December 6, 2004
Are We Playing In The Right Ballgame?
M.J.McKeown, MD, FACOG, FACS
There is no health care! There is only sickness care! The costs of sickness care are open ended and grow exponentially as population ages. The only control of the costs of sickness care is some form of rationing. True health care would teach one how to get and stay healthy and have a meaningful reward for doing so. Without the development of a true healthcare system rationing disguised as non-covered procedure, experimental, and insufficient qualifying information will continue and expand.
It is ludicrous to bring a basketball to play a baseball game or a football to play a soccer game. It is suicide to bring a knife to a gunfight.
A definition of healthcare seems obvious. It is the care of the health of a person, a group, a country or the world. It is the delivering of immunization to Africa. It is the treatment of HIV with the latest drug cocktail. It is saving the life of a mutilated victim of inner city violence. It is the re-building of the worn out joints of an arthritic patient.
However, this is not healthcare! This is sickness care! Since the early days of health measures in the Bible through finding contaminated water in a London well to the latest molecular medicine or genetic breakthrough it has all not been healthcare. It is the attack and cure or alleviation of one sickness or another. No practitioner since Imhotep, Aesclepius, Hippocrates,or ibn Sina has mainly practiced healthcare.
The great advances in Public Health and immunization and water purification and sewage treatment are all attacks on disease vectors. Nations have fallen for reasons of poor Public Health and one only need to read a little about the Black Plague to understand the need for and benefits of organized systems of Public Health.
However these population based attacks on disease vectors are still not healthcare. They are sickness care on a grand scale that results in a healthier environment for the populace at large who will hopefully really practice healthcare.
True healthcare is at a person by person level. It is promoted by living in a healthy environment but it does not happen unless the individual person is taught how to get and stay healthy. One can observe a great deal of public information on how to get and stay healthy in books and magazines and on television. However there is no systematic, aggressive system that teaches this knowledge and then rewards the individual for being healthy. It is easy to publish information on the perils of smoking and highlight the dangers. It is easy to publish information on the perils of high fat fast foods and highlight the dangers to ones blood vessels. It is easy to publish information on the epidemic of obesity in the United States and highlight the dangers of high blood pressure and stroke. However none of this information motivates a change in behavior with a tangible reward!Societies have spent billions of dollars enhancing and promoting health. However if one looks closely the dangers of poor self care are not punished. If a person contracts lung cancer they are not told they should not have smoked and then let die. Certainly not since that would be an uncaring reaction. They are given the benefit of advanced diagnostic and therapeutic techniques that cost millions of dollars to develop and most likely many thousands of dollars to treat this individual. Of course it is not the responsibility of the smoker that lung cancer arose it is the fault of the nefarious tobacco companies and they pay a hefty penalty for their perfidy. If the obese person who has spent years dining on fast foods develops coronary artery disease or peripheral artery disease or has a stroke they are not abandoned as just reward for their indiscretion. They are the recipients of incredible feats of vascular surgery, clot busting medications and superb rehabilitation therapy.
None of this is healthcare it is sickness care!However we still do not have healthcare we have sickness care! All of these wonderful treatments and preventive techniques are expensive. If one just examines the logic of the cost of a sickness care system it is obvious that the cost factors are open ended. If one is willing to spend unlimited money on the discovery of ever more miraculous diagnostic and therapeutic systems then there is likely little limit to the goal of fixing most illness or accidental events in the life of an individual. However, at least in the United States, the body politic has discovered there are a limits to the amount society is willing and able to spend on this miraculous sickness care system.
A huge international industry has arisen as wonderful new diagnostic and therapeutic techniques are developed. Immense international companies depend on the economics of people being sick! If one looks at the economics of the development of this sickness care industry two important events fostered its development. A certain level of societal public health has to be obtained before the individual's sickness is worth the economics of treatment. If the water is bad, the group floats in sewage, rats and their ticks infest most domiciles then it is the survival of the society that is important and not so much the health of any one individual. The life expectancy of such a society is too short for many reasons to even bring to the fore the treatment of coronary artery disease or a worry about the long term effects of hypertension of the possibility of dying of cancer from some chemical initiator. Once the society in general is protected from large population diseases then attention can be directed to treatment of individuals and individual diseases states as the primary goal. In the current times of the 21st century investigators are working at the molecular and genetic level. Life creation can be manipulated and perfect individuals produced. Eggs and sperm from selected donors can be used to build a desired embryo. Viral or bacterial vectors can be developed that will carry cell modifying molecular biologic and genetic treatments into the afflicted individual. Fetuses can be operated on in the uterus and death dealing defects repaired. It is only a matter of time until even more amazing treatments are available at the cellular and intracellular level.
The United States was unique in its developments on the pathways of sickness care. The society in general has a can do attitude and there was honor and reward to the individual who developed these new miracles. The United States then had the luxury of the strength of economy to let this sickness care industry grow and expand with blazing speed as new diagnostic technique piled on new diagnostic technique and aggressive therapeutic attacks on the disease conditions discovered by these new diagnostic were developed. Cutting edge development in these diagnostic and therapeutic techniques is costly. However as a result of industrial and political forces arising in WWII and continuing for many years afterward the economic power of the Federal Government and private healthcare insurance insulated the developers and users of these techniques and the recipients of this amazing care from economic reality. A seminal political event occurred in the early 1960s that precipitated the coming economic crisis. It was a political decision that it was the right of every American citizen to have full access to this amazing new healthcare. The unions found that negotiating for added health benefits was of greater benefit to their members than a raise in salary. Soon most of the working populace realized that jobs providing healthcare were of immense importance. The system thus received the economic shock of millions of new paying customers that had not thought of limiting their use of the system and the providers of such care gave no thought to limiting their use of these new techniques because some third party was paying the bill. The recipients of care were happy, the providers of care were happy since they could employ these wonderful new tools in the best interests of their patients without a thought to what it all cost.
Then the acronym TANSTAFL (There Aint No Such Thing As A Free Lunch) came home to roost. Politician's realized the percentage of the Gross National Product this healthcare beast was taking and found that they couldn't fund other projects nearer and dearer to their political survival. Was their solution to examine the basic logic of the system? It was not! They merely applied the only control mechanism that can be used in a sickness care system and that is some form of rationing of care. Now since it was the right of every US citizen to have the very best of this new technology they were unable to just say the whole thing was too expensive and needed re-thinking of the general approach to the problem. Pronouncements were made of how various entities in this intricate sickness care system were benefiting more economically than they should. There was an abortive effort to develop a federally controlled system for the whole country. That did not survive because of the basic individualism of the American character but even more importantly it did not survive because of the power and lobbying efforts of the sickness industrial complex. The business leaders of this sickness industrial complex convinced the political powers and the people of the country that good old American free enterprise and the forces of the market could control this problem. Then the MBAs and the demographic statisticians waded into the problem. Payment to the least able to defend themselves in the system was slashed and this worked for awhile. Then in order to continue the control of costs and to keep a profit for the companies managing this sickness care entity the real teeth of rationing became evident. Sophisticated models of what any given demographic group was likely to cost to take care of arose. The organized medical system weighed in with its own scientific analyses and rules to attempt to limit diagnostic testing and treatment to what was proven to be cost effective and to produce the greatest amount of quality of life years for a given dollar amount. The organized medical approaches are truly much more from a caring about the benefits of a particular diagnostic or therapeutic procedure in the life of their patients. This evidence based delivery of care approach is beneficial primarily because it limits costs of the system without the denials of service, high co-pay, high premium rates, high deductibles or labeling an expensive technique as experimental and denying payment. The MBA worked from a background of costs of goods analysis and developed the infamous per member per month cost of the goods of medical treatment. The organized medical system worked from a real caring that any individual diagnostic technique or therapeutic treatment should have some medically demonstrable benefit. One can easily get lost in what is the most appropriate definition of quality of life years but the intent is to help the individual recipient of care get the best result.
Now circling about this fat school of fish of the healthcare system were the trial lawyers and the concept of malpractice. It is true that many medical therapies or tests have significant risks. It is also true that there are practitioners of medicine that cause egregious outcomes. However we now know there are CEOs of large companies who knowingly cheat thousands out of millions. In the case of medical malpractice a duel has developed between the plaintiff attorney attempting to prove negligence of some part of the healthcare system and the healthcare system attempting to develop methods and standards of care which if followed shield the practitioner behind the small but inevitable risk of any diagnostic or therapeutic technique. There can be a possible cost increasing effect of this battle when the deliverer of healthcare practices defensive medicine and builds a defense of care with a multitude of tests and procedures to prove that all possible had been done.
All of these cost factors and control mechanisms have led to the development of managed care in the United States. The recipients of care under this system are frequently unhappy because they don't get the care they think they deserve. In some instances the shaving of the economic margins of the system comes close to poor care. The providers of care under this system are unhappy because they are frequently told what they can do in the way of diagnostic or therapeutic care and yet with the trial lawyer buzzard ever present in their peripheral vision they have an additional stress factor. The MBA administrator of a large medical group is not going to take night call or get sued for malpractice. Now we have unhappy recipients of care, unhappy providers of care, unhappy politicians since the costs in a sickness care system are always open ended and unhappy MBAs who find that the easy cost of goods control mechanisms are gone and they still have a financial problem which they must defend to the politicians and their stockholders.
This unpleasant stew has been a long time in cooking and is just now coming to a boil. However in a sickness care system with a sickness industrial complex such a state of boil is inevitable. If we look at other nations around the world most have just nationalized the system and the bureaurocrats have done what they do best and generated rules within rules and adjustments within adjustments. In the United States today the Medicare system changes its allowable coding of healthcare diagnostic techniques and procedures every three months! In a nationalized system the recipient of care gets whatever diagnostic or therapeutic technique the system allows. Now if the rule limiting service is generated from the cost of goods MBA there may be little evidence other than cost for such a limitation. If the rule limiting service is from the medical practitioner using evidence based medicine it may have sound medical statistical reasons for limitations. However no matter which mechanism of limitation is applied in an individual case it is still rationing of care since that is all that is possible in sickness care!
Is there a better way to control some of the costs of keeping persons fit and able? The answer is a resounding yes! The development of true healthcare would go a long way towards rationalizing these costs.
The development of a comprehensive system of true healthcare requires education, responsibility and meaningful reward. Some of the general Public Health measures that society has developed over the years qualify as true healthcare but only a few. True healthcare must operate at the individual level and not at the general population level. Many of the immunization procedures that have been developed require individual effort. They require education of the persons involved, they need the personal responsibility of the persons involved and they reward the immunized with protection from the particular disease process and thus give them many more meaningful life years.
However the major illnesses of the world are currently a result of life environment and lifestyles. There will always be genetic based diseases, malignancies, and major accidents. The human body will wear out and the degenerative diseases will likely be with us for a long time. In the best of all future worlds the genetic diseases would be preventable, the malignant diseases would be preventable and the degenerative diseases would be greatly attenuated. It will likely be true in the foreseeable future that environmental and lifestyle forces will be the major determinants of disease processes. If one lives in an area of great industrial pollution they will be affected. If one neglects their nutrition and batters their body with noxious chemical habits then disease will result. Environment and personal lifestyle are amenable to changes if the people involved receive the proper education, are imbued with a sense of personal and societal responsibility and receive a meaningful reward for their efforts.
Incredible amounts of money have been spent on health education at a personal and general society level. Some good has come of this but never the degree of good expected by the proponents of the particular educational effort. This is true in developed and undeveloped countries worldwide. Governments have realized that a healthier population gives a healthier, more productive workforce and is less of a financial drain. Unfortunately in this sickness care approach to the problem the large medical industrial complex has grown and it has powerful lobbies. If educational and preventive measures were able to wipe out something as ubiquitous as the common cold just think of the loss of income for all those companies that produce a plethora of medications, nostrums and devices to help heal those with the common cold. The economic impact would be enormous. If education, responsibility and reward were able to reduce the incidence of cardiovascular disease by only 50% many companies would approach bankruptcy. Thus the economics and economic politics of any trend toward true healthcare will need to be studied in great detail to avoid some unintended consequence. When these effects of true healthcare are studied and the consequences of change in the system are evaluated then it will become apparent how committed the economic and political forces behind the scenes are to a real attempt to improve the health of the populations of the world. If economic and political self-interest triumph then the path to true healthcare will be more arduous and perhaps unattainable except in isolated groups with common economic and political interests.
If the development of true healthcare requires education, responsibility and meaningful reward at the individual level then how is this to be done? The concepts of education are well known in how to teach people to get and stay healthy. In the best of worlds this education would begin at the lowest levels of the educational system and continue through all levels. These would be required courses with required curriculum and rewards for achievement and penalties for lack of achievement. At all levels of the system the rewards and penalties would have to be calculated to be meaningful to the particular society involved. Rewards and penalties that are appropriate for Australian aborigines would likely not be equally appropriate for Parisian French citizens. Development of appropriate and meaningful rewards and penalties will likely be the hardest part of the system. It will require intensive efforts by sociologists, educators and politicians of each society involved to work out these details.
In the United States the most useful reward is an economic one. The most respected penalties are loss of such rewards and loss of the secondary gain of the power and adulation that would go with them if they were sold with care. The worker in the United States that works for a company that provides healthcare benefits costs his/her employer $4000 per year on average. The employer deducts this from their taxes as a cost of doing business. The worker is only rewarded for good health with esoteric concepts of feeling that good health will let him/her be more active in their recreational life and that when they get old they will be more able to enjoy life if they are healthy. Most persons know someone with a chronic disease that limits their activity and most know some older member of the family that is severely limited by one or more disease processes. However when one is young and fit and full of verve and vigor the concept of today's actions limiting future's activities is vague at best. The current education system in the primary and secondary public schools has health courses but the student is not filled with a concept of the need to really learn of these subjects, there is no really meaningful system of reward and penalties attached to motivate a strong inner grasp of the subject matter as it pertains to the individual's own life. One need look no further than the general failure of a health educational system that teaches the terrible effects of drugs or the failure of an educational system to slow the real epidemic of sexually transmitted diseases. To tell the young that they will die younger or be infertile or suffer long term disability just does not seem to get through to the basic motivational levels of personal thought. The anointed guides of society at most levels have negated personal responsibility for the adverse effects of such destructive behavior. They have thus removed one of the basic building blocks of the development of a true healthcare education system at the primary and secondary level. At the primary and secondary educational level the meaningful reward is very hard to define. The United States with it's most meaningful rewards being economic is hard put to come up with an economic reward at these ages. The grounding in the basics of self health care and the rewards of that will only be possible if concepts of personal responsibility and self-reward and the intangible rewards of one's peers can be developed for the age groups of primary and secondary education.
The United States motivation to true healthcare is easier at the level of the employed workforce. In essence it is the use of some kind of modified Medical Savings Account system. If one were to give the $4000 dollar premium to the individual worker, sequester it in an interest bearing account, and then if no health claims were made at the end of any one year let the worker spend 10% in any fashion they chose that would be motivation. In addition the individual worker should be allowed to deduct that $4000 from his/her taxes. If an individual were to begin such a system in his/her twenties and work into their 60s and follow all the guidelines to get and stay healthy there would likely be a reasonable sum of money accumulate. This could then be rolled over into continued costs of Health Care.
There are obvious medical necessities that would need to have another system of healthcare insurance. There would need to be coverage for unexpected catastrophic illness, accidents, pregnancies, genetic diseases, and degenerative diseases of age that occurred despite the very best preventive medicine. However the biggest drain on the healthcare dollar would decrease dramatically if the individual were educated, given personal responsibility and rewarded in a meaningful fashion.
The medical industrial complex would need help to restructure such that it made most of it's income by getting and keeping people healthy. The personnel that are currently employed in delivering the care of the sickness care industry would need retraining and ultimately there would likely be less need of skilled sickness care professionals. Preventive medical exams and checkups and advice would be paid for by the individual from his/her personal funds. Insurance as it is now known would be needed only for major problems and could perhaps be partially funded from some of these personal funds and for the more major and catastrophic illnesses by the country's government. The temptation to have the government fund everything and not give the individual personal responsibility and reward would have to be resisted. The current anointed have demonstrated to any thinking person that total governmental systems with little or no personal responsibility and reward just have continuous increases in costs and must keep costs down by some form of rationing.
Can all of this be achieved? It will definitely not be achieved if we keep playing in the wrong ballgame. If we bring players with no personal education, responsibility or reward to the ballgame then it will always remain a game of sickness care and be manipulated by politicians and pressure groups to achieve a tightly rationed and unequal level of care. The development of a system that requires personal education and responsibility means that the power of the anointed that run the current sickness care system would be eroded and they would not likely give that up easily. The anointed speak of knowledge of what is good for society and how they will guide society to those ends. However if examined closely it is frequently the case that the end goal is the retention of the jobs and the power of the anointed. In a game of real healthcare all of the players are their own anointed and are playing to win for themselves which in the end is a win for society at large. If the sickness care ballgame is continued under the coaching of the current anointed then there will be no true winners. There will only be some that lose less than others.We have brought a knife to a gunfight! It is now evident that as the poor nutritional habits of this affluent Western society impact other societies with an intrinsic healthier nutrition then these societies begin to develop the adverse health outcomes associated with poorer but in vogue nutritional habits. The underdeveloped nation child that is living an intrinsically healthy diet of fish and vegetables is lured by the bag of potato chips with its allure of the bigger nation and its wonderful taste. He/she does not know of the adverse effects of hydrogenated oils or of the high salt content. The potato chip tastes good, it lets him/her dream of the society it came from, it provides many in the supply chain with a profit. However it is similar to a bullet fired into a crowd.
The problems of achieving a true healthcare system are immense but unless one acknowledges they are playing in a sickness care game and decide to play in a real healthcare game then the goal of generally improved society health is somewhat hollow. In this United States we can do studies that show that angioplasty is the best way to achieve long term best outcomes for myocardial infarction. However would it not have been better for the individual concerned and for society in general if the infarction had not occurred in the first place. In the first instance one is playing in the game of sickness care. In the second instance the outcome is from playing in the game of healthcare.
The choice is yours. To borrow a phrase from a recent movie, Choose wisely.