Healthcare and Health Care

I have to revisit this subject in light of recent news and developments. It pains me to see the confusion that has caused the pollsters and pundits to be able to take shots at something that everyone wants.

There is concern about cost that is well founded. The problem is that costs come in a variety of disguises. Now discussions of cost have assumed inordinate importance in the questions of access. Once again, healthcare is about cost and health care is about access. These are two distinct issues.

There is virtually no one who advocates the denial of medical care on the basis of inability to pay. The entire health insurance industry emerged in response to a rise in costs driven by improvements in the science and technology of medicine. These improvement demanded better education for medical practitioners (added cost) and the technology has become more complex resulting in increased cost for both development and support.

While all this was happening, we became a nation of sedentary, over-eating, narcissists who believe in the idea that modern medicine can fix whatever we do to ourselves and make us all(well, me anyway) into beautiful people. We have learned to game the system to get the plastic surgeries we want and the pills we want and the therapies we read about.

Insurance coverages have been broadened continually in response to forces too numerous to mention with the result that more premium dollars go out requiring more premium dollars to come in. The insurance companies have developed bureaucratic defenses, requiring second opinions, demanding justification based on diagnostic testing, even making a practice of denial of the initial claim to filter out those who aren't really serious. The additional staffing and data handling is paid for by premium increases and forced out to the medical providers who increase their charges. Rising costs are everywhere and no one can join the debate with clean hands. Everyone wants someone else to absorb the costs.

In the midst of all of this, we sometimes lose sight of those who simply stay away from health care because they don't have enough money to pay for the other, even more basic necessities. We always lose sight of those who try to take care of themselves by buying health insurance, which they can afford only by accepting caps and deductibles or limitations on coverages. These people looks good in the statistics but rarely show up in the doctor's office because paying the premiums has put them into the same category as the uninsured in that they have no financial resources left over to pay for the visit. Further, they now have to live within the insurance bureaucracy that demands diagnostic justification, turning what might have been a $100 office visit into a $300 one.

Access to health care for everyone should be the sole topic in Washington. Access has relatively simple solutions. Let's solve that problem first, and, by the way, we have already agreed that ability to pay will not limit access.

Costs are a completely different issue and one that will require all interested parties to make substantial changes in thinking, planning and delivery.

It is deplorable (to use a word employed by a past President in a slightly different context) that we continue to allow doctors, administrators, insurance CEOs, technology vendors, pharma, and politicians to continue to point fingers at each other while the full cost of inadequate health care is borne by me and you, the patient/consumer.

The Health Care (or Healthcare) Vision

I have a vision that can only be fulfilled from the office of the CIO. This vision is characterized by

• The patient of one is the patient of all
• The history will be available wherever and whenever the patient presents
• The patient may know immediately about the services delivered and the charges for those services.
• The revenue cycle can be reduced to same-day for covered (under contract) services
• Costs can be reduced by as much as 50% through attention to the quality of the information captured and used within the system
• People will accept a system of standards when they see that their own interests are satisfied
• The people in health care are highly motivated and need only a shared vision to be fully productive
• Alignment is possible when the vision is clear
• Good, reliable, current information is the key to all of this and getting that will demand the careful cultivation of cultural and attitudinal changes.

I firmly believe that this vision can come to pass with blinding speed in an environment of openness and honesty in which people are encouraged to care about and for each other.

Arm Waving and Obfuscation

"Pay no attention to the curtain!" "Do not look behind the curtain!"

There are two areas in which it seems necessary to ignore the Wizard. One is in the nature of "healthcare" itself. Most spell checkers refuse to recognize healthcare as a valid word, suggesting "health care" instead.

Clearly, spell checkers have not been sensitized to the politics involved. Since the dawn of the HMO nearly 30 years ago, health care has gradually given way to healthcare. What does that mean for you and me? I don't know if you've noticed, but even the physicians have been shifting attention away from their own role toward the insurance end.

More than 15 years ago, I attended a software engineering conference in Chicago at which [former] Surgeon General C. Everett Koop was a keynote speaker. I became disturbed during his speech when he made comments seeming to grant insurance companies a gate-keeping role in health care. When I got back home, I wrote him a letter mentioning my impressions and asking whether that was his intent. Some weeks later I received an envelope with Dr. Koop's return address and which contained my letter. My "gatekeeper" question was circled (red pencil) and "NO!" was written (large) in the margin.

Today, physician leaders don't even blush when they tell us that the solution to our healthcare problem is better access to [insurance] coverage.

Health care can be linked to medicine. Healthcare is a business, pure and simple. When people are talking about money and where it will come from, they aren't talking about health care.

I do not question the motives of individual physicians in health care, but I question everyone's motives in healthcare unless they are talking about profits. Even the insurance companies are being edged out for control. Today, healthcare cost is controlled by third-party (neither doctor nor patient) vendors of everything from pharmaceuticals, to technology--especially technology. This isn't necessarily a bad situation--it all depends on what the goals are. Pick your favorite goal from this list (or suggest another):

• Profit
• return on investment
• market dominance
• a healthy populace
• access to medical care
• control
• benevolence/compassion
• giving back
• ???

If you are a person who has a need for (or interest in) health care, you really do need to peek behind the curtain of healthcare to avoid wasting your time, money and energies.