Incentives In US Health Care

Until the health care system is rewarded for delivering good quality care, and more importantly for delivering exceptional care, US health care overall will continue to languish if not deteriorate. The problem is not (only) for doctors to find more efficient ways to take care of people; rather, it is to find some way for doctors and the entire health care system to get paid for care that improves people's health.

As it is now, the health care delivery system gets rewarded for doing "stuff", regardless whether it helps people's health or not. Sometimes it does stuff that improves people's health, then doesn't get paid. How long do you think that's going to continue? Other times, it does stuff that adds little or nothing to people's health. So -- no surprise here -- the payment system has in response erected many steps by which the "stuff" health care does gets scrutinized and evaluated: does this make (economic and/or medical) sense?

To correct for its faulty reinforcement of tech-y procedures, the payment system has created obstacles to the delivery of services. This results in a reduction of care, arguably in the quality of care, and poorer outcomes, despite all the money being spent. Only when the system brings back the goal of improving people's _health_ will this situation change. Of course this brings up the very real question: what measures establish health? What defines health?

We might do well to make a list, and then change whatever needs changing to meet that standard. Things like the US government's GPRA measures were created in part to do exactly this, but any even momentary examination of these standards shows the great gap between some of these measures and the system that's designed to meet them.

Only when measures are created that correctly match health care actions with patient health will a system of performance measures improve health care. If the health care system does certain things, and those things are directly connected to patients' health, then it makes sense to reward the health care delivery system for doing those things. But if there are things the health care system does that at most only indirectly support the health of patients, then the only measure of the system's performance should be whether the system has done those things, NOT whether patients' health has improved. Further, to the extent the health care system's performance is measured by those actions that only indirectly contribute to patients' health, that system will "learn" to either ignore or "game" those performance measures, and patients' health will not improve.

Specifics makes this clear: If it is known that the Z vaccination reduces the incidence of a condition that causes poor health, then the monitoring system can use either the delivery of the Z vaccine OR the occurrence of the condition (that the Z vaccine prevents) in the population to assess how well the health care system is working. However if, in another situation, it is known that avoidance of health condition X requires an action by each patient, and the monitoring system chooses to measure the performance of the health care system by using the incidence of health condition X, then it no longer is enough that the health care system's performance include merely informing patients to do this action; they must have some means to compel patients to follow their recommendation!

Enforcement does enter health care today when there is an epidemic illness. But in most other situations, patients are allowed and expected to make their own choices, and live the consequences of those choices.

So in many health care situations, the health care delivery system can only make available resources that people might or might not choose to use. To expect more from the health care system introduces a new department into health care: a sales force coercing patients to act in certain ways. Certainly in both product- and service-oriented industries quite apart from health care, the marketing division plays a major role. Advertising and "sales" has only recently become a facet of health care, and then only in certain arenas within the health care industry. Laser and cosmetic surgery, drug promotion, and tobacco cessation are examples.

The marketing of actions people can take to preserve or improve their health has never previously been industrialized. Until very recently, common perceptions of marketing in health care were connected with shady remedies -- "snake-oil" salesmen and their ilk. Now we see every day promotion of drugs, non-regulated (OTC) treatments, and myriad other health-related products and services that have at least as much investment in self-promotion and profit as they are concerned about people's health. And regulation has entered this arena as well, and politics too.

The result of the marketization of health care is that people no longer are certain about who has authority -- who has the truth -- about staying healthy. Further, ever increasing scientific and technical advancements now confuse the patient with new possibilities and new paradigms. No wonder people are becoming numb to the barrage of entreaties by health advocates. All these changes have transformed the patient into a customer, one who often simply wants to press the mute button.

This arrangement has had one major effect socially: it has released almost everyone from responsibility! Against this tide, various agencies have created the outcome measures discussed above, with both useful and unexpected effects. Further, we now see a national dialogue that seeks to establish how much responsibility, if any, society as a whole has toward the health of individuals. Perhaps unsurprisingly, this is a contentious issue, with some people endorsing a collective effort and others insisting it's "every man (and woman) for him(her)self". Judging from the progress in our government on this issue, it is not going to be resolved or go away any time soon.

Meanwhile, health care for the nation overall appears to be far from optimal and possibly worsening, and health care financing plans seem certain soon to reduce funds for health care (under any system). Without a radical shift, or at least a concerted shift, from how this industry functions today, the health of US citizens -- where health is one of the pillars of every nation's strength -- seems likely to weaken and make less certain within a few decades the continuation of this nation as an egalitarian society.