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Jay Parkinson

The Road to Wellville


Booger Hollow Road, Dover, Arkansas. Photo: Windy Richardson

I grew up outside St. Louis, Missouri. When I was a child, my grandparents lived in northern Arkansas. I made that road trip countless times. I distinctly remember riding in the backseat as we crossed the state line and noticing that the two-lane Missouri highway became almost gravel the second we entered Arkansas. I always wondered why the road had to change just because we traversed a border. I now know the reason. When decisions and processes are left up to the whims of individuals and municipalities, a patchwork of solutions results. Such decisions feel and act different. They are often dysfunctional. They don't work together to form a true interoperable, efficient system focused on an excellent experience for each user. Our healthcare "system" is a perfect example. Unlike the interstate highway system, which did produce smooth roads across state lines, healthcare wasn't designed. It just happened. And you, the patient, had no say in it.

One hundred years ago, our nation's health looked totally different from today. The six leading causes of death in the U.S. were pneumonia, influenza, tuberculosis, diarrhea, heart disease and stroke. The average life expectancy was 47 years. Ninety-five percent of all births took place at home. People who called themselves doctors hung up their shingles and used the latest potions to heal their neighbors. They got paid when their patients were sick and wrote an entire medical history on a 3x5 index card. Only 10 percent of all U.S. physicians graduated from college. The best doctors who had degrees merged and formed institutions that eventually became Johns Hopkins and Harvard and all the other greats.

In the past 100 years, we've sure come a long way. We invented antibiotics and cleaned our water, so there's much less pneumonia, flu, tuberculosis and diarrhea. The average American dies at 78 years, although a 65-year-old today will live only six years longer than a 65-year-old did a century ago. The 30 extra years of average life expectancy can mostly be attributed to our ability to save young people with antibiotics, clean water and vaccinations. Healthcare has always been best with relatively simple problems: illnesses that can be mitigated with a pill, prevented with a shot, or cured by a scalpel. In fact, that's why hospitals were built — to treat people with acute conditions such as tuberculosis and pneumonia. Now we're left with a bunch of infrastructure designed for acute problems but a country full of complex chronic behavior problems — obese elderly folks who've terrorized their bodies for a half-century with processed food, stress, and couches. And we don't have a pill that erases 50 years of unhealthy behavior.

Doctors still have very little idea about how to get you to change your behavior and live better. That's not what we've historically done nor is it part of our training. Also, there's no money in preventing office visits and surgeries. We prescribe and we operate as much as we can. That is our healthcare "system." The more diseases individual doctors can diagnose or invent, the more they make from the insurance companies that pay your bills. In reality, our system wasn't designed to keep you well; it was designed to profit off your sickness.

And how we deliver healthcare hasn't changed much in the past 100 years. You still see the doctor in an exam room, after you've become sick. Doctors still get paid for your sickness. We operate with robots and write about it in your paper chart — only 20 percent of doctors use computers. You call to make an appointment for a mammogram two months out. In the waiting room for your preventive visit, you're infected by people who are there to be cured of their diseases. The traditional exam room and sick visits made sense when we, as a nation, suffered mostly from acute illnesses. But our country now has different needs.

Let's pat ourselves on the back. We solved the simple acute problems. Now we have to tackle the complex chronic problems. Currently, healthcare delivery in America is a messy business full of convoluted processes that tries to provide all things to all people. We need to clean up how we deliver healthcare and start creating focused services that allow all players to do what they do best. We need a system designed around our nation's health needs — chronic care management, prevention and acute care treatment — not history, doctors and their profitability.

We need designers to create from the ground up a new, sustainable, healthcare experience that's split into three arms, each paid for with different business models than are applied today. Most important, these three systems should be focused on your needs, interoperable and powered by a platform that looks and functions like a secure Facebook designed to power health communication. You would be able to schedule your own appointments and email, IM, and videochat with your health professionals. You'd also have a guide, an expert in medical triage, to show you what kind of professional you need, how much you should spend, and who would be best for you in your area.

The first arm is run by doctors and focuses on acute illnesses like appendicitis and broken hips. We're really good at solving those problems. Ninety-five percent of the time, a hip replacement is a standard process, much like manufacturing a car, without costly surprises. So these would be paid for by a flat rate per fix with bonuses for efficiency and quality.

The second arm focuses on prevention. This would be run by wellness experts. Doctors aren't good at keeping you well, nor are we trained in it. So we would turn this duty over to experts who are paid for prevention. Also, if you're well, why should you be sharing examination or consultation space with sick people? There would be recommended preventive services for each age and gender. These services would be yearly fixed costs. Wellness experts would be paid on a per-member, per-year basis with bonuses for volume.

The third focuses on treating and managing behavioral-based chronic diseases like diabetes, obesity and congestive heart failure. In this system, doctors would only be involved in the treatment of complications of chronic disease, not the day-to-day management of disease. Currently, you spend only about 1 hour per year with your doctor and 8,765 hours on your own. Again, we're no good at changing behavior. So we would turn this over to professionals who'd keep you out of our office by managing your diseases on an everyday basis. This is the most important arm because 75 percent of $2.5 trillion comes from chronic diseases. Disease managers who can help you with education and support on an almost daily basis would run this system. Doctors would be paid a flat rate per fix when disease management failed. Disease managers would be paid on a per-member per-year basis depending on the complexity of individual patients, with bonuses for keeping you out of the sickness industry.

We should start designing this system now. It currently costs employers about $13,000 per employee per year. In 2019, it will cost $28,500. That's simply not sustainable. Soon only the wealthy will be able to afford today's version of healthcare. And the only way to save our nation's health is to redesign how we pay for healthcare in conjunction with innovative, intelligent, user-centric healthcare delivery. Many say this is impossible. But it's simple supply and demand. You, a nation of people wanting a better, more affordable experience that keeps you well, are the demand. This new system is the supply. Demand something better, and someone will supply it. Isn't that how the world works?


Posted in: Health + Safety, Ideas

Comment 11  |     |     |   Like 0  |   Tweet 1
Comments [11]
This makes sense to me.

Organize the demand to make it heard.
Terri Swiatek
12.23.09
04:46

This is by far the most sensible health care argument I've ever heard.

If an initiative such as the one you've described should go forward, I would be more than willing to get involved in any way possible to make it a reality.
Jeremy Swinarton
12.24.09
03:25

The irony is that the 3rd arm is already being built... by payers. They benefit the most from keeping people well.
Chris
12.24.09
04:21

This is one of the best things I've read in a long time. If there is anyway a student can help, please let me know.
David
12.27.09
12:25

The average life expectancy 100 years ago most definitely wasn't 47, but 60. The numbers have been skewed in support of big pharma.
Robert
12.27.09
08:56

I was going to write a similar blog concerning this topic, you beat me to it. You did a nice job! Thanks and well add your rss to come categories on our blogs. Thanks so much, Jon B.
Motion Graphic Design
Fundoo
12.28.09
06:41

Well done - this does make sense and would be a lot better than the way things are now. Please keep this message alive and well!
Jimmy
12.29.09
11:13

You see hints of insight into these issues in various health settings. The clinic I take my daughter to separates waiting rooms for those with contagious sicknesses and those coming for routine checkups or other problems.
Larry Irons, Ph.D.
01.15.10
11:55

Dr. Parkinson,

I am a retired health educator and health services administrator. Prevention and wellness education is not something insurance is willing to pay for at this time. This part of health and staying healthy is almost long lost-up to each individual. We do seem to have a society where most people are not very healthy.

In my mornings paper today, Arizona Republic, there is a very large article about lack of Primary docs in rural areas;however, it is also true in the big metro area of Phoenix. Doc's are jumping out right and left of Medicare assignment. The impact of this seems to leave us with the elderly paying for individual insurance (the highest cost that I know of in this system).

This system is broken, but it is a $64,000 question as to how it could be fixed. All parties-health care providers, hospitals, pharmacy, administrators, government officals do not appear to be able to agree on anything. We all seems to be children in a sand pile fighting over who gets to keep the goodies in the box.
Kathy Clevenger-Burdell
01.24.10
12:18

Excellent article and I agree fully.

The difficulty is that many people believe that health care should just "be there for them" and do not understand that their health depends on being actively involved in their own care...not a passive recipient of care.

Your vision has the potentially to engage more patients more actively.

I'll admit that not all patients will be able to participate in a system that you outline, but if those who could, did, then we would be on our way to transforming the system.

As a family physician in Canada, I can say that for many providers and patients, things are going from bad to worse. We have "free health care" which we pay for with relatively high levels of taxation but cannot necessarily access care when we need it.

In Canada, huge amounts of tax money is going to measuring a few wait times and not providing care...Canada is beginning to become an expert in how NOT to deliver care. Very sad.

Our system needs to change as well.

Thanks for your most original thinking and creative expression, as always.

Dr. Merrilee Fullerton
02.05.10
12:07

I would love to love this article but I can't.
In theory, it is great, but in a health insurance system nothing sounds as bad as it can get when implemented and gamed on by companies.
A simple example where it usually goes wrong - without it being part of the "plan": the sudden difficulty and extra bureaucracy when real sickness activates the policy. This can never be changed by any bill because the measure of effort is not quantifiable. A sick person calling on a policy, usually gets reverted back to someone in a call center where they have to battle - while sick - to the rights they supposedly have. Because it they do a misstep and try to rush the process - because they do not feel well - they will have to pay for the "mistake". After paying $5000/year for years, while healthy, and doing solely annual blood work, one's policy is suddenly questioned….
Second example: many "hospitalizations" are already actually managed by external protocol clinics which allow insurance companies to theoretically cover hospital costs in their policies and then actually avoid paying them. In many policies, you find out your "hospitalization" costs amounts to a few cotton pads….

Unfortunately, the 3 proposals you propose fall back in 2 of its own named pitfalls:
- doctors will receive money for your sickness
- insurances will profit from avoiding to treat patients

All this can be still powered up by:
- diagnosis risk sharing

1. "The first arm is run by doctors and focuses on acute illnesses like appendicitis and broken hips."
The doctor here is an ever increasing mechanic which receives an already diagnosed patient, and puts him through an automated procedure for his "type" of problem. Increasing pressure from Insurance Companies will increase the probability that your "type" of problem can only be solved by 1 "type" of way. This opens the way to automated care (as automated responses in call centers) in the sole only place where doctors still existed, under this new plan.
Not all doctors specialties are as clear-cut as those of surgeons.

2. "The second arm focuses on prevention. This would be run by wellness experts. Doctors aren't good at keeping you well, nor are we trained in it."
Maybe you should.
The first step in having good health might be to actually believe that doctors will tell you something that you do not know before, and which you might have not requested, and which you have to respect. Again, though many doctors might give you too much care you do not need, others will actually be interested in your welfare and use your annual visit to check for anything you might have without knowing so.
Family doctors - an actual expertise - focuses exactly on following individuals within their genetic context and history so that health conditions are seen from their possibly unique perspectives (on the rise rare diseases are just a branch of the real potential of diversifying/differentiating illnesses).
How many people will voluntarily go to prevention?
If annual checks are made mandatory (as in "recommended preventive services" which would constantly rise) - maybe a bit more people have to go. But it does sound like one more fee to add to the ones paid to the ever availability of the doctor.
And the prevention seems to be the proposed as a place that might become a filter between a probable patient and the doctor in case you actually have something mild or serious but with mild symptoms.
As well, this creates risk sharing between doctors and prevention offices with convoluted modes by which diagnosis liability could never be uncovered.

3. "The third focuses on treating and managing behavioral-based chronic diseases like diabetes, obesity and congestive heart failure."
"Again, we're no good at changing behavior."

Again, maybe you should be. If a doctor is not listened to, why would someone with a liability proof bullet-point of things a patient has to do, be of sudden interest to the patient? He can read it thousandfold online. Appearing in the office might actually make him liable to comply with them by committing to buy some pills. Not complying (and not paying $200 for a pill that costs $10) might deem the patient "irresponsible", and subject it to loose his coverage later on - when they finally needed it.

"So we would turn this over to professionals who'd keep you out of our office by managing your diseases on an everyday basis."
Yes, they would. But they could also keep patients out of their own offices, or make themselves available only through large fees.
Also, how many illnesses would become categorized "behavioral-based chronic": few cancers?


The truth is that the more you automatize diagnosis and convert into typologies for care at the main selection/triage level, the less specific you are about the uniqueness of the patients and the more you are separating medicine from knowledge that is acquired through know-how (the difference of the cases within similar conditions), the more you are fostering under-qualified doctors and promote liability-free care which is not dignifying to patients (which we all ultimately are).

The proposal focuses on the problem raised by patients, and dedicates no time to the possibility that an insurance system that has too many closed gates and opacities is what really inflates costs.
Also, by creating easy typologies of care for the doctors it increasingly fosters their specialization, while slowly devaluing the role of holistic doctors. The more you simplify knowledge, the more you will open doors to oversimplification of education as well (2 years graduations on eye cataract surgery, anyone?). This increases its capacity to become meaninglessness of knowledge, lack of communication between experts and does not account or value approaches/expertises such as "internal medicine".

Unfortunately, the health care problem could get solved by raising and helping to raise conscious, aware human beings. Moderate and less wasteful in their habits but also informed and socially responsible, interested in the well-fare of others and available to think difficult subjects through, rather than playing along with oversimplified issues and unquestioning of what they know.
And could also get solved by educating doctors which have to be committed to actual medicine.
This, however, will never pass on a bill.
CL
09.28.10
09:03



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