Scott MacStravic, Ph.D.
Almost everyone seems to be convinced that we are in the midst of a “health care crisis”, that the unsystematic health care system is broken and needs fixing. And almost everyone seems to have a good idea as to who is to blame for this mess, though opinions vary widely. Many blame consumers for lifetimes of unhealthy living and their sense of entitlement to expensive fixes when they’re sick. Others blame doctors and hospitals, pharmaceutical firms and lawyers for their greed being placed ahead of consumers’ best interests. Still others criticize payers, from employers to insurers to governments for only reacting to problems, never either preventing or totally fixing them.
Clearly there is plenty of blame to go around. Consumers have reached unprecedented levels of health risks, thanks to their appetites for too much of the wrong kinds of food and drink, as well as their too comfortable physical and mental indolence. But entire industries depend on and promote such unhealthy habits, and employ all the tricks of the marketer’s trade to persuade consumers in unhealthy directions.
Providers can claim that insurers have forced them toward the far more remunerative reactive sickness care, making proactive health management largely unaffordable to either patients or providers. Pharmaceutical firms and medical device manufacturers depend on encouraging as much dependence as possible among patients for the profits their shareholders and Wall Street demand, where prevention rarely pays off big.
But one thing seems clear—if we are to be able to afford to insure or otherwise ensure that everyone has access to the sickness care they need, we have to reduce the amount that they need. The current game of shifting costs and blame to different constituents may make everyone feel better, but holds little promise for actually reducing the incidence and prevalence of diseases, risk conditions and behaviors, while promoting health, all of which will help and are probably needed to make total health care, reactive and proactive, anything close to affordable in both present and future.The answer is likely to lie in getting as many parties who have contributed to this mess to sit on the same side of the table, as in any successful negotiations. “Getting to Yes” [R. Fisher & S. Brown Getting Together: Building Relationships as We Negotiate New York, NY, Houghton Mifflin 1988] We need to recognize that we are all to blame, but more important, that the solution to the problem lies not in assigning blame at all, but identifying and exploiting the most promising avenues for change.
Governments may help by shifting regulatory emphasis and incentives toward commercial avenues of promoting health, perhaps taxing unhealthy products and services, for example tohelp make it as profitable for providers and manufacturers to promote and protect health as it is to threaten and cure it today. CMS’ offers to “gainshare” 80% of expenditure reductions achieved beyond a 2% minimum with the providers responsible may be a good way to get providers and payers on the same side of the table, for example. [“Physician Group Practice Demonstration Bonus Methodology Specifications” Centers for Medicare & Medicaid Services Dec 20, 2004]
By contrast, the many suggestions for making consumers more “responsible” for their own health and care by shifting more of the costs of care to them is sure to have huge “collateral damage”. HSAs are fine for young, healthy consumers, but penalize those already sick. Moreover, if they fail to make proactive health investments affordable for consumers, they will do little to reduce future sickness care needs, while failing to pay enough to make currently essential sickness care affordable to the sick, leaving them and the providers who serve them to hold the bag.
We truly have no idea how much proactive health management, combining the efforts of all health system constituents, might reduce the need for reactive sickness care. Only indiscriminate studies of disease management, for example, have been done, concluding predictably that DM hasn’t been proven, because they lump all DM together, regardless of how promising the disease or how good the managers. And most have reached this conclusion while considering only health care expenditures, with no regard for labor costs savings, which often double or tripe the amount of sickness care cost savings.
Having one set of interests blame another set of interests is both futile and inaccurate. We truly have a health care “system”, at least in the systems dynamics sense that anything done in one part of it affects what happens in other parts. So all parts have to voluntarily get together to solve it, rather than choosing whom to blame. As Pogo so eloquently put it many years ago: “We have met the enemy and it is us!” But we are also the only possible solution.
It is clear that we have a crisis—one we are already in, and can do nothing but get dramatically worse with the aging of the population, and the decline in the number paying into compared to drawing benefits from government insurance. Rather than wasting time on blame, we should be joining in a “war” on disease and injury, with everyone possible enlisted, since virtually everyone will benefit. That way, by making sure everyone does benefit, as well as pay, with equitable balance, we might have a chance to actually achieve the kind of system we both will need and can afford.
Remember Me
