July 16, 2012

Switching To A True Health Care Model

By  Michael D. Shaw

Last week’s piece—Obamacare and the Supremes—generated a fair amount of buzz. While many agreed with my take on the matter, there were also criticisms of the fire insurance analogy, along with objections to my characterizations of the Supreme Court. Some e-mailers did not want to believe that given adequate insurance, the current system still doesn’t work.

But no one, absolutely no one, disagreed with my contention that a system dominated by a disease care—rather than a true health care—paradigm cannot possibly survive. Many wanted to know more about what true health care might include, and how the acute disease care model came to dominate the proceedings.

Once you recognize that virtually all human actions are inspired by the need to relieve distress or discomfort (euphemistically called “problem solving”), the ironclad and historical dominance of acute care in medicine is easy to understand. Yet, even in the 5th century BC, Hippocrates, in his Epidemics and other works, showed a strong interest in the cause, and by inference, the prevention of disease.

Unfortunately, preventive medicine would lie dormant until the Renaissance. Quarantine measures were invoked in the 15th century against the plague, and primitive epidemiology was introduced in the mid-17th century. As such, informal study of milkmaids’ immunity to smallpox led to the organized practice of vaccination by English physician Edward Jenner in 1796.

Enhanced sanitation—surely the best preventive measure of all time—would promote the control of many diseases, with the notable exception of polio (poliomyelitis). Being an enterovirus, poliovirus replicates in cells of the human gastrointestinal tract and is excreted in the feces. Inadequate sanitation assured that nearly all individuals would develop a natural immunity.

By the same token, as sanitation improved, and herd immunity was lost, polio became a frightening summer threat. At its peak incidence in the United States in 1952, approximately 21,000 cases of paralytic polio (a rate of 13.6 cases per 100,000 population) were recorded. For most Americans alive today, the Salk (1955) and Sabin (1962) vaccines represent the crowning achievement of preventive medicine.

Our love affair with preventive medicine would die in 1965 with the advent of Medicare, and its later embrace of Diagnostic-Related Groups (DRGs) and Current Procedural Terminology (CPTs) for billing purposes. Note that from the outset, Medicare greatly influenced how all medicine would be practiced in the US, especially when private insurance companies began to follow most of its policies. Overwhelmingly, the most money was to be made in procedural, rather than cognitive medicine (which includes preventive). Indeed, much of what is spent on “preventive” covers procedures such as colonoscopies and mammograms.

Money is the most objective rating system in the world since it establishes a value for everything, and health care is no exception. Procedural medicine and acute care are more highly valued, and thus dominate the system. Of course, it costs much more to treat a heart attack than to prevent it, but that’s the idea! There are only two problems with this model: Many people suffer a lifetime of poor health and we can’t afford it.

If we are willing to spend hundreds of thousands of dollars per patient on acute care, why not pay bribes to people to lose weight, stop smoking, and exercise? In the wake of enormous agricultural subsidies and artificial food prices, why not underwrite healthier foods? Why not offer lower corporate health insurance rates to those businesses that can prove they have reduced stress levels in their employees?

At present, hospitals generate the lion’s share of their revenue with billable acute care. Far too often, billability (a great 1960s term) drives treatment modalities and affects outcomes. Why not award bonuses to hospitals on positive outcomes instead?

Life insurance policies are rated, based on any number of lifestyle factors. Why should medical insurance be any different? Smoking and being obese are not really preexisting conditions, as that term in properly used.

The Government and the private insurance industry could easily incentivize better health, if only they wanted to. Drawing on the fire insurance analogy from last week’s article, the sorry state of fire safety in the US can, quite sadly, be attributed to the fact that there is way more money in fire than in fire prevention. Sadder still is that there is far more money in disease than in health.

We delay changing this paradigm at our peril.