Lightning goes to ground

I respect and admire Lucien Engelen, the spirit behind the REshape Center for Innovation at Radboud University Medical Center in the Netherlands, so when he recently posted an article entitled, "10 TED talks that change(d) healthcare," I was intrigued.  Who doesn't love TED talks, after all?

But then I concluded that he was off base.

Not because the talks aren't great.  They are great.  They are stimulating, well presented, thoughtful, and challenging.

But they have not changed health care.  Look through the talks and see what's imagined in them. Now, compare them to what's happening on the ground in most places.

(By most places, I am talking about the economically developed countries.)

What we see in those countries is the presence of two inexorable forces.  One force comprises underlying demographic factors.  The old are living to an ever-older age and are putting unprecedented demands on the health care system as we take care of their chronic and acute illnesses.  Meanwhile, the next generation (the Baby Boomers) have entered the age of hospitalization, compounded by an extremely high level of entitlement.  ("I hurt my knee playing soccer.  I need to be able to play as soon as possible.  I demand an MRI and arthroscopic surgery to repair that rip.") And, finally, the next generation is characterized by a sedentary lifestyle, which has and will lead to obesity, diabetes, and the sequelae of those diseases.

Meanwhile, in the face of this demand, pharmaceutical and technology companies invent new diagnosis, treatments, equipment, and supplies.  They seek to grab their portion of the growing health care budget.  Very few of their inventions, whether efficacious or not, lower the cost of health care.  They tend to be additive.  (And, by the way, many are not efficacious.)

So what we find around the globe is a persistent growth in health care expenditures.  Because there is a limit to society's ability to absorb such expenses, the costs are being pushed down--step by step--to those least able to seek alternatives, the general public.

Daniel Palestrant, the highly thoughtful CEO of Par80, has recognized this phenomenon and has likened it to Benjamin Franklin's most important invention, the lightning rod:

In this country, when it comes to healthcare, lightning has indeed struck.  Like a bolt of lightning hitting a colonial building (which were largely made of wood), the energy must find a path to ground as quickly as possible, scorching everything on the way down.  The question isn’t whether it will find ground, it is only how much collateral damage it will do as it gets there.  The healthcare crisis is lightning hitting our society.  If it isn’t managed carefully, it will burn down the house.

As healthcare costs have exploded, the cost and responsibility has been shifted from private companies paying for employee benefits, to physicians, to insurance companies, the American taxpayer, and most recently, the Chinese (who we have been asking to lend us the money to pay for these costs).  In turn, each of these parties has now found a way to either defer the liability or signal they are no longer willing to finance the effort to sustain the status quo.

Lightning grounds when costs and responsibility are shifted back to the only remaining entity….the patient.  That’s where we are heading.

Daniel offers a hopeful prediction:

It’s not all bad, though.  Directly engaging consumers in their own healthcare will inevitably lead to two trends:

Disintermediation - As the lightning accelerates, it will look to cut out as many intermediaries as possible.

Price to Value - Once consumers are more responsible and accountable for the cost and manner of their own care, it will become more likely that healthcare goods and services will be priced on relative value, rather than an arbitrary value set by a third party.

Well, maybe. I think that some consumers will have those opportunities, but I think that most will not.  Taking just one recent item, the trend to high deductible health plans, we already see the growth of inequity based on income.  Lower wage people choose the high deductible plans to reduce their monthly premium, but then they systematically choose to avoid spending more of their disposal income by deferring or avoiding appropriate medical care.

As the Institutes of Medicine recognized years ago, a health care system that is not equitable is one that fails.

I bet if we surveyed the viewers and listeners of TED talks, we would find a bias towards higher educated and wealthier people.  Sure, they're really excited about the ideas Lucien proclaims as changing the system in the direction of higher quality, greater safety, and lower costs.  And sure, many firms in the marketplace will aim their products and services to those groups.  How much will trickle down to the rest of society?

My fear is that what trickles down will not be the innovations that bring about higher quality, greater safety, and lower costs.  What makes me pessimistic?

Frauds already abound, attacking the economically weakest in society.  As Al Lewis, Vik Khanna  and Shana Montrose have documented, the so-called wellness industry has started to impose its own form of tax on the health care system.  In cahoots with the HR departments of firms that have pushed deterioration of employer-sponsored plans, the wellness companies offer a "goody bag" of options that appear to help you save money on your premiums.  Well, that's the first step.  The next step is that you get penalized if you don't "comply" with the wellness plan your employer has chosen.  Who won't be able to comply with the exercise and diet programs?  I'm willing to predict it will be disproportionately the lower wage earners.

On this blog, I've documented aspects of how direct-to-consumer approaches have empowered medical device companies to charge consumers for unnecessary costs.  I've pointed out how the medical-industrial-government complex aids and abets such practices through opaque rate-setting and rule-making procedures highly influenced by those same companies.  When those higher costs get passed along directly to consumers, they act as a regressive tax on those with lower incomes.  When they get passed through indirectly through Medicare, they end up stretching the government's budget.  Searching for budget relief, CMS engages in arbitrary penalties for failure to meet arbitrary quality metrics.  Which organizations tend to do worse on those metrics and pay the penalties?  The hospitals serving the lower income portions of society.

Let's look at other industries that have moved in the directions predicted by Daniel for health care--disintermediation and price-to-value--like finance and banking and telecommunications..  While we can point to overall societal gains in each of these fields, the predominant part of the value obtained from these structural changes has tended towards the wealthier components of society.  Why should we expect health care--which is intensely more complex than any of those other sectors--to behave otherwise?

I don't offer these thoughts out of some socialist desire or expectation.  I offer them to remind Lucien and others that their job isn't done until or unless there is a greater democratization of the benefits of all those innovations.  That democratization will not arise from lovingly produced TED talks viewed by the elite in society.  It will require a movement from the patient advocacy world.

That world, however, remains inchoate.  Many patient advocates arrive to this field as a result of personal injury to themselves or a loved one.  They are not trained in the skills needed to build coalitions.  They are on their own, without sufficient resources to get their own word out, much less have the time and energy to meet with other and build a national movement.

There is no established organization in America or, from what I have seen, other countries that has devoted itself to the promotion of a vibrant, widespread patient advocacy movement.  Those that might have done so have shied away from this kind of engagement--perhaps because they know that any movement so constituted will be unpredictable and beyond their control.  Yes, some hospitals seriously try to engage patients in a clinical partnership, using advisory councils and the like, and these efforts are useful.  But they only go so far in that they are islands of activity with little or no crossover beyond the catchment areas of each hospital system.

Years ago, I came to know a wonderful man, V.B. Mishra, who was engaged in trying to stop the pollution of the Ganges River.  He decried the lack of political support for this effort, saying, "The river needs its Gandhi." Well, the truth of the matter is that Gandhi's and Mandela's and M.L. King's come along very seldom and usually only in times of great change and crisis.  During most times, it is not a single leader who brings about change: It is a coalition of many local leaders who figure out how to join hands and bring persistent pressure on the body politic.  Until the patient advocates figure out a way to create that coalition, the lightning will go to ground in a manner that many of us will consider inequitable and inconsistent with the objectives of political stability and economic prosperity for all.