The Amazing Maze of US Health Care

How often have you heard the phrase, “The United States has the best health care system in the world.”?

What is wrong with that statement is the word “system”.

We could rephrase it – The United States can deliver some of the best health care services in the world (to those who can pay for it).

We could even argue  – The United States has some of the best health care systems in the world: the Mayo Clinic, the Veteran’s Administration, the Department of Defense.

But to assert that we have a system or that Americans (all Americans) receive the best care in the world is a stretch.  Why?

Over the last two weeks I wrote about our fragmented health care system and the closely related fragmented payment system.

I wrote about how patients are equally fragmented, migrating during their lives through several health plans, what I call patient delivery systems.

Why does this matter?

In most measures of health system performance the United States ranks embarrassingly near the bottom or at the bottom among industrialized countries.  From 2000 to 2009 male life expectancy fell six slots to 24^th in the world and female life expectancy fell from 28^th to 35^th.  Some would counter that life style, diet, or poverty had more influence on those drops than health care.

Isn’t that fragmented thinking?  If we had a health care “system” then it would take comprehensive approach to population health.

What are the incentives for doctors and hospitals?  Just as sunflowers follow the sun, health care providers, like the rest of us, follow the money.  And the money is paid for doing stuff, surgeries and tests, for example.  It is not paid for talking with or listening to patients, giving them lifestyle or treatment compliance assistance.

What are the incentives for patients?

Patients often lack the freedom to choose just any doctor.  Their incentive is to change doctors to conform with their current health plan rules.

It is not just patients who change health plans.  I have seen Participants change health plans during open enrollment, because a doctor they wanted was in the new health plan.  A couple of months later, they learn that their doctor is leaving that health plan over some real or imagined dispute.

Patients approach the delivery system through different health plans under different sets of rules regarding covered services, payments and bureaucratic processes. It’s not just that different patients are in different health plans.  The same patient migrates though different systems at different times.

Is it any wonder that doctors are confused and frustrated?

When doctors don’t know the rules

When doctors move in and out of health plan networks

When patients move through health plans – sometimes voluntarily, sometimes not.

When payment depends less on your own talents and more on who your patient is

When information systems are focused first on recovering payments not on coordinating care

When providers are rewarded for doing things, but not for advice, or just plain listening

Is it any wonder that care coordination should fall to the bottom of the priority list?  Not because its undesirable, but because its hard.

Is it any wonder that a long term perspective on patient care is totally lacking?

Disease management – an example

One of the burgeoning trends in the world of employer sponsored health plans are wellness programs and disease management programs. Wellness programs are  programs to promote healthy living.  Disease management programs are designed for people with chronic conditions such as asthma, hypertension, coronary artery disease or diabetes to help them better manage their disease.

Like many other ideas that originate in the United States, it has found strong adherents in other countries.  The Germans have incorporated individual and provider incentives for disease management in their recent reform efforts.  Curiously, the German word for disease management is Disease Management (Germans capitalize the initial letter of “their” nouns).

The logic  for such program is compelling.  That these are relatively new concepts may be puzzling.  But what is truly baffling is that they are not part of the package of services that is included with health care.  Our plan had the option of purchasing disease management services from our health plan, from our pharmacy benefit management firm, or from an independent specialty vendor.

Providers offer little resistance to disease management efforts. But why must they deal with a plethora of vendors?  Why aren’t they the organizing force behind disease and chronic condition management?

Geisinger Medical Center in my home state of Pennsylvania is often cited as model for delivering quality integrated health care to its community in north central Pennsylvania.  Ron Paulus, the Chief Technology Officer for Geisinger wrote in Health Affairs about its strategy for sustaining innovation.  In his conclusion he wrote:

Finally, for many organizations, the spread of value-enhancing collaboration and integration is restricted by regulations that preclude effective collaboration among payers in designing incentive systems and that impede collaboration between hospitals and physicians or among physician practices in a given region. Each payer has its own, largely fee-for-service, payment system—failing to align incentives to enhance value in the way that Geisinger has strived to do. New mechanisms that support collaboration and coordination of policies among private insurers and public programs are needed to achieve replication on a broader scale and sustainability over the longer term.

In other words even an integrated delivery system like Geisinger is thwarted in its efforts to enhance the value of health care by fragmented patient and payment delivery systems.

Does anyone think that health care reform will make the system simpler?

This entry was posted on Sunday, October 25th, 2009 at 4:00 pm and is filed under Health Care Reform, Health care quality, Payment Reform, The Amazing Maze. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.