Pandora’s box:  opened.

As I sit to write this, I want to make a few things clear:

• I work in healthcare as a mid to high level administrator
• The opinions in this piece are mine.  They do not represent the opinions of my employer, anyone I work with, or the guy down the street who has a Trump sign in his yard.
• This isn’t about politics.  This is about healthcare.
• I love what I do.  I love what I do because I know that my job makes a difference in the health of our patients.

An important distinction needs to be made up front.  There is a difference between healthcare (doctors, hospitals, clinics. . .) and insurance.  The entire system is systemically broken because money and people are involved.  Money and people will always be involved, so to a certain extent, I believe the system will always be broken in a way.

THE “VALUE” OF HEALTHCARE

Let’s go back a bit in history.  Let’s go back to a time when doctors traveled on horseback or horse-drawn carriage to farmhouses to treat sick patients.  The doctor brought his black bag and stethoscope and performed his/her service and received a fee.  Many times, this fee wasn’t cash.  Why?  Because the service was not, “affordable.”  It was still paid for.  The fee was paid in labor, goods, promise of future monies. . .  The point is that it was paid for. It was paid for because it was valuable.  It was necessary.  Not everyone had access to care, and not everyone who did have access didn’t have conventional methods of paying, but they still paid.

Today, things are different.  As a country, we have determined that none can be turned away from an accredited hospital based on their ability to pay.  We have established, “free” clinics for those who can’t afford medical care.  We have government programs that aid those who fall into a certain income range which help or completely cover healthcare.  We have federally qualified community health centers to help ease the medical burden in lower income areas. . .

I’m not getting into the argument of whether person “a” deserves healthcare because of their ability to pay, but I feel like we have made healthcare worthless to some people.  By making it free, and assigning a value of zero to healthcare services, we have removed the worth from the service.  Not for everyone.  But for many.  I only point this out to state that there is a value to healthcare.  It is worth something.  It is worth “paying” for.  That’s not up for debate to me.

HOW WE BROKE THE SYSTEM

Imagine with me (if you will) that you’re hungry.  You pull into your local fast food chain, walk inside, tell them that you’re hungry, they ask a few questions to determine your hunger level, and hand you a bag with food and you leave.  You look inside the bag with some surprise to see what they gave you, you eat it, your hunger is cured.  Three weeks later you get a bill in the mail for the food they gave you (that they decided you needed) and you’re now expected to pay it.  “Wait just one minute,” you exclaim, “I mean sure, I ate the hamburger, and the fries, and the ice cream sunday, but I would have been just fine with just a hamburger.”  Now you’re irate.  You didn’t order that, and you don’t even think you needed all that. . .but now what?  How long would that type of system last?  How long would fast food chains remain open?

Our current medical system isn’t all that different.  It’s the only industry that I can think of (please comment below if you can think of another) where you show up with a problem, are seen by a professional, are completely at their discretion for what you are charged, aren’t immediately told what you’re charged, and yet are expected to pay whatever bill you receive.  And hey–it gets even worse.  Often, you only get a number code with little or no description of what was performed along with the charge you’re now expected to pay.  Sure, you can go to a different doctor, but the process is generally the same.

You wouldn’t tolerate this in any other industry, but it is the accepted practice in medicine.

I’m not advocating a mass protest against the industry’s fee for service algorithm, I’m just pointing out one area where I believe we can make massive improvements.

AFFORDABLE CARE ACT

Is it though?  Is it really affordable?

Some folks have access to healthcare in a way they never have before.  This?  This is a good thing.  Some folks can’t afford care and have been priced out of even basic preventative healthcare.  This?  This is a bad thing.  And, it gets even worse.  For folks in the latter group (who can’t afford healthcare) who decide not to take a plan in the marketplace, they are taxed for their inability to afford the “affordable” plan.  (Look, I get it…you want to have a semantic debate over whether it’s a tax or a penalty or a fee. . .but that’s not the point is it?  The point is to get affordable healthcare into the hands of all so why are we penalizing people who can’t afford it?  Call it whatever you want to–it’s still an unaffordable fee for those who can’t afford healthcare.  This?  This is an insult.)

There are some good things about Obamacare:

• Improved access to basic healthcare
• Improved access to basic (and advanced) healthcare plans
• Improved guidelines for care
• Standardization of visit types
• The start of data mining for health outcomes

I’m sure there are some more good things about it, and I don’t pretend to have listed them all.  I just want it to be plainly known that I don’t think it is all bad.

IT’S MOSTLY BAD THOUGH

I don’t believe people should be forced to buy a healthcare plan through the federal government’s marketplace.  Let’s not be confused about a simple fact:  you have to have healthcare in America if you don’t want to pay a tax/fee/penalty.  That’s not, “free healthcare.”  Not even close.  Let’s stop calling it free or affordable.  If it isn’t affordable for all, then it isn’t affordable.  That’s basic english.

The plans are confusing.  I’ve spoken to multiple patients and family members who legitimately didn’t understand what they were signing up for.  This?  This is bad.

The plans aren’t equal.  The benefits allowed from one plan to another and from one company to another aren’t equal.  Maybe this should be included in the area of “confusing” but there are many folks who get to the healthcare exchange and believe that by clicking on the most economical plan, they now have free universal healthcare.  Why??  Because that’s what they hear in the media.  That’s what gets votes.  This isn’t true.  In this country, there is no such thing currently as free universal-cover-it-all-whenever-whatever-you-want healthcare.

“Preventative medicine” doesn’t mean what you think it means.  This is important as preventative medicine is what’s truly, “free” in most plans.  Zero co-pay, zero co-insurance.  Preventative medicine/Annual Visit is not a time for you to bring a laundry list of complaints to your primary care provider.  It’s not a time to save up all of your potential medical concerns and cover them in one hour.  It’s a time where your doctor will ask you a basic set of questions, run some standard blood tests and if all comes back normal–see you in a year.  As soon as you start to talk about your sleep troubles, your occasional indigestion, your intermittent knee pain…it’s no longer a preventative medicine visit, and thusly no longer considered a, “free” visit.  You don’t have to agree with that.  You don’t have to think that’s right or wrong.  That’s not why I bring it up.  I bring it up as a point of clarification.

It’s too political.  At some point, the healthcare discussion stopped being about actual healthcare and instead both sides decided to use it as a primary method to take shots at the other side.  Stop it.  Keep it about health.  Keep it about patients.  Keep it about what’s best for the patient, not what’s best for the party.

The government is involved.  Ronald Regan once said, “Government is not the solution to the problem. Government is the problem,” and I tend to agree.  Government programs aren’t flawless.  In fact, and in many instances, they are the most flawed programs in this country.  Giving healthcare to the government to manage is a mistake.  How many policy makers really understand healthcare?  How many policy makers really understand what happens in an exam room, an operating theatre, an emergency department?  1%?  Why are they making the decisions?

The emergency room isn’t your primary care provider.  Hospitals are expensive.  Hell, all healthcare is expensive, but in the hierarchy of costs, hospital care is at the top–and there isn’t a close second.  The emergency room should be reserved for emergencies.  Obstructed airways, unconscious/unresponsive persons, trauma, etc.  Not, a cold, a sore throat, a hangnail, tooth pain, twisted ankles, etc.  The cost of using the emergency room is exponentially higher than using a primary care provider.  At some point, it became acceptable to go to the emergency room for whatever ailed you and this has been one of the highest drivers in the increasing cost of health care.

HOW WE FIX IT

Again, this is my opinion.  These are my thoughts.  These are not the thoughts of a political party–these are the thoughts of a guy who cares deeply about patient care.

Firstly, get rid of the insulting tax/penalty/fee.  If you decide you don’t want to pay for healthcare (as many healthy individuals have decided for one reason or another), you shouldn’t be penalized for it.  If a family of four above the poverty line but still in a range where healthcare isn’t affordable decide to do without health insurance, they shouldn’t be taxed for making that decision.  That’s simple.  That’s easy.

Increased education.  We have no problem forcing students to learn about generals in the civil war in a high school civics class, but that in no way prepares them for the real world.  Healthcare education is something that people need to know.  What is healthcare?  What constitutes a visit?  What do you get?  What is excluded?  This needs to be taught and it needs to be learned before you need healthcare–then it’s too late.  You don’t want it in schools?  Ok.  Lets have seminars. . .educational sessions. . .whatever it takes.

Make it valuable.  Healthcare shouldn’t be an entitlement program.  We have removed the, “worth.”

Put healthcare professionals in charge of it.  Let doctors make the decisions.  Let healthcare professionals design the plan.  I promise you the plan will be better, more inclusive, and more cost effective than any government designed plan.

Make healthcare billing more transparent.  People should understand what they are being charged or what they could be charged prior to receiving the service.

Get rid of fee for service.  Now, this is already starting to occur and it is needed.  Badly.  When doctors (hospitals/systems) are compensated based on the service they perform, they are incentivized to perform more services.  It’s how they are paid.  The more, “things” they do, the more money they receive.  In contrast, we need a system based on patient population health.  Again, we are already moving in this direction.  Doctors need to be compensated based on keeping people out of the hospital, keeping people out of the emergency room–and this is coming.

Keep emergency rooms for emergencies.  Look, this is a tenuous line.  I understand that.  Some people have a very different  view of what is an emergency to them and I understand that–but there should be a disincentive for overutilization of the emergency department for individuals who incorrectly overutilize it.  Currently, none exists.  Costs continue to be driven up as people utilize the emergency room for primary care.

I DON’T HAVE ALL THE ANSWERS, AND NEITHER DOES ANYONE ELSE

This has to be an ongoing discussion.  What we have isn’t working, and it won’t ever work in its current state.  Stop clinging to it as a means of political party affiliation.  Until people from both political parties agree that its really only a start (not even a good start. . .just a start) we aren’t going to get anywhere.  I’m not saying your political party sucks because you support the current plan, nor am I saying your party is good because you disagree with the current plan. . .I’m saying the plan is bad and we need to fix it.

Stop.  Step back.  Take a real look at it.  Look at Medicare (which everyone agrees will be bankrupt in a matter of years), look at Medicaid (which is being accepted by fewer and fewer providers because of the bureaucratic red tape involved with it), take a look at the VA. . .all of these are the government’s response to, “health care.”  Do we really need more of that?  Do we really need more of the already broken systems that exist?