The Road to Wellville
Booger Hollow Road, Dover, Arkansas. Photo: Windy Richardson
I grew up outside St. Louis, Missouri. When I was a child, my grandparents lived in northern Arkansas. I made that road trip countless times. I distinctly remember riding in the backseat as we crossed the state line and noticing that the two-lane Missouri highway became almost gravel the second we entered Arkansas. I always wondered why the road had to change just because we traversed a border. I now know the reason. When decisions and processes are left up to the whims of individuals and municipalities, a patchwork of solutions results. Such decisions feel and act different. They are often dysfunctional. They don't work together to form a true interoperable, efficient system focused on an excellent experience for each user. Our healthcare "system" is a perfect example. Unlike the interstate highway system, which did produce smooth roads across state lines, healthcare wasn't designed. It just happened. And you, the patient, had no say in it.
One hundred years ago, our nation's health looked totally different from today. The six leading causes of death in the U.S. were pneumonia, influenza, tuberculosis, diarrhea, heart disease and stroke. The average life expectancy was 47 years. Ninety-five percent of all births took place at home. People who called themselves doctors hung up their shingles and used the latest potions to heal their neighbors. They got paid when their patients were sick and wrote an entire medical history on a 3x5 index card. Only 10 percent of all U.S. physicians graduated from college. The best doctors who had degrees merged and formed institutions that eventually became Johns Hopkins and Harvard and all the other greats.
In the past 100 years, we've sure come a long way. We invented antibiotics and cleaned our water, so there's much less pneumonia, flu, tuberculosis and diarrhea. The average American dies at 78 years, although a 65-year-old today will live only six years longer than a 65-year-old did a century ago. The 30 extra years of average life expectancy can mostly be attributed to our ability to save young people with antibiotics, clean water and vaccinations. Healthcare has always been best with relatively simple problems: illnesses that can be mitigated with a pill, prevented with a shot, or cured by a scalpel. In fact, that's why hospitals were built — to treat people with acute conditions such as tuberculosis and pneumonia. Now we're left with a bunch of infrastructure designed for acute problems but a country full of complex chronic behavior problems — obese elderly folks who've terrorized their bodies for a half-century with processed food, stress, and couches. And we don't have a pill that erases 50 years of unhealthy behavior.
Doctors still have very little idea about how to get you to change your behavior and live better. That's not what we've historically done nor is it part of our training. Also, there's no money in preventing office visits and surgeries. We prescribe and we operate as much as we can. That is our healthcare "system." The more diseases individual doctors can diagnose or invent, the more they make from the insurance companies that pay your bills. In reality, our system wasn't designed to keep you well; it was designed to profit off your sickness.
And how we deliver healthcare hasn't changed much in the past 100 years. You still see the doctor in an exam room, after you've become sick. Doctors still get paid for your sickness. We operate with robots and write about it in your paper chart — only 20 percent of doctors use computers. You call to make an appointment for a mammogram two months out. In the waiting room for your preventive visit, you're infected by people who are there to be cured of their diseases. The traditional exam room and sick visits made sense when we, as a nation, suffered mostly from acute illnesses. But our country now has different needs.
Let's pat ourselves on the back. We solved the simple acute problems. Now we have to tackle the complex chronic problems. Currently, healthcare delivery in America is a messy business full of convoluted processes that tries to provide all things to all people. We need to clean up how we deliver healthcare and start creating focused services that allow all players to do what they do best. We need a system designed around our nation's health needs — chronic care management, prevention and acute care treatment — not history, doctors and their profitability.
We need designers to create from the ground up a new, sustainable, healthcare experience that's split into three arms, each paid for with different business models than are applied today. Most important, these three systems should be focused on your needs, interoperable and powered by a platform that looks and functions like a secure Facebook designed to power health communication. You would be able to schedule your own appointments and email, IM, and videochat with your health professionals. You'd also have a guide, an expert in medical triage, to show you what kind of professional you need, how much you should spend, and who would be best for you in your area.
The first arm is run by doctors and focuses on acute illnesses like appendicitis and broken hips. We're really good at solving those problems. Ninety-five percent of the time, a hip replacement is a standard process, much like manufacturing a car, without costly surprises. So these would be paid for by a flat rate per fix with bonuses for efficiency and quality.
The second arm focuses on prevention. This would be run by wellness experts. Doctors aren't good at keeping you well, nor are we trained in it. So we would turn this duty over to experts who are paid for prevention. Also, if you're well, why should you be sharing examination or consultation space with sick people? There would be recommended preventive services for each age and gender. These services would be yearly fixed costs. Wellness experts would be paid on a per-member, per-year basis with bonuses for volume.
The third focuses on treating and managing behavioral-based chronic diseases like diabetes, obesity and congestive heart failure. In this system, doctors would only be involved in the treatment of complications of chronic disease, not the day-to-day management of disease. Currently, you spend only about 1 hour per year with your doctor and 8,765 hours on your own. Again, we're no good at changing behavior. So we would turn this over to professionals who'd keep you out of our office by managing your diseases on an everyday basis. This is the most important arm because 75 percent of $2.5 trillion comes from chronic diseases. Disease managers who can help you with education and support on an almost daily basis would run this system. Doctors would be paid a flat rate per fix when disease management failed. Disease managers would be paid on a per-member per-year basis depending on the complexity of individual patients, with bonuses for keeping you out of the sickness industry.
We should start designing this system now. It currently costs employers about $13,000 per employee per year. In 2019, it will cost $28,500. That's simply not sustainable. Soon only the wealthy will be able to afford today's version of healthcare. And the only way to save our nation's health is to redesign how we pay for healthcare in conjunction with innovative, intelligent, user-centric healthcare delivery. Many say this is impossible. But it's simple supply and demand. You, a nation of people wanting a better, more affordable experience that keeps you well, are the demand. This new system is the supply. Demand something better, and someone will supply it. Isn't that how the world works?