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Some thoughts about healthcare

I’ve often said that one of my favorite things is to listen to smart people talk about smart stuff. And I had the opportunity over the last couple weeks to do just that; to listen in on two series of discussions on different, but semi-related topics with incredibly articulate experts weighing-in.

Because the discussion topics were at least somewhat related, a lot of the same terminology and themes turned up again and again so it provided the ability for several of them to get really stuck in my mind. Two of them in particular.

The first is the concept for which many in the healthcare industry would say they advocate, which is the idea of care being “patient-centered.” This says, in essence, that the patient should be the focus of everything we do since our reason for being is to care for them.

Now, let’s not kid ourselves here folks. Healthcare is a business and the fundamental goal for a business is to stay in business. Therefore, the patient can’t possibly be at the center of what we do because the real center is - with very few exceptions - profit.

Even for “non-profits” a primary driver of the organization is often to bring in dollars and manage them well so they can be pumped back into the organization.

This is absolutely not to say that there are not caring and compassionate individuals within the healthcare industry, whose missions may actually be to put the patient at the center. In fact, in my two decades of experience, that would describe the majority of individuals I have had the privilege to meet and work with.

However, there is a certain amount of naïveté that goes along with believing that an individual’s mission translates into the focus of a larger organization or industry.

At best, I think patient care is simply one factor that gets considered and it’s far from the foundational one. Most often it seems to get fitted into the broader context of how an organization can be competitive. That is, if one organization provides better care, they might gain an edge over their competitors.

The second idea that I have really been mulling is the one described as “patient accountability.”

I think the term is often characterized as empowering to a patient. As opposed to the olden days of paternalistic healthcare, the patient is now seen as an important part of the team and so, as with other members of the team, they are held accountable for the results.

From an admittedly more cynical point of view?

This term implies, hey, if we’re paying the tab, we expect a return on investment. Or, on the flip-side, if you’re doing something detrimental to your health - the best example here is smoking - or if maybe you’re just unlucky enough to have a condition that’s expensive to treat, we’re going to charge you more; either by way of higher premiums or cost-shares or by limiting your access to benefits healthy people get like premium reductions.

And as we get deeper and deeper and try to separate those things for which a patient “should” or even can be held accountable, things get tricky.

Even breast cancer and some autoimmune disorders often get lumped in with so-called “lifestyle conditions,” or those that can be impacted by, or have an increased risk of developing from lifestyle factors like diet. It’s a euphemism I can’t help but interpret as we think they’re at least sort of your fault and/or we think it’s sort of your fault if you don’t get better.

Weight is another common example.

There is a certain amount of excess weight that is associated with increased risk for some conditions, like cardiovascular disease, and weight loss can improve some conditions, like arthritis. For both of these reasons then, it’s an area that gets a lot of attention. Improving the overall weight of your population provides a lot of “bang for your buck,” meaning that a focus on improving that one metric can also improve spending across a variety of other ones.

Unfortunately, though, excessive weight is often “treated” as a mathematical equation and as something for which an individual has absolute control, rather than being seen as a complex situation of genetic and physical and mental and often social issues like having access to certain foods, money to afford them, or the privilege of the time to consider such things.

It seems like this might just be another way of stacking the deck against some people, and then judging them for being adversely affected by these circumstances.

Lastly though, back to the cost consideration, patient accountability is also used to describe a more “equitable” spread of spending across those footing the bill like patients, employers, and insurance carriers.

But how equitable can it ever really be when patients have near-zero leverage?

As consumers, they can’t always just go down the street to save a few dollars or choose not to spend at all like they can with many other goods and services.

There’s also a point to be made in asking the question of how much a few thousand dollars from a patient who may already be struggling really impacts the sometimes hundreds of thousands of dollars - or even as is the case now, millions - drug therapies, in particular, cost? Should we trade an individual's financial health for their mental or physical?

Tough questions to consider undoubtedly, but ones I think we need to keep at especially as we continue in and beyond the year we've had.

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