The healthcare system in the United States is begging for solutions. Rampant cost increases, a bureaucracy and insurance system that, despite intentions, focuses resources and decisions in directions that maintain the status quo at best and are actually deterimental to health in many cases, have put our healthcare system in an unsustainable position. The addition of an explosion in lifestyle related and otherwise preventable disease that accounts for nearly 70% of our nation’s $2.7 Trillion healthcare spending further illustrates the need for substantive change in the way people look at making decisions regarding their health and healthcare.
For acute illnesses or traumas, there is no better place to be than in the United States. Investment in and availability of the latest technology and knowledge for treating acute conditions is second to none.
Unfortunately, if one is seeking the resources, access and knowledge to effect a preventative, wellness focused strategy in a way that pays dividends on both financial investment and quality of life, the current system simply isn’t set up to accommodate such a person.
Who’s to Blame?
The truth about who is to blame provides both dismay and, ultimately, hope. There is both no one to blame and everyone to blame. With the exception of a few, although influencial, entities motivated by maintaining a lucrative advantage in a broken system, most of the problems can be traced primarily to consequences of the system, whether intended or all-too often, unintended.
Health care providers, insurers, and consumers, whether individual or group, are all making decisions based upon the current system.
In order to describe the current situation there needs to be a starting point which in this case will be the health care providers. In reality it is apparent that this is a circular system with a complexity that is extremely resistant to change. Consideration of these complexities and their consequences suggest the need for a paradigm shift.
Health Care Providers
A patient calls her primary care doctor to schedule an appointment. It takes two weeks to get an appointment because the doctor’s schedule is full and the patient is advised to go to the ER if she has an urgent concern. In a free market world of supply and demand a shortage of doctor appointments should cause the price to rise so that two things happen: 1) Some people decide that they’re not in fact sick enough to warrant an appointment and more importantly; 2) More doctors (supply) choose to become primary care physicians because the rewards now make it more worthwhile to do so.
In the present system, this is not what happens. In reality, primary care physicians made about 25% less in 2006, before any adjustment for inflation, than they did in 1996. Yet all the expense of becoming and remaining a physician have risen by an amount that usually exceeds that of inflation. The net result is that the financial reward for being a primary care physician is declining in most cases. We’ve all heard and experienced being treated “like a number”. Thirty minutes in the waiting room, $30 co-pay, 15 minutes in the exam room, 4 and half minutes with the doctor and you leave with a prescription for one or more pharmaceuticals that treat the symptoms you’ve described. Rarely is anything done to address the underlying cause of a symptom… and over 70% of illnesses have been shown to have preventable, and often, reversible causation.
Most physicians make their career path decisions with at least some expectation of being able to truly help and hopefully cure many of their patients. It is not their intentions that relegate them to the average 4.5 minutes spent per patient where symptoms are treated “by the numbers”. The primary causes are based within the regulatory and financial system in which most primary care practitioners find themselves. With increasing costs and falling reimbursement rates, a practice has a minimum number of office visits that it must bill for every day in order to survive as a business entity. Medicare regulations and negotiated insurance contracts make charging more for a more in-depth visit difficult at best. If an office accepts insurance and spends too much time with each patient then that business will ultimately fail.
Additional pressure arrives in the form of liability. Rising malpractice premiums and the devastating results of malpractice lawsuits force the physician to “follow the numbers” in order to have some semblence of protection. Health care providers often feel compelled to practice “Defensive Medicine”. The overweight patient with borderline high blood pressure, blood sugar and cholesterol’s best chance at a cure is a lifestyle change that includes modified diet and activity. The best treatment plan may include explanations of this along with a plan to evaluate again in a few weeks in hopes of avoiding the prescription of pharmaceuticals. This best treatment plan cannot be explained, let alone developed, within the typical 4.5 minutes available. Often the physician feels sending the patient away with a prescription for a blood thinner and a statin along with an admonition to “eat healthier and get more exercise” is a safer course to take than risking the legal ramifications of not “following the numbers” should something go wrong.
Most insurers are for-profit business entities and like any such entity a requirement for continued existence is the ability to take in more revenue then they spend on expenses. A majority of these companies are also publicly traded corporations with a legal obligation to make their best efforts to maximize shareholder return, including growth. Claiming that the problem with insurance is that these often extremely profitable companies are greedy misses the mark. Maximizing profit in an ethical and fair business sense is not only their jobs but their legal obligation. A private or non-profit company can return as much of their profit as they want to anyone they wish. A public company has to either return its profit to its shareholders or invest it in a way that can be reasonably expected to benefit the shareholders at a later date.
Common sense would indicate that insurers might realize higher profits if they were to strongly promote and reward healthy lifestyle practices, thereby lowering the incidence of chronic, preventable disease. The reality is that under the current system most insurance is purchased by employers and since employees trend to changing jobs (and insurance plans) approximately every 2 years, there is little incentive for an insurer to invest in the long term health of its clients.
As healthcare costs, especially those associated with acute care, continue to rise, premium prices necessary to provide coverage of those risks along with acceptable profit also rise. Additional costs can be attributed to a movement from simply distributing risk of unexpected costs to the current situation of distributing costs where many planned procedures and events are expected to be covered in addition to the unexpected occurances.
As consumers people tend to make decisions based on comparing cost versus perceived value. The complexity of the current healthcare system, combined with market forces that naturally align with the concentration of potential revenue, results in a skewed decision basis.
Insurance is most effective when applied to shield the relative few from the full costs of the unexpected or unlikely misfortune or accident. Insurance is most effective when covering things like broken bones, cancer or non-elective surgery. As unsettling as these needs are, they remain fortunately, relatively infrequent with respect to the overall population – many more people will never need surgery or a cast in a given time period than those who will – so it is relatively inexpensive to insure the group against these unlikely events.
The effectiveness of insurance begins to break down when it is used to cover treatments for chronic conditions. Especially when more and more people are added to the list of those needing care for chronic conditions like diabetes, heart disease and other diet/lifestyle related diseases. If 1 in 10 people can expect to require care for a chronic condition, then each person in the insurance pool can expect to pay a little more than 10% of the potential cost for that care. As that number rises, especially with largely preventable diseases, the amount an individual can expect to pay as insurance rises as well. At some point a number is reached where individuals engaged in a preventative lifestyles no longer perceive the same value of insurance against chronic disease. As risk and prices rise, people willing to invest in healthier lifestyles will tend to drop out of the insurance pool. As healthier people drop out of the insurance pool, the cost of insurance rises even more to keep pace with the increased percentage of those who will experience chronic disease.
Where insurance really starts to make no sense is when it is used to cover most planned expenses like annual primary care check-ups or visits for minor injuries or illnesses. Auto insurance isn’t expected to provide for windshield wipers or tires or fuel but health insurance is expected to pay for check-ups and any minor office visit. Minimal efforts at prevention mean that insurers may somewhat subsidize regular office visits to keep out-of-pocket costs down, but since there is little return for the profit motivated insurer the burden is split between reduced compensation for the provider and increased co-pays for the consumer.
Because insurance is often bundled and included in a workplace compensation plan, consumers rarely have the opportunity to consider the overall cost of their insured healthcare. If they did, they might be surprised and seek alternatives since co-pays and deductibles are added to the average $8,000 – $12,000 or more spent per person on yearly premiums.
Are We Getting the Whole Message?
Since pharmaceuticals and expensive procedures are very profitable, a great deal of money is spent communicating the benefits of these healthcare products. With literally billions being spent convincing healthcare professionals and consumers of the effectiveness of pharmceuticals and virtually nothing being spent convincing either of options that have no obvious profit center, it is natural that the acknowledged standard is somewhat lopsided.
Overwhelming communication of pharmceuticals effectiveness is reinforced by their ability to actually dramatically improve the measured areas of the disease symptoms. Blood pressure improves, cholesteral numbers are better and blood sugar stabilizes, but rarely has anything been done to address the underlying cause of the disease yet the consumer, or now, patient, goes away secure in the belief that the best course of action has been taken.
In most cases only the symptoms have been addressed and often the consumer, armed with the not-quite-accurate knowledge that the problem has been dealt with, is even less likely to pursue the lifestyle or behavioral changes necessary to prevent or reverse the underlying disease cause. This can result in a worsening of the disease state and the resultant worsening of symptoms requiring more and more pharmaceutical and procedural intervention…but still no curative measures.
The best means of limiting this cycle is better knowledge of the realities and cost/value relationships of lifestyle and diseases. The consumer must find other sources of information, knowledge and motivation in order to balance that produced by the obvious profit centers communication efforts.
One of the most effective sources would be the patient’s primary care physician…but conveying that kind of information in 4.5 minutes is extremely difficult.
So we’re back to where we began.
But Elite Integrative has the solution.