American HealthScare

Dr Young thinks healthcare in the United States costs too much and delivers too many services that are not cost effective. Erroneous assumptions about healthcare have made Americans think more is always better and no cost is too high when it comes to the latest test, drug or procedure that various interest groups tell us we need. As a result, he thinks we are endangering our nation's economic health and robbing our children of their future; a future in which healthcare costs threaten to gobble up most of our GDP

When you look at the facts — that American healthcare costs more than twice as much as any other developed nation, but produces some of the worst results — it's hard to argue with these conclusions. They are pretty much the same conclusions I have come to in my lifetime of living with American healthcare and the financial burden it has imposed upon me. According to a government website, healthcare expenses in the US averages $9,255 per person per year.

WHO SHOULD PROVIDE OUR CARE?

Much of Dr. Young's anger is against the way services are delivered, centering on the type of physician who should deliver most services. In his doctor-centric viewpoint, costs could be considerably lower if Americans took their health issues to a Family Physicians who would care for the entire family: mother, father, babies, children. They would rarely see a specialist because their needs would be met at the one location, their family doctor's office.

Why doesn't this happen now? For starters, America does not have enough family doctors to service the American population. Medical students don't choose family practice because they can make more money as specialists, and they need the money to pay their huge college tuition debts. After so many years of expensive learning and training, can you blame them for going for the specialty that pays well? We need to make some changes in medical education and reconsider payment for medical services to more equitably value family practice.

THE ASSUMPTIONS WE MAKE

But the reasons we are paying so much for healthcare go beyond just a lack of doctors willing to be family doctors and the high cost of college. Our healthcare system is a collection of competing interests, increasingly driven by a profit motive and often by defending a particular turf. Hospitals, insurance companies, drug companies, medical device makers, university medical schools, large employers, disease advocates and big charities all have an interest in how health care is delivered and paid for.

So does the Federal Government, which pays for almost half of all healthcare through Medicare, Medicaid and the VA. Policies and incentives mostly encourage more services, with little interest in researching what actually works or any concept of cost-effectiveness.

Dr. Young tells us he began to see that all these institutions think alike. He calls them Government-Industrial-Medical Coalition (GIMeC - pronounced "gimmick") and says the assumptions they begin with are the cause of our extraordinarily high costs in this country compared to others. These assumptions are:

- Prevention saves money
- Ologist (specialist) care is best
- Early detection cures everything
- More treatments equals better care

AN OUNCE OF PREVENTION COSTS A FORTUNE!

GIMeC buys into the contention that screening tests save lives, that early detection means more chance of a cure or living longer, that more "looking inside" the patient through X-rays, CAT scans, UltraSound, MRI etc will benefit the patient, along with the follow-on tests and procedures that might mean biopsies to seek out the tiniest bit of indication that disease might be lurking. All with no regard to any evidence of actual benefit from these medical interventions. Evidence shows so-called "preventive care" does NOT save money, but it IS very expensive and it can also do harm.

Dr Young does not have a favorable opinion of most services provided by specialists. He calls these doctors the "Ologists" and thinks Americans see too many of them when better and less expensive services could be provided by a family doctor. It is the Ologists who are mainly responsible for ordering too many tests and doing too many procedures at too high a cost. Dr. Young strongly favors his own type of medical practice (which, unlike specialist care, does not simply focus on "one body part"), where the doctor knows and serves the whole family, keeping track of all their health concerns over time; in this model of healthcare, specialists are infrequently consulted. He states:

Life-style choices and opportunities to live in a safe environment, eat healthy food, breathe clean air and have breaks from the stress of life also contribute. Money spent on healthcare cannot be spent on other things that contribute to our well-being and happiness. Most people just think about their own out-of-pocket medical spending, but we must learn to think about the overall cost to the whole nation of these excessive services, and how that hurts all of us.

WHAT IS THE ROLE OF INSURANCE IN HEALTHCARE?

Dr. Young uses mostly examples of people working for employers which provide good health insurance, making the point that the costs to their employers are really coming out of pay they could be receiving. People with these benefits mainly concern themselves with the co-pays, not the real cost, which they don't see. I imagine doctors have a lot of these people — people who have very good insurance coverage — as regular patients because they are the people who can actually afford to go to a doctor, but see fewer people with poor or no coverage or large deductibles.

In my own case, I now have Medicare, but throughout my working life, I either had no insurance or had "individual" coverage for which I paid outrageous premiums and had minimal actual coverage of services, plus I always had to STILL pay out-of-pocket at the doctor's office because of my high deductible. So I am only too well acquainted with the ridiculously high cost of health care in America. I am also acquainted with the concept of overuse of medical services by the well-insured running up the cost of insurance for the rest of us, and the particular unfairness of the so-called "individual market" for health insurance.

ObamaCare has reduced somewhat the total unfairness, but costs are still way too high for anyone of average income. Those with good job-based group policies don't see the in-your-face actual absurdly high cost of health insurance like those of us who were paying the whole premium each month. With ObamaCare, many people now get federal subsidies that go right to the insurance company, again disguising the actual cost, and continuing health care inequality in America. We still have millions of people who don't qualify for any help, or the help they get will still leave them with burdensome medical bills. Expensive drugs and procedures may mean even their copays will be so high they could be pushed into bankruptcy.

Dr. Young sees insurance as just one part of our problem, but I think it is a major part because of how Americans have come to receive health insurance. Job-based insurance is (In My Humble Opinion) a crazy way to provide people with health care. Not everyone works for an employer who can pay most of their medical costs. So, one working American is entitled to receive all the healthcare services he wants, thanks to his prosperous employer, while another working American must pay a large percentage of his income to obtain access to limited services. Job-based insurance creates this distortion!

Health insurance as a job benefit has been under a lot of pressure. It has been in decline, with 68% of the employed population aged 18 to 64 having health insurance through their own or another person's employer (as of 2010 census - the percentage is probably smaller now). Job-based health insurance can be a trap. Some people feel stuck in a job they remain in only because it provides a very good health insurance benefit for them and their family. I have no doubt people stay in bad marriages for the same reason. Why should there be health insurance consquences for changing jobs, or starting a business? That doesn't happen in other countries.

A growing number of people find themselves on their own to figure out how to get health insurance. ObamaCare provides online exchanges that let people compare plans, and seeing the actual cost may drive more people to question why our healthcare costs so much. Employers receive a tax break for money they spend on health insurance for employees, but you as an individual generally do not. (It's complicated. If you're self-employed, you DO get to deduct the premiums, something that wasn't true for most of the years I bought my own insurance. Insurance companies were also allowed to charge individuals ridiculously high rates and turn people down.)

DR. YOUNG'S SOLUTION -- TWO MODELS OF HEALTHCARE

Dr. Young proposes his own solution, which involves a rethinking of what a healthcare system should be. He suggests insurance could be offered on a two-tier model, with different pools of enrollees for each model. One would offer healthcare much like today, but eliminating some of what is done now that does not work. The other would work on a different assumption, one that counts medical services as only part of what keeps people healthy, and doing a great deal fewer tests and procedures. It would operate with an assumption that death is inevitable for all of us and there comes a time when screening and multiple medications make little sense and should be stopped. It allows higher levels of cholesterol and blood pressure before going on maintenance meds. Care would be provided by a family doctor, who would always take costs into consideration. Dr. Young thinks this is a way of providing Americans with choice in what kind of healthcare they want to receive and how much they want to spend on it.

Dr. Young's proposal seems unrealistic to me. While I would have loved to have the option of his "Basic Care" (the less-treatment, lower cost option) during the years I was paying those huge insurance premiums, I don't think insurance companies will ever pool subscribers in this way. They have shown they will extract every last dollar possible from everyone scared enough to believe they must have health insurance. Their business model is to make profits, not benefit patients. They never pooled all their "individual" subscribers into one pool, so why would they create this type of pool now?

I'll concede that new companies offering health insurance built on a non-profit "social insurance" model that pays for services based on cost-effectiveness, as envisioned by Dr. Young, might find a market, if enough people come to feel reduced services for lower cost is a worthwhile trade-off. But we once had the non-profit Blue Cross companies that were more centered on serving patients, and they were driven out of business (or taken over) by the for-profits. The health insurance industry has been consolidating into a few big companies, and I doubt they want any new competition. They have been big winners with ObamaCare, as everyone must now purchase their products.

WHAT ABOUT THE GOVERNMENT?

Dr. Young thinks government-funded universal healthcare would not work well in the US, but he fails to distinguish between total government ownership of healthcare, as in Great Britain, and a government insurance model, as in Canada, where doctors are not on the federal payroll. I think Americans could live with a system where everyone has a right to a very basic set of services and all emergency care, with a role remaining for private insurance for services beyond the government coverage. This would save the extra costs imposed by insurance, including multi-million dollar CEO salaries and shareholder profits.

Many Americans would choose to have only the government benefit, as I have chosen to have only Medicare, without a supplemental plan or a drug add-on plan (these come from private, for-profit insurance companies). This works for me. I will be 70 years old in August 2015 and I take no prescription drugs. Medicare alone is better coverage than I had during most of my working life as a self-employed or contract worker. I always resented the "deluxe or nothing" model of healthcare. If you cannot afford (or lack access to because of your insurance status) the maximum amount of healthcare services, then your only alternative was .... nothing! No insurance? No service! This is why we lead the developed world in preventable deaths. To improve our healthcare outcomes, we must include everyone in our healthcare system, and to do that, we must bring down the cost of providing basic healthcare to all.

FAMILY DOCTORS: A GOOD IDEA!

I also agree with Dr. Young that a family doctor can provide most of our medical needs. My husband and I go to the same family doctor, and he is very good about listening to us and our wishes to limit medical procedures. We get any blood tests and other tests through him and all test results are available to us online. If we DO go to specialist, we insist they use the test results from our last tests from our family doctor, not order more. My husband sees a Dermatologist yearly (he had a melanoma on his arm removed a few years ago) for a skin check and I go to an Opthmologist every two years (I have had cataract operations on both eyes) for a general check of my eye health and vision. I like the transparency and availability of online records, and we can email our doctor too. But when we have to go see him (we try for at least once a year for our Medicare "wellness" visit), his office is just a mile or so from our home.

My husband and I go to each others' appointments so we'll each have all the information about the other. I have used my husband's appointment to ask about or to update the doctor on some of my own concerns. I now understand, thanks to what Dr. Young reveals in this book, that a family doctor can only get paid for two issues at an appointment. He certainly can't be paid for addressing the concern of a spouse of the patient he is seeing. But my doctor does that anyhow. The rules should be changed so multiple family members can be seen and treated together and the doctor can be fairly paid.

GOVERNMENT HEALTH AGENCIES NEED TO CHANGE AND IMPROVE

According to Dr. Young, the government agencies that should be helping us learn which services actually work and are cost-effective are not doing a very good job. The FDA should stop approving $1000 pills and $100,000 treatments. It should compare new expensive drugs to older ones for cost-effectiveness and make that information available to all. The drug companies seem to be controlling the FDA to an alarming extent. The NIH should do more research on what works and tell us the results, instead of endless promises of "medical miracles" that are always years out, but never delivered. Anyone remember the "War on Cancer?"

I love Medicare, but it should negotiate with drug companies for lower costs and quit paying for screening tests that have been shown to provide no benefit. Ditto for expensive drugs that deliver a few more weeks of life, possibly in pain and suffering, for astronomical cost.

SUMMARY: LOTS OF GOOD INFORMATION IN THIS BOOK

Dr. Young provides a valuable look at how a Family Physician sees healthcare in America. He provides chapters where he puts you, the reader, in the place of a family doctor, with hypothetical cases and asks you to consider ways to deal with a variety of patient complaints and behaviors. This builds a good picture of the broad base of knowledge and skills needed by family doctors. The book is very much a pitch for more emphasis on family medicine as a way to save money and provide excellent care. The book is readable and illustrated with facts and figures. If you have an interest in health care policy or just want to know how medical care could be made more sustainable, this book is worthwhile reading.