The Problem

Why is American health care so expensive?

1) The majority of Americans do not take enough responsibility for their own health, nor are they incentivized to do so. By subscribing to behaviors known to be pleasurable but harmful [excessive caloric intake, sedentary lifestyles, and substance abuse are common examples), they develop chronic conditions such as obesity, diabetes, and premature vascular disease. These people then turn to the health care system to manage these problems with costly interventions [bypass surgery, kidney dialysis, joint replacements, and chronic pain management programs].

2) People are living longer and reaching an age where they develop a myriad of medical and surgical conditions for which they will seek treatment. They don't just sit at home and pass away quietly in their sleep. They access the care system repeatedly over decades for to fix their sexual function, skin cancer, arthritic hip, failing bone marrow, and heart failure. (More people) X (more years of life per person) X (more dollars spent per person) = growing costs with no end in sight.

3) Our health care culture is plagued with non-evidence based medical practices that rely on expensive unproven interventions that have not been demonstrated to improve outcomes. Yet, numerous health care providers and patients subscribe to such practices because "newer and more expensive must be better." Pharmaceutical companies that practice direct to consumer advertising to promote products they cannot convince physicians to prescribe exacerbate the problem. The result: total body CT scans and expensive "me too" drugs.

4) The practice of medicine has become much more complex, complicated, and costly. Yet, most health care providers who direct health care dollars through their decisions do not have the tools that allow them to leverage data and technology to improve outcomes and control cost. How can a doctor prescribe an equally effective and less expensive therapy if he/she is blind to the evidence and cost behind the various options?

5) The increased demand for services, emphasis on metrics for purposes of regulation and outcomes analysis, and rising costs across the board eliminate room for inefficiency and financial profit. Yet, human and systems inefficiencies and greed are constants. Thus, total health care costs continue to rise.

6) We have a problem with setting limits and saying no. The day of allowing people to do whatever they want and then access the health care system for any and all services regardless of cost is over. It's admirable but unsustainable. It's time to start linking behavior to cost and benefits. For many people, that's the only sustainable path to fundamental lifestyle changes. If you smoke cigarettes, your premiums are higher and you are at the end of the line for kidney dialysis. Draconian in a world of abundance; essential in the world we live in today.

Don't believe we have reached a health care crisis? Read on.

1) Nearly 50 million Americans, or 20% of the population under 50 years of age are not covered by health insurance. Double digit premium increases have become the norm and this is unsustainable for purchasers.

2) Over $2 trillion, or 20% of our gross domestic product, is spent on health care. Yet, we do not compare well with many other nations in health care outcomes.

3) Young physicians are shunning careers in primary care and opting for more lucrative and sustainable careers in the specialties. A health system without an adequate supply of bright, motivated, satisfied primary care physicians is doomed to failure. A primary care physician has the most intimate knowledge of the patient's total being and acts simultaneously as coach and quarterback to maximize the health care team's service to that patient.

4) In some cases, labor unions stress the system by negotiating extraordinary pay and benefits and protecting workers and practices that are not in the best interest of patients. The auto industry has demonstrated that such practices are unsustainable.

5) The menu of patient care options is growing in breath and cost: tailored interventions based on one's genetics; lighter, stronger, more durable replacement parts for your body; stem cell products for tissue regeneration. These all come with a hefty price tag. In this new world, is newer and more necessarily better and who will be the arbiter of who gets what?

Suggested Solutions

John F. Kennedy once said when lobbying Congress to pass a bill: "I'm backing this not because it will solve the problem, but because it will help solve the problem." These suggestions are made in that spirit.

Re-establish the relationship between self care, good health, and reduced financial risk. Financially incentivize patients to:
1) adopt healthy lifestyle practices that will reduce their risk for disease
2) follow evidence based treatment algorithms once they have been identified as having a disease
3) interact with the health care system through cost effective remote technologies such as broadband computer access from home, email, and text messaging.
Comments: Premiums and co-pays should be linked to behavior and compliance. Asynchronous technology based interaction between patients and providers can be more efficient for non-urgent issues.

Mandate the adoption of web based electronic medical records
Improve legibility, reduce mistakes, maximize data mining, optimize metrics for the purposes of quality tracking and improvement and regulatory compliance.
Comments: the days of paper charts and chart rooms are over for innumerable reasons. Good riddance.

Expand the role of telemedicine, especially for the purposes of bringing specialty consultation into the primary care interaction when needed and remote locations where specialists are scarce.
Comments: not only is this patient friendly (reducing the time and distance barriers to specialty access) but it will also help to redistribute the physician workforce by reducing the need for specialists and empowering primary care physicians in all settings to provide expert care at the point of service.

Implement evidence based best practice algorithms, especially in the areas of preventive care, screening, and chronic conditions management. Maximize the automation of care in those cases where algorithms are widely accepted in order create capacity and access to providers for clinic visits.
Comments: the way to attract physicians to careers in primary care is to offer them competitive compensation and to liberate them from the rote implementation of algorithm based care that can be carried out in an automated fashion or by an assistant under protocol (e.g. adjusting a lipid lowering medication dose based on an LDL cholesterol lab result). This will free up primary care physicians to focus on effective communication, evaluating chief complaints, and panel management.

Marry data bases to practice algorithms to create a web based medical home for patients which clearly displays and communicates the essentials of their medical care including: compliance with recommended protocols, preventive care and screening, chronic medical conditions, surgical history, social history, medications, allergies, and advanced directives.
Comments: nothing screams accessibility, benevolence, and respect like a low cost portable medical record that leverages data bases and treatment algorithms to demonstrate familiarity and enhance quality.

Maximize the integration of health plans, hospitals, provider groups, and ancillary services in order enhance collaboration between different arms of the medical care team, streamline paperwork for patients, and facilitate the free flow of patient information required to make decisions at the point of care.
Comments: there is not enough margin in health care for anything less than collaboration.

Provide incentives for careers in primary care. Educate premedical and medical students about the rewards and advantages of primary care careers under the new paradigm (better pay, reasonable hours, and the opportunity to develop long term relationships with patients and their families). Provide scholarships and loan repayment programs to those who choose primary care careers, especially in under served areas. Develop public policy that requires federally funded medical schools and residency programs to produce the type of physicians that our society needs. Comments: no models of care work when only 5% of medical students choose careers in family practice and general internal medicine. Everyone should be scared if this trend is allowed to continue.