I'm sure you know that the American healthcare system is struggling...
And the scapegoats seem to be the fee for service model, the insurers, the product corporations, and the bulging bureaucracy. This makes sense. These are factors making it harder and harder for Americans to access healthcare.
I'm very interested in what the solutions on the table are. The golden nugget seems to be the value-based healthcare model, where doctors are paid by the outcomes produced not the services rendered. This aligns incentives more reasonably.
But how I evaluate a solution includes how feasible it is to implement. Because if dollars are being spent on something that could have been spent on something else, that's bad.
I think value-based healthcare is too hard to implement at scale. To be clear, it is still a good idea, and I think in advanced cases with perverse incentives on the order of millions (like cancer), it works quite well. The indisputable "they had cancer now they don't" situation is sensible, but how many others are that black and white? Value-based healthcare involves actually measuring the outcomes produced attributable to the doctor against a baseline. What if the patient doesn't comply, why would you knock the doctor? What if it would have just gotten better on its own, why would you reward someone taking credit? It's much too sticky. A whole area of study could be created just parceling out whose action solved the problem, and that means billions of dollars of research going to the attribution of awards versus coming up with new solutions.
Other than feasibility, the problem I see with the value-based model is that it persists the practice of making decisions FOR the patient in a parent-like fashion, versus WITH the patient as the ultimate responsible party for how they live their life. The power of doctors is limited to the short time-span between when the patient walks in and when the patient walks out. Then the patient chooses whether or not to come back, to exercise, to take their medication, to stay safe, etc. Being accountable for the health outcomes of someone you cannot control is unfair, and so every detail will be fought.
The fee for service model is at least a model doctors can agree on. But along with its other vices, it is parenting yet again. We all know children rebel against parents. Especially in a hierarchy where they see the parent as higher on the chain socioeconomically and out of touch with their daily struggles. I don’t mean to say adult patients act like children, but anyone’s inner child comes out whether they feel stressed or misunderstood. I’ll commit to piano lessons if I’m actually interested in them, not because mom said so. Personally, I can’t help but think about my doctor rolling away in a luxury BMW at 5pm while I need to run back to work and I know the pharmacy is going to take at least 45 minutes and my insurance may get declined. So I will go less, and I will not trust him when he demands that the best thing for me is a $1500 root canal. Its human nature.
So why is this happening? Why isn’t the average doctor changing the way this works and allowing patients to run their lives? I believe it’s the incentive structure.
1) Requirements to provide the ‘best’ treatment possible: Because of how litigious the system has become, doctors are understandably vulnerable. So many are recommending the most expensive treatments versus those that work reasonably at much lower cost. This protects their quality ratings and malpractice risk (they did everything they could medically to get the patient optimal treatment) and puts the liability on the patient should they refuse treatment, which in turn frees them from the liability. But the expensive treatments may not be appropriate to the way patients prioritizes spending time and money.
2) Requirements to robustly disclose: The human body is complex, and the side effects and things that can go wrong in a treatment plan are numerous. Doctors are required to disclose a slew of specific information, which, while it builds credibility to talk through at length versus hide in some disclaimer, overwhelms patients. It is on the patient to understand, at least they told them. And we know comprehension varies by education level. Clear metaphors are not going to be the priority.
3) Restrictions on who can do what: Given the supply constraint, doctors are stretched thin, and understandably busy. And medical professional below doctors are not empowered to treat and make judgments on their own, no matter their experience level. They take charge when doctors are distant, but few beyond nurse practitioners can sign off. This caps their salaries, adds unnecessary wait times, adds people needing to see the patient before they go, adds white coat anxiety, and multiplies costs.
4) Priorities of medical education: Medical schools are having students spend inordinate amounts of time learning each bone in the human body and going through complex medical cases. For most medical professionals, these cases are rare. Beyond dealing with patients in difficult emotional states, the job of a regular physician can indeed get mundane. And so getting to the root of a complex issue is fascinating, resulting in more tests being ordered, which helps the doctor look for these cases and is again a protective measure. Do we always need the best and the brightest? As the population grows and the spots stay limited, only the super-clever get them. Wouldn't just those who are clever suffice?
5) Gaps in medical education: Medical schools are not teaching business. A physician’s salary is usually capped at the specialty level they choose. The salaries of business people are highly variable. Given all their education, doctors often have great ideas on how to improve healthcare in America. But they do not have business acumen, and so the best they can do is write papers. Few break the mold by being natural leaders or being able to partner with business people to get going on game-changing projects that can creatively modify this model.
So what can we do? I propose that for most cases, we go for the "a la carte" model. What is it?