Making American Health Care Healthy Again

Dana S Kellis MD PhD MBA

“Make America Healthy Again.”  - Robert F Kennedy Jr

I appreciate Dr. White’s conscientious, thoughtful, and well-presented proposal - Universal Access to Affordable Basic Health Care ꟷ The System.  Incredibly, some of our elected representatives are crafting legislation as we speak that would withdraw health care coverage from millions of Americans, making it hard to believe even a modest acknowledgement of the desperate needs of many of our countrymen and women would have even a hint of a likelihood of becoming a reality.  While I have little sympathy for or even understanding of the motives of lawmakers willing to trade the health and welfare of the very people they have promised to protect, I am compelled to admit that we, the American health care industry, have only ourselves to blame for the situation in which we find ourselves. 

American Health Care confronts an existential crisis born of decades of unmanaged expansion, unmitigated profiteering, unfettered monopolistic and monopsonistic behavior, unlimited growth of disability and disease, and the unmet health care needs of millions and millions of Americans.  The pervasive myth or dream that free market forces will bring the health care  Cerberus  and its three heads of vigilance, power and ferocity to heel is belied by health care’s intransigence to patient-based reforms, its power to thwart cost-cutting efforts, and its success in obscuring its excesses and its failures.   As a result, millions of loyal, hard-working Americans live with constant risk of an accident or injury precipitating catastrophic economic, physical, emotional and social devastation as impossible health care bills lead to bankruptcy, which in turn creates stress-induced mental, emotional and physical illness for which, having unpaid outstanding medical bills, finding adequate treatment becomes difficult or impossible.

The nature of our crisis gains increased clarity daily as Americans, frustrated by their perceptions of corruption, deceit and malfeasance by health care institutions – doctors, hospitals, insurance companies, and drug companies to name a few – manifest their loss of trust and confidence in the system by turning to uneducated and untrained charlatans, or worse,  knowledgeable practitioners who choose to forsake their training and ethical standards  to promote  disproven remedies and false theories of disease,  or worse, to sow confusion and doubt about life-saving treatments and preventative measures, often with the goal of gaining notoriety or of generating personal income, or both.  Incredibly, but not surprisingly, we thus find ourselves today with national and local political leaders actively undermining public health, promoting unproven and dangerous therapies, defunding health care research, and threatening to scale back governmental health care coverage for the poor, sick and disabled. 

The following list enumerates some of the most egregious examples of failure within our health care system.  I will then advance a set of principles which could significantly reverse our current course and recenter our system on a sustainable and defensible path.  Parenthetically, while I passionately feel our health care system suffers from systemic decay, I do not extend this indictment to individuals within the system.  The vast majority of health care workers, whether clinical or administrative, work hard in the positions they hold to achieve the outcomes for which  they’ve been hired or contracted.  While most sense a brokenness of the system in which they work, they also correctly perceive the impossibility of an individual or even a company significantly changing  or fixing the system’s flaws.

1. Hospitals colluding with insurance companies and drug companies to set fees and prices  for their services and products, to maintain the existing health care economic structure, and to perpetuate the grotesquely unfair practice of charging uninsured patients multiples of the amounts insured patients pay for the same services and products. 

2. Health care providers’, including hospitals, physicians, radiology groups and many others, deceptive, misleading, and ultimately unfair billing practices.  This includes things like designating hospitals’ owned physician practices as “hospital outpatient” settings, and then charging grossly inflated fees, designating hospital admissions as “outpatient” and thus saddling patients with a significant increase in their non-insured responsibility, despite rendering the same care given to “inpatient” admissions.

3. Proceduralists performing unnecessary procedures or using  unnecessarily expensive implants, such as placing titanium joint implants in non-ambulatory nursing home patients.

4. Groups of hospitals, physician practices, and service entities (radiology groups, radiation centers, etc.) joining together to form market-controlling monolithic health care systems which, despite promises to the contrary, cause prices to increase and quality to decrease.

5. Hospitals, physicians, and insurance companies colluding to withhold quality and safety data from patients, regulators, and even internal stakeholders, leaving patients to make health care decisions based on word-of-mouth, innuendo, advertising, and other unreliable information.

6. Total failure of health care providers to coordinate their treatment strategies, resulting in such things as gross over-medicalization of Americans.  I have seen individual patients being given nearly 100 different medications prescribed by dozens of practitioners involved in the patient’s care who expend little effort to coordinate care and treatment.

So, what can be done to “fix” health care?  How can we regain the confidence of those we ask to entrust their lives to our care?  True, suggesting these steps may seem delusional; however, are they any more delusional than idly standing by while our health care system implodes on itself, fervently hoping American will overlook our disingenuous claims of providing health care excellence, and ignore the fact that Americans fare worse in their health than many third-world countries, and waste a third or more of the trillions of dollars they spend on this mediocre care?

• Provide Medicare or similar coverage to all Americans.  In this day of crowded airplanes, airports, restaurants, subways, classrooms and  packed entertainment venues, we delude ourselves by thinking health care is a personal matter.   We don’t pick and choose who can call police in an emergency, who our armed forces defend, who gets to drive on public highways, etc.  So should we ensure all Americans can access the care they need, not only for their own welfare, but for the welfare of all of those with whom they interact, and ultimately, for the welfare of the country.

  This long-overdue expansion of health care coverage would be more than “paid for” by removing at least part of the 30% of current health care expenditures that go to waste, including:

  • Making the majority of insurance premiums unnecessary and transferring the savings to the Medicare-like universal coverage.

  • Reimbursing hospitals and other providers based on their outcomes, not on their volumes.

  • Empowering community, state, and federal leaders to truly manage health care entities for costs and outcomes

  • Restructuring medical malpractice  so that physicians who follow established guidelines are protected, while patients who are harmed by poor practice are compensated  without lengthy and expensive legal proceedings. Providers who repeatedly demonstrate an inability to provide quality care are repositioned into non-direct patient care roles.

  • Incentivizing health care systems to use professionals to the full extent of their training, allowing physicians to maximize their contributions to patients’ outcomes by appropriately supervising other professionals, and so forth.

  • Moving the majority of current inpatient care to home-based care.  Reserve inpatient facilities for intensive care, including post-operative care for major procedures.  Parenthetically, I am aware of several health care systems who found they could provide, using home-based care, outcomes that were as good or better than inpatient care for considerably less cost; however, they chose not to pursue home hospital care because it would have cannibalized their inpatient profits. 

  • Creating and then providing decision-makers with full report cards for each provider on measures of quality (STEEEP), cost, and patient-based surveys, and use these report cards for contracting and assignment decisions. 

These are only a few of the changes our health care system must adopt in order to remain relevant and functional in a future marked by rampant mistrust of the system, introduction and adoption of alternatives to standard medical care by growing numbers of people, loss of public willingness to support embarrassingly excessive incomes of administrators and practitioners in the face of declining outcomes, emergent and chronic demand outstripping the capacity of hospitals who increasingly base resource decisions on profitability rather than community need, and so forth. 

Some would deem these suggestions to be extreme.  In response, I assert that nothing is more extreme than having health outcomes worse than most third-world countries in neighborhoods in the very shadows of mirrored skyscraper hospitals operated by health care systems who extract billions of dollars annually  from these same neighborhoods. 

Respectfully submitted,

Dana S. Kellis, MD, PhD, MBA

Dr. Kellis is a retired physician-administrator, internist and educator. and also has experience as a physician advisor in South America.  His current interests include healthcare reform, service as a missionary and a pastor, flying small planes, and spending time with his children and grandchildren.  He currently lives with his wife Connie in Farmington, Utah.