The reality of computer errors is that the deeper the error is — the closer it is to the core of the operating system — the wider the consequences when it causes trouble.  That’s when the “blue screen of death” or (on a mac) the “beach ball of death” show up on our screens.  That’s when the “illegal operation” progresses to a “fatal error.”

The Fatal Error in Health Care 

Yeah, this makes me nervous too.

We have such an error in our health care system.  It’s absolutely central to nearly all care that is given, at the very heart of the operating system.  It’s a problem that increased access to care won’t fix, that repealing the SGR, or forestalling ICD-10 won’t help.

It’s a problem with something that is starts at the very beginning of health care itself.

The health care system is not about health.

Yes, the first word, “health” is inaccurate.  Our system is built to address the opposite of health, sickness, exchanging money for addressing illness.  The clinician is paid for matching diagnosis with procedure (ICD for CPT, in code).  Economically, more (or more serious) diagnoses and more (or more complex) procedures result in more pay.

Last I checked, more/more serious diagnoses and more/more complex procedures are not in the definition of “health.”

So is this just a case of bad nomenclature, or not wanting to use the term “sick care system” for PR reasons?  What does it matter what it’s called?  The problem is that health is what the patient wants (although it’s hard to call someone a “patient” if they are healthy), but the system does nothing to help people each this goal.

In fact, our system (as constructed) seems to be designed to discouraging providers from helping people toward the goal of health.  After all, the system itself becomes unnecessary in the presence of health.

Getting What We Pay For

So what do you get from such a backward system, one that rewards the outcomes people are supposed to avoid?  You get what you pay for:

• A premium is placed on making diagnoses, since they are rewarded.
  • Unnecessary tests are done to “fish” for problems to treat.  I got my vitamin D level drawn at my last doctor’s visit, but was not displaying any symptoms/signs of a deficiency and know of no evidence that treating it in someone like me would do any good.  To what end do I have this diagnosis?  I am not sure.
  • New diseases are created to promote intervention.  “Low T” syndrome is a perfect example of this, not only rewarding the provider by adding complexity for the visit and the lab for the test run to make the diagnosis, but also the drug company who brought the “disease” to the public consciousness.
• The likelihood of a person being considered “healthy” is much less.
  • Obesity, depression, poor attention at school, social maladjustment – things that used to be considered different points along the range of normal human existence – are now classified as diseases.  Risk factors, such as high cholesterol, are made in diseases to be treated.  The end result is a diagnosis for everyone.
  • Overdiagnosis leads to overtreatment with medications that themselves can cause problems (which is rewarded by increased pay for doctors, hospitals, drug companies, etc).
• Little effort is made to do things that would lead to health.
  • Spending more time/resources on people to educate them about their health is bad business, as it decreases the number of diagnoses and procedures a clinician can do in the course of the day.
  • Since there is no motivation to prevent little problems from becoming big ones, they tend to be neglected.  Patients often report the need to be “sick enough” to go to the doctor’s office, and seem embarrassed when their concerns are found to be “nothing serious.”

Why Payors Won’t Change

So why don’t payors just stop paying for unnecessary medications, tests, and procedures for invented diagnoses?  They did once, actually.Back in the early days of HMO’s, when most doctors and patients were used to getting any medication, test, and procedure without question, the payors changed: they stopped paying for everything.

“No, sir, you don’t need an MRI scan for back pain.”  “No, ma’am, you don’t need the brand name drug that costs 20 times more.”This attempt to control cost was not met with praise, but instead by the demonization of payors by both doctors and patients.

Insurance companies quickly became public enemy #1, said to be denying care to those in need.

In reality, they were not denying care; they were simply refusing to pay for it.  Patients could get the MRI or brand medicine if they wanted, they’d just have to pay for it themselves.  But that wasn’t in the discussion.

In the end, they did what every God-fearing person does with a problem they don’t want: they passed the buck.  Instead of refusing to pay for unnecessary procedures, they did two things:

1. Required authorization by providers – this meant that the denial was because of the provider’s inability to justify it, not the payor’s unwillingness to pay for it.
2. Started penalizing/reporting “bad” providers – this started with the use of “pay for performance,” and has come to full fruition recently by the “transparency” movement, where doctors’ and hospitals’ utilization are publicly reported.

The analogy I’ve used in the past is that of an alcoholic who blames their spouse for their inability to control their drinking.  “If only those damn doctors would stop ordering those unnecessary tests and prescribing those unnecessary drugs, I wouldn’t have the need to irresponsibly pay for them.”

Rethinking Reform

The root financial arrangement in the health care system is to promote more: more diagnosis, more disease, more tests, more interventions, and more medications, with each of these being rewarded with more revenue.  It seems the obvious cause of our out-of-control spending – spending which does not yield better health.

Attempts to reform the system have ignored this root problem, instead focusing on other things:

• Improving access to care (a la the ACA) – which addresses the real problem of uninsured/underinsured people, but ignores the fact that care became inaccessible for a reason: it costs too much.
• Measuring the care of providers and hospitals, attempting to manipulate them into reducing the cost of their care.  The HITECH act (and our old pal “meaningful use”) does this via computerizing and capturing the data of clinicians, as do the ACO’s (accountable care organizations) for hospital systems.  While there is a small shift of financial incentives in these arrangements, they greatly increase the complexity of the system, creating huge areas of spending that did not previously exist (yes, I am talking about the EMR companies, with Epic at their head).
• Changing who is in charge – either by privatizing Medicare and Medicaid or by going to a single-payor system.  If a ship is sinking, the priority is to fix the hole, not to change captains.

Warning!  This is where I get on my soap box.