No Payor System

By de-emphasizing the role of “medicine” in caring for the sick, healthcare blurs the original intention. Funded by government or insurance companies, these payors are ultimately constrained by their fiduciary responsibility. Thus, to protect their interests they choose neither to increase taxes nor to reduce profit. As a consequence, these choices lead to cost containment as a logical business strategy. But this choice presupposes that growth in healthcare follows a predictable pattern and that the payor has absolute control over the means of production. Neither is true. Growth in medicine follows the needs of patients while the payor’s control is confined to the ability to manipulate insurance packages. This is a total disconnect.

Moreover, cost in medicine is driven by the economics of accelerated change. The universe of medicine is constantly expanding. Each advance in medical science, developed to serve patients, must, by any ethical standard, be incorporated into the continuum of care. Each such change reverberates throughout the system until medicine’s metamorphosis is complete. Prexisting healthcare budgets will bear little resemblance to medicine’s ultimate needs. In this environment cost containment is a flawed and ineffective tool. The payor’s budget choices must lead to an ever narrowing definition of medicine. Healthcare is no longer geared to care for the sick but exists to protect the financial interests of the funding agency.

We see this actively played out as medicare seeks to control its budget. They begin by winnowing out costly therapies. They stop paying for outpatient intravenous antibiotic therapy. They introduce separate pharmacy coverage which includes co-pays. Like private managed care policies these co-pays are higher for more expensive new drugs, effectively financially punishing the sick. Some patients will either manage to pay these higher fees or die.

Healthcare is a triage system.

All such restrictions are de facto rationing. Furthermore, by targeting diseases which require active treatment, healthcare becomes a triage system designed to support the healthy and to marginalize the sickest patients. The focus on cost containment leads to a relentless disenfranchisement of the sick and the elderly. This new definition of healthcare leaves the impression that it is meant to sustain the productivity of the young and that those too old to work are expendable. It is disheartening to realize that some form of economic triage is practiced by all existing universal care programs.

There is another trend. Problems in healthcare have attracted both economists and epidemiologists. These disciplines take a dispassionate view of healthcare. They consider solutions in terms of populations, broad issues and statistical analysis. Out of this has come the recognition that obesity, smoking, hypertension and diabetes are all public health epidemics whose resolution will have an enormous positive impact on the population’s general health. This will translate into longer healthier lives for a larger percentage of the population. The belief is that addressing these problems will have the greatest effect on the general health of all people. But they are top down initiatives with little infrastructure to support them. They must inevitably deflect resources from other deserving healthcare programs. These are general public health issues which become vague abstractions when dealing with the immediate needs of sick patients.

The effort, in America, to devise an effective system to deliver medical care is hopelessly lost in the cacophony of past political agendas. Healthcare is now the province of epidemiologists, economists and political strategists. None of them believe that access to competent medical care for all is possible. But to be valid universal care must be based upon the treatment outcome of thousands of diseases measured one case at a time. Population statistics must not be allowed to rob individuals of their access to potentially successful treatment. Universal care will only work if all aspects of the endeavor are locked into the same objective: to ameliorate illness and, where possible, to save lives. How do we begin? In seeking universal care we must not be blinded by the now vague concepts of healthcare but concentrate upon and fund the delivery of good medical care. No answer will be cheap, but let’s develop an answer that serves our medical needs, not economists’ projections.