Health Care's Raison d'Etre

Whether you are fixated on newspapers, addicted to radio, or mesmerized by TV, you get the same clear, unambiguous message: what we want healthcare to do is to cut costs.

• "Medicare Demos [Demonstration Projects] Fall Short On Savings"
• "Cutting Costs Doesn't Cut Costs"
• "To Reduce Military Spending: Cut Benefits Or Cut Armor"
• "ACOs -- A Promise Unfulfilled"
• "Pelosi Assures That ACA Will Cut Deficit"
• "Healthcare Spending Is Out Of Control"

It appears that the purpose of our health care system -- its raison d'etre -- is to avoid spending money. Of course that is crazy, but overspending and cost cutting is all we ever talk about or hear.

Why do we have a health care system at all? What is its raison d'être -- French for reason for existence?

A system is a way to organize objects, people, and tasks. A healthcare system organizes nurses, drug reps, hospital managers, and regulators in order to do... what? What is its raison d'etre? Before you answer the question, remember two truths that systems analysts have proven over and over.

1) All systems produce results: intended and unintended, ones you want and ones you don't. Some patients suffer, after "perfect" care. Low flush toilets use more water.

2) All systems try to encourage (reward) the outcomes the system presumably wants and punish the ones it doesn't. A commercial enterprise wants profits: it therefore rewards people who sell, and gives pink slips to those who don't. A military system wants courage and bravery. It rewards those behaviors with honor, such as rank and medals, and court-martials those who run away from battle.

We should be able to uncover the raison d'etre of health care by learning the results it wants. We can determine what results health care wants by observing what it rewards.

Using this logic, the raison d'etre of healthcare is the following.

• Not giving health care, as we reward insurance -- both private and government -- if they do not spend money.
• Photogenic medical disasters, as malpractice lawyers get millions when a patient, preferably a child, is maimed during medical care.
• Ordering lots of tests; doing expensive procedures; and spending the least time with each patient, as we revere (and reward) the doctor who generates the most RVUs (relative value units). "Pay for performance" is the way providers are paid, so they "perform."
• Not knowing your patients names, as the more patients a nurse is responsible for, the more efficient she is deemed, and efficiency is rewarded.
• Keeping people in their hospital beds, as hospitals make money when they are at "optimal utilization."
• Being "out of compliance:" this rewards regulators by generating a whole new round of regulations, which of course requires hiring more regulators.

Wait a minute! That is ridiculous. No care, medical disasters, over-usage, stuck-in-hospital, and non-compliance are precisely what we do not want from health care. It is, however, what health care rewards. Maybe the health care system wants different outcomes from what we want.

Conclusion: the incentives in health care are contradictory and perverse. The system rewards the very things we do not want and discourages the things we do want.

We The Patients want to live a long time and to be healthy. That is what individuals want, for their personal wellbeing. Long life and good health of the populace is also what our nation wants, because that is how the U.S. competes successfully. Apparently, long life and good health are not what health care wants -- the system does not even measure and therefore cannot reward those outcomes.

You can call health care's problem perverse incentives, disconnection, or mis-alignment, but whatever you label it, you now understand why We The Patients get from our health care system the precise outcomes we don't want: more cost and less service.

If you practice medicine on health care the way that Washington does, you will simply treat the overt symptoms. That is how we get the ACA, with more regulations, six while new bureaucracies, and less money for service. They call this health care reform (change for better), but in reality, it is health care exacerbation (makes things worse).

If you want to practice good medicine on health care, you will do the following. A) You will evaluate all the evidence including what has happened in other systems such as Canada or Great Britain). B) You will do root cause analysis to find out why we get the outcomes we don't want and not the ones we do. And C) You will try to change the system so that the problem -- mis-alignment -- ceases to exist.

Relatively simple? Straightforward and doable? Now? Yes, yes, and definitely.
Politically possible? Likely to happen? No, and not a chance.