Manatory Healthcare Reform – Part 1

 Peeling cross

Healthcare reform is perhaps as complex an issue as we are facing in our society today – and the recent bill passed in Congress promises to further murky the waters.  On one hand, the diversity of the intertwined issues that constitute the fabric of our system may simply be too impossible to unravel.  But on the other hand, solving this dilemma may well hold the key to preserving life as we know it today.

For an introduction, I figure that’s pretty dramatic and intentionally so because I think the shoe fits.  The issues are circular and I honestly can’t imagine a more significant domestic issue both requiring and demanding our attention.

So buckle up as I attempt so share some information, resources and opinions on this dynamic topic.

Typically, I like to simplify complex issues into their component parts.  This does not remove the complexity per se, but it affords me a greater appreciation for the dynamics at play while increasing my grasp on each.

This American Life – one of my favorite podcasts – perfect illustrates this principle in a recent two-part series on the dynamics driving healthcare.  If I’ve established any credibility with some of you guys, then I want to invest it in a strong encouragement for you to grab the free downloads and give listen to these wildly informative and thought provoking stories.

More Is Less

Someone Else’s Money

At least listen to one and then make your call on the second.

In these podcasts, the diverse issues driving the healthcare debate are explored via storylines in which, for example, they colorfully explore an amazing series of events that led to today’s employer based system, which is the answer to the question asking what Texas school teachers, the depression, WWI, and committee income tax rulings have in common – for those unwilling to wait.  The episodes also elaborate on how often those affecting the most good on and within the system are also the most vilified.  Ironically, as is demonstrated in the show, we as consumers are often our own worst enemy – sometimes knowingly but mostly not – when it comes to running the system off the rails.

Here is how these seemingly impossible statements are manifest as fact.

The American health system as it exists today is comprised of 4 primary players – Physicians, Pharmaceuticals, Payers (Insurers), and Patients.  Each publically embraces an egalitarian agenda but each also maintains objectives relative to their personal preservation.  At times, these duel pursuits abide in harmony but frequently they collide, leading to less collaborative and more manipulative behaviors.



Our physicians have a mandate, an oath, to work on our behalf to protect and heal us.  They dedicate huge portions of their lives to the study and training to perform against their objective as well as humanly possible.  But at times the system seems designed perpendicular to this outcome.

A myriad of impossible and ever evolving codes assigned to the granular specifics of our ailments must meticulously and perfectly be registered in order for physicians to be paid for the services they render on our behalf.  The complexity drives increased staffing requirements and mistakes and rework and corruption potential and widget-cranking-like patient care.  Drug manufactures dispatch product reps to promote their latest wares and in this charge they enjoy the unprecedented luxury of not having to disclose their product pricing.  Value is easy to both sell and perceive when no price tag is attached, and this quirk is made possible because the system is designed to pass the bulk of the, not insignificant, cost burden to the insurance companies.  Besides, exact pricing is nearly impossible to know due to the vast array of products, dosage options, indications, and payer-specific pricing contracts and it is often not a consideration for the treatment providing doctor.


Big Pharma is the research industry driving tremendous advances in medicines.  As our life expectancies continue to increase, we have modern medicine to thank.  When we find a cure for cancer, it will be the end result of billions and billions of Big Pharma dollars spent in search of this medicinal Holy Grail.

Having worked for years with pharmaceutical manufactures, I have a keen appreciation for the mantra that the first pill or dosage unit of a publically consumable medication costs roughly $1 billion to produce while the second might cost only a dime.  Accounting principles treat the cost distribution differently, but the truth remains.  Huge investments are made in this boom or bust industry where a company’s stock value is a clear function of the depth and maturity of its product pipeline.  In fact, much of the consolidation this industry group has experienced over the last 10 years has been mostly about pipeline takeover.

In my estimation, the darkest of the gray areas exists in this arena and justifiably so.  Inventing a new and viable medical compound is not as precise as updating a vehicle model year over year.  It is a mystery and profits must be wrung from the process to ensure the ability to conduct future research.  But how much profit is too much and how are research budgets allocated?

Further complicating the question is the harsh reality that rare but medically advance-able ailments are sometimes evaluated against their profit potential rather than the localized good that may be brought.  It is easy to characterize the situation as a classic ‘greater good’ dilemma with research budgets allocated against ailments impacting a larger population.  It is equally valid to question the politics of medicine today if felled by a rare and less researched malady.


Insurance providers are the easiest to paint as villain.  Doctors treat and drugs medicate but insurance companies push paper and too often, so it seems, draw tight the purse strings.  But this is a simple and unfair characterization.  In a mega industry like healthcare, the simplified role of our payers is to manage the flow of data and oversee the exchange of dollars.  And that’s not to mention that insurers are staffed deep with good people that genuinely care for their “covered lives”.  Again, knowledge gained from my years working with several name brand coverage providers.

As the cash flow conduit – they collect our premiums and pay our claims – they are uniquely positioned to help drive down, or at least manage, costs.  They ensure correct medical coding, incent low cost medical and drug alternatives, and staff more MDs and registered nurses than you might imagine in an effort to help manage our care and assess the medical necessity of a prescribed course of treatment.

For example, drug co-pays were for years used to incentivize patients to select a perfectly equivalent generic in place of a name brand product slightly modified to extend its patent protected high prices.  But this tactic designed to benefit the collective, has been subverted by, among others, a pseudo informed patient base trained to clamor for name brands and eschew generics as if comparing Oreo’s and Hydrox.


Enter the most vexing factor in the equation – us.  We have the most vested interest, not in healthcare as a whole, but in our healthcare as a being.  Yet, often our actions (think diets and exercise regiments), do not lend themselves as evidence to our own cause.

We have historically unprecedented access to medical information, which often does us more harm than good.  Consider the illustration offered by The American Life of “Medical Student Syndrome”.  It is a registered, certifiable, defense-able syndrome whereby medical students, after investing countless hours in the study of disease and sickness will begin self diagnosing all sorts of rare ailments and maladies simply as a result of their proximity to the data.  How much more then, do you think the general public will cultivate phantom symptoms and diagnosis when they are doing a medical word search on a phrase like “flu-like symptoms”?  Or, even more precarious, are bombarded with marketing campaigns designed to illicit fear and consumer actions.

That this access to knowledge drives us to the healthcare provider community for either treatment or validation is itself a good thing.  Illnesses are being found earlier which affords a greater array of treatment options, which in turn, drives more positive outcomes.  However, it is the attitudes we now carry with us to the doctors’ office that wrecks the most damage to the global cause.

Having spent an hour, or day, or even week investigating my case, I am prone to question my doctor’s judgment, never mind his years of study and experience.  In this instance, we are talking about MY healthcare, not that of the anonymous collective.

In this moment, in our society, I, as the patient-consumer, hold the ultimate trump card – legal action.  Run this expensive battery of tests I learned of on the internet, I demand, meanwhile, ignoring my doctor’s 99.99% confidence rate that it is unnecessary.  Flush with my own sources of knowledge, I know I am unique, I am an exception, I am me., and me (I) will sue as hard as the day is long.  So this leaves our physician with a decision that is at once impossible and obvious – short sell my experience and knowledge and oath to heal, or order another battery of tests that, rather than simply costing me nothing, will provide me with more complex codes to log, ensuring me a fatter check from your insurance company.


And so our modern day system continues to spiral off its axis.  Factions forced into coexistence fighting against each other and sated only by the flow of money – other people’s money.  But the system is failing us.  The richest economy and most advanced medical capabilities in the world support a healthcare system that has feasted on itself for so long that it is beginning to implode.

The reality is that in America, we spend 50% more on healthcare than anyone else in the world but our results are substandard.  Infant mortality ranks 45th (behind Cuba) and life expectancy ranks 50th (behind Bosnia).  At our current growth rate, within the next decade, it is projected that the average household will spend more than half of its income on healthcare.  It is an untenable outcome desperately within our grasp.

Which circles us back to my now not so over the top introduction; we are faced with an impossible issue which we must solve immediately.

Stay tuned, as next time I’ll share my thoughts on how we might begin addressing the issue.

Photo By: 96dpi

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