President Trump announced infamously in early 2017 “Nobody knew health care could be so complicated.” Yet, it shouldn’t take a rocket scientist to understand how complex a health care delivery system (and this nation’s in particular) can be. This is a stew of health plans, insurers, pharmacy benefit managers, physicians, other clinicians, hospitals, health systems (public and private), drug and device manufacturers, and other suppliers that don’t always mesh well. Their incentives are extremely different, and their relationship to patient outcomes and public or population health in general, are well, let’s say it—complicated.
Think of it in the following way. Elon Musk’s brainchild, SpaceX, went through extensive development before coming up with a rocket that could lift off from the launch pad. It took numerous attempts to actually reach Earth orbit and complete the overall goal of returning the booster stage to a recovery site intact for reuse. Many have seen the brilliant, colorful explosions of NASA’s attempts in the late 1950s and early 1960s to prepare one of the military’s missiles as a launch vehicle.
A different example is Mr. Musk’s current troubles in mass producing his Tesla Model 3 electric cars. Tesla has been dealing with numerous obstacles and glitches. Production is currently a fraction of what Mr. Musk predicted and investors expected. However, given time and capital (which is not a given), few doubt that he will succeed.
Are We Confident We Can Fix Health Care?
People often say, “It’s rocket science” when describing something that is incredibly difficult to understand, manage, and/or overcome. But rocket science, like car manufacturing, is based on engineering problems, mechanistic solutions, and the laws of nature. In fact, rocket manufacture, operation, and mission success has been achieved repeatedly because although individual problems do arise, they are eventually overcome.
We have confidence that eventually, the production of electric cars, orbital and interplanetary vehicles, and even efficient use of renewable energy will occur. These are scientific and engineering problems; it may take a while but collectively, we believe the problems will be conquered.
How many of us can say the same thing about our muddied, muddled health care system? Health care is a messy business that is confounded by human behavior, access issues tied to socioeconomic factors, unpredictable flaws in human physiologic function, and our own self-inflicted constructions (e.g., health plans, pharmacy benefit managers, and odd benefit designs) to address them all. Although we may have some confidence in the ability to reach limited and incremental goals, cost-effective, high-quality health care for all our citizens remains a distant, uncertain dream.
We have been trying to fix the US health care delivery system since the HMO Act was signed in 1973. Numerous attempts have been made to address increasing costs (with very limited success) and improve quality. A rocket scientist wouldn’t want to touch this problem (nor would a brain surgeon—Ben Carson is attempting to lead the Department of Housing and Urban Development, not Health and Human Services).
Good Bets, Bad Bets, Sad Bets
We have made significant gains in increasing care access and reducing the number of uninsured. This has largely been achieved through the Affordable Care Act and Medicaid expansion. Yet, political efforts to strip away the ACA threatens to add millions of Americans back onto the rolls of the uninsured.
Nonetheless, we’ve place various bets in several areas over the decades. For example:
- Value-based care (/value-based insurance design/value-based purchasing)
- Primary care gatekeepers
- Implementation of electronic medical records
- Greater use of technology (including “big data” and diagnostic testing)
- Emphasis on quality reporting (NCQA, MIPS/MACRA)
- Access to biosimilars
- Direct contracting with providers
Perhaps we should have bet more heavily in some of these areas, and others, like biosimilars, are not nearly fully evolved. Yet, the problem remains. Medical expenditures continue to rise at multiples of the consumer price index. True competition does not exist at the practice or hospital level. Nor does sufficient competition exist in most parts of the country at the health plan level. The concept of value-based care has been around since at least 1995. In 2018, we’re still struggling mightily to prove the value of the care we purchase, as well as institute broad-based value-based purchasing of care.
Mediocrity at High Cost
The US health system has not distinguished itself as the best in the world, only the most expensive. Our quality metrics in many important areas are mediocre compared with those of other advanced countries. Further attempts to measure quality have resulted in push back from providers on data reporting (witness the recent MedPAC recommendations to stop MIPS in its tracks). Pharmaceutical scientists have made great strides in effectively treating life-threatening diseases, but the costs of these therapies challenge the system’s ability to afford them for patients in need.
Forty-five years after attempting to “fix” the health care system, our cost problems have only deepened. The system has become so complex that no ordinary system can understand it (much less rocket scientists). Further engineering a broken system, which rarely responds as intended to repair efforts, should no longer be considered a reasonable response. Drastically simplifying the system, with consumers choosing among competing doctors and hospitals for their routine and urgent care, is.