Complexity in Health Care – Redefining Our Approach to Policy

Benjamin F. Miller, PsyD

Benjamin F. Miller, PsyD

Benjamin F. Miller, PsyD
Chief Policy Officer, Well Being Trust

Current debates in public policy continue to focus on health insurance coverage and tax breaks. These two issues are very much related, and our Congress will undoubtedly try to continue to tackle them. One of the problems with focusing primarily on coverage is that it is only one piece to a much larger puzzle of health reform. Our Congressional leaders continue to recognize the complexity inherent in changing health care, specifically around coverage. And while wildly unpopular on the Hill amongst some political parties, the 2010 Patient Protection and Affordable Care Act (ACA) has become a benefit that most Americans do now not want to give up.

If the ACA remains the law of the land, and our policy quibbles will be around coverage, how can we begin to pursue other factors that are necessary to bring about more comprehensive change in health care? To truly understand some of these issues, we have to reexamine some of the most basic principles in health care.

No one has highlighted some of the challenges of change and complexity in health care more than a wonderful review article by Moses et al:

“Current taxonomy is frequently misleading and fails to describe the complexity of the entirety of the US health care system. Health is a misnomer, because most activity involves illness. Health care and medical care are not synonymous. Prevention requires tools that are often unfamiliar because educational, behavioral, and social interventions, not usually considered to be part of medicine, may be most effective for many diseases. Provider does not accurately describe the dozens of different professions and organizations required for a patient’s care. Payers are paid not to pay too easily; insurers do only modest amounts of insuring because government and employers accept most risk. Economic concepts of cost and value are ambiguous, as measurement is elusive and because one segment’s cost is another’s value. Market is a misnomer because few prices are transparent and many are controlled. Above all, US health care is not a system, as it is neither coordinated by a central entity nor governed by individuals and institutions that interact in predictable ways.

The Moses article is important on multiple levels. If you have not read the article in its entirety, stop reading this blog post and go read his article immediately. There are so many gems in this article around policy and the facts around health care, it is important to try to break down a few of these points in service to beginning to look at ways we can tackle more progressive and transformative issues in health policy.

Let’s start at the top:

“Current taxonomy is frequently misleading and fails to describe the complexity of the entirety of the US health care system.”

It’s true – our most basic taxonomy for health care only highlights some of the major issues that are easily grasped. Things like health insurance, while complex, are understood at a basic level for most Americans. However, when you begin to look deeper into health insurance, one can see that it requires a relatively high level of expertise to truly understand how complex health insurance really is. So yes, our language is misleading as to the complexity of health care. And if you really want to begin to look at how our taxonomy misleads, spend some time considering how there are different taxonomies for mental health care from more general medical care!

“Health is a misnomer, because most activity involves illness. Health care and medical care are not synonymous.”

Health is the foundation for achievement. It is not simply the absence of disease, but multifactorial and systemic. Consider that some of the most significant predictors for your health are where you live. Further, care for our health may have little connection to the medical care we receive. This now classic article discussed how health care is only a small percentage of what makes up our health whereas other factors take a more profound role.

The problem with focusing on the “sickcare” system is that we do not give adequate attention to upstream factors that could better help prevent people from becoming sick in the first place. If all we do in our policy is design better ways to address sickness and disease, we lose an important opportunity to ultimately bend the cost curve.

“Prevention requires tools that are often unfamiliar because educational, behavioral, and social interventions, not usually considered to be part of medicine, may be most effective for many diseases.”

Rather than spending time talking about some of the issues of “direct-to-consumer advertising” for pharmaceuticals, let us just accept the fact that we pay a substantial amount more for medications than other countries. This desire to have a pill that can fix all our ails says a lot about our culture in the U.S. The point here Moses and colleagues make is that we rarely factor in, prioritize, and pay for interventions that are non-pharmacologic. Why do we not better educate on health? Why do we not address behavior and lifestyle until it is too late? And most critically, why do we not choose to invest in the social strata that are so critical for our health?

If we want to shift the dialogue around public policy, perhaps we should spend more time assuring people that prevention is not a bad word. Of course, the irony is that health care is truly a business that profits on the sick. We do not yet have the incentives in place to have clinicians, systems, and policy makers invest in keeping people well. There truly could be no more transformative issue in our society than how we shift our investment and policy strategies to create a culture of well-being whereby these upstream factors are prioritized.

“Provider does not accurately describe the dozens of different professions and organizations required for a patient’s care.”

Divisions divide. An entire article should be written about this point alone.

“Payers are paid not to pay too easily; insurers do only modest amounts of insuring because government and employers accept most risk.”

Some have referred to the health care system as the “wealth care” system precisely because everything that can be done to maximize profit is a primary consideration. This statement sounds cynical, but as many have pointed out, costs in U.S. health care system have grown uncontrollably. And when asked why this is the case, the simplest answer I always give is because it can. Can we shift the culture of health from wealth? For this to happen we will need our respective communities to rise up and begin to demand more for their dollar.

“Economic concepts of cost and value are ambiguous, as measurement is elusive and because one segment’s cost is another’s value. Market is a misnomer because few prices are transparent and many are controlled.”

Similar to the above comment, how well do we understand the economic and market principles that keep us stuck where we are in health care? If we pursue policy change without acknowledging or addressing these massive forces, will we ever truly bring about substantive change and truly decrease cost?

For the collective movement to advance health, we must start knowing that before we can create solutions to health, we must first create a true system of care. As the authors state:

Above all, US health care is not a system, as it is neither coordinated by a central entity nor governed by individuals and institutions that interact in predictable ways.

Yes, it is true, there is no true system in the U.S. for health care. There is no true system for mental health care. What we have is our brilliantly isolated pieces that may have moments of connection, but most often are not incentivized to partner or coordinate. Most people think that health care is fine until they are sick. Having to navigate the myriad of pieces in health care is hard in the best of times, and even harder when you are facing the stress of being sick or having a sick loved one.

And to add insult to injury, we have made mental health care one of the most difficult specialties to get access to in health care.

Sadly we do not have a system in health care, but yet it’s referred to every day as something as if it does exist.

In the journey to advance health through policy, the need for strong leadership has always been a need. Without leaders advocating for some change, critically important topics like mental health are not likely to rise to the level of critical importance for policy makers. However, none of our ideas around change are likely to make a difference if we do not consider the issues outlined by Moses.

It is time to be more proactive in our policy. No longer is it sufficient to take a defensive stance and wait on someone else to control what happens next for health and then react to it; no, now, more than ever, a community of leaders must outline what they want to see happen for health and wellness. Let us move forward knowing our focus, knowing our facts, and knowing what we are not willing to settle until we achieve the change we seek.

Decisions are being made as you read this – do you want to react to them or be involved in what they look like? And most importantly, how can you assure that they are meaningful? Using principles from above can be a useful guide in assessing the meaningfulness of policies being pursued and likelihood for change.

So let’s embrace complexity in health care – and let’s see health care for what it truly is and truly is not. Our next steps in policy must recognize our shortcomings if we are to ever create an actual system for people that can take care of all their health related needs.