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Saturday, March 30, 2013

What does American healthcare want?

I know what I want, in healthcare, that is. I want it to be efficient, effective, thoughtful and inexpensive. I want it to create healthy people who don't need very much health care. I want it to involve elegant solutions to problems that take less time, money and effort. I want it to be so much easier and less expensive that taking care of all of our people uses even less resources than taking care of only some of them, as we do now.

But the healthcare industry in America is bigger than me, and bigger than all of the doctors who work in it, even if we could all agree on what we want. So what does it want?

Is it even reasonable to think about healthcare as an entity? I propose that it is, that this way of looking at it makes the direction it has taken much more understandable.

We observe that bureaucracies grow, even though we complain about how they should shrink and become more efficient. Agencies beget more agencies, and attempts to reduce bureaucracies often don't work. I've seen what happens at our local university when educational budget cuts happen. They cut positions, but the people who remain are expected to pick up the functions of the ones who lost their jobs, which leaves the scope of the bureaucracy the same size as before, but temporarily overworks the people who remain (until they hire new people to unload them.)

The healthcare delivery system in the US has progressively grown, primarily driven by the growth of insurance, both government and privately funded. This has brought financial professionals heavily into the delivery of care, and has also increased the amount of money available for services. The availability of financial resources makes it more  possible to continue to treat patients who become sicker and more dependent upon it. It is also more feasible to develop very expensive technological approaches to illness, which expands the system to include scientists, device manufacturers and the companies with their own workers and advertising professionals. This just gets bigger geometrically.

Even if individuals within this vastly complex system want care to be cheaper and less complex and patients to be less dependent, the system itself does not want this, and continues to grow. It's hard not to invoke the metaphor of a large, stupid and perpetually hungry giant. Even without the metaphor, mathematics explains why complex, inefficient technological medicine that creates dependency wins out over elegant, efficient and cost effective medicine. The complex and inefficient version is bigger. By its nature it is bigger, which, in the absence of an external force deterring it in some way, or some catastrophic imploding event, means it will continue to be the bulk of what healthcare is.

So why even try to find the elegant solutions? There is abundant talk of implosion and the affordable care act has made some attempts to externally deter the growth of the healthcare industry. I don't see the former as happening anytime soon and the latter seems unlikely to have a major impact, but if we keep looking for ways to make healthcare be less expensive and more of what we, as patients, really want, those solutions will be available when we really need them.

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