Ounces of prevention, pounds of cure, tons of inadequacy

The above title is my description of the current health care system. 

Our current system is driven by money.  Thus, the infrastructure all goes towards that which generates revenue, and leaves many gaps.  Politicians speak of methods to finance health care and increase access.  To make any effective change, we must control costs.  Until we do this, there will be no long term solution to our terrible health situation.  

I will be addressing many health issues.  As we talk of the health of the public, we seem to under value public health.  

The issue of financing healthcare, access, and public health tie into two larger problems.  We are primarily focused on the biology of illness.  As we develop our biotechnical system for illness in every way, we often leave the aspects of psycho/social and environmental factors aside.  There is no end to how much money we can spend on the biology of illness.  As we go down the tracks pursuing dollars, we have a very fragmented system with no one in charge of the total picture.  This leaves us with duplication and inadequacies.  We need one integrated system with communication and coordination. 

The health of the population has improved over the last 100 years primarily because of public health improvements.  Consider work place safety, food safety, control of communicable diseases from emphasizing safe water to prevention programs, etc...  However, a polluting factory often isn’t addressed until enough people are ill and the lawsuits appear.  We do consider unhealthy aspects of nutrition in schools, exercise, etc., but not as well as we should.  We have a chief of police and a school superintendent, but no one locally ‘supervises’ the entire health of the community. 

In my 27 years of practice in Corvallis, the most significant health event a few years ago was educating and moving the voters by initiative to not allow smoking in the workplace.  I believe the financial and health savings of this is probably greater than any other ‘health event’ including a new hospital, new technology, new specialists, new drugs, etc.  Many people working low income jobs will be spared significant illness from second hand smoke, and no one working on this initiative was paid for this effort.

Since the 1980’s we have simply been patching the current system.  Cost Shifting was well underway (see below).  Managed care came in (in the form of HMO’s) and billions of dollars were saved by such measures as decreasing ‘utilization’ of healthcare.  These big dollar savings kept the train on the track and prevented collapse until all of the money was “squeezed out” by the HMO’s.  We went to the brink of intolerable utilization decrease while the corporate executives made more money, and managed care came to an end.  We tried to patch drug utilization with formularies.  Money was saved as dollars flowed under the table from the drug companies back to the insurance companies (called rebates by some, kickbacks by others).  None of this has saved the patient any money—it has only slowed the rising costs and caused patients and doctors major frustrations, and sometimes risks.  Other patches to the system have included such things as prior authorization, disease management, utilization review, schemes with incentives for certain performance by providers, etc.  Most recently, the insurance company “benefit packages” are being reduced or limited either overtly or sometimes simply by a stricter interpretation of the contract and denial of services once covered.  HSA’s are another “patch” which have the potential to postpone the inevitable without solving the underlying problems.

Some final issues need to be addressed as we ponder a system spending more dollars and not providing better health.  Many countries in the world have a lower infant mortality rate than the United States.  Cuba recently surpassed the U.S. and it is a very poor country that does not have the option of simply throwing money at every problem.  The Cuba system has achieved this result by ACCESS and NUTRITION for pregnant women.  The U.S. has had over 20 million children living in poverty with poor nutrition for as long as I can remember, and this number is not improving.

Along with access, the major issue of COST SHIFTING has to addressed.  The legislative draft seriously considers this, but at this point, increasing access will not do enough to prevent this.  Stated simply, cost shifting results from more people not having health coverage which raises the cost of coverage for those who do.  As this happens, costs for health coverage rise, and more people become uninsured, and the cycle takes off.  All of the band aides described above only held this phenomenon at bay.  We are running out of cost saving measures.  I believe we are at the point of inflection on the curve of cost acceleration with financial consequences to the economy beyond our predictions.  More and more people and employers are finding insurance unaffordable and in short order, only Bill Gates will be able to afford insurance.  Make no mistake though—our biological expenditures will break him too.

Norm Castillo, D.O.

Family Practice

Corvallis

castillo@castillofamilymedicine.com

Post Script:

Many of my comments are based on local observations, but apply broadly.  I believe we have system problems, and what I say in no way reflects on any individuals or groups in our area.  In fact, we should all remember that we “waltzed” into this situation together—doctors, patients, hospitals, insurance companies, government, and pharmaceutical houses (some people do dance faster than others).

As all know, the situation is extremely complex.  I did not address many issues such as patient education and responsibility, physician compensation, medical school debt, liability costs and effect directly and indirectly, pharmaceutical costs, priorities of care (prevention, the dying patient, etc.),  hospital systems and costs, expectations, administrative costs, Medicare, Medicaid, alternative care, etc.