Andy Slavitt noted that we tend to have a major discussion about healthcare once every decade. Trouble is, that when we talk about it, we focus mostly on cost and not enough on quality. I am not sure we even have a good way to think about what good healthcare is. That’s not totally surprising. Healthcare is big business with many different stakeholders. But we will all be patients one day. So I am going to approach the question of quality as a patient. You might call this essay a focus group of one. What do I want from healthcare? Three things: easy access, right treatment, and results.
Cost is a big part of access. Even people who have insurance can be forced to sell their homes to pay medical bills. Unless you have Medicare (and increasingly even then) people live in panic that something will happen and they won’t be able to pay. Plus, some life-saving treatments are simply out of reach for most. If you have to come up with over $3 Million in less than a month, could you do it? That’s how much effective cancer treatment costs today and the price is only going to go up. But cost of care is not the only way we “measure” access in our everyday lives.
Most of the time, we need regular care and just want to see our health provider quickly. We need to be able to get to our appointment, not have to fill out endless forms, not wait for a prescription. That’s why concierge medicine where you retain a doctor to see you on your schedule is becoming so popular with the wealthy. What do people pay for when they fork out thousands more extra for house/office calls? Easy access.
Brookings found that how much care you get and whether it’s the right care, depends on where you get it: “While many patients often do not receive medically necessary care, others receive care that may be unnecessary, or even harmful. Research has documented tremendous variation in hospital inpatient length of stay, visits to specialists, procedures and testing, and costs—not only by different geographic areas in the United States, but also from hospital to hospital in the same town.” Scientific American puts it more baldly, “when a patient goes to his primary-care physician with a very common problem like lower back pain, the physician will deliver the right treatment… about half the time.” I pay a lot of money in premiums alone and at least half the time I get the wrong care. Why?
The American Medical Association estimates that, because our healthcare system is so fragmented, physicians in private practice spend 49.2% of their time doing paperwork and 27% of their time seeing patients. In other words, the doctor is so busy working out the minutiae of your insurance that he doesn’t have time to really see you. I am amazed they get it right half the time.
Here, the picture is mixed. Overall, the US healthcare system does really well in providing acute care for people admitted for life-threatening conditions like heart attack or stroke. Our healthcare system also does pretty well when it comes to treating people with cancer. On the other hand, we do a pretty dreadful job in helping people manage chronic conditions. For example, mortality rate for respiratory diseases is higher in US than in other wealthy countries. And here’s the kicker: Of all the money we spend on healthcare, 19% goes for inpatient care (where we have great results) and 42% for outpatient care (where results are not all that great).
Part of the problem, as I mentioned elsewhere is that our providers are paid a lot but don’t get the right training. Our licensure laws make it difficult for the right mix of caregivers to see most people most of the time. In other wealthy countries, nurses and allied health professionals play a much bigger part in healthcare. This keeps the cost of outpatient care down and improves quality because community health workers (for example) help people figure out the system and get the care they need. This is very different from what doctors and nurses do. These “diagnostic professionals” listen to you describe your symptoms, make a diagnosis, prescribe a medication and send you on your way.
When we are in the hospital and trained professionals work our fragmented system on our behalf, we often get good results. But the minute we have to work the systems ourselves, the sheer fragmentation of our healthcare system defeats us.
That may be something to think about as we begin our once-a-decade conversation about healthcare. We need reform—if only because it’s stressing us out. But as we do so, we should keep in mind what our current system does well, what it does poorly and fix what’s broken.