Medical Examiner


Health care reformers should look to the banking collapse as a cautionary tale.

Operating Room.
Health care workers

The condition of the U.S. economy can be described generously as bleak. But while unemployment is on the rise and the Big Three automakers struggle to remain afloat, the business of making people well seems relatively insulated. While some discretionary health care sectors are not growing, such as LASIK eye procedures and plastic surgery that patients pay for out of pocket, most health care workers still have jobs and can afford the occasional $4 latte.

But the health care industry is no oasis. The very problems that brought our country to its financial knees are still at work today in health care. It comes down to the disordered competition that exists in both the mortgage and health care industries.

If you pick up your college econ textbook, you’ll read all about Adam Smith and how competition is fundamentally good. When companies compete, it results in a better product for the consumer: McDonald’s competes with Burger King to make a better, cheaper hamburger. Problem is, in both the old, defunct mortgage business and current health care industry, the “invisible hand” fails to produce low-cost, high-quality, sustainable products.

In the mortgage industry, this competition failure produced the banking crisis. During the housing bubble, banks competed with one another to sell risky mortgages that had a high likelihood of default. Now, entire neighborhoods have been left nearly deserted because of waves of foreclosures. In health care, competition similarly fails to produce better community health. Instead of competing with one another for the best outcomes, providers compete for patients with the most profitable diseases. Hospital care for cancer and heart surgery makes more money than hospital care for diabetes, pneumonia, or mental health. While all these services get reimbursed, some bring in more cash than others—in effect, cancer care is like gold while diabetes is like silver.

As a result, form follows finance: Gilded diseases get the best care while the silver diseases are given lesser priority. (Ever notice that hospitals have hardwood floors in some areas, like the cancer units, while general medicine gets linoleum?) Mining gold generally means doing high-volume elective procedures and state-of-the art care—the stuff patients think will make them better in a short period of time. Mining silver involves primary and preventive care, like managing blood pressure. Because it’s less lucrative to mine silver, even patients with comprehensive insurance are made to wait for doctors’ appointments and often get bumped to E.R.s for regular care. In Redefining Health Care,economists Michael Porter and Elisabeth Teisberg detailed how this gold-mining scheme interferes with creating the best health outcomes because it devalues certain treatments and marginalizes patients with particular diseases. Improperly treated diabetes can be just as lethal as untreated cancer, but while hospitals roll out the red carpet for cancer patients, diabetics get the shaft.

E.R. patients make less money for the hospital than elective admissions. Therefore, running an overcrowded E.R. is a passive form of cherry-picking: By restricting the influx of these second-tier patients, the hospital can focus on the gilded cases by preferentially reserving space for surgical and cancer patients at the expense of others who suffer  for hours in E.R. hallways. This is perfectly legal and increases profits but does not produce a healthier overall community. The University of Chicago Hospital has taken gold-mining to the next level, according to reports: The Urban Health Initiative is designed to actively cherry-pick by shipping out “routine cases” (read: less profitable) from the E.R. to local community hospitals so they can reserve inpatient beds for more complex patients (read: more profitable). But there has been some push back by regulators: Government officials may actually challenge the hospital’s “nonprofit” tax status. And, as of this month, Massachusetts hospitals will no longer be able to use ambulance diversion (which is also profitable) to divert E.R. cases to other facilities.

And just as mortgage companies used adjustable-rate mortgages to convince homebuyers they could afford homes they couldn’t, health care is rigged to promote overuse at the expense of the consumer. This overuse comes in two forms: the excessive testing and limitless treatments by doctors and the voracious demand for these services by patients. Many of the health care services that people want and doctors recommend really have no proven value—like the full-body CT scan that Oprah bought. The patient doesn’t really bear the brunt of the cost for most health care services—the insurer does—but these practices inflate premiums for everyone. There’s no downside for doctors who order unnecessary tests, and no one really watches what doctors prescribe unless they are handing out narcotics like Percocet or directly hurting people. Most doctors practice conscientiously and do what they think is in their patients’ best interests, but the point is that the system encourages the delivery of as many services as possible. More liver transplants equal more money.

Neither medical care nor mortgages are fundamentally bad. But there are too few checks in the system to prevent people from getting the equivalent of a crappy burger.

How can health reformers learn from the mortgage industry? One solution is paying for health care outcomes instead of health care services. Under this system, if the doctor makes you better, he gets paid—otherwise, no dough. But reimbursing on outcomes is problematic because it is difficult to know who should have gotten better but didn’t, and who would have gotten better even without treatment. Doctors who take harder cases would look like they were bad at their job and maybe get paid less, possibly creating incentives for refusing harder cases.

Another concept is the Federal Health Board (touted in a new book by the incoming secretary of health and human services, Tom Daschle). This board would be similar to the Federal Reserve and make nonpartisan recommendations on which medical tests and treatments Americans should get (i.e., which will be reimbursed). But critics of his plan worry that many treatments that actually do work don’t have a lot of science backing them up. While this government scrutiny on medical care would likely tamp down costs, it could also result in the rationing of services.

Yet another proposed solution is the medical home, where primary-care providers would get special incentives to manage and coordinate chronically ill patients. When we get sick, it can be quite a challenge to navigate the system and manage the myriad specialists. The medical home might make the lives of the chronically ill easier and reduce system costs by preventing expensive hospitalizations.

But, ultimately, what needs to happen is an overhaul of the structure of the system. Just as financial reform is needed to ensure that mortgage companies don’t hand out loans to those who cannot afford them, health care reform should focus on aligning what patients demand (to be and feel healthier) with health care reimbursement. An ounce of prevention is a lot cheaper than a pound of cure. Healthy diet and exercise are better than getting a heart stent and spending a week in the hospital after a heart attack. We need to reform the health system now so taxpayers don’t get saddled with another trillion-dollar bailout.