Tips to treat sclerosis of your arteries, ahem, healthcare system (Part II)
And how insurance is like Costco.
In Part I, we time-traveled to witness the construction of our current health system in making make short work of short-term acute illnesses, such environmental attackers like infection. However, as our health problems have shifted towards chronic illness and long-term preventive needs, the same system is not producing equal improvements in health. How did the characteristics of 20th century challenges influence the structural elements of our health system? What is still in place from these first defenses and (in honor of heart health awareness month) what elements might be candidates for catheterization of system-level sclerosis?
1. You bill for what you do, not what you prevent.
My daughter recently came home rapping about the signs of a stroke and informed me it was heart health awareness month. In this spirit, let’s list some possible treatments for heart disease, according to the American Heart Association: quitting smoking, good nutrition, managing stress, ACE inhibitor medications, cholesterol lowering medications, and laser angioplasty.[1],[2] Heart disease is a chronic disease, the leading cause of U.S. deaths in 2023, and typical of the newer long-term challenges described in Part I. [3] What on the list above is an intervention with long-term results vs. a short-term acute fix? Wait- before you answer that- what on that list is billable? Of course, only the pharmaceutical and surgical treatments are billable. Not a coincidence, these treatments are usually implemented in an acute manner—only performed after a heart attack or prescribed when certain health metrics cross a threshold.
The current big healthcare players, such as pharmaceuticals and medical care providers, exist in a structure that disincentives focusing on preventive care, since lifestyle interventions, although cheap, long-term, and effective, can’t be billed for. What’s more, many healthcare markets are highly concentrated, such as insurance, pharmaceuticals, and regional medical systems. While there is debate about benefits of industry consolidation for costs and negotiating power, this also means that large financial interests are heavily entrenched in the current system of billable, acute treatments.
2. Stuck in an upward system loop.
As our health risks transition to chronic disease rather than unexpected acute problems like infection or bodily injury, modern insurance functions more like pre-payments for future medical treatments than truly insuring us against uncertain bad stuff. If an individual pays $8,435 per year in premiums, just to gain access to insurance coverage, we start thinking we should get our “money’s worth”![4] Instead of insurance functioning as a tool to smooth out an unexpected disastrous outcome (like falling ill as a cabbie in 19th century London), health insurance has evolved into a bulk discount purchasing plan. Do you ever over-buy at Costco? It’s cheaper in there! Plus, you need recoup your membership fee, right?
Besides patients, health care providers are also stuck in this upward spiral. The costs of medical school can top $250,000, not to mention at least four years of study on top of a four-year degree.[5] This leaves new medical providers with a load of debt. Since compensation in specialty care compensation can be over two times higher than in primary care, this pushes providers into more expensive areas of medicine, which exacerbates the focus on billable treatments versus prevention.
3. Angioplasty for a healthcare system?
If you take these forces together, with both sides stuck in a structure that disincentivizes prevention and pre-pays for sickness care, it becomes easier to understand how medical services have come to be viewed as a ‘right’ – something that should be provided and paid for by benevolent governments -, yet lifestyle choices are viewed as just that- individual choices peripheral to the “healthcare” system.
How can we change this? Angioplasty uses a catheter and a balloon to widen blocked arteries and improve blood flow to the heart. As our medical needs evolve, what is preventing adaptive changes from flowing through the healthcare system? Some adaptive policies have appeared in the past 10 years, such as “value-based care,” where payments are linked to quality outcomes such as control of chronic conditions, but these initiatives can be complex to implement and slow to spread. Much of healthcare’s sclerotic inability to adapt is linked to high levels of regulation throughout the sector. These regulations arrived sometimes to monitor quality and sometimes to prevent competition for the large financial interests mentioned above. The result, however, is that trying new ideas for new problems is harder.
Covid-19 created encouraging examples of temporary pauses on regulatory sclerosis, for example increasing physician supply and creating at-home preventive testing. If you could design a system to make and keep you healthy, what would it look like? Let me know in the comments and stay tuned for an imaginative Part IV discussion about better healthcare.
As always, keep me updated on what you’re up to or reach out to chat with me about these issues!
Best,
TMD
[1] American Heart Association, “Lifestyle Changes to Prevent a Heart Attack” Oct 16, 2023.
[2] American Heart Association, “Heart Attack Treatment”, Oct 5, 2023.
[3] Centers for Disease Control and Prevention, “Leading Causes of Death, 2023” Jan 17, 2024.
[4] Kaiser Family Foundation, “Section 1: The Cost of Health Insurance” 2023 Employer Health Benefits Survey. Oct 18, 2023.
[5] “The high cost of a medical education” Yale Medicine Magazine, Yale School of Medicine. Spring 2011.