Not a System

I unfortunately have a lot of experience with our health care system. I’ll leave the specifics out.

My first observation is, it isn’t a system. If you Google “system” one definition that comes up is “a set of things working together as parts of a mechanism or an interconnecting network.” “Working together” or “interconnecting network” have nothing to do with how we deliver health care in this country, as far as I can tell. Let’s take a hypothetical example: let’s say my pinkie finger hurts. So, my first decision is… do I go to a primary care doctor, or do I go to a pinkie specialist? If I don’t have health insurance, the likely answer is “neither” since it would be prohibitively expensive to do either, unless I think I might die, in which case I go to either an ER or Urgent Care and declare bankruptcy after that (although I think I’ve heard medical debt can’t be discharged in bankruptcy???).

So, let’s assume I have health insurance. Maybe a high deductible plan. Now I have to decide if a PCP might be able to help. If I don’t think so, then I should go straight to a specialist since the PCP will cost me money, for nothing (with apologies to Dire Straits). Then the real fun begins… is there a specialist in pinkies, who is on my insurance, who is accepting new patients, who has an appointment available anytime in the next 6 months. Trying to answer this question involves logging into insurance websites (and frequently, giving up and calling) and calling multiple offices. We’ll assume I’m retired or independently wealthy so I have time to do all this instead of working all day every day.

Assuming I can get over that hurdle, and get an appointment, the next issue is that when I go to the pinkie specialist, unless they are part of some larger org that I’ve already been a patient for/at, I have to fill out my ENTIRE MEDICAL HISTORY. The pinkie doctor (or, maybe more likely PA or Nurse Practitioner) has zero context for my health problem. Is it related to when I broke my hand last summer? Or some other existing condition? No one knows, and they won’t know unless you tell them, and even if you tell them at the appointment, they don’t have time to really think about it. So, chances are you’ll get treatment that is totally random (well, not random, but 100% driven by the specific problem you are seeing them about, versus a holistic evaluation of your overall health and how this problem might be related).

I’m not demonizing the individuals who provide health care in this post. My guess is they hate the (lack of) system as much as I do. They probably joined the profession to try to help people, but truly helping anyone is exhausting since you have to swim upstream against the system, and any job that is exhausting on a daily basis leads to burnout, cynicism, or worse.

I don’t know what the fix should be. But, a few brainstorm ideas:

• The world needs more GPs, and people/patients need a closer relationship with those individuals. The medical profession and those that pull the financial levers in that profession should heap financial and other rewards on good GPs. Specialists have their value, but are less useful in one off, out of context care situations. A good GP should be widely admired by all, and paid accordingly.
• Medicine should either be much closer to market driven, or single payer government run. Our current model where a random third party (insurance) removes most/all consumer incentives, all while adding a ton of administrative drag to the (not) “system” distorts the market in unhealthy ways. If we want medicine to (continue to) be heavily regulated, market driven is honestly probably not compatible.
• There are probably some technology solutions for the data sharing problem that could be implemented. If I go to a new Dr., why am I filling out paper forms? I should have a smart card and pin (or phone app with biometric protection) that allows the new office to view my ENTIRE history, that I can revoke permission for at any time.
• We need to provide people with medical concierge services. AI could make this automated, but if you have a problem, you should be able to type your symptoms in (in free text) and get a recommended course of action, including scheduled appointments (already triaged – if your symptoms scream appendicitis, you should be able to go see a Dr. in the next couple hours)

The return on our investment in healthcare in the U.S. is terrible. We can do better. We need to do better.