With help from independent health care analyst Skip Snow, I did my best to reveal the perverse logic of American health care.
It all comes down to one thing: when the people who use a service aren’t the ones who pay for it, the whole system functions chaotically. Here are #5BullshitThings:
Nothing has a fixed price tag.
How are we supposed to make smart health care choices when you can’t tell what things actually cost? This leads to absurdities like this $153,000 bill for a snakebite treatment. Go ahead, ask that hospital what it’s going to cost you to get that dailysis treatment or hip replacement. Just don’t expect a straight answer.
What’s really going on. You’re under a misconception. You think that you, the patient, are the customer for health care. You’re not. Your insurance company is the customer, because they’re the ones paying most of the bill.
Your insurance company has negotiated rates with suppliers like hospitals and doctor’s offices. Those rates are a lot less than the “rack rates,” which very few people ever end up paying. Since the negotiated rates aren’t public, you don’t see them. If you did, you’d see that the rate varies according to the agreement, which is why there is no fixed cost.
You need to fill out the same paperwork in every doctor’s office.
You go to a doctor. You go to a specialist. You go to a hospital. Everybody gives you a form on a clipboard. Every form asks for your medical history. This is bullshit. Why can’t you just fill this out once and make it available to everybody?
What’s really going on. There are two kinds of medical information. There is self-reported information, which are you are free to share with anyone, but which providers don’t necessarily trust. And there is your health record (things like test results and doctors’ notes), which is protected by HIPAA. HIPAA allows health care providers to share information when needed, but there’s no easy way to do it.
There are plenty of people trying to fix this, like Medicare’s “Blue Button” initiative, the electronic health records company EPIC, and initiatives from Microsoft and Google. But so far they’ve failed to make sharing and privacy easy. So we have to fill out the same paperwork over and over again.
The Affordable Care Act (Obamacare) isn’t actually about insurance.
The backers of Obamacare would like you to focus on the number of people who are insured now. The ranks of the uninsured have decreased from 15% of the population to 11%. But that’s just the opening salvo in the transformation that Obamacare is trying to create.
What’s really going on. Right now, your insurance pays for things medical providers do, like tests, exams, and procedures. But what we as patients really want is to be well. The Deloitte Center for Health Solutions says we’re at the beginning of a transformation where insurers will pay for value provided, not just for tasks. According to Skip Snow, “The ACA moves the system to deliver care based on value. Providers will get paid when they do good job managing a person and a population’s health state.” That would be a complete transformation in the payment models for health care.
As you might expect, those measures of value are controversial. For example, Dr. Wayne Altman** is part of a group called Care That Matters, studying quality measures designed to incent physicians to provide better care, not just save costs. Don’t expect this fight to settle down any time soon.
Our healthcare system is the most expensive, but not the best.
The Commonwealth Fund ranked America’s healthcare system last of 11 developed nations, even though, at $8,500 per person per year, it is by far the most expensive.
Why it happens. As shown on this map, most western countries provide health insurance for all citizens. This is the “single-payer” system. The system is overall more efficient. On the other hand, it means that, at least in theory, everyone gets the same basic level of care; it’s hard to turn being rich into better treatment.
Skip Snow points out that although the US system based on insurance companies is more expensive, it has a benefit: it makes it easier for medical entrepreneurs and pharmaceutical companies to create breakthrough treatments and profit from the results. Much of the medical innovation happens right here in the U.S. And if it succeeds, we end up paying quite a bit for it. That’s capitalism in health care.
You can’t get help by email.
Or apps. Or videoconference. It’s 2015 — we’ve got any number of ways to communicate. I can get a notification when my flight is late and an email when my car repair is done. Why can’t I ask my doctor a question that way?
Why it happens: Nobody can figure out how to reimburse doctors appropriately for electronic communication. There’s the liability issue, as well: who’s responsible if you read the doctor’s email and interpret it incorrectly? We’re all suffering because the incentives in the system don’t allow for technology. Yet.
** Disclosure: Dr. Wayne Altman is my partner in the non-profit WellnessCampaign.org.
“Universal health care” map by NuclearVacuum, Obi-wan Kenobi, Apatens – This file was derived from: BlankMap-World6.svg. Licensed under CC BY-SA 3.0 via Wikimedia Commons