As we now head into the 2020 election, healthcare has emerged as a principal focus of policy discussion.
Like the weather, it affects all of us, we complain about it, and yet somehow seem unable to do anything about it. This year we have seen Nobel laureates in economics issue a sweeping condemnation of physicians with an assertion that our system "delivers the worst healthcare of any country." Alternatively, President Donald Trump issued a condemnation of those who seek dramatic change by claiming that Americans have the best healthcare in the world and are pleased with the system they have.
These are examples of the hyperbole that has overtaken a debate about a critical aspect of our social fabric. We are presented with data, sometimes true, sometimes not, usually presented out of context, and often skewed on the basis of philosophic predispositions designed to reinforce hardened positions rather than enlighten a critical discussion. The result has been an all too frequent cycle of information, generalization, recrimination, and then resignation that consensus and progress will elude us. In one study of 5 million consumers, 25 percent had delinquent debt of which 58 percent was medical. Medical debt affects decisions about housing, food and education. The problem is real and carries over into quality and equity. All the more reason to restructure the debate.
Here are four areas of the healthcare discourse that need more nuance:
1. We are not one: A first consideration is to acknowledge that we are not a single healthcare system, but a nation of over 350 million people whose care is provided by a loose mosaic of systems at the national and local levels. The diversity of systems, their structure, quality, efficiency and other metrics renders generalized statements meaningless. Individuals change systems when they move, change employment or simply age. A one-size-fits-all analysis will yield neither insight nor solution. We will need to be more focused to see what should be retained and to replace that which is dysfunctional. The challenge can be met, but it is simplistic to think that it is going to be with a single piece of legislation, policy or stroke of a pen.
2. The fallacy of foreign solutions: Other countries' systems are touted as the solution and critics are bewildered at why we have not followed their lead. There is indeed much to admire in what others have achieved. However, like us, these systems are facing major challenges. They are quite different in terms of structure, practice and the role of the private sector. Like us, they are not static but are having to change to reflect new demands on the part of patients, providers, and strained budgets. Patients want more immediate and expanded access to services, providers are feeling overworked, underpaid and under resourced, and there, as here, there are challenges in quality. This is not to say that other countries are moving towards our system. Given a choice those countries prefer their systems to ours. But we should remember that they, too, are very much in flux and are finding a way to achieve an optimal balance.
3. Cost: There is no denying that the relative cost of care is a staggering figure with relentless growth. Government, businesses, families and individuals are finding the challenge to be increasingly acute. However, the political mantra of "eliminating fraud, waste, and abuse" is a convenient slogan but insufficient solution. Fraud and abuse are present in both the private and public sectors, but the issue of cost can't be solved through eliminating fraud and abuse alone.
By some measures we do well on cost and utilization. Our frequency of admission to hospitals and associated length of stay is low. The U.S. continues to be a leader in the development of alternatives to hospital-based care and our advances in this arena are being adopted internationally. When comparing U.S. per capita healthcare costs to those of other nations, we track fairly close in the early years of life. However, at age 55, per capita healthcare costs diverge significantly without any indication of benefit and, once admitted to hospitals, patients receive a questionable intensity of services, which, like pharmaceuticals, are priced in a manner that remains mysterious.
American healthcare workers are also paid significantly more than their international colleagues. Nursing and technical staff in the U.S. receive significantly more income than their counterparts elsewhere. To a large extent this reflects their more sophisticated training and specialized skill sets. As labor costs are about 50 percent of a hospital's budget this is no small consideration. As often observed, physician income is also much higher in the U.S., though this is starting to even out as more physicians become salaried employees, trading higher incomes for more work-life balance. Finally, our massive administrative overhead speaks to the complexity of a system whose fragmented nature, regulatory burden and fiscal complexity distracts from the core mission of care. Also, an ever-growing number of formal and self-appointed groups have positioned themselves as arbiters of care with unique requirements for data and programs that are at times contradictory and distracting.
4. Quality and access: As with cost, there is very much a complex mixed message here. It should be noted that the worldwide movement for quality and safety had much of its roots in the U.S. Many programs to address infections and complications had their origins here. In some measures, such as infection and mortality rates directly associated with care, we do well, though still not at the optimal level. Where we find more murky results is in areas such as infant mortality and chronic disease. Here, we fare poorly; however, results appear to be a function as much of the socioeconomic support systems as they are of the acute care systems. In such circumstances, the emphasis will need to be at least as much on social support outside of the traditional healthcare arena.
Healthcare stakeholders need to step up
We must engage in a reasoned restructuring of this single largest part of our social and economic base. To do that we need a better understanding where we are and what we are doing. Then, those of us engaged in healthcare need to stop defending a status quo that is eroding faith in our commitment to change. We need to engage as leaders of transparency, quality, and equity. A robust and honest debate will be of no use if it is not followed by a commitment to substantive change. Equally important, we will need to address the magical thinking that this can be done "on the cheap."
Reuven Pasternak, MD, is the former CEO of Stony Brook University Hospital, vice president for health systems at Stony Brook Medicine, former CEO of Inova Fairfax Hospital and executive vice president for Inova, and former vice dean at Johns Hopkins Medicine. He currently serves on the board of Sparian Bioscience, a startup pharmaceutical company; is a senior advisor to the private equity firm The Riverside Company; serves on the advisory board for Stony Brook University's Master of Health Administration program and is a business/scientific advisor to the health science program at the Johns Hopkins Carey School of Business.
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