Rich doctors and the Dying People

RICH DOCTORS AND THE DYING PEOPLE WHY OUR FOR-PROFIT HEALTH SYSTEM IS CRIPPLED AND ALWAYS WILL BE.

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Christopher Chin IGE 224 Peg Lamphier Winter 2016

Rich Doctors and the Dying People

When thinking of healthcare, what is the first thing that comes to mind?

Doctors, hospitals, stethoscopes? For me, it is the dreaded payments and unpredictable outcomes. It is widely known that patients in the United States pay significantly more than patients in other countries with universal or socialized medicine for similar or equal treatments. In this sense, United States healthcare has low value, which is defined as cost over outcomes, so we have a healthcare system that is in need of a disruption. Due to the for-profit nature of the U.S. health system, all trends past, present, and future will be driven from what is most financially beneficial to medical institutions; the problem with the current system is that it is unregulated and based upon traditional private practices.

The next step for healthcare is preventative care, or population health, which is essentially prevention of unhealthy habits that lead to sickness and terminal disease farther down the line. This essay will briefly explain why America performs the worst among larger industrialized nations, provide a case study of France, and explain how the next phase of healthcare - consumerism or retail healthcare, will not alleviate the inherent problems in a primarily for-profit healthcare system.

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My interest in this topic stems from being an architecture major, with a healthcare concentration, and also from the general embarrassment in our global healthcare rankings. I find healthcare, especially healthcare architecture to be extremely complex and fascinating due to its highly technical and trend driven nature. It is a profession that is based off of the most complex thing we know - the physical self. The body is a realm of the unknown, a hyper-complex puzzle, the house of our psyche, and the vessel through which we are conscious.

One of the reasons why America's healthcare system performs like a ballerina with a sprained ankle is that it is a for-profit system. As it is life that healthcare providers are dealing with, providers justify unreasonable premiums; unreasonable due to bureaucracies, medical waste, lawsuits, and profit margins. It is a highly complex system that needs to change and adapt just as humans do very well. The problem lies in the basic business model of making profit - charge the highest competitive price for the lowest service. Thus, healthcare is a highly lucrative business that allows corporations and insurance companies to charge seemingly wanton rates for basic services, leaving many Americans stranded. To frame the current state of matters, "The United States meanwhile is ranked 72nd of 191 countries for “level of health” and 37th for “overall health system performance”, just behind Costa Rica and Dominica and just ahead of Cuba, all countries with a fraction of America’s wealth. One reason the U.S. is ranked so low is that nearly fifty million Americans — one-sixth of the population, including millions of children — have no health insurance at all" (Hill 2011). This is the root of the problem, I believe that in health care, priorities should be eudemonia;

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providing health related services is essentially an altruistic position. So the question is, and therein lies the problem - should we have a for-profit healthcare system? I think not.

Why would America, with its clout and innovation be 37th in global healthcare rankings and last of the 11 wealthiest countries? (David, Ballreich 2014). The answer is troublesome, as it is fraught with historical precedents and irony. America is largely known as a country leading healthcare innovation, however it stands next to Costa in healthcare rankings. As perplexing as it might be, we must recall the history of the American healthcare system during the early 20th century. According the article, From Sick Care to Health Care- Reengineering Prevention Into the U.S. System, by Fani Marvasti and Randall Stafford, economic and technological factors have influenced current U.S. healthcare trends including the "piecemeal, task-based system that reimburses for “sick visits� aimed at flickr.com/denisejones. Healthcare vs Sickcare

addressing acute conditions or acute exacerbations of chronic

conditions. Economic incentives encourage overuse of services by favoring procedural over cognitive tasks (e.g., surgery versus behavior-change counseling) and specialty over primary care." Thus, the comparison between cultural techniques serves my point -

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Eastern medicine is "hot" and Western medicine is "cold"; America favors quick fixes often appearing to solve the problem, rather than eliminating causation.

The problem is that many of the major acute problem that American faced in the early 20th century are largely accounted for, however the system is still largely based on this specific and acute care. In addition, due to the highly technical nature of many medicinal institutions focusing on disease cures and bioengineering, healthcare scientists have traditionally catered towards the targeted, deployable solutions to isolated problems such as chemotherapy, disease prevention, chronic disease, etc., ultimately resulting in a highly specialized healthcare treatment system, not meant for population health. Also, due to the highly technical nature of care, new technology is commonly adopted thus adding to costs. In addition, prescriptions are often haphazardly prescribed in a blind hope to fix a problem, contributing to medical waste. These factors, among many others, are the reasons in which value for care is so low compared to that of other countries, ultimately causing the United States to be ranked 37th globally.

As searching for a "cure" has been the primary objective of the current system, the next big step for American healthcare is to implement a system that focuses on preventative care. Preventative care is any type of care, whether social, psychological, or physical that contributes to health in order to avoid sickness. It is a sustainable strategy that is cheaper and more effective than treatment of acute and severe disorders. A new way of thinking needs to start from the bottom up, with educational changes, emphasizing the importance of combating a profit-based, technically specified system. "Medical school curricula should emphasize homeostasis and health, rather than only disease and diagnosis, and provide training in the science and practice of

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cost-effective health promotion. In turn, payers will need to reimburse for health maintenance and prevention activities, primary care physicians will have to act as health coaches, and all health care professionals will need to embrace a coordinated multidisciplinary team approach. Systematic steps must also be taken to change the culture of medicine so that primary care is valued." (Marvasti, Stafford 2014). According to the same article, cardiovascular disease, cancer, and diabetes contribute to 70% of U.S. deaths and account for 75% of healthcare expenditures. Thus, the majority of health expenditures go towards the last 6 months of life when diseases are terminal and death is near.

So where did this all start, and where is it going? The birth of "sick care" came from the Nightingale ward from the 19th century. These were, "open-plan dormitories for 24-30 patients. The wards are now considered undesirable by the Department of Health (DH), which reports that they offer 'very little personal privacy or peace. They were the dominant form of UK hospital ward before 1948, and a significant number Staticflickr.com. Nightingale Ward

remain in use" (Lomas, Giridharan 1). As so little was

known back in the day about sickness, germs, or bacteria, the best that doctors could do was treat sickness as the patients requested. This was the birth of the system that remains ideologically unchanged. However many studies conducted in the 20th century

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revealed correlations between unhealthy habits such as smoking and highly processed food with terminal diseases. And in combination with wearable biometric readers such as wrist devices that include pedometers and heart rate monitors, gathering data combined with the internet of things make current times exceptionally receptive to revolutionary change. Again, the key is in prevention. If you can't afford to be sick for a year, then if you're going to get sick, be sick for the time you can afford to be, or don't be sick at all. This is the ideal situation: shortening the timeline for terminal disease and sickness. Nearly all senescent people suffer from a terminal illness during the final year(s) of life, however if life expectancy is static and markers of morbidity are dynamic, then the farther back one can push the onset of the onset of terminal disease, the better the overall quality of life will be. The technical term is Compression of Morbidity and it occurs when the age of the first appearance of chronic disease increases more rapidly than life expectancy (Fries 2005). It is an interesting concept that through incentivizing people to live healthier lifestyle that they can reduce the amount of time spent in the terminal disease phase and therefore increase the amount of time spent actually living rather than worrying about morbidity.

The French Healthcare System ranks first in the world. We could learn a few things from them. First of all, France has a mostly socialized health system with part private care, in which its government spends 53% of GDP as compared to the U.S., which spends 36%. In the article, $200 Minus $200, an American lady living in France compares the French welfare system with that of the U.S., in the context of being pregnant and having a child after living there for 6 months. One of the main points outlined in her article is that pricing for health related costs is very predictable in France

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as the government sets fair prices for appointments and procedures. In addition, transparency in the price of medical care is a legal requirement in France. For example, getting an ultrasound in the U.S. can run you (without insurance) anywhere from $200$2000 (Lundberg 2014). As new immigrant, without her Care Vitale, which is a French insurance policy card, it cost her $200 out of pocket beforehand, which she was fully reimbursed for later. In California, out of 100,000 complication free baby deliveries, clients were charged anywhere from $3,200 - $37,000, whereas in France the author paid $542 for a five day stay at a private clinic. So what we can learn is that in a highly lucrative field such as healthcare, government needs to step in to regulate prices, when there is such a great knowledge gap between patient and doctor. There are laws and institutions in the French government that oversee any spike in medicine pricing to ultimately prevent fraudulent drug pricing. These are the measures that only a socialized system would offer, which is exactly the model that needs to be immediately implemented here at home.

And maybe, as a country we should not spend an exorbitant amount of military spending, as we spend 37% of the total global defense expenditure and 3% of our GDP. The amount of resources spent overseas on preventative care is immense, policing the world to prevent communism, external conflicts, and to prevent threats. For example, according to the Congressional Research Service, the United States in 2007 had nearly 150,000 troops in Iraq and Afghanistan, spending $5.15 billion per month to sustain this conflict. During all post 9/11 conflicts involving Iraq, Afghanistan and others, the U.S. spent over 1.147 trillion dollars. Among these expenditures, many of them are unnecessary. Many of the foreign matters the United States involves itself in are money

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pits. Often times when a foreign country is entered militarily, plans are to discover the threats, build military infrastructure, eliminate the perceived threats, establish and rebuild diplomatic relations and build new infrastructure. We have comprehensive plans for the overtaking of other regimes, but do we have such a thing for our own citizens' health?

Unregulated prices in healthcare are a large problem to patients. Procedures and medicine costs exponentially more in the U.S. than the same medications in other countries. Unfettered price gauging is commonplace because the system is for-profit, allowing companies such as Turing Pharmaceuticals to raise the price of Daraprim by 5,500%, from $13.50 a pill to $750 (Mullin 2015). If the U.S. spends 17% of

trbimage.com. Martin Shkreli indictment

GPD on healthcare expenditures and France

spends 11% of GDP, how can a system exist in which country A (France) has no uninsured citizens and country B (U.S.), 1/6 of citizens are uninsured? Much of it has to do with unnecessary pricing that feeds back into the pockets of healthcare facilitators.

Almost 1 million people a year go bankrupt from ridiculous medical bills (Fleetwood 2013). a CT scan in Taiwan costs $100 when the same scan with the same technology costs $1200 in the U.S. This makes for situations in which people with dual citizenship to other well ranked nations in healthcare could travel thousands of miles away and still pay less for medical care than to stay in the U.S. This is not a practical solution.

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Another reason why healthcare is so expensive is because of medical inefficiencies, or waste. In April 2008, PricewaterhouseCoopers held their 180 degrees Health Forum in Washington D.C., bringing together government representatives, and drivers in the healthcare and insurance arenas to determine new approaches to solving some of the health systems largest problems. As part of this conference, PrC interviewed 20 participants and reviewed 35 studies about waste and inefficiency as well as surveying 1,000 customers to understand the public perception of these problems. They key findings were that wasteful spending in healthcare has been calculated at $1.2 trillion or the $2.2 trillion spent in the United States, and that the largest perpetrator is defensive medicine, meaning redundant or inappropriate tests or procedures. According to PwC, the three major factors driving healthcare costs up are: "Behavioral, where individual behaviors are shown to lead to health problems, and have potential opportunities for earlier, non-medical interventions. Clinical, where edical are itself is considered inappropriate, entailing overuse, misuse, or under-use of particular interventions, missed opportunities for earlier interventions, and overt errors leading to quality problems for the patient, plus cost and rework. Operational, where administrative or other business processes appear to add costs without creating value. When added together, the opportunities for eliminating wasteful spending add up to as much as $1.2 trillion. The impact of issues such as non-adherence to medical advice and prescriptions, alcohol abuse, smoking and obsesity are exponential, and fall into all three baskets" (PwC 2008).

Medical waste and consumer satisfaction are inextricably linked. As mentioned earlier, the United States healthcare system is largely built on an acute treatment

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system, in which treatments are given post-diagnosis to try and solve the problems that could have been avoided in the first place, which is preventative care. It makes sense then that Americans go to their doctors for many health related problems asking for fixes. These fixes are usually dealt with in terms of prescriptions for many reasons. One reason is that the doctor may actually believe that a certain drug may fix a problem such as hypertension, or high blood pressure, or ADHD. Many of these issues that we as a nation plague us can be very successfully treated with alternative methods or with preventative care. These methods include diet, exercise, nutrition, and stress management. Lifestyle changes are the most effective way to curb acquired acute disorders or to increase morbidity compression. In 2011, people aged 0-18 were prescribed an average of 4 prescriptions, and people aged 65 and over were prescribed an average of 31 prescriptions per year (Mercola 2011). Examples of misprescription include the increased use of anti-Parkinson's drugs to treat drug-induced parkinsonism caused by the heartburn drug metoclopramide (REGLAN) or by some of the older antipsychotic drugs. Also, an increased use of laxatives in people with decreased bowel activity that has been caused by antihistamines such as diphenhydramine (BENADRYLE), antidepressants such as amitriptyline (ELAVIL) or some antipsychotic drugs such as thioridazine (MELLARIL). Thus, we see the issue with treating prescription problems with more prescriptions.

Unfortunately, although Medicaid and Medicare were steps in the right direction, prices will undoubtedly remain high despite future changes. Although population health is the next step for the American healthcare system, one must keep in mind that this trend is profit driven. Again, the step that the system needs to take is one towards

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socialized medicine. The reason why population health, healthcare consumerism, and retail healthcare are over hyped and dramatized is that they allow the provider to lower expenditures while providing the same care. Large scale hospitals often cost in excess of $350-500/square foot to build, whereas clinics and retail based clinics cost $200300/square foot. This is purely why there is a shift from the large hospital to the smaller clinic. Many surgeries and operations can be done in a sized-down facility, essentially decentralizing service. So population health is just another attempt to increase profits.

The way that population health is accomplished is through engineering a system that does have some perks; this is known as healthcare consumerism.

Healthcare consumerism is a system which advocates patients' involvement in their own healthcare decisions, which is a departure from the doctor says/patient does model. It essentially is a system in which the patient shops for cost effective treatments and products enabling consumer driven products to gain popularity. Chris Bernene from Oliver Wydman said, "We need a model that combines the convenience, access, and price transparency of retail with the quality and trust of traditional medicine". The complementing view is that providers need to be able to more successfully reach patients if services are to be sold to them. Consumerism, much like retail is concerned with the end to end experience of the user; designing the right products for the right price for the right person. This includes discussion forums in which patients can read reviews of doctors and operations, and patient portals in which patients can securely log in to upload data and view personal information. This is all driven by technology and personalized technology. By being able to track consumer trends as well as personal metric with wearable medical devices, healthcare providers will be able to more

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successfully design a more seamless experience for those in healthcare, allowing people to shop for the best services. This is what healthcare consumerism represents.

However, how successful is this "retail" approach to medical services? As healthcare costs are not only high for patients, but also for providers, in order to bring prices down, something must give. Healthcare in the U.S. is run like a private business; drive profits up by lowering overhead and increasing prices. The idea behind consumerism in healthcare is that by allowing consumers access to ratings, rankings, and health data, providers have financial skin in the game as they must compete for business. But is allowing people to manage their own care the best option while blindly applying thinking from consumer oriented businesses? Sachin Jain with Forbes magazine states that sick people do not like to shop for healthcare. Most people do not delight in buying a CAT scan or an MRI, or logging into their health portal. Optimizing purchases and decisions is the last thing on patients' minds. He also states that, " If healthcare were like any other consumer purchase, it would simply be a matter of buying the best service in every category. The reality is far more complicated—how the pieces fit together is just as important as the quality of individual parts". Meaning that people will pick and choose care at varying locations due to either quality or convenience. Most patients will make healthcare a destination if they know they will be receiving the best care for their money. And conversely there are other patients who do exactly the opposite, choosing convenience over quality of care. So sometimes the sum of the parts is worse, better, or different than the component parts. In addition, one size does not fit all. Sachin states that " Much healthcare remains about a patient’s human connection with their physician. There is an art and style to clinical medicine, and real

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variability what style patients respond to and prefer. As my colleague Brian Powers and I have written elsewhere, all physicians are not right for all patients—and vice versa.

Some patients will happily wait an hour in a waiting room if a physician spends quality time with them in the exam room whereas others will be furious at wait times regardless of the quality of the clinical interaction. Some patients prefer physicians who communicate directly, while others want bad news sugar-coated" (Sachin 2015). And lastly, healthcare is much about convenience. The last thing a sick patient wants to do is book a travel itinerary to travel hundreds or thousands of miles to receive treatment or therapy. Many patients prefer to be in the close comfort of friends, family, and loved ones. When patients have chronic diseases and need to make weekly or monthly visits to the doctor, they almost need convenience and the support of those who are close.

Thus, as consumerism in healthcare is an attempt to lower prices by cutting overhead, we see that healthcare is much more complex than retail.

Healthcare is such a complex and complicated system that it requires much more than innovative ideas. Patients vary so much that customized solutions are not only desirable, but also necessary. Patients need customized care that responds to their each and every need, so the next step in healthcare is really to materialize a more complete model from consumer-driven trends, looking at accurate models of patients' goals and priorities. Doing this allows providers to cut out waste, remedy health concerns with customized care, not prescriptions, and give patients ultimately the best bang for their buck that American healthcare can provide. It is only after prioritizing population health and adopting systems from other countries that we can start to see better value in the health system. For now, prescriptions are prescribed for prescription

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induced illness, wastefulness runs rampant, and prices are unregulated. However, new technology that records personal metrics is promising, allowing providers to customize care for patients as well as warn them of unhealthy habits. The future of healthcare lies in population health, and highly regulated practices, as to not distract from the altruism that healthcare should be. It is only when America's health system rids itself of the remnants of the acute care system that we will see a rise in global rankings and most importantly, a healthy population.

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Works Cited

Adams, John L. "Site-wide Navigation." Retail Health Care Clinics. Rand, n.d. Web. 23 Feb. 2016.

Fleetwood, Blake. "'Stupid' Spending on the Military and Health Care Is Leading to National Suicide." The Huffington Post. TheHuffingtonPost.com, 2013. Web. 19 Feb. 2016.

Jain, Sachin H. "Getting Consumerism Right In Healthcare." Forbes. Forbes Magazine, Oct.Nov. 2015. Web. 23 Feb. 2016.

Kamrany, Nake M., Jessica Greenhalg, and Rohini Chugani. "Obamacare vs. the French Health Care System." The Huffington Post. The Huffington Post, 1 Oct. 2014. Web. 23 Feb. 2016.

Lundberg, Claire. "In France, a “Costly” Doctor’s Appointment Is Actually Free." Slate. Slate, 27 Jan. 2014. Web. 23 Feb. 2016.

Mullin, Emily. "Turing Pharma Says Daraprim Availability Will Be Unaffected By Shkreli Arrest." Forbes. Forbes Magazine, 21 Dec. 2015. Web. 19 Feb. 2016.

"RETAIL HEALTH CLINICS: STATE LEGISLATION AND LAWS." National Conference of State Legislators. Ncl.org, 11 Nov. 2011. Web. 14 Feb. 2016.

Yoder, Ed. "What Retail Can Do for Healthcare." Radiology Management, 35.3 (2013): 43.

Davis, Karen, and Jeromie Ballreich. "Equitable Access to Care-How the United States Ranks Internationally." - The Commonwealth Fund. N.p., 27 Oct. 2014. Web. 23 Feb. 2016.

FRIES, J. F. (2005), The Compression of Morbidity. Milbank Quarterly, 83: 801–823. doi: 10.1111/j.1468-0009.2005.00401.x Lomas, K. J., Giridharan, R., Short, C. A., & Fair, A. J. (2012). Resilience of 'nightingale' hospital wards in a changing climate. Building Services Engineering Research & Technology, 33(1), 81-103. doi:http://dx.doi.org.proxy.library.cpp.edu/10.1177/0143624411432012 Fleetwood, Blake. "'Stupid' Spending on the Military and Health Care Is Leading to National Suicide." The Huffington Post. TheHuffingtonPost.com, 2013. Web. 19 Feb. 2016.

Marvasti, Farshad Fani, and Randall S. Stafford. "From “Sick Care” to Health Care: Reengineering Prevention into the U.S. System." The New England Journal of Medicine.

U.S. National Library of Medicine, 6 Sept. 2012. Web. 23 Feb. 2016.

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"The Price of Excess: Identifying Waste in Healthcare Spending." PwC. PricewaterhouseCoopers, 2008. Web. 01 Mar. 2016.

"Experts Say Overprescription Is Rampant." Mercola.com. Dr. Mercola, 2 July 2011. Web. 06 Mar. 2016.