The Business of Healthcare Is Business

Kim BellardHmm, that headline doesn't seem right, does it? I mean, shouldn't the business of healthcare be, well, health? Or, at least, caring? Actually, shouldn't the business of healthcare be patients? After all, everyone in healthcare says it's all about patients. Everyone says they're patient-centered, whatever that means.

But think about this: who in healthcare gets paid for you to be healthy? Or, conversely, who in healthcare doesn't get paid when you get sick, or when you don't improve under their care? Whether we planned it or not, whether we admit it or not, or whether we like it or not, our healthcare system is a business that has become about making money.

We have a healthcare system that is like a bizarro world. It operates unlike any other business, treating its supposed customers like second class citizens while violating most laws of economics that apply to other industries.

Let's look at a few recent examples:

• Kaiser Health News reported on a $48,000 allergy test. The patient's insurer "negotiated" it down to a mere $11,000, leaving her with more than $3,000 to pay out of pocket. As one billing expert told KHN, "That charge is astronomical and nuts." The patient expressed her confusion: "No one cut into me. No one gave me anesthesia. I had partly open plastic containers filled with fluid taped to my back."
• Denver's 9News reported on how patients are going in for what they assume will be in-network surgeries, and coming out with liens placed on their houses due to bills from out-of-network physicians involved in their care. This despite Colorado having a law that is supposed to prevent balance billing. As one patient -- no, let's call him what he is: one victim -- told 9News: "This whole system is crazy. You have insurance. You have an emergency. It should be taken care of."
• "Non-profit" hospitals continue to claim the benefits of that status, but often don't act like it. As health economist Gerald Anderson told NBC News: "The tenor and the responsibility of hospital CEOs has now changed over time. They focus on the bottom line and … they get performance ratings based on profitability."
• Pharma keeps raising prices and coming up with new, always-more-expensive drugs. Novartis, for example, is talking about a one-time dose for a gene therapy that they think is worth $4 million. There are already other drugs that cost near $1 million a year.
• Yet another study confirmed that "serious illness often means financial disaster for Americans." For example, nearly half of cancer patients spend their life savings in the first two years of treatment. No wonder, then, that medical bills now account for 1/3 of GoFundMe campaigns.
• The chief medical officer for the American Cancer Society just resigned in protest to some of the (lucrative) partnerships it has formed with businesses like Herbalife, Long John Silver's, or Tilted Kilt. ACS is far from the only advocacy group with ties to companies with dubious health credentials, and KHN found that patient advocacy groups also take millions in from pharma.

I could go on and on, but Elizabeth Rosenthal's An American Sickness covers this ground at greater length (and with greater eloquence).

Bottom line: Healthcare. Should. Be. Embarrassed.

Still, though, I would be remiss if I didn't include an example of how technology fails in healthcare, as again reported by Kaiser Health News. It seems that Epic, the largest EHR vendor, can't even handle the switch to/from daylight savings time.

As one RAND researcher told KHN: "It's mind-boggling. We expect electronics to handle something as simple as a time change. Nobody is surprised by daylight savings time. They have years to prep. Only, surprise, it hasn't been fixed."

No wonder, as Atul Gawande wrote in The New Yorker,

Something's gone terribly wrong. Doctors are among the most technology-avid people in society; computerization has simplified tasks in many industries. Yet somehow we've reached a point where people in the medical profession actively, viscerally, volubly hate their computers.

Many believe they're so bad because they're neither about physicians nor patients, but about billing. As seems all-too-usual in healthcare, it comes down to the money, not the care.

And, yet, we seem to want the healthcare system, bizarro though it may be, to take on ever greater responsibility. Dhruv Khullar, MD, wonders if we've "medicalized everyday life," He worries: "But we may also be medicalizing much of normal human behavior - labeling the healthy as diseased, and exposing them to undue risk of stigma, testing and treatment."

Dr, Khullar concludes:

More fundamentally, we need to reconsider where the upper and lower bounds of diagnosis should be. Many experts believe the pendulum has swung too far, such that much of normal human behavior now falls within treatment thresholds. This reassessment is particularly important because those with mild or borderline symptoms may be less likely to benefit from treatment than those with more severe symptoms.

It shouldn't come as a surprise, then, that an article in BMJ asks if "lifestyle medicine" should be a new medical specialty, or that we talk about getting "prescriptions" for exercise. "Exercise for Medicine" is an actual initiative. Honestly, should we really need a prescription for exercise, and should our lifestyle be under the purview of our doctor?Where is the line between our life and our medical care? Who should be making money off of it -- and how?

Healthcare is slow-walking its way to outcome-based payments and value-based purchasing, but we don't really know what either of those are and we're not really anywhere near ready to put anyone at major risk for them. Let's be realistic about what they might accomplish, and when.

Look, I don't mind that healthcare is a business, or that people and organizations make money in it, even large amounts of money. What I do mind is how we're treated by that business, and how little we seem to know about what we are buying with all that care it delivers.

It's time -- way past time -- for the business, and the business model, to be about our being healthy, not about paying for what happens to us when we are not.