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Why I think the American healthcare system is failing

The Organization of Economic Cooperation and Development (OECD) is a large database of 38 industrialized countries which collects information on economic, demographic, healthcare and other statistics.

Here is how America ranks compared to those other 37 countries:

  • Life Expectancy – Bottom 50% (meaning worse)

  • Infant Mortality – Bottom 35%

  • Maternal Mortality – Bottom 33%

  • Obesity – #1

  • Healthcare cost per person per year - #1

In America today you have a higher risk of dying, lower life expectancy and yet spend more per person per year than any other country. We have failed each other and, sadly, this failure has been going on for quite some time, in some cases decades. The data is clear: the American healthcare system is failing.

The question is why.

My front row seat

For over 30 years I have had a front row seat to the gaps in our system as an emergency physician. I had the privilege of taking care of any person who walked through the door regardless of ability to pay, race or sexual orientation. If you needed care, my team cared for you and did what was needed to be done to alleviate your pain, provide comfort, and make sure you did not have a life-threatening condition. Occasionally, we saved your life. In every emergency department in this country this care continues every minute of every day.

I have watched as people have had to make choices between medicine or a meal. I have taken calls from friends regarding where best to take their teenage son or daughter who was in crisis and needed urgent intervention to stabilize their mental health. I have counselled relatives regarding how to find the best doctor for a particular condition since they did not seem to be helped by their own doctors in finding a solution to their issue.

America is the envy of the world when it comes to advanced cancer care, as well as our advanced cardiac or orthopedic procedures. I used to say that if you are seriously ill or injured you are better off in a U.S. Hospital than anywhere else in the world. Although sadly, in many rural areas of our country that is simply not the case due to staffing issues, both nurses and doctors.

America is bad at the basics

We are simply terrible when it comes to providing basic high quality primary care to the vast majority of our citizens.

Ask yourself if you are completely satisfied with your primary care doctor. I’m not referring to concierge level care where your doctor is available to speak with you within 24-48 hours if you have an urgent medical issue. I am talking about the ability to access high quality primary care for you or a family member when you need it on a timely basis. Most of us can’t.

It is certainly not because your primary care provider does not have the knowledge or the ability to do so. Primary care clinicians, general internists, family practitioners and pediatricians should be able to spend time with you to guide you and craft a plan that allows you to live your longest and healthiest life. They simply DO NOT HAVE THE TIME TO DO IT.

Why? Their reimbursement model is broken and the only way for it to work is for them to cram more patients into a day spending less time with each of us to pay their overhead or leaving and becoming one of those concierge doctors. (And in full transparency, my practice at Dignity Integrative is a subscription based model where you pay for my time and 30 plus years of accumulated knowledge.)

America prioritizes procedures

Here is the average salary by specialty from a recent salary survey:

As you will note we pay ‘proceduralists’ much more than we pay non procedurally based doctors. In some cases, 2-3 times as much.

This payment model extends to hospitals. It is one of the many reasons you will never see a new hospital ‘tower’, often costing tens or hundreds of millions of dollars, dedicated to prevention. It will most likely be a temple to cardiovascular, neurosurgical, orthopedic surgery or, increasingly, cancer care.

Americans are paying the price

On top of not being able to see a doctor most of us can’t pay for the care when it is given effectively.

As mentioned, in the U.S., healthcare costs outpace the world by a factor of 2:1 per person per year. These data from the OECD makes this clear. As a participant in the healthcare 'system’, each of us knows what has happened over the last 15 years. More and more of healthcare expense has been shifted from the insurer to the insured.

It is now not uncommon to have deductibles of $10,000 per family before your actual insurance starts to pay for care. Some basic primary care is reasonably covered but there is a persistent and rising ‘out of pocket’ component for most of us in the U.S.

In the U.S., medical debt is one of the leading causes of personal bankruptcy. A study conducted by the Kaiser Family Foundation found that 11% of adults with medical debt reported filing for bankruptcy, compared to only 2% of those without medical debt. The average medical debt is $2,000 with 20% of Americans having over $4,000 of medical debt.

Where the money goes

Who makes money from health care?

Quite a lot of organizations including, of course, your local doctor and hospital.

Insurance companies also do quite well. Let’s look at the revenue and profit numbers for the largest health insurers in 2021, based on data from the National Association of Insurance Commissioners:

  1. UnitedHealth Group: $300.5 billion (profit: $18.9 billion)

  2. Anthem: $133.6 billion (profit: $4.8 billion)

  3. CVS Health: $268.7 billion (profit: $7.2 billion)

  4. Humana: $84.4 billion (profit: $2.5 billion)

  5. Cigna: $160.4 billion (profit: $4.2 billion)

  6. Centene Corporation: $111.1 billion (profit: $1.5 billion)

  7. Molina Healthcare: $22.9 billion (profit: $703 million)

  8. WellCare (now owned by Centene Corporation): $24.7 billion (profit: $328 million)

  9. Kaiser Permanente: $84.5 billion (profit: $6.4 billion)

  10. Health Care Service Corporation (HCSC): $61.9 billion (profit: $1.2 billion)

Finally, and perhaps most concerning, is the rapid expansion of large insurers to employ (some suggest control) physicians. The largest employer of physicians in the country today is Optum health, the 54-billion-dollar arm of United Healthcare. Optum currently employs 70,000 doctors.

There are glimmers of hope such as new startups focused on providing comprehensive primary care using advanced AI in conjunction with the wisdom of great primary care physicians to structure a plan for optimal health. Sadly, some of these are only available to select members of society but the promise of lower costs over time promises to bridge the current gap. Personal biometrics use, however, is rising, placing in the hands of individuals immense personal data on sleep cycles, movement metrics, stress levels, and continuous glucose levels to name a few.

Yet the point of this article is to point out the current realities.

Specifically, America has:

  • Highest cost healthcare per person in the world

  • The bottom third outcomes on some of the most important health metrics

  • A healthcare system focused on disease management vs prevention

  • A medical reimbursement model rewarding doctors who perform procedures vs prevent disease

  • A health insurance system designed to shift more of the financial burden and risk to the individual while reaping multibillion dollar profits

We are at a tipping point

My belief is we are at a tipping point in healthcare.

Having witnessed the success and failure of our system up close and personal for nearly three decades allows me to propose a few things to do to avert this collapse. Little of this actually has to do with changing the system. The component in this system which needs to change is how we look at being a patient and what that actually means.

When a patient comes to see me, I often say that 99% of your personal health happens outside any doctor’s office, including mine. Your health is a summation of the hundreds of decisions you make every day, from the food you eat, to how you move your body, to getting enough sleep and rest.

But we have been trained as patients that when we are not feeling well the answer lies in a blood test or a drug. I agree that having a set of baseline tests to assess your long- and short-term risk is important. Just as important is finding the right provider to interpret these tests and come up with a plan you can implement. I disagree that the solution lies in a pharmaceutical to ‘fix’ your problem.

Beyond the baseline testing, how can a person intentionally move to a state of optimal health?

Start with these six things:

  1. Understand that your doctor does not have the answers to your problems. They may be able to give you some general direction on good nutritional strategies or exercise routines but they will not be able to provide specifics. They are simply not trained in those area with the requisite knowledge unless they have done a significant amount of self-study.

  2. Understand that it is YOUR LIFE we are talking about and, yes, you need to invest a small amount of effort on being an informed consumer regarding what principles are known and what you can specifically do to impact personal health and longevity. According to the World Health Organization up to 70% of all chronic disease is preventable (not treatable, preventable). This includes over 50% of all cancers. Understand also that type 2 diabetes, the vast majority of diabetes in America and the world, is completely reversible.

  3. Build your personal health care team. These includes integrative practitioners such as chiropractors, acupuncturist, medical massage therapists, nutritionists, and others. You need to search out people who can help you and more of these are covered by traditional insurance.

  4. Take simple steps like cutting out all ultra-processed foods and added sugar beverages

  5. Walk or do something, literally anything, that involves moderate movement, for 30 minutes a day.

  6. Take 10 minutes to start your day building a mind balancing practice like meditation, breath work, gratitude or prayer. You will be amazed at the impact it has.

While we can talk about changing our healthcare system, and we should, those changes will take a generation to implement. We simply do not have the time. Each one of us needs to be more proactive and involved in our personal health. Your life, literally, depends on it.

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