Fixing America’s Health-care System

We all hear politicos talk about solutions to health-care: “They want ‘socialized’ medicine!” “We will require everyone to have insurance!” “America has the best health-care system in the world!” “If you can afford to pay!” I don’t know about you, but it just irks me. I hear a lot of talking points and ideas that don’t really change anything. It’s time that we take a step back and look at goals and how to achieve them…and then worry about the political talking points.

I suppose I should start with my little disclaimer. I’ve paid 100% of my health insurance premiums since the 90s—when I first started caring enough to actually get health insurance. I’ve only had ONE employer offer health insurance. It was with the same insurance provider as the plan I got myself, but a lesser plan, so I never switched. My brother gets a higher-level plan than I do, but he works at a health-care facility, so he gets access to that level of health-care at lower premiums than I pay. My mother is in a senior version of the plan (with Medicare) that’s all but paid for by my dad’s pension. Lastly, I’ve seen first-hand how useful Medicare and Medicaid can be, the first with my dad’s illness (we’d have had trouble paying for everything had it not been for Medicare), and Medicaid for various other family members when they had to have the help.

The Ideal

I guess we should see what the highest expected goal should be. Too often, if you don’t shoot for the moon, your arrow doesn’t rise far from the ground.

The ideal would be freely accessible health-care to everyone, the result of such exemplary federal money management that it imposed no tax or other financial burden on the populace. All procedures and treatments would not only be free, but would be so available that it was effectively on-demand—appointments wouldn’t even be necessary as you could just drop by any time 24/7/365. The record system would track you to wherever you went so there would be no more filling out of the same forms. The care would be at a high level, and if you needed a hospital bed or in-home care, there wouldn’t be a problem getting it.

The Reality

Three hundred million people (and growing) are a lot to try to keep healthy. Let’s say that each saw a doctor for only one hour every year and that no other expenses came into play. The bill for that alone would be 300 million x 1(hour) x 50(dollars per hour…about $100,000/yr for a doctor working 40-hour weeks) = $15 billion. Clearly, when we start adding in everything else, it’s going to be some serious money.

We currently manage our health-care “system” with private and government organizations who each have their own ideas about how things should run. (I put “system” in quotes because it’s really less a system than it is a condition.) Even within each part, access is restricted to certain doctors, facilities, and treatments.

My family’s experience with the private part of the system is that we get decreasing care for increasing premiums. Every year we get a new list of what our plan provides. Every year we find our plan provides for fewer conditions and fewer treatment options (we’d switch, but the other plans do the same thing). Medical coverage recommended by a doctor will get refused by the non-physician suits upstairs for economic, not medical, reasons. I’m fortunate in that my plan allows me to go see who I want, within reason, without having to be referred. Everyone else in my family has to ask permission from their over-worked Primary Care Physicians.

The irksome thing is that even those aspects of care that are supposed to be handled, aren’t. Because emergency rooms and staffs are largely operating beyond their capacities, patients are strongly encouraged to go to their urgent care clinics if they need non-emergency care. In my family’s case, they closed the urgent care clinic, transferring all of their patients to—you guessed it—the emergency room. Let me tell ya…I’ve spent a lot of hours with family in the emergency room over the past few years. Thank goodness for portable electronic entertainment and books.

One-stop Shopping

A lot of folk, myself included, think that it’s in the best interest of government to have a well-maintained populace. To that end, I think the only sane solution is to have all of health-care placed under one large umbrella. Before some of you scream “socialism”, it doesn’t have to be a government umbrella. It could be a business institution just as easily. Thing is, it’s clear the current patchwork of providers offers no useful path to efficient health-care.

Also, regardless of who runs this, it’s going to cost. Whether it’s called “taxes” or “premiums”, the fact remains that it’s going to require money to run, and that money has to be gotten from the group that uses the system: people. But how much?

I think the elephant in the discussion is more a philosophical one than a procedural one. The ultimate question is whether care should be provided “at cost” or “for profit”? The first is often referred to with “socialized” as an adjective, while the second gets the label of, “greedy”. If it is to be for profit, then how much profit and to what end (i.e. how is the profit to be used)? I’m going to focus on the “at cost” model, as the “for profit” model pretty much just requires raising prices.

Let’s just look at something that’s expensive but useful: the MRI. MRIs are oft-used tools as they can help diagnose soft-tissue injuries and don’t use X-rays. Unfortunately, they are a little slow, so this becomes a significant bottleneck, therefore requiring a significant number of them. MRI scanners and CT scanners had been thought to be ultimately affordable because if they were used to capacity then their amortized costs would be low. Let’s crunch some numbers:

A good-sized MRI is going to run about $3 million. If we assume it takes 1 hour per patient (which would be a slow average), and the machine is run 9 hours a day, that would give 9 patients a day. Let’s assume the clinic closes for one day a week, and that the machine is off-line for four weeks a year for maintenance. That gives 9 x 6 x 48 = 2,592 patients a year. If they all pay the same MRI co-pay as I now do ($750), that comes out to $1.95 million a year. That means the machine has paid for itself in about 1.5 years. After that, it’s just profit. Of course I left off utility costs, materials, personnel, facilities…but you see my point. At just a nine-patient-a-day rate of use (it’s typically more, plus a waiting list), it doesn’t take a lot of time for these machines to more than pay for themselves. So why aren’t the prices going down, and where is the money going to?

Well, that’s neither here nor there. The fact is that there are a lot of known costs for non-pharmacological supplies and equipment that can be budgeted for, needs assessed, and amortizations calculated. Yes, there will need to be allowance made for new technologies, but adding/transitioning to those new tools can be forecast just as easily. After all, all equipment has a usable lifespan and will have to be replaced, so this can be factored in as well.

Facilities

During the last months of my dad’s life, he was admitted to hospice care. Because the unit only had about a dozen beds, time in the hospital unit was carefully managed. During his first visit, to adjust his meds, he was released a couple days earlier than the doctors and social worker had hoped because they needed the bed for someone with more immediately critical needs. The second time he went it, he was the one with the immediately critical need…and he was going to be there for the duration, which turned out to be just a few days. It took almost no time from when his body was released to the funeral home until a new resident was heading in to use the room.

One of the biggest dreads of going to the emergency room is having them find something significant enough to warrant a stay and then the hospital people saying, “We have to find you a bed.” I think this is criminal. Unless there was just a major trauma event going on (say a plane crashed into a high school), hospitals should never have to scramble to find a bed for patients in need. That patients are routinely placed in ER holding patterns in the corridors is something you’d never expect to happen in a first-world country’s medical facility.

I’ve been hearing about the losses of hospital bed space since the early 70s. It’s time we reverse that trend and start giving cities and towns the ability to actually care for their citizenry. Yes, many beds will be unused in a given period of time. I don’t think it’s unreasonable to have hospitals rotate occupancy regions. Some areas can be sealed off for brief periods. If an area hasn’t been used for a few weeks, then start moving patients from the longest-used area to the new area and then close down that first area for a while. While a little bit of a hassle, it should be able to be done through the constant cycle of admissions and releases. Some long-time patients will be exempt once they are placed in a non-rotation area.

But it’s not just hospitals. Clinics for chronic care, e.g. dialysis or physical therapy, need to be set up (especially in rural communities) so that no one has to endure hours of traveling just to get care. I have an aunt that has to travel a couple of hours each way to get to her thrice-weekly dialysis. Considering that the town she lives in has enough patients with need to be able to support a clinic in her town, it’s nonsensical that there isn’t one there to tend to the needs of the town and other much smaller towns surrounding it.

As with equipment, facilities are a fixed-cost item. Some new facilities will from time-to-time need to be built, and of course there is the constant need for maintenance, but these costs don’t drastically change from year-to-year.

Health-care Professionals

The doctors, nurses, aides, and others that are the foundation of health-care need to be given their due. First, for the health and safety of all, none of these workers should be working more than 50 hours a week, and not more than 12 hours in a 24-hour period unless there is a VERY major emergency requiring their participation. To that end (which means an end to overtime), these workers need to be fairly compensated. Period. A nationally comparable salary (approximately mid-to-high middle class at the top end), from which a portion is automatically deducted for loans used for training, based on experience + ability + local cost-of-living should be the norm. Bonuses, of course, for teaching and advancing the art of medicine.

I do think that there needs to be a good mechanism in place to remove bad and low-marginal doctors from being able to practice medicine on the living (human or animal). Self-policing isn’t sufficient. Perhaps a periodic computerized review of patient files to evaluate the effectiveness of a medical worker followed up by a jury of both medical peers and civilians to judge the ambiguous cases. In any event, by asking for excellence, but allowing for mediocrity (after all, half of all doctors graduated in the bottom 50% of their class), the quality of health care should remain high.

The Pharmacopoeia

The cost of drugs is something that, even with insurance, becomes irksome. Thank goodness Medicare covered my dad’s meds else we’d never have been able to afford the rather impressive numbers of pills he was taking (before hospice took over, the co-pays were starting to significantly impact our budget).

The drug companies whine that drugs are expensive because of research costs and whatnot. Perhaps so. Some of the more exotic extracts must not only be expensive to find but also be difficult to produce. Then there is research in finding replacement drugs that could be made with greater efficiency (e.g. flu vaccine). Inventories age and have to be destroyed…basically, there is a lot of cost and a fair amount of inevitable waste.

That said, it does seem that the more useful drugs should be most affordable to the medical community and public. Let’s face it, Viagra® is at best an optional drug and at worst a novelty. On the other hand, blood-pressure, cardiac, and neurological drugs probably have a bit more relevance in practical day-to-day medicine.

Perhaps instead of considering individual drugs, we should instead consider treatment drugs. The cost of drugs to prevent transplanted organ rejection have got to be higher than those necessary for treating toe-nail fungus, if only for sheer quantity. On the other hand, the transplant patient will have a more dire need for the medicine. So…how to pay for this? Per patient? What if you are the one needing it? Feel so “per patient” then? (For an informed answer: a liver transplant, for example, averages about $250,000 +/- $150,000, plus about $900/month for the necessary meds afterwards.)

If there is any black-box portion of health-care, it is with the drugs. When it comes to creating new drugs, then the black becomes pitch. By definition, innovation doesn’t run on a budget or a deadline. Innovation happens when it happens. It can be very expensive. The expense doesn’t necessary belie the need, however. If there is one floating budget box to the health-care equation, it is this one.

To somewhat lessen costs, I propose that drug patents be changed. The patent needs to be for the obviously useful chemical structure of a drug. The process to make the drug cannot be patented unless new equipment uniquely necessary for the manufacture of the drug needs to be used. Also, minor dubious changes to the structure of the drug’s chemistry (like adding a superfluous hydrogen atom) are not considered significant enough to warrant a new patent. The current culture of milking every last dime out of a pharmacological chemical…even when after it’s due to pass into the “generic” world has to stop.

Fixing the Broken Parts

As we’ve seen, there isn’t too much fundamentally wrong with the health-care system basics, save for bed space. So where does everything break down? Two areas: insurance costs due to legal issues, and administration—neither of which has any direct place in doctor/patient care and yet are perhaps currently the most obvious.

Our administrative bureaucracy is out of control. Recent estimates place total health-care spending at $2.1 trillion (yes, with a “T”) with some 31%, or $650 billion, going for administration. This means that for 300 million people in the United States, each person pays an average of $7026 in health-care costs—of which some $2178 goes to the bureaucracy, not actual doctoring. Honestly, with what I’m paying, I’m not happy about nearly a third of my dollars going to service some overpriced desk-bound paper-pushers.

So…let’s solve a lot of the administrative inefficiencies. First, we standardize on filing codes nationwide. EVERYONE has to use them. Now, even various branches of the same institutions are often implementing their own special dialects that makes sharing information a nightmare. Whatever system is developed must be workable both electronically and physically (in the event of power-and-network robbing disasters). Second, the government must mandate (and fund, at least in part) a national high-speed medical Internet that serves all medical facilities from urban megaplexes to the two-room rural clinic. Every person using a medical facility would be tracked via a variety of methods which would include biometrics (fingerprints, retina scans, and possibly DNA markers). A person’s medical history will be available from any of several crazy-secure data centers (backup via redundancy, don’t you know).

That done, much of the wasteful data manglement will be eliminated. The next step is to have the bean counters limited to counting the beans and not making medical decisions. With the advent of “managed care” too often medical decisions have been taken from medical professionals and given to the money managers who only care about bottom lines and not health-care.

Next: there needs to be a limited blanket protection for health-care workers. Malpractice rates are insane, and some medical judgments by juries go into the realm of “Ohmygod, are you serious?!?” Some specialties carry with them higher risks, and some greater emotional loss (I’m thinking OB/GYN, especially). The fact is that medicine is as much art as science, and even the best possible care strategy in a given circumstance will be difficult to distinguish from a total cluster-fuck. It is what it is.

The trouble is that random civilian juries are ill-equipped to judge medical practice. Even so, a jury of medical professionals will tend to start protecting their own. It might be necessary to create a specialty of medical jurisprudence. You set up a “jury” of, essentially, para-medicals who have been given a few semesters worth of training into medicine and accepted practices, but who are otherwise not permitted to be employed in the medical field. They can then effectively evaluate if there is legitimate malpractice versus innocent error versus no error. Hopefully, having already started drumming out the incompetents, these sorts of lawsuits can be lessened to a reasonable degree.

Figuring It Out

Ok. As I said, we’re spending $2.1 trillion a year in health-care, and rising. What does $2.1 trillion mean? That mean that if we had one doctor (a General Practitioner) for every 1,000 people, then that doctor would get an average of $7 million a year. If the doctor paid out-of-pocket, do you think they’d be willing to bet they could treat those 1,000 people, keep them in good health, and still make a good living? After all, on average, people don’t get all that sick. Shoot, I haven’t had a useful doctor visit since I broke my arm when I was a kid. Those savings hypothetically add up to $250,000+ to be used for others.

Of course the trick to all of this is the fancy stuff: the organ transplants, the chronic illnesses and conditions, cancers, and end-of-life care. All of these tend to gobble up funds quicker than you can say “gobbling up funds”.

Making Choices

So, it sort of comes down to the question of how much health-care should a nation be expected to pay for? Everything? Perhaps we can, but I don’t think it’s necessary. First, we distinguish between healthcare and vanity. Medical care would not be covered by the system and would include things like non-reconstructive plastic surgery (e.g. cosmetic breast/pectoral/gluteal/etc implants), ED drugs, and other such non-health related items (unless there is a complication that makes it a health-care issue).

I think that some of the shortcoming of the systems of other nations can be overcome by simply equipping ourselves to handle the population. With enough equipment to service the needs of the population, and enough personnel, there is no need for the apocryphal delays of weeks and months for biopsies and MRIs cited for other countries.

Basically, if we choose to make the system so that medical care is provided at cost plus overhead to cover research and new technologies, we can spend a whole lot of money to do a whole lot of good for just about everyone at little or no direct cost (i.e. not much more than what we are paying now).

The only correct solution is to single-source our health-care as an entity designed to be adaptable, to not stagnate, and to not be more concerned with money than its mandate to provide quick health-care to all who can afford it. Some will choose to call this “socialized medicine”. It isn’t. Some will insist that it is, and to that the only response can be: big fuckin’ deal. It’s needs to be a monopoly (like that word better?). Get over the idea that thousands of independent entities will magically come up with a solution in their own enlightened self-interest. I think we’ve amply demonstrated that the corruptibility of man thwarts that sort of Pollyanna approach.

That isn’t to say that there won’t be areas for money to be made. New technologies still need to be developed: not just drugs, but monitoring equipment, transportation, power supplies, portable/rural health care technology…the list is limited only by imagination. The thing is, primary, in-your-face health-care should not be a for-profit entity. The goal should not be dividends to stock-holders, but the quality of life of the population.

You will notice that I didn’t make a comparison to any other specific country. We need to make our own way with this. Even so, just because we didn’t think up an idea doesn’t make it a bad one. We need to take what works. Also, we need to stop using fear as a substitute for greed in regards to issues that really matter. Health-care is most decidedly one.

It’s time to talk seriously about serious solutions. The proposals for mandatory health insurance are less about a serious solution than about political expediency. The fact is that employees don’t want to pay for their own health-care (I know I don’t enjoy it), and employers really don’t want to have to pay for it, either. That pretty much just leaves the feds. I truly believe that clamping down on the non-medical stuff and fixing the data collection and exchange problem will fix just about all the major problems we have save for medical staffing. After that, it’s really a simple matter to put all of the oversight under one umbrella.

This is not a political issue. Honestly, if I thought the marketplace could do it via enlightened competition, I’d be overjoyed to embrace it. But it won’t. At a minimum it will require a lot of added government oversight which will result in more paperwork, more expense, and no simplification. That is the wrong solution. The time has come to take a step back, look at the expectations and how we can use what is already in place to get us to our goals, and then get all “mavericky” and get the job done right. It might hurt for an instant, just a little pinch, but we’ll be happy we did it years down the road.

I don’t pretend that this brief outline is the best solution. There are a lot of details left unexplored. But if you don’t start looking at the large picture first, the details aren’t going to matter. We’ve been drowning in this ocean of details for decades and it’s time we come up for air. Nothing big is ever accomplished by sweating the small stuff before you know what your big-stuff needs are first.

Here’s a suggestion: let’s have everyone in Congress be forced to pay for their own health-care as a percentage of their income equal to what most other Americans pay with theirs (congresspeople being mostly rich and all, it wouldn’t register otherwise) . Have them buy the same plan that their constituents do, too. Do that, and I expect there would less talk about how effective the current system is. No more Mayo clinic, lots more emergency room waiting. (Or, maybe I should just get myself elected to Congress so I can get all of those nifty perks.)

We are in difficult financial times. Health-care is, at the family level, one of the most terrifying aspects of modern life. There isn’t a quick and easy solution to fix everything, but the time has come for us to stop patching and begin a major renovation. It will be messy for a while, but in the end what a wonder it could be.