No Man Is An Island
Remarks for the City Club in Boise, August 4, 2009:
Dr. John Symynges was one of London’s most successful physicians in the late 16th Century. He housed his family in upscale Cheapside, on Trinity Lane. He was wealthy, holding property in three counties, and widely respected throughout town. He was a senior member of the Royal Academy of Medicine. It is said he owed all of this to his shrewd business sense. His mantra for his medical practice was simple: “Before you meddle with (a patient) make your bargaine wisely now he is in paine.” Quite simply, he urged fledgling doctors to settle the fee for treatment while the patient was unable to really negotiate.
Dr. Symynges and his self-serving style of practicing the business of medicine, despite his pre-eminence during his own lifetime, would be entirely forgotten to us now, and deservedly so, but for the accident of history that by marriage he became the step-father of John Donne, one of England’s greatest poets. John Donne received training in the law and later in life took holy orders and became the Dean of St. Paul’s, where he served for the last decade of his life. By this time in his life, Donne had already become more famous than his step-father because of the poetry he had written. However, the sermons and meditations which he penned while a clergyman sealed his enduring fame. Once while too ill to arise from bed, he heard the church bell tolling and wrote his seventeenth Meditation: “Perchance he for whom this bell tolls may be so ill, as that he knows not it tolls for him; and perchance I may think myself so much better than I am, as that they who are about me, and see my state, may have caused it to toll for me, and I know not that. . . The bell doth toll for him that thinks it doth. . .No man is an island, entire of itself; every man is a piece of the continent, a part of the main. If a clod be washed away by the sea, Europe is the less, as well as if a promontory were, as well as if a manor of thy friend’s or of thine own were: any man’s death diminishes me, because I am involved in mankind, and therefore never send to know for whom the bell tolls; it tolls for thee. . .Another man may be sick, too, and sick to death, and this affliction may lie in his bowels, as gold in a mine, and be of no use to him; but this bell, that tells me of his affliction, digs out and applies that gold to me, if by this consideration of another’s danger I take mine own into contemplation.”
Here we have an entirely different approach to the possibilities that contact with illness provides than that of the opportunistic practitioner. For Donne, illness in another, no matter how remote our contact, is to be shared, contemplated, and learned from. Wealth generated from the sick comes not as coin, but as shared human experience, for which the observer can be grateful. Applied to my professional life in clinical care, Donne’s words signal me to accept my calling as a requirement to subsume my self-interest and seek to attach myself to a cause greater than my own, because I am involved in mankind. Donne would have all of us contemplate our own personal danger as we make ourselves aware of the afflictions of others.
These lessons of 300 years ago need relearning now. Medicine, once again, has been reduced to a business opportunity. In a nation where tens of millions have no financing for basic health care services, leading to tens of thousands of preventable deaths annually, our body politic has become paralyzed by a market oriented health policy. Bells are tolling yet we pretend that we are not diminished by the suffering of our fellow countrymen. We pretend that the afflictions of the uninsured are not ours to share, as if we individually are an island, entire of itself. This despite the fact that we pay twice as much per capita for health care than do the citizens of the rest of the developed world, mostly in the form of the highest per person taxes for health care in the world. What we are missing is the contemplation of our own danger. Americans are least likely in the developed world to avoid death amenable to health care. We have allowed the business of medicine to so deviate our health system from its principle mission that preventable injury to hospitalized patients has become the 5th leading cause of death in our country.
More than ten years ago, Tony Snow, who died from colon cancer while serving the Bush White House as press secretary, made this statement: “In the real world, people stampede when somebody slaps up a sign that reads “free”. This is the theory behind bargain basements, but it also applies to hip replacements and appendectomies.” This is Dr. Symynges approach to medicine reiterated in modern parlance and it makes no more sense now than it did then. I have never met a patient willing to have his appendix removed because a hospital had bargain basement appendectomies for sale. I doubt that Mr. Snow actually behaved this way when he was a patient. As far as I know, Mr. Snow did not attempt to start his course of chemotherapy before he had cancer because he found the drugs on sale. After having the experience of colon cancer, would he still maintain that Dr. Symynges’ approach, to make the bargain with the patient while he is yet in pain, is the correct one? Is medicine a commodity, efficiently traded and distributed by markets? Are patients shoppers or customers, or are they the people for whom the bell tolls?
The Wall Street Journal, an authority on markets and customers, may help us with an answer. A couple of years ago an opinion in the Journal published by John C. Goodman, President of the National Center for Policy Analysis, entitled “Perverse Incentives in Health Care” included this thought: “Research at Dartmouth Medical School suggests that if everyone in America went to the Mayo Clinic, our annual health-care bill would be 25% lower (more than $500 billion), and the average quality of care would improve. . .Of course, not everyone can get treatment at Mayo. . .But why are these examples of efficient, high quality care not being replicated all across the country? The answer is that high quality, low-cost care is not financially rewarding. Indeed, the opposite is true. Hospitals and doctors can make more money providing inefficient, mediocre care.”
If the statement that hospitals and doctors are paid to deliver inefficient, mediocre care confuses you, let me illustrate with data from a hospital in central Utah. In the mid-1990s, a family physician practicing at San Pete Community Hospital observed that patients presenting for treatment of pneumonia were not receiving optimal care and therefore were becoming sicker and dying more often than should have been the case. He organized a protocol for optimal treatment of community acquired pneumonia, persuaded every one of his physician colleagues at the hospital to follow it, and induced the hospital to adopt it. Almost overnight the care of pneumonia improved. 25% fewer patients became sick enough to require hospitalization. For those patients admitted to the hospital, length of stay dropped by 1/3. The length of time before the instigation of proper antibiotic treatment dropped by ¼. And the cost per case fell by one-half. This is the optimal outcome in a market: the quality of service goes up and the cost drops by half. In a functioning free market, the provider of such service should be handsomely rewarded. Unfortunately for San Pete Community Hospital, there was no reward. In fact, the amount paid for pneumonia care fell even more than per case cost; the hospital took a financial hit for providing better treatment for pneumonia. Hospitals and doctors get the best payments when they let their patients get as sick as possible. This is what Mr. Goodman meant when he said that there are perverse incentives in the American health care system. The fact that American health care pays doctors to harm patients through mediocre care is evidence that market principles are not at work in health care. A market does not have perverse incentives. And a market commodity does not have a lower price for higher quality. Health care is not a commodity. Dr. Symynges was wrong, the best bargains are not driven by the patient’s pain.
If you want further evidence that health care is not a market commodity, consider this: $1.5 trillion of our nation’s $2.5 trillion health economy comes from our taxes. What market is 60% tax funded? Why do we taxpayers agree to fund healthcare with so much tax money? Because, in our hearts and minds, we know that John Donne is right—any man’s death diminishes me. It matters to all of us whether the uninsured tuberculosis patient receives appropriate care; his illness places society at risk. In health care, we do not believe in caveat emptor, because the buyer is a patient, neither prepared nor able to shop. We place ethical obligations on physicians to serve their patients’ needs ahead of personal interest. John Donne was right: when it comes to health care, Americans have always known that no man is an island.
To be fair, it is not generally today’s health professional who is manipulating the moment of need created by injury and illness to extract profit. Rather, doctors are commonly victimized with their patients by the business model of American health insurance, illustrated by the following passage from the advertising literature of a California health insurer: “We believe that the cost of covering someone whose health can be predicted to require costly care should not be subsidized by someone with minimal health care needs. . .All enrollments are subject to medical underwriting. We may change or terminate coverage. . .with 30 days prior written notice.” In any given year, 80% of health care costs are accrued by only 20% of the population. But that bell tolls for each of us, because none of us have any way of knowing when illness or injury will strike within our family and place us within the costly highest quintile. If we have not forced change on the health insurance business model before that happens in our own household, we will be isolated on an island, entire of itself, making our health care bargain while we are in pain. Half of all personal bankruptcies in the US are caused by illness and injury. Half of households driven to bankruptcy by medical costs had health insurance at the time the health problem occurred.
These two examples, San Pete Community Hospital and the California health insurer, illustrate the two principle problems created by the modern American health business model: quality waste and inefficiency. Mr. Goodman, in his Wall Street Journal article, pointed out that if all Americans received the higher quality care delivered routinely at the Mayo Clinic, we could save $500 to $750 billion per year as a nation. In health care, unlike a commodity in a free market, higher quality costs less. Because as a nation we follow Tony Snow and pretend that health care is a market, where competition will drive better bargains, we get poor quality health care in three ways: we are given inappropriate or unnecessary care, we are injured by the care we receive, and as often as not, we do not receive proven clinical interventions at the proper time. The experience at San Pete Community Hospital demonstrates that if all of a region’s health professionals and institutions cooperate together to solve a community health problem, they can deliver higher quality care at a lower price, by eliminating unnecessary surgery and patient injury and consistently getting the care right the first time. This is how we can save up to $750 billion per year with quality improvement. But remember the poor reimbursement for improved pneumonia care at San Pete Community Hospital, which illustrates that our health financing system based on the health insurance business model must also change, or the efforts of doctors and nurses to improve care will go unrewarded and therefore not be sustained. Health insurers have a two part business model: exclude the potentially ill from coverage and creatively deny benefits. Both parts of the business model are expensive and distract from patient centered care. Credible estimates place the excess costs for the health insurance business model at $400 billion per year. Taken together, quality waste and inefficiency cost the American taxpayer about $1 trillion per year and 100,000 premature, preventable deaths.
There is another almost universally ignored cost of wasting $1 trillion each year on quality waste and inefficiency, and that is opportunity cost. What else could we be doing with that $1 trillion of wasted health care spending? As already stated, health care is principally funded through taxation and therefore competes for revenues with other tax funded enterprises, such as education. Because we spend a greater portion of our gross domestic product on health care than do other developed nations, we spend a lesser proportion on education. McKinsey and Co. recently released a report stating that if we had improved our education system over the past generation, our gross domestic product last year could have been as much as $2 trillion larger. That is one opportunity cost of health system waste. As a nation our businesses spend less on new product development than do those in other first world nations, in part because of ridiculous health care costs. American auto manufacturers have for many years spent $1200/car more on health care than has been true of their competitors in Japan and Germany. How has that affected the viability of the American auto manufacturing industry? The opportunity costs of health care spending in the US threaten our tax base and our economy, and therefore threaten our way of life.
Perhaps you are among those who remain hopeful that President Obama and the Congress are seriously working at solving our nation's health care crisis. If that’s the case then beat the rush and wallow in frustration now. Whatever health care bills are passed and signed this year will not forestall the coming health system meltdown for at least three reasons.First, Congress is principally debating how to cover the uninsured, as if that is the principal problem of our health system. Should we have a public plan option? Should we expand Medicare? Medicaid? Should there be a mandate to buy health insurance? Like Congress, Obama has joined Congress and has indicated that health system reform will require a massive infusion of tax money to cover the uninsured. Both Congress and Obama are wrong. The issue is not coverage, it is cost control, or more specifically, waste elimination. Per-capita taxation for health care is higher in the U.S. than anywhere else in the world. More than one-third of the $4 trillion collected in state and federal taxes this year will go to health care. If we limited health spending to just those tax dollars we would be spending more than any other nation on health care. Yet we add another $1 trillion to our health spending through private payment of employer premiums and family co-payments, co-insurance, deductibles, premiums, and outright individual purchase of care. Per-capita health spending is twice as high as it is in any other nation, and rising faster, because we waste up to half our health spending on inefficiency and poor quality. For example, overhead in American hospitals is five times higher than in other first-world nations and post-operative wound infections occur up to 10 times more often than should be the case, at an average cost of $14,000 per case. Wasteful health system spending is the direct and inherent result of the business models of American health corporations. What I call waste they call profit. These corporations spend $1 million per member of Congress per year on lobbying to defend their business models. Nobody has dared challenge them. Until they do, no amount of additional health spending will ever sustainably cover the uninsured, because half of each additional dollar will be wasted.Second, Obama frequently states that reform should build on what works, by which he means employment based health benefits. He often reassures those with insurance that they can keep the health benefits to which they currently cling. This is the premise of current American health system reform. Trouble is, nothing works, the whole system is dysfunctional. Former Health and Human Services Secretary Mike Leavitt has his own oft-repeated phrase: Medicare is only good at writing checks. He means this as a disparaging retort to those promoting "Medicare for all," but this is actually a tacit admission that, other than efficient claims payment, Medicare has not functioned significantly better than private sector payers in promoting quality and containing cost. Which means that Obama's premise is wrong, employee health benefits are riddled with faults, including poor quality, rising costs, inadequate coverage and ridiculously massive overhead. One of our nation's leaders in health system quality, Dr. Brent James of Intermountain Health Care, recently testifying before Congress, said the American health system pays doctors to harm patients. How does that leave any room to argue that we should be building on "what works"?
Third, not only is the wrong issue being discussed with the wrong premise, but I believe that Washington DC is the wrong venue for this discussion. Idaho and Utah both have higher than average health care quality and therefore lower than average health care costs. Why should we be forced into a federalized health system where national average costs will raise our health care expenditures? And why shouldn’t Louisiana, the state with the poorest quality and therefore the highest cost health care have the opportunity to learn from states that are succeeding? Justice Louis Brandeis once said that the states are the laboratories of democracy. If Congress acts at all on health care, it should act to set a minimum national standard for state performance and then provide a pathway for states which choose to improve on that minimum standard to negotiate out of federal rules and restrictions. A serious proposal has surfaced here in Idaho which would transform health system financing into a regulated monopoly, much like a public utility. Why shouldn’t Idaho have the opportunity to experiment with that proposal?
In summary, let me outline what will work for health system reform, regardless of the mechanism proposed for reform. I will suggest six criteria by which you will know whether Congress or other elected officials are presenting health system change favoring Dr. Symynges or John Donne. In Utah, one legislator once said that he was tired of hearing what people wanted to see in health system reform, he was much more interested in what they were willing to give up. That is a good standard for judging the prospects of a health system reform proposal. Since we want to give up wasting so much money on our health care system, we must be willing to give up some of the expensive parts of our health system business model. Here is my list of six health system practices which should be eliminated:
1) Health Underwriting: Every critically ill or injured person will be treated in our health system whether they have health insurance or not. Therefore, we should not waste resources trying to identify persons likely to have an expensive illness in order to exclude them by price or refusal from acquiring health financing. Community rating, guaranteed issue and risk sharing within the largest possible pool of beneficiaries will increase health system efficiency and eliminate the unfunded mandate that is called cost shifting. Cost shifting is the awkward administrative procedure conducted behind closed doors by health care providers wherein they make up for the cost of caring for the uninsured, non-paying patient by shifting that cost to those with a source of payment. Estimates in Utah place the impact of cost shifting on employer paid health benefits at about 20%, meaning about 1/5 of the cost of employment based health insurance pays the price for the self-serving practice of health underwriting.
2) Unsafe hospital practices: The fifth leading cause of death in the United States is preventable injury during hospitalization, which is associated with more deaths each year than are breast cancer, HIV or auto accidents. Caring for hospitalization associated injury wastes $30 billion each year, and could be virtually eliminated with relatively little upfront investment through standard mandatory public health surveillance methods.
3) Inappropriate care: Back fusion surgery for uncomplicated degenerative disc disease occurs tens of thousands of times each year, but there is no clinical evidence that this surgery reduces pain or impairment more than nonsurgical care. Like all surgical interventions, back fusion surgery is associated with many complications, including infection, bleeding, device failure, neurological problems and clotting. Many other common medical or surgical interventions are likewise inappropriately used without basis in clinical science at great expense. We need a society wide mechanism for applying clinical science to our health benefit. What we pay for communally should be those medical interventions supported by clinical science.
4) Perverse incentives: Let me reiterate Mr. Goodman’s comments from the Wall Street Journal on April 5, 2007: “Research at Dartmouth Medical School suggests that if everyone in America went to the Mayo Clinic, our annual health care bill would be 25% lower (more than $500 billion) and the average quality of care would improve. . . .Of course, not everyone can get treatment at Mayo. . .but why [is] this example of efficient, high-quality care not being replicated all across the country? The answer is that high-quality, low cost care is not financially rewarding. Indeed, the opposite is true. Hospitals and doctors can make more money providing inefficient, mediocre care.” Perverse incentives distract hospitals and doctors from their true mission: caring for patients.
5) Market-based health policy: If we are to eliminate the perverse incentives that lead to inefficient, mediocre care, we have to give up the cherished notion that health care is a commodity efficiently distributed by market forces. We do not principally fund health care through the private sector—60% of revenues paying for health services come from taxpayers, making our citizens more taxed for health care than any people in the world. Beyond that, health care is not subject to market forces, such as a lowered price increasing demand. No one ever had an appendectomy because the price was right. The rate of occurrence of illness and injury primarily determines demand for health services. Patients are not shoppers. They do not have the years of clinical experience necessary to make sense of symptoms, anticipate disease progression, or triage their health care needs. Most patients would be unable to even begin to generate a list of possible interventions for complicated symptom presentations. And what if, as so often happens, the principle presenting symptoms include immobility, altered consciousness, or agonal pain. What shopping can possibly be done then? This is exactly the situation which Dr. Symynges taught his medical students to exploit. 80% of the dollars expended on health care are spent in situations like this. To pretend that this spending represents market forces at work is to agree with Dr. Symynges that the health care bargain should be made while the patient is yet in pain. This market pretense has created a health-care ripoff with an annual cost of $1 trillion and 100,000 lives lost to preventable patient injury. Shopping is perhaps the quintessential American experience, but patients are not shoppers. Until Americans move beyond the medical market mirage, we will continue the self-inflicted damage to our economy, tax base, family finances, and health that is done by the medical-industrial complex and threatens the American way of life.
6) Benefit denial: Claims costs for health insurance are at least 10% higher in Utah than would be optimally efficient, a situation undoubtedly true of Idaho as well. This is due primarily to the health insurance business model which features competition among health plans to most creatively deny payment for health services. In response, doctors and hospitals staff up their billing departments to fight for payment, leading to billions of wasted dollars in Utah alone. US doctors and hospitals have overhead costs five times higher than international comparisons, mostly because they must conduct a massive guerilla billing effort in order to stay financially afloat. Benefit denial is one method of doing what Wendell Potter, former CIGNA Public Affairs director now outspoken health insurance critic, calls “dumping the sick”. He mentioned this term in multiple interviews he held during July 2009, as he was trying to explain the increasingly dysfunctional business model of health insurance. He points out that this business model is intended to (and does) maximize health insurance profits. I encourage everyone to take the time to find the July 10, 2009 recording of Bill Moyers’ interview of Wendell Potter on the web and view it.
When you see a health system reform proposal that is eliminating the health insurance business model, including underwriting and benefit denial, while improving quality by protecting patient safety and reducing inappropriate care, you can be sure that the principle objective of that reform proposal is cost control. We will get that kind of health system reform when we stop talking about market forces in medicine and instead speak about our shared social responsibility to care for the sick and injured. We pay for our roads and highways by taxing ourselves, even though no one has a Constitutional right to pavement, and no one calls these roads the socialized highway system. Likewise, we pay for very expensive, high tech hospitals, clinics, and medical education principally with taxes, and yet there is a pathologically insane degree of anxiety about socialized medicine. In 50 years, no one that I know of has made a serious proposal for government ownership of hospitals and government employment of doctors. I oppose socialized medicine, but I also recognize that market forces have no useful deployment in health care delivery. Highways and health care are both infrastructure needed by the 21st century American business and family. We share the responsibility for all infrastructure together, as a community.
We are currently witnessing a national discussion about our health system. This is the sixth time in 50 years that our nation has contemplated whether there might be a better way to finance the care of the sick and injured. This time is different. Health spending is on an unsustainable trajectory and the opportunity costs of $1 trillion in health system waste every year are threatening our tax base, our education system, our businesses, and our way of life. If Congress fails to eliminate health system waste, then we must be prepared to do so through state government. Let us embrace our current opportunity to redeem our health care system and reject health care as business opportunity. Remember, no man is an island, entire of itself. Every man is a piece of the continent, a part of the main. Never send to know for whom the bell tolls, it tolls for thee.
Dr. Joe Jarvis