Using a bazooka to swat a fly: the overinvestment in America's medical infrastructure
The medical system is becoming increasingly expensive and complex– with exponential growth of additional symptoms, diseases, fellowships, technology, standards of care, research studies, journals, and quality metrics on a yearly basis.
Thinking about all that is complex– and yet we expect our physician colleagues to run ever faster and do ever more with ever shrinking reimbursement for their time. Its no wonder they’re at wits end!
The problem in healthcare is a focus on doing/ knowing/ fixing more rather than doing what is necessary– making ever more investments in the “nice to have” without the financial counterbalance at the point of service.
Charlie Baker of Harvard Pilgrim highlights an excellent article in the Boston Globe titled “The folly of the 1% policy“. The premise of the article is the position that “if there is a 1% chance of
an approach to decision-making in American medicine that misallocates resources and undermines primary care. By focusing maximum resources on preventing an extremely rare but potentially disastrous outcome over necessary preventive care, this model has shaped healthcare decision-making in areas ranging from hysterectomies to coronary bypasses.
Hysterectomy is an informative example– many women with fibroids were told by doctors to have their uterus taken out– because they might have additional problems in the future.
The issue at stake is one that is similar to events being played out in the financial and real-estate arenas– having a strong understanding of risk and making prudent investments to maximize overall return on resources and efforts. However, in medicine we don’t have a strong understanding of risk/ probability, and our practitioners have been trained to take action that doesn’t leave them exposed if the worst happens–legally or in their own head. They follow the 1% doctrine.
Examples:
- General hospitals use regulation under the guise of “safety” and “fairness” to shut down outpatient surgical centers– rather than publishing safety statistics allowing people to avoid the worst offenders themselves (think how many restaurants with poor posted hygiene grades you’ve seen) or innovating to add additional value to recapture cherry-picked patients
- Primary care docs push regulations restricting usage of retail nurse practitioner clinics for everyday illnesses– taking away convenient access to professionals for many who now just stay at home
- Physicians need to be licensed (and potentially Board certified at some point) within the state they practice — the other states must really not be up to snuff
- Terminally ill patients can be legally prevented from trying experimental therapies– I guess the new therapies may kill them
- Developing tough FDA requirements for drug safety cited to cost $800M per success– preventing a number of risky, innovative ideas from being explored commercially at all
- Insurance mandates in the state of NY and MA make insurance 2-3X more expensive than low premium plans in states like CA
So we have well-meaning people, trying to prevent a catastrophic outcome if they do nothing…and they forget about all the collateral damage of the action they do take.
Ultimately, nothing is completely safe and spending huge sums in the hopes of engineering a different outcome is an exercise in futility. A bazooka will kill a fly, but wipe out everything else around it as well. And by requiring these over engineered solutions at the “flat of the curve”, we raise costs dramatically with little to no (and potentially negative) benefit.
Add in other aspects of life– education, housing, transportation, nutrition– and we see that massive additional spending in medical care can cause a net detriment to the “beneficiary’s” overall health status.
We have a responsible system when we provide an appropriate level of resource to address the complexity/severity of a problem and its solution. This is where the over engineered health system of today will break and markets will start dictating the appropriate level of care for the complex needs and circumstances of individuals.
