As doctors, we work "to cure sometimes, to relieve often, to comfort always": there is a dispute over who first said it, but little over its truth. It seemed like conventional wisdom, a statement of the obvious, from the beginning of human history -- until about 20 years ago, in the U.S.
Today, the primary mission of medicine, in this country, is to keep healthy people healthy. Yet the result, paradoxically, may be sicker Americans.
How Did This Happen?
What we would consider the first scientifically effective medical treatments -- early surgery -- began around the 1870's in the U.S. with the development of aseptic technique and anesthesia. Doctors could cure previously fatal illnesses (appendicitis, tumors), and perform surgical repairs (instead of amputation), without introducing infection. Surgery was more expensive than a typical doctor's visit -- requiring a hospital operating room, sterile equipment, nurses, etc. -- more than most people could afford, so in Houston in 1929, surgeons started the first health insurance company, what became Blue Cross, for hospital expenses.
Health insurance, covering both inpatient and outpatient medicine, took off in the U.S. after World War II: it was generally funded by employers, as it was deductible, and tax-free to employees. Most people were healthy most of the time, most illnesses were acute; courses of treatment were short, patients either recovered or they died. As far as we knew, most people were at the same low risk.
The system worked well for about 30 years.
Starting in the 1970's, however, Western medicine in general was transformed. Medical knowledge expanded at a white-hot pace. As we learned more about injury and disease, scientists developed more effective, and more expensive, treatments -- new procedures, like dialysis, organ transplantation, open-heart surgery; new drugs, like antibiotics, anti-cancer agents, synthetic insulin and cortisol. Acute illnesses -- heart disease, diabetes, Parkinson's disease, rheumatoid arthritis, cystic fibrosis, even HIV/AIDS, became chronic -- some patients could live a normal lifespan, as long as they continued lifetime treatment.
Changing Healthcare Demographics
For insurers, these medical advances radically altered the demographics of their customer base. Illness and injury were no longer randomly distributed across the population; today we know that roughly 5% of the population is responsible for 50% of U.S. healthcare costs. In general, these are the people with multiple chronic diseases: they are easy to identify, and no one wants to insure them, or share a risk pool with them. (Even in 1965, the elderly, the most likely cohort to have multiple chronic diseases, were uninsurable; that's why Congress passed Medicare.)
All of the recent efforts to reform the Affordable Care Act (ACA) -- by Democrats or Republicans -- included provisions to protect health insurers from that 5%. The Democrats offered federal reinsurance for the most expensive cases; the Republicans supported "high-risk pools" where a different entity, generally not specified, but not commercial insurers, would cover the 5%.
The result of this lopsided distribution of risk and cost is odd, but crucial. The market for health insurers is healthy people: the market for medical care is the sick and injured. There is only limited overlap. The people who need health insurance the most have the most difficulty getting it. The healthy people who have the insurance generally don't need much care, so their premiums go for insurance company profits. (The ACA tried to limit that, requiring insurers to refund customers' profits over 20%.)
Next question: how to get medical care to the people who need it, while reducing the cost of U.S. healthcare overall.
One way would be to extend Medicare to everyone, probably in stages, starting with those who do not have employer-sponsored care, or perhaps people ages 55-65 -- after all, high risk limiting insurability was the reason Congress passed Medicare in the first place. Medicare also costs less, per person and per disease, than private insurance, because it imposes price controls on doctors and hospital services. Congress could, and should, extend price controls to other healthcare services like drugs and imaging -- free market "competition" has failed to bring prices down.
The health policy community, however, has a completely different idea for reducing overall cost: keep people healthy, or health promotion and disease prevention, also called "wellness." Here is a typical definition, from a :
"Health promotion and disease prevention programs focus on keeping people healthy. Health promotion engages and empowers individuals and communities to engage in healthy behaviors, and make changes that reduce the risk of developing chronic diseases and other morbidities."
American policymakers believe that to implement this strategy, we must radically transform the system for delivering healthcare and reimbursing providers (doctors, hospitals and others) in the U.S. In a transition phase, insurers will pay providers only for "good outcomes" (pay-for-performance) instead of fee-for-service.
The goal, however, is to create large, vertically integrated healthcare systems (accountable care organizations, or ACOs) that will take financial risk for providing care to their patients: they will be paid by capitation, a fixed fee for each patient. If the ACO can provide good care for less than it receives, it makes a profit. If proper care costs more, it takes a loss. There are "performance metrics" in place to assure good outcomes and no skimping. This is called "population health". A successful ACO can make money by keeping its patients healthy -- what could be wrong with that?
Healthcare for the Healthy?
The patients who have good outcomes are almost always the patients who are the healthiest to start with. "Good outcomes" are things like a blood pressure under 140/80, or good glucose control in a diabetic. For example, with diabetes, today we have good, if expensive, oral medications, so a patient with no other problems can control his sugar just by taking a few pills a day, although of course we always recommend lifestyle changes first.
But what about someone who has to take prednisone (a synthetic cortisol) for an autoimmune disease like Crohn's disease, or cancer, or because his adrenal glands don't make cortisol, (which is necessary for life)? Prednisone will push up his sugar and his blood pressure. He may have to take insulin, which will push up his weight, and also put him at risk of hypoglycemia. People can die from hypoglycemia. Such a patient requires intensive, and expensive, medical care, and may still not have a good outcome.
Hence the surest way to succeed with "population health" in a capitated system is to recruit as many healthy patients as possible: they will have the best outcomes at the lowest cost. Healthcare systems are going all out to stimulate so-called consumer engagement, offering, for example, convenient service with extended hours in urgent care centers for vaccinations and minor acute problems, and 24/7 nurse help lines.
In fairness, some ACOs also work hard caring for the sickest and most difficult patients -- coordinating care, arranging for social services and transportation for frail elders, or patients with cognitive impairments, which help keep them out of the hospital and the emergency room. This is good medicine, and reduces cost for American healthcare overall. But it is a hard way to make money unless capitated payments are carefully risk-adjusted or tied to some high baseline.
Extra services for healthy people, on the other hand, are often of and , money that would be better spent taking care of the sick. Indeed, I believe we ought to get healthy people out of the healthcare system, where unnecessary or low value care can be not only expensive, but dangerous. It is hard for the medical system to make a healthy person healthier.
The best way to achieve true population health, for all Americans, is to improve what are called the : ensuring that all citizens have access to good jobs, good education, adequate social supports and services, a healthy environment at home and at work, and good public health measures (imagine if we had left smoking cessation to doctors and patients alone!). These are not appropriate tasks for the medical system, but for society as a whole. that this is how the Europeans get better health outcomes with much lower medical costs.
Medicine ought to return to its true mission, what we do best -- care for the sick and injured. With modern technology, we can achieve amazing things, even cures, along with relief often, and comfort always. That's what patients need and want.
, is an attorney and internist in Bethesda, Maryland. She is a former staff internist for the National Naval Medical Center, and currently practices medicine part-time at the Arlington Free Clinic in Virginia. She also consults for law firms on Medicare and Medicaid fraud.