The Continuing Abject Failure of US Healthcare
William Bestermann, MD
No matter how far up the food chain you are, the failure to reform US healthcare puts you and those you care about squarely in the crosshairs of physical and financial catastrophe. Almost everything that you love about life depends on your health. You may have the wherewithal to have a vacation home and a yacht. You may have access to the best interventional cardiologist, but almost no one has access to optimal medical therapy to treat and prevent chronic conditions.
No one has access to the best new science and systems because of an abject failure of leadership at multiple levels. If you don’t get best practice medical treatment and develop a heart attack with congestive heart failure, your endurance and enjoyment of life will be diminished. The failure to improve health and lower costs creates a medical financial bubble that puts every segment of our economy at risk. Men will frequently ignore their own health for a dollar, but are you really ready to throw your spouses, parents, and best friends under the bus? Are you ready to put national security at risk? Really?
Moneyball tells the story of a team manager who turned baseball on it’s ear by using data, evidence, and systems to do more with less. Money medicine isn’t like that. Money medicine defends old expensive treatments that are proven ineffective, while failing to apply new data, evidence, and systems.
We know how to do this. We know how to develop a system that serves patients and voters. The way forward has been spelled out in detail years ago. The Institute of Medicine (IOM) brings together the best and brightest in American healthcare to provide advice on health policy. In 2001, the IOM called for drastic change and provided a roadmap for reform that has been entirely ignored. Nothing has changed 18 years later.
“The American health care delivery system is in need of fundamental change. Many patients, doctors, nurses, and health care leaders are concerned that the care delivered is not, essentially, the care we should receive The frustration levels of both patients and clinicians have probably never been higher. Yet the problems remain. Health care today harms too frequently and routinely fails to deliver its potential benefits….Americans should be able to count on receiving care that meets their needs and is based on the best scientific knowledge. Yet there is strong evidence that this frequently is not the case…. Quality problems are everywhere, affecting many patients. Between the health care we have and the care we could have lies not just a gap, but a chasm.”
The Hill is a website read by the White House and lawmakers. It recently published an article that provides a careful analysis of the problems with American healthcare and how they may be effectively addressed. Our leaders cannot claim ignorance. Here is one of the most important quotes from that piece.
“free marketers have expressed hopes that the market would resolve these problems with new technology and charity. Alas, no progress has been recorded. The markets do not work because they have been captured by vested interests, reflecting a wider problem of current American crony capitalism.”
Healthcare leaders and national politicians have an ethical, moral, and fiduciary responsibility to those they serve—patients and voters. One can only conclude that many are serving themselves. They are not functioning effectively in their vital role as patient advocates. The legal term is “knew or should have known.”
Crony capitalism is the swamp. We don’t have government “of, for, and by the people.” We have government “of, for, and by the crony capitalists” who have bought the political process. Crony capitalists and the politicians they have bought will never fix the problem. We have a fight on our hands.
This is not a political observation at all, but American experience has proven that free markets will not solve the health care cost quality problem– period. We have been talking and writing for decades and still the problems remain. The lawyers would say “res ipsa loquitor” or “the thing speaks for itself.” Free markets work well if you are manufacturing phones or televisions. Consumers can understand those products. Health care is the most complicated product in the world and there is no way they can understand that. They don’t have the broad base of knowledge to make an informed choice. They don’t understand the complexities and they are unable to identify best practices. Our current system takes advantage of that vulnerability. Therefore, some sort of consumer protection is essential. Patients need advocates that are not conflicted.
We are all in the same boat. I have worked all my life as a primary care physician. I have followed all the rules. I have had the best health insurance I could buy all that time and now my wife has relapsing polychondritis. This is a chronic autoimmune disease in which the patient makes antibodies against their own cartilage. Without excellent medical care the trachea is destroyed and collapses and the patient smothers to death in five years. Humira blocks this process and prevents inflammation and cartilage damage but it is very expensive. She has a serious preexisting condition. I have had health insurance for 50 years and paid premiums every month. I have faithfully put as much money as I could in a 401k. I drive a Honda Accord. Even so, if I did not have health insurance, I would be financially ruined. Medical costs are the leading cause of bankruptcy in the United States. Twenty states are suing to remove the pre-existing condition protections in health insurance. That is insane. A rational system could cover costs and protect sick people.
We can all agree that there are some things that all Americans need. Think water and electricity. We have highly regulated utilities that provide those and for the most part they work very well. There are fundamental problems in American medicine that contribute to increasing mortality rates and continually escalating costs. A rational consumer-owned utility model may be an option. That’s what a government system could be in its highest form.
The problems are not just with insurance, payments, and benefits design. They involve the type of care and the way it is delivered. Health care today can be highly effective. You all know that 85% of costs come from patients with chronic conditions. Recent scientific advances mean that primary care can be much more effective in addressing these chronic conditions. Chronic diseases are all related and new treatments for cardiovascular disease can prevent gout, rheumatoid arthritis, osteoarthritis and cancer. You also know that in Europe, the physician force is 70% primary care and 30% specialist. Here those numbers are flipped. That fact has huge system implications.
It is not just that the numbers are flipped, in Europe primary care doctors are expected to manage the patient and they are given the tools to do it. Here is a concrete example. When the landmark COURAGE trial came out, it literally stunned me. You know this trial proved that optimal medical therapy plus a stent is no better than optimal medical therapy alone. I am an internist who was practicing preventive cardiology and I had sent hundreds of patients to have stents thinking that I was preventing heart attacks and saving lives. After I recovered, I called the lead author, Dr Bill Boden. I told him that this was a really great study and that it should transform American health care. He agreed. But what he said next was very sobering. He had been working in a large health care system and left it to take another job. When the new job fell through, he tried to go back to his former job. They did not take him back and he thought both lost opportunities were due to the fact that shifting to COURAGE-based health care would reduce system revenue. He was extremely disappointed that the Europeans were adopting the findings in COURAGE and his fellow Americans were not. This difference persists to this day. Look at the British Guidelines to manage stable angina. Now look at the American guideline for the same condition. The American guidelines could not be more different. The British Guidelines provide primary care providers with a layered pathway that distills the evidence to guide care. It is very user-friendly and incorporates the evidence from COURAGE and multiple confirmatory studies. The corresponding American guideline is over 100 pages and written by interventionists for interventionists. It is effectively useless for primary care. Our whole system continues to be arranged around opening blockages. We pay for dialysis for everyone but we don’t pay for the simple primary care measures that could reduce dialysis six-fold. That is irrational.
At another level, we have 1100 electronic medical record vendors in the country and the guts of the machine are secret to protect business interests. So, none of the machines communicate. As a result, if you have a medical crisis at night and you are away from your own health system, your medical records are often not available when you go the emergency room. In Europe, they use a common electronic health record across the country and so they have big data available now. As a result, the British know that if type 2 diabetics are on metformin, they live a little longer than normal people. Ordinarily, type 2 diabetics die ten years earlier. Europeans have proven that type 2 diabetics on metformin, statins, and ACE inhibitors live 8 years longer than patients in usual care and chronic complications like cardiovascular events are also delayed 8 years.
US healthcare is utterly broken but a rational fix exists. We cannot keep doing the same thing and expect a different result. Extensive change is required for progress. Our current situation represents an abject failure of American medical leadership. Many current medical and political leaders are going to fight tooth and nail to keep the current system in place. Change is a threat to their power and money. Achieving a rational healthcare system that improves health and reduces costs will involve a vicious fight. Sitting on the sidelines is not an option if you want better government and healthcare.
William Bestermann is a preventive cardiologist and the CEO of Epigenex, a cardiometabolic care management firm.