a few thoughts from a tumor surgeon

8th September 2009

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Ditch health insurance altogether ? Sign me up ! Not much to do with HC Reform, though.

A business executive, David Goldhill, recently wrote a damning recollection of his dying father’s five week stay at a hospital in the Atlantic. His basic question was why

… has this technologically advanced hospital missed out on the revolution in quality control and customer service that has swept all other consumer-facing industries in the past two generations?

The article was prominently featured in the magazine and quickly gained further national attention when David Brooks featured it in his NY Times editorial in which he said this is the first thing he would put in front of President Obama.

Mr. Goldhill does a beautiful job (albeit very disturbing) of highlighting the absurdities of our “system”.

Among his gems is “… confiscating all the profits of all American companies, in every industry, wouldn’t cover even five months of our health-care expenses.”

He notes, quite wisely, that “insurance” is generally used to pay for unexpected expenses (tree falls on your roof, car accident) not routine expenses. Thus (his example) nobody would think it reasonable that you would use car insurance to pay for gas while we all expect health insurance to pay for every checkup.

Therefore, he reasons, no amount of mandated cost control can overcome the intrinsic distortion created by a third party paying consumers’ costs.

His suggestion is that

a guiding principle of any reform should be to put the consumer, not the insurer or the government, at the center of the system.

By this he means that health insurers do not pay your bills, you do. By promoting price transparency and allowing providers to compete on quality and price, we will get better care at a much better price.

This sure sounds radical and his outsider’s perspective is very compelling.

Jay Parkinson even thinks an alternate system will spring up for the dissenting 20% who don’t like the government owned “Sickness” industry.

The thing is, these ideas are not new.

For those who are interested, Regina Herzlinger, has been writing about this in the academic and lay press for years. She is convincingly confident that lay people would be perfectly able to gather enough information to make rational choices about health care providers.

They do it now in all sorts of purchases (cars, computers) which are intrinsically technical.  Providers would align themselves in multi-disciplinary verticals addressing broad needs (say, kidney disease) and compete on outcomes and price.

I actually find these ideas very compelling. As a physician, I’d much rather deal with my real “customer”, i.e. my patient, than a third party payor with its own agenda.

Examples of consumer driven healthcare are indeed popping up everywhere (including Hello Health, of course). In my world of oncology, some groups of surgeons and radiation oncologists have teamed up to provide prostate cancer care. Prostate cancer can be often be treated by either modality. In the older procedure-based model, these two groups would have fiercely competed for the same patient. But, working together, they can actually do what’s best for the patient.

I guess my problem is that mixing these “fundamental” reform ideas up with the present health care reform debate is not particularly logical. Consumer Driven Healthcare (Prof Herzlinger’s term) will arise as “consumers” themselves slowly chip away at the walls and take over city.

The financial interests in the system are enormous and dislodging the current stake holders was difficult when 30 years ago when Nixon last suggested universal coverage. Now, as Paul Krugman noted, they are essentially unmoveable by any mandated “reform”.

What we have to do first is abolish the most egregious and unconscionable excesses of the current system that deprive access to care for the sick and most vulnerable. As Josh Marshall noted, this current (limited) attempt of reform irreversibly makes tending to the health of its citizens, a government’s rightful duty.

Even David Goldhill says these changes will take a generation. That sounds about right.