User talk:QuestionEverything

US Healthcare System DISC 2/24/22

I was blown away by Eric’s episode #18 on the DISC – blown away in a good way! It made me realize that what I have been seeing is probably idea suppression.

Let me give a little background. I have been interested in the healthcare system for many years. I want to understand what’s wrong, why it’s such a mess, why efforts to improve it only make it worse. I spent many years in an insurance career and more recently am closer to academia and health services research (HSR). I have been saying for a long time that we use the mechanism of insurance way too much in healthcare, and that’s a large part of the problem. I now see the level of groupthink that exists in academia and HSR, and to a lesser extent among physicians and others working in healthcare. For a few years I’ve been focusing most of my efforts on studying primary care as it’s the foundation of healthcare delivery in some important senses, and I’ve become particularly interested in direct primary care (DPC), a way of financing and delivering primary care in which insurance is not used for primary care. Usually DPC is done as a membership model like a gym membership. Patients (or employers on their behalf) pay about $75 per month for unlimited access to a defined set of primary care services. Cutting to the chase, DPC fixes pretty much everything that’s wrong in healthcare. It’s really astounding. At first, I thought it had to be too good to be true, but I’ve been researching it (and I have strong, relevant credentials in this area) for a long time and the more I look at things, the more different things I look at, the better its results look. I feel a bit like the Bitcoiners who say “Bitcoin fixes that” when confronted with a problem in society. I essentially say “DPC fixes that” when people talk about any specific problem in healthcare delivery and financing.

For a while I have been focusing more broadly than DPC by saying we should not use insurance to pay for routine care, and that changing our mindset about healthcare in this fundamental way would dramatically improve the results we get in healthcare. When I listened to the Portal episode #18 I started looking at it as idea suppression. I started asking, how can it be that an idea that everyone accepts as obvious in their daily life, that it doesn’t make sense to use insurance for routine expenses for our cars or houses (oil changes, new tires, furnace filters, etc), does not enter our minds for healthcare? And perhaps more interesting than asking this about the general public, I started asking it about policymakers and scholars and researchers. In particular, there is continuous hand wringing about the state of primary care. Primary care physicians (PCPs) earn a fraction of what specialists earn, they are overwhelmed and burned out and committing suicide at alarming rates, reimbursements are getting squeezed to the point where they have no choice but to do more and shorter visits, and independent practices are being consolidated into health plans and hospital systems. Primary care scholars and policy makers know that these problems have huge consequences for patient health, downstream care and spending. Yet what's so fascinating is that NO ONE gives any consideration to not using insurance to pay for primary care. Particularly as DPC grows and its benefits are known, it’s amazing that no mainstream primary care scholar or journal article or initiative, even ones that purport to turn over every stone looking for ways to pay PCPs differently to start to improve the terrible problems in primary care – NO ONE even mentions the idea. It’s not as if they mention it and then dismiss it with some reasons. It’s fascinating.

I recently signed up to give a talk about some of this and in the process of preparing, I’m finding more and more things that concern me. The American Academy of Family Physicians (AAFP) is the membership organization of family medicine, the largest primary care specialty. In researching primary care scholarship and initiatives farther back in time, I am finding that big efforts, big new initiatives are launched to much fanfare, but there is never an update on how efforts to implement the recommendations are going and whether the improvements they assume will happen are actually playing out. In a few years, the initiative and supporting documentation are quietly buried and a new initiative is launched. The website that’s supposed to house the supporting documentation of the Future of Family Medicine (FFM) initiative reroutes to the latest family medicine initiative at the AAFP, as one example.

The other thing that jumps out at me when I read about primary care initiatives is that they make some huge assumptions that seem never to be examined. The FFM initiative, for example, proposes a “New Model” of primary care delivery, but there is no discussion of where this model came from or the evidence behind why they think it will improve things. It’s just stated as a given. The Institutes of Medicine released a big report on primary care in 1999. Of the 19 members of the Committee on the Future of Primary Care, the IOM committee that produced the report, almost all are physicians or hospital/health plan executives; one is an economist. The report takes as a given that managed care and integrated delivery systems will continue to dominate healthcare. The view even seems to be that primary care should serve these “systems.”

Certainly one could make the case that the hubris of physicians and policymakers and scholars has led them to believe expertise in medicine is all that is needed to improve healthcare, that expertise in economics is not needed. But two critical questions remain unanswered. 1. Where were the economists? Why does it appear that no economist spoke up about the financial aspects of these initiatives? Did some speak up and they were pushed aside? And there are surely others who should have seen that what was being proposed would not work out as assumed; actuaries come to mind. Not using insurance to pay for routine expenses is a basic actuarial principle that underpins the modern world. Why is healthcare permitted to try and ignore economic and actuarial principles in such a flagrant way? 2. Why does no one in primary care leadership or scholarship or policymaking have any desire to track and measure the success of initiatives? Don’t they want to know why results they say they want are not materializing?

At first I assumed that the AAFP and other organizations are simply inept. But I’m beginning to think corruption is more likely. Yes, the level of groupthink in academia and policymaking is stunning. But in order for things to go on like this for so many years (probably 50 at least), how can it not be purposeful? How can it not be corruption? Or is this the DISC?

My interest in primary care for the focus of my broad questioning about why healthcare is in such bad shape in this country, is also the reason it’s an important place to drive the healthcare system from. If you can get patients into the system early, if you can make it confusing and complicated, if you can make them believe they need lots of downstream care, you generate huge revenue for the system. The problems in primary care actually drive lots of revenue for the rest of the system. More specialist visits because PCPs are so rushed, it’s so hard to get an appointment, and patients don’t have a trusting relationship with their physician. ED and urgent care visits rise, patient health is poorer since they lack good primary care. Getting insurance involved right away in primary care dramatically ramps up the bureaucracy and complexity, which adds to costs and convinces patients that they can’t understand or afford healthcare. I could go on and on.

On the other hand, if PCPs have time to spend with patients (DPC patient panels are roughly 25% as large as patient panels of PCPs who take insurance) and there is a fiduciary relationship in which the patient trusts that the physician is acting in their best interests, the experience for both patient and physician is dramatically different. The DPC physician is motivated to take the best possible care of the patient, to do as much themselves as possible rather than referring to specialists, to arrange low cost labs, imaging and prescription medications, etc, as the patient is a valued customer. They want to care for all aspects of the patient, including financial. DPC physicians are highly satisfied with the way they practice and that they are able to take care of patients the way they envisioned when they went to medical school.

It seems clear that it’s in the interest of the healthcare system to suppress the idea that patients should pay directly for primary care (to the extent they are able – safety nets are a separate issue). I believe the Portal community could be instrumental in discovering the mechanisms of suppression and to what extent the big players in the system (such as insurance companies, hospital systems, and pharmaceutical companies) might be somehow driving it. For example, where did the “New Model” of the FFM initiative come from? Where does AAFP’s funding come from? Has the purpose of all of this been to eventually lead to Patient Centered Medical Homes (PCMHs), Accountable Care Organizations (ACO), and the Affordable Care Act (ACA)? Perhaps eventually to lead to a complete government takeover of the healthcare system? PCMHs, ACOs, and the ACA were also accepted and implemented with little evidence supporting them. One could go further back to community rating, another huge failure.

I am convinced that the benefits of changing our mindset about healthcare, which leads to dramatically different behaviors with regard to health, healthcare and health insurance, could be absolutely revolutionary. Our country is in deep financial trouble and one of the main reasons is how much we spend on healthcare. Once the mindset starts to shift and large numbers of people are engaging differently and behaving like consumers and demanding accountability from the big players as well as government bureaucrats, regulators, etc, we will be able to craft reforms to Medicare and Medicaid that can begin to turn them around, too. Certainly, this will be a historic level of disruption to the economy and country perhaps only comparable to the level of disruption we have been through since early 2020. My interest in understanding the DISC of the US Healthcare System is primarily to set the stage for challenging it, for making people aware of what’s been happening, to take away the power of the suppressers to suppress ideas and control the healthcare results we get. The DISC harms all of us.