Why 'Health Care' Reform Cannot Work

I have for several months now been referring to the current national debate as a 'health care' reform debate --using quotation marks around the words health care. Though I have made oblique references as to why I am doing this, it is time now to explain why.

But first you have to take a little trip with me.

That trip is one in both time and space. The time is June 2009. The place is Nashville, Tennessee.

One of the hospitals in my community is in the multi-year process of installing a fully-electronic health information system, with the ultimate goal of becoming as paperless of a hospital as a hospital can be. And they embarked on this path even before the HITECH Act was even thought of, much less passed. The time had come in this process to start gearing up for the conversion to computerized physician order entry, or CPOE. As part of that endeavor, the computer vendor sent a delegation from the hospital to a seminar at Vanderbilt University. This seminar involved more than just how to set up CPOE; it involved the why of CPOE and how to start thinking in a CPOE way. As a member of the information technology advisory council, I was a member of this delegation. In fact, I had to finagle my way onto the trip, as I was not one of the physicians originally chosen to go.

(As an aside, let me say that this seminar was one of the most innovative, exciting, thought-provoking conferences that I have ever had the good fortune to attend. I don't want to mention the name of the software vendor involved, but if you, dear reader, ever get a chance to go to this seminar [if you get involved with this company, you will hear of this seminar as it's an important part of booting up their CPOE], fight, scrape, and claw your way onto the trip. It's worth it.)

At this conference, one of the 'why' lectures was being given by one of the first people to start seriously thinking about the need for computers in medicine. The basic gist of the talk was that, due to the increasing depth of medical knowledge and medical technology, the number of pieces of information necessary to make a rational medical decision is increasing. And it is increasing at a rapid pace; so rapid, in fact, that within 5 to 10 years, the number will exceed the ability of the human brain to hold all that information and do anything with it. And it will still keep on increasing with no end in sight. So we will need computers to keep track of all that information and organize it in a way that our brains can make sense of it.

While the professor was lecturing, one of his associates was writing on a huge mark-sense board behind him. Ostensibly he was charting the important points, but about half of what he wrote on the board was only peripherally related to the talk at hand. The following is a near-direct quote of one of these peripherally related comments:

The U.S. spends $3k-$4K more per capita on our health care than France does. We have the best rescue care system in the world, but we are no better at treating chronic disease than is France.

I read this, and then I read it again and again. It wasn't just a light bulb that went off in my head -- it was a full-blown supernova. I even lost track of the lecture for a few moments. In that moment, with that statement, the true nature of the national debate became apparent. And it also became apparent that 'health care' reform was doomed to fail, could not work, cannot work, will never work, no matter whose plan is implemented or who implements it or how much money we do or do not spend doing it.

That's because we do not have a health care system. We never have had one. Since you cannot 'reform' something that doesn't exist, it follows that any such 'reform plan cannot work.

The statement above crystallized my thoughts on this matter in a blinding flash, but obviously my subconscious had been processing its way toward this conclusion for a long time. Otherwise I wouldn't have had such a sudden epiphany. For those whose subconscious is not as postally twisted as mine, let me explain.

The obvious point of the statement written on that wall was that we are spending more money on our 'health care' and not getting anything for it -- "we are no better at treating chronic disease than is France". But I chose to look not at the money but at the outcomes -- not "The US spends $3K to $4K more per capita than France does", but "We have the best rescue care system in the world..."

I'm sure that when most people hear the phrase 'rescue care system', the first thing that comes to mind is paramedics, fireman, ambulances, the Jaws of Life, and the like. But that's not what's being referenced here by 'rescue care'. What rescue care means here is 'emergency care' or 'acute care' -- what happens after you get to the hospital or emergency room.

Despite what you hear in the news (from the liberal press doing everything in their power to promote the programs of Dear Leader), if you have an illness in the United States, you have the best chances in the world of surviving. If you show up in the ER having a heart attack, in the throes of acute heart failure, or with a severe pneumonia, you have a better chance of surviving than anywhere else in the world. If your physician diagnoses you with cancer, your survival (in terms of percentages and duration) is better here than anywhere else. I could go on and on with examples. But none of this has anything to do with health care. It's medical care.

What's the difference? Medical care is what gets you over that acute MI, CHF, pneumonia, or cancer. It's the care provided by physicians and surgeons based on a tradition of treating acute medical problems that dates back more than two thousand years, to well before the time of Hippocrates. It's treatment based on anecdotal and then scientific observations of medical illnesses and treatments performed during those two thousand-plus years. It's the application of chemicals and fluids and electromagnetic radiation and invasive interventions to find the cause of a deranged physiological process and correct it.

Health care is none of these things. Health care does not involve fixing a deranged physiology. It involves maintaining a normal or optimal physiology for as long a time as possible. This rarely involves chemicals (other than vitamins), radiation, or invasive interventions. It does involve diet, exercise, avoidance of unsafe activities and toxic agents such as illicit drugs and excessive alcohol, the use of proper safety equipment, and the like. These are not the things that physicians and surgeons do. They are the things that each and every one of us should be individually doing but most of us do not, or do not do well.

Physicians and hospitals and home health nurses and physical therapists provide 'rescue' care -- medical care, not 'health' care. We have a medical care system, not a 'health care' system. This country doesn't have a health care system and has never had one! So there's no way we can reform it.

Trying to 'reform' the medical care system to try to be simultaneously a health care system will not improve health, as the medical care system and the people who work in it have no real training in it (such is not part of the system's two millenia-long tradition), and it will degrade the quality of the medical care system we have now, as these people cannot do that job and a second even more difficult one and not have the first job suffer.

It might be to the benefit of our nation to create a new system to encourage, support, cajole and reward health care. Exactly how to do this is beyond me; recall I am a physician and a member of the medical care system. Shoehorning it into the medical care system is a bad idea and is unlikely to work. And it's going to have to be a system that works at an individual level, as that problem starts at the level of the individual.

Let's reword the statement that was written on that wall in Nashville:

France spends $3K-$4K less per capita on health care than the U.S. does. France is no better at treating chronic disease than is the U.S., and its rescue care system is not as good.

When you look at it that way, France doesn't look that good any more, does it? You could replace France in that statement with any other country in the world and it would be just as true.

But look at both statements. France spends less and the U.S. spends more, and neither country is better at treating chronic disease (most of which is caused by poor health care choices) than the other. This tells you that spending more or less money is not the root of the problem. And it tells you one other thing.

France doesn't have a health care system either.