Healthcare lacks system-ness.

An individual who viewed this web site commented as below. I want to thank him publicly for his time and thoughtfulness. Responses to his questions follow.

“Deane: Like most who have looked at the current situation in U.S. healthcare, I agree that the status quo will lead us to ruin: that “tweaking” the current system only prolongs the agony; that the current “system” has no core, guiding principles, and that those who benefit most from it are most certainly not the patients. You’re calling for a national dialogue on healthcare as the means for diagnosing our sick non-system, which seems a prudent step toward reaching a diagnosis and prescription. From what I can tell from your posts, you see bureaucracy as a (if not “the”) primary cause of our ills in the status quo. So does this mean that you advocate a “laissez faire” healthcare system, in which there are no regulations, and no government involvement in the healthcare industry? Do you believe 100% market-driven healthcare is the answer? Can the patient ever reside at the very center of a system whose assumptions and decisions are, at the end of the day, based on profitability?”

Bureaucracy is not the root cause, just a major – okay, an overwhelming and unsustainable – symptom of disease in our healthcare system. The primary problem with the U.S. healthcare system, what doctors call the etiologic diagnosis, is that it lacks system-ness. It calls itself a system but it is internally contradictory, perverse, and works against the very people it claims to serve.

For any system to have system-ness, to be systematic and coherent, it needs principles as a foundation, just like the Bill of Rights underpins the U.S. That is why “Uproot U.S. Healthcare” calls for an extended national dialogue leading to a consensus of principles.

While I, amongst many others, rail against the massive, unnecessary and magnificently inefficient healthcare bureaucracy, that does not mean that the system can function without any bureaucracy at all. All systems need administration based on general, non-punitive guidelines rather than rigidly enforced mandates.

An effective healthcare bureaucracy must stop considering regulatory compliance an acceptable surrogate metric for medical quality. Healthcare should measure and follow those outcomes that patients want: good health and long life. Part of the reason that healthcare lacks system-ness is its dependence on surrogate measures, like not dying after surgery as a surrogate for full and rapid recovery after surgery.

The best way to inject system-ness into any bureaucracy, whether healthcare or something else, is to require long-term cost/benefit analysis before implementation of any rule or regulation. If a regulatory agency or some bureaucratic process cannot show hard evidence that the benefit to patients outweighs the costs, then smile, say sayonara, and as the politicians should do but don’t, “apply the sunset option.”

If Congress had done cost/benefit analysis with PPAHCA or HIPAA (or Medicare and UMRA for that matter), we would not have the bloated bureaucracy that is currently destroying healthcare.

The commenter asked: “Do you [meaning me] believe 100% market-driven healthcare is the answer?” A functional system of any kind must balance supply and demand. A government-controlled system can do that, but at an exorbitant price with strict rationing as its end-point. Just look at what is happening in Great Britain.

A market-driven system would balance supply and demand using market forces but could leave the less fortunate without care. A hybrid market system, one that includes personal responsibility as well as a medical safety net, is the best answer. Does such a system exist anywhere? Not that I know of. That is the reason we must create one. After all, America is (or was) the place for innovation.

The commenter ended with a vital question. “Can the patient ever reside at the very center of a system whose assumptions and decisions are, at the end of the day, based on profitability?” The answer is a resounding Yes! But true “profitability” must be at the level of the country, not necessarily profitable for each individual element such as insurance companies.

If healthcare were recognized as a key element of national infrastructure and handled as such, things would be very different. Who profits (or should) if the U.S. has a healthy population that lives a long time? Answer: both the individuals but also the nation as a whole. People and their health care should be viewed not as a cost center but as an investment in the future. People are the most, in a sense the only, APpreciating asset that the U.S. or any country has.

Therefore, the people should be treated like any other critical corporate asset: maintained and repaired, upgraded and improved as much as possible. As we have more people, as they “live long and prosper” (from the original Start Trek), and as they make our capitalist system compete successfully, the more profit our nation will realize.

“Can the patient ever reside at the very center of a system…based on profitability?” Yes, we can develop a patient-centric system with system-ness, one that is based on a national consensus of principles, carefully constructed but self-correcting, and protected like the vital infrastructure that it is.

Am I an optimist? Certainly. Only optimists can achieve miracles, miracles like fixing healthcare. The doomsday realists create self-fulfilling (and self-defeating) prophecies that preserve the untenable status quo.

System MD

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