentivized to keep us unhealthy. The reasons for this are very simple and will be highlighted in this blog post. Taking action against these reasons will prove to be much more challenging though. This is because so many people are making so much money on the current system. As such, many individuals and entities have intentionally added complexity and regulations in order to keep profits locked in for years to come. Fortunately, our healthcare system is becoming so unaffordable and so bad, so rapidly, that new doors are being opened. For those willing to stop accepting medical insurance, stop paying obscene prices for drugs and diagnostics, listen to their patients, and think outside the box, opportunities are on the horizon.
Everything about fixing the United States healthcare system depends on one thing, change. Unfortunately, humans are not good at changing behavior. Humans fear change and the discomfort it can initially bring. However, if we want things to get better than we are all going to need to change. If not for us than for our children!
Lack of Transparency in Pricing
In order for consumers to make informed decisions they must know how much things cost. Healthcare bankrupts more people in the United States than any other industry. The idea that healthcare access is more important than being able to pay for food, education, a gym membership, and have meaningful employment is false. Without price transparency, costs will continue to spiral out of control and people will continue sign up for care they cannot afford. The medical industry loves the lack of transparency in healthcare because they know patients would say no to things a lot of the time if they knew the price. The lack of price transparency in healthcare is criminal! People should literally go to prison for this. Instead United Healthcare’s CEO made 50+ million in 2019. Put that guy in prison and let the guy who got caught selling a bag of marijuana out!
Insurance for Every Part of Medical Care that is Completely Unaffordable
The medical insurance companies in the United States have gotten away with murder. They have continued to make money hand over foot while pushing healthcare providers to their limits and bankrupting their powerless and supposed beneficiaries. Insurance protects us financially from unforeseen costs and expenses. Having medical insurance to cover for catastrophic injuries and unforeseen life changing medical diagnoses makes sense. Paying insurance for routine outpatient care is simply not insurance. Instead its allowing a middle man in who needs to be paid each time we access care while providing no benefit. This insuring every part of healthcare mentality has driven healthcare costs up 100% in the last ten years. On top of driving up costs, insurance and not your healthcare providers now call the shots. Its simple, who-ever controls the money has control. Doctors and other providers have completely lost control of their own industry, and our patients are suffering. While medical insurance costs have gone up 100% in the last 10 years, provider salaries have stayed the same and even gone down. Doctors wake up! This is our show, lets take it back!
Business People that Provide no Additional Value
Healthcare business departments have grown exponentially. They have created jobs for themselves while squeezing nurses, CNAs, doctors, and other healthcare providers to their breaking point. When I talk to my business counterparts, they tell me alarming facts. Things like ½ or 1/4 of the business team does most all the work. Most of your hospital business department employees twiddle their thumbs and try and figure out how to eliminate valuable human resources on the front lines. It is time to kick all these inefficient business people out of healthcare and hire our front line support staff back. Wander Medicine clinic has 4 employees. A doctor, nurse practitioner, registered nurse, and medical assistant. All of the money that patients pay Wander Medicine go straight to the people providing them with care and this is how it should be. In insurance based healthcare, hundreds of hands end up touching the money before it ever reaches the providers that do the work.
Regulations that are out of Date, Add Complexity, and Provide No Value
HIPAA or the Health Insurance Portability and Accountability Act was passed in 1996. News flash, this was almost 25 years ago. HIPAA limited my clinics ability to purchase and utilize modern software, payment systems, and other easy workflows tremendously. This act is out of date and places unnecessary complexity on the healthcare system. The idea that our medical information needs to be more secure than our credit cards is ludicrous. This is just one example of the regulatory burdens which make it so much more difficult for innovative businesses to enter the playing field and disrupt our horrible healthcare system. The biggest cause for error in healthcare is communication breakdowns. Nothing limits communication more than HIPPA. It is a patient killer.
Poor Communication by Design
Our hospitals, clinics, and public health systems communicate horribly. In fact, many healthcare entities try to avoid communication with other healthcare entities to force patients to stay completely within their system. Sadly, many of these unethical behaviors are utilized by 501C3, tax exempt companies. Electronic Medical Record or EMR companies are the worst about this though. Epic, a major EMR company, tries to monopolize healthcare systems by making communications with other EMRs impossible. When the federal government mandated that healthcare go electronic, they should have also mandated that all healthcare electronics be able to communicate using a universal application programming interface (API). This was a huge miss. The reality is that big corporations control the government and both the government and corporations control all of us. Perhaps the most important long term benefit of hospital and EMR intercommunication is improved research capabilities. Free flow of data between systems allows us to study our entire population in one combined data set. Many modern countries like Canada and the United Kingdom have such capabilities. The future of medicine and our society depends on research and research depends on data. From a data standpoint the US is lacking big time. If we do not understand our population we will not be able to offer them high level care. We are prioritizing the profits of EMR companies and hospitals over the health of our population.
Drugs and Diagnostics that are Obscenely High Priced
The United States needs to start paying the same prices for drugs and diagnostics that the rest of the developed world pays. Open up our pharmaceutical market to other countries that utilize similarly rigorous quality control systems. Furthermore, pharmaceutical companies, device and diagnostic companies, and especially academic physicians need to stop pushing diagnostics and therapeutics with obscene costs and limited benefit. Wander Medicine gets medical equipment on ebay that costs 1/10th or less of the price from medical distributors like McKesson. Our clinic also buys generic medications that are dirt cheap and work. Unfortunately, most doctors are so removed from costs due to insurance middle-men, that they are literally unable to recommend cost effective treatments. This needs to stop. Providers need to know how much things cost and stop recommending therapeutics and diagnostics that patients cannot afford.
Upside Down Provider Workforce
In every industry besides healthcare, the smartest people, with the widest knowledge base, hold the most important, and highest paying jobs. For instance, the CEO of a company knows about everything. A company would never consider putting someone in charge who has a narrow focus. But in United States healthcare system this is the norm. The brightest doctors go into specialties and subspecialties. Such specialty fields often make more money, are intellectually easier to handle, enjoy a better quality of life, and offer more prestige than those broadly trained in fields like primary care. What we have are the smartest providers focused narrowly while less intelligent providers try to put together the big picture. This is backwards. It is why so many people are treated like a heart, lung, or kidney, and not holistically. We need the smartest people going into the broadest fields of medicine and again calling the shots. We need primary care to flex its muscles and take on a broader scope of care. The era of referral based primary care needs to end. It is just too expensive and communication breakdowns undermine any of the benefits afforded by specialty expertise a lot of the time anyway. We need real doctors that can take care of most anything and only rely on specialists only in a minority of cases. It is time for primary care to take over and use specialists as the consultants they are meant to be. All of our financial, lifestyle, and prestigious incentives shunt doctors away from primary care and toward specialties. Some major academic centers like Harvard do not even have a family medicine program. Talk about being lost!
Fear and Defensive Medicine
Doctors and other providers practice medicine in fear. All of us work in systems that essentially suck due to the regulatory burdens and poor information availability mentioned above. It burns us out and decreases the quality of care we render. Meanwhile we are always afraid about being sued. This makes us practice defensive medicine. You have probably seen defensive medicine in action. You call your doctor, say you are dizzy and almost fell over, and they tell you to go to the emergency department. You say you have chest pain, and all the sudden you are sitting in a hospital bed overnight. You are recommended a test that shows nothing and costs over 1000$. We live in a medical culture that does not except missing anything. So we end up ordering every test to cover for this. In the process we bankrupt our patients, cause them anxiety, cause harm, and add no value to them. All providers need to start being completely honest with patients, treat them just like they would want their own family treated, and stop worrying about being sued. I ask myself two simple questions every time I care for patients.
1. Would I make such a recommendation to someone in my own family?
2. Would I want myself to be my own doctor?
Upside Down Incentives Regarding Wellness and Disease Prevention
We put no money in preventative health and pay a hero’s ransom to treat disease. In fact we pay money even when care is futile and provides no benefit (sadly this is very common). Before COVID19 hit, every hospital in the United States was trying to build a cardiac catheterization lab, new operating rooms, or other advanced procedure based facilities. These cath labs and surgery suits pay big bucks from medical insurance. However, they represent a reaction to existing medical problems. Ever heard that an ounce of prevention is worth a pound of cure (mg is worth a kg). Meanwhile, I am yet to see a hospital system investing in primary care and prevention. I am also seeing alarming trends in the funding of public health. The United States even recently defunded the World Health Organization. Most of the health of our population comes from public health and has nothing to do with doctors, hospitals, or medical insurance. But yet we continue to decrease public health funding to pay for things like Medicare. If we want health and wellness, our financial incentives must align with this goal.
So this is what I propose:
1. Mandate that all healthcare entities make prices fully transparent
2. Provide medical insurance products that only cover catastrophic care on the individual and group insurance markets. These must be affordable, like 50$ a month or less for young healthy people.
3. Kick most of the business people (suits) out of healthcare. Keep only those individuals who add value.
4. Modernize regulations to reduce regulatory burden.
5. Mandate that EMRs communicate with each other using a universal API.
6. Start paying the same prices for diagnostics and therapeutics that the rest of the developed world pays.
7. Incentivize primary care so that the smartest people enter this field and subsequently practice an extremely broad scope of care.
8. Stop worrying about being sued and start doing what is right for patients.
9. Incentivize preventative medicine and public health by paying for them
I know what some people are thinking right now…..If we just had a universal payer system than everything would be fixed and things would be better. If that universal payer you are considering is the United States federal government then think again. As stated earlier, the federal government is controlled by corporations which in turn control us. Legislators literally do not even write bills anymore, corporations do it for them. Do you really trust our federal government with a monopoly on healthcare? I certainly do not. From what I have seen in my short life, anything the federal government touches becomes obscenely expensive and its quality deteriorates. Just take a look at what has happened to the price of education since federal student loans were invented. No thank you. If I trusted the government I would be all for a universal healthcare system. On paper it makes a lot of sense. But only a fool would hand over such power to Washington DC, having seen their track record, and reckless spending habits.
Change needs to come from the bottom and work its way up. United States healthcare needs disruptors and innovators. We need healthcare providers willing to leave the toxic environment of medical insurance, and start taking care of patients again. It is time for providers in every field to step up and take action. In reality, providers, and particularly those in primary care have all the power. We are the gatekeepers, on which the entire healthcare referral system is built. If all of us in primary care banded together than the federal government, medical insurance, and hospital systems would be forced to listen to us. I started Wander Medicine clinic, a direct primary care in Boise, Idaho to break away from this toxic healthcare system. I am going to build a career on doing what is right for people. Such a goal felt impossible working for a hospital system and using medical insurance. My skills are too good to waste on an oppressive system. If you are a provider, I bet your skills are too! Join me in the rebellion against our corrupt healthcare system.