Sunday, December 6, 2015
Rarely Articulated Truths about U.S. Health System
• The Washington political establishment and the medical-industrial complex together make up a huge business enterprise, spending $3 trillion a year, 17.5% of GDP, $9375 for each American man, women, and child, and is projected to grow at rate of 5% to 6% a year for years to come, which is unsustainable and will crowd out other important priorities.
• The political establishment understands that those control and direct the health system yield the nation’s political power and set the political agenda.
• Both parties know that the people of the United States are dissatisfied with the current medical system, and that something has to change, either more concentration of power in Washington, more power for health care markets, or a better combination of both.
• By far the biggest player and payer in the health care system is CMS, the Centers for Medicare and Medicaid, which now covers 125 million to 130 million Americans, and whose expenditures grew 11.7% in 2014 and will grow even more in 2015.
• Unbeknownst to many Americans, CMS in concert with the AMA, establishes the clinical codes and fees, for which Medicare and Medicaid pays doctors, hospitals and other health care providers.
• The health care law is designed to change the way doctors are paid by micromanaging how health providers are reimbursed by switching from paying for fee-for-service medicine (derided at “volume” medicine) to bundled payments for disease management, from diagnosis, to operation, to treatment, to rehabilitation or death ( designated at “value" medicine, based on “coordinated” outcomes across the “continuum of care.”
• “Big Data,” the use of metadata or megadata generated by clinical algorithms, artificial intelligence, apps, electronic health records, as a basis for paying medical providers for “quality” and “performance” is in vogue, and can be traced back to the federal government devoting $30 billion in the stimulus act in 2009 to promoting and financing the use of electronic health records as the foundation for documenting the “meaningful use” of the accumulated data.
• America’s doctors are restless, and sometime resentful, of what member of “the system” – managed care, insurers, and government – have blamed them for – ordering unnecessary tests for personal gain and imposing upon them - nonproductive, clinically useful, and distracting regulations - that are causing doctors to retire early, become locum tenens, work part-time, become hospital employees, not accept Medicare and Medicaid patients, or enter direct pay independent practices devoid and immune from 3rd party interventions.
• The government, with its professed good intentions, wrapped in the swaddling clothes of compassion, rigid regulations, and the language of “we’re all in this together, “ has neglected one fundamental truth of human behavior – medical care is personal. Most people prefer that their personal data be kept confidential, and most people prefer personal choice of doctors, health plans, and providers, rather than narrowed government directed choices.
• The government has neglected this fundamental reality: the health system is comprised primarily of patients and doctors , other health professionals, and hospitals, not of government or managed care overseers. If you set out to change “the system,” you had better include doctors in the reform equation if you are to develop a workable system and to provide access to them without creating doctor shortages due to lack of incentives to remain or become doctors.
• The United States has middling life expectancy and other mediocre health statistical results because of its diverse culture and its desire for personal freedoms and behaviors, not because of its health system. A nation’s medical system accounts for only 15% of a nation’s health. Poverty, lack of family cohesion, poor education, bad health habits, and gaps between prevention, and inadequate access to social support services, including medical care, but othr services as well. Due to a variety of factors, we are the most obese major society on the planet, leading to an epidemic of diabetes, hypertension, and cardiovascular disease both the young and the aging. In the words of Pogo, when it comes to our indifferent national health statistics, “we have met the enemy, and he is us.”