Thursday, July 23, 2009

Some thoughts about health care from a 23 year veteran in the system

This is a non-writing post.

For 23 years, I have been a practicing physical therapist. I also have a degree in the history and economics of health care. I feel I am fairly qualified to muse about the US health care system and I have been keenly disappointed in the conversation about health care and medical insurance thus far.

If *they* were to ask me, this is what I would say. ("They" being the policy folks in D.C., but they haven't knocked at my door yet.)

Health care delivery may be a business, but health is not something that can be bought, sold, or easily quantified.

Health care reform talk usually centers around cost containment. Here are 5 sacred cows I am prepared to slaughter (metaphorically, of course.)

1. The cost of delivering health care cannot be successfully contained by simply cutting payment to health care providers.
(Cutting the amount you are willing to pay for a good does not make that good less expensive to produce.)

2. The cost of delivering health care cannot be successfuly contained by mandating electronic records or common paperwork around reimbursement.
(Some savings and economies of scale will result from these changes, but not enough to fix health care. We should do them, but we shouldn't expect miracles.)

3. The cost of delivering health care cannot be successfully contained by analyzing outcomes and only reimbursing care that is proven "effective."
(For the most part, those studies have not been done. And if they have been done, they are often sponsored by organizations that have a vested/monetary interest in their treatment coming out on top. In addition, health care is also an art, not only a science, and individuals react differently to different treatments offered at different times. The best we can aim for is to know what NOT to do.)

4. The cost of delivering health care cannot be successfully contained by limiting malpractice suits and awards.
(There is not enough money in the malpractice system to rescue the rest of health care even if lawsuits ended today. One thing we must begin to understand: malpractice is not the same as bad outcome. Suing for bad outcome in the absence of malpractice is a drain on the system.)

5. The cost of delivering health care cannot be successfully contained by providing everyone in the US with access to preventative care.
(Even as I believe health care should be a basic right, just like clean air and clean water, enrolling every human on the planet in a good preventative care program in the absence of anything else, will not keep costs down. It will only add more episodes of care to a straining system.)

Why do I believe these things? Because the cost of delivering health care is, in part, due to our expectations of the medical system, our inability to face our own mortality, our over reliance on technology, and our belief that there is an external fix to every problem.

If we look at the history of medicine, more lives have been saved as a result of lifestyle and public health shifts than medical interventions and technology. Clean water, access to appropriate nutrition, the development of basic immunizations, and sanitation are what raised standards of living and lifespans.

Most of the cost of medical care delivery is in treating end of life and chronic medical conditions. There is no technological fix for death and many, many chronic medical conditions can be managed or prevented with lifestyle changes.

It's not sexy and it's not something we can legislate, but consider how much better our lives would be and how much less we would need to spend on medical care if:

a. nobody smoked
b. everybody exercised or practiced an active lifestyle
c. everybody ate a balanced diet and maintained a healthy body mass index

But that would require every single person in this society to take responsibility for their own health and well being.

How's that for an impossible dream?

1 comment:

  1. Bravo! I was just saying (on FB) that if I send a family member or a friend to our chiropractor, I know that they will get better if they follow his recommendations. Same thing for our physical therapist. If I send someone to a doctor I have to monitor progress very, very closely and intervene. Some doctors are miracle workers, but they are limited by the products they use and counter measures often have to be taken.

    I agree, health is totally a self-responsibility. That's not taught in schools. That attitude is pooh-poohed in some medical establishments. But without the knowledge and the willingness to maintain health, no one will get better.