Thoughts on the Healthcare Debate

I have many years of experience in the IT side of the healthcare industry, having worked for ten years at a major medical center (the Mayo Clinic) renowned for its efficient and high quality healthcare system.  I also worked nearly three years for a major nonprofit that provided healthcare (and other support) to those in need, worked for three years in support of the Veterans’ Health Administration, worked with the Red Cross and UNICEF while Director of IT at a company that provided services to nonprofits, and worked for a year or so as a contractor supporting a small company in the medical insurance industry.

I’ve also dealt with the challenges of attempting to provide healthcare for myself and my family as a self employed, underemployed and unemployed person.  Finally, in my current status as a student working towards ordination, I am constantly meeting and working with those who are underserved, if they are served at all, by our current healthcare system.

In other words, I’ve seen many aspects of our current  medical system, and its’ evolution over the last 20 years or so, from the “inside” – working closely with Physicians, Nurses, Technicians and other support personnel; as well as from the “outside” as a person looking for affordable and reasonably good quality healthcare services and insurance.

Let’s start with the obvious: the current system is evolving in an unsustainable direction, of providing high quality healthcare to fewer and fewer people, with costs rising at a rate that significantly exceeds inflation, meaning that we pay more and more each year while getting less and less for each dollar we spend.  In other words, it’s broken, and it will get worse, much worse, in the foreseeable future.

That good quality healthcare at a reasonable cost can be achieved is a certainty: the Mayo Clinic does so by providing highly centralized, well integrated services to its patients, supported by sophisticated manual and automated systems that ensure that each and every physician seeing a patient has accurate and timely information when they need it, and that every patient is able to rapidly get all of the tests and procedures they need for a correct diagnosis, followed by a course of treatment that works hard to take into account all of the complexities presented by the patient’s medical history and condition.  No wonder Mayo is rated as the best place to go for treatment of complex cases involving multiple disease processes.

What’s really astounding is that Mayo does all this for a cost much less than most other medical practices can achieve.  This is due not only to the volume of patients Mayo sees, but also due to Mayo’s sustained (nearly century-long) effort  to integrate and standardize medical care while ensuring a consistently high level of care and quality across every medical discipline in the practice.

There has been much talk of how the implementation of databases for patient medical records and the building of interfaces to allow such databases to talk to each other will be a “golden bullet” for high quality medical care.  I’ll agree, as one who played a significant role in the building of such systems at Mayo, that such systems are needed.  But, let’s not forget that Mayo built such systems itself primarily due to their need to share medical information and test results rapidly, if not simultaneously, among multiple healthcare professionals.  Paper-based mechanisms to store and share such information, and ensure its consistency and quality, had already been in place at Mayo for decades.  The business case for the expense of such automation was built on the need to speed access and to handle the ever increasing volume of such information.  The quality of the data, and the quality of the care itself, was already there.

In other words, automation is a great tool in healthcare: one that can provide great benefits, but an infrastructure that can take advantage of such high quality information must be in place, too.  That requires the creation of business processes to acquire, manage and utilize such information.  It means rethinking how medical practices (hospitals, labs, doctors, insurers, and other healthcare professionals, services or organizations) are managed internally, how they interact with each other, how they are regulated, and how they are compensated for their efforts.

It is not a small task.  It cannot be done piecemeal, and we cannot afford to avoid the challenge of doing so any longer: if you want to have a healthcare system that can meet your needs ten or twenty years from now, then we need to begin to make such changes now, as it will take years to implement such changes across thousands of medical institutions, hundreds of thousands (if not millions) of healthcare professionals, and within every government agency, hundreds of insurers, and thousands of companies that are involved in every aspect of healthcare.

The changes also impact our schools, which need to train not only new healthcare professionals, and retraining many of  those already in the field, but also ensure the correct mix of skills are being taught – not just in terms of ensuring enough Primary Care physicians are there, but training thousands of new administrators skilled in managing to ensure high quality, or skilled in integrating systems and practices: not skilled just in generating maximum profits for their employers.

The system cannot fix itself.  Only external pressure can redirect current trends into a more constructive direction.  Any person with knowledge of business ethics will tell you that a company that ignores or avoids social responsiblity for its actions will always be able to provide services cheaper than those that do seek to be socially responsible: just as it’s always cheaper to dump raw sewage and chemical waste into a river than it is to clean it up.

In terms of healthcare, it is always cheaper and more profitable to squeeze those individuals out of the system who are likely to incur greater healthcare costs.  This includes the elderly, those with chronic medical conditions, or anyone with an increased risk of becoming ill.  We see this in the ever increasing list of “pre-existing medical conditions” that are not covered by insurers.

On the other hand, as insurance costs increase, it becomes more and more desirable for those of us who are healthy to simply avoid buying insurance.  We put off doing so as long as possible, and only buy insurance when we get older, and/or think we’re likely to need it.  This is a major problem because it means we are not paying into the system: we’re expecting the money to somehow magically be there when we need it ten or twenty years from now, even though we have not put anything into the “bank” for our own future medical care.

Who then is paying?  We are: those who do have insurance have to foot the bill, either in terms of paying more for insurance (to cover for those who refuse to pay into the system, or who cannot afford insurance to begin with), and the escalation of costs at hospitals due to the need to pay for expensive emergency room care for those without insurance.

Every aspect of the healthcare industry is facing greater and greater challenges every day because of the current situation.  Insurance companies have to cope with an unbalanced pool of “customers” for their services and have to cope with competitors who seek to increase profits by reducing costs through reduced insurance coverage in their policies, excluding more potentially costly clients, and finding new ways to avoid or delay payment for covered services.  Hospitals have to deal with increasing malpractice and emergency room costs.  Doctors are avoiding critical professions (such as obstetrics and pediatric care) due to the high costs of malpractice insurance.

We all feel the impact of overall inefficiencies of the system due to inadequate and management and sharing of healthcare information among (and even within) healthcare organizations and individuals.  We all pay for payment practices that encourage volume over quality, and for insurance rates that discourage or prevent many from getting insurance at all (which simply raises costs for everyone else).

We have vicious circle after vicious circle – an ever escalating mess that can only get worse, and which will rapidly escalate with each passing year: like the compound interest on an overdue credit card bill.

Those who think they are safe from loss of benefits or “rationing” of healthcare in the future are kidding themselves.  Within the lifetimes of most of those reading this, we are likely to see a situation where only the extremely wealthy will be able to afford decent quality healthcare — assuming the entire system doesn’t collapse well before then.

President Obama’s speech before the joint houses of Congress earlier this week certainly contained suggestions for healthcare reform that not everyone agrees with.  (Even I, a [relatively] Liberal Democrat, don’t agree with all of his suggestions!)

Yet, he had a critical message that we must all take seriously: the overhyped and overheated posturing we’ve seen from both liberals and conservatives must stop.  If the attempts that we’ve seen to derail reform through ridiculously overblown rhetoric succeed, then we will all lose.  No matter how good your healthcare is at present, the course we are on as a nation will inevitably turn all of us into “losers” if changes are not made.  A debate that is reasoned and constructive, one where moderation and respect are the order of the day for everyone at the table, is the only way that our healthcare system can be reformed.

As Obama has said, the status quo is not an option: if you don’t like the proposals on the table, then provide an alternative and back it up with facts.  Those who work to destroy the opposition’s position in a game where political “points” are all that matter are being irresponsible and playing with fire: they are putting everyone at risk, including themselves.  If they succeed in derailing healthcare reform, it will be a Pyrrhic victory: one where they will be called upon to pay the price for their irresponsible actions far sooner than they can imagine.

Copyright (c) 2009, Allen Vander Meulen III, all rights reserved.  I’m happy to share my writings with you, as long as you are not seeking (or getting) financial benefit for doing so, and as long as proper credit for my authorship is given (via a credit that mentions my name or provides a link back to this site).