Reforming Health Care

HouseMDConfession time. The reason for my late and sporadic postings over the last week or so is that I pinched a nerve in my neck, and I’ve been doped up since then. The choice of the Resilience topic for the Open Thread during my absence was a bit ironic — the injury came from doing strenuous physical work (mowing and pushing my heavy scrub-cutter around our very hilly lot), when I get almost no proper exercise of any kind and have lousy posture. It’s given me some time to think about our troubled health care system, about why idiots like me get injuries like this when we know better, and about a suggestion from several readers that perhaps the solution to health care is to pay people for staying healthy.

The idea has a kind of immediate provocative appeal, but I don’t think it can work. In the first place, systems that provide financial rewards for staying healthy (like some insurance schemes) don’t actually reward you for staying healthy, they reward you for not seeking medical help and for not filing claims, which is not the same thing at all. This is the same perversity that encourages people who are victimized by vandals from not filing a perfectly justifiable insurance claim because they know their insurance premiums will then rise by more than the amount of their claim. This is a depraved but very profitable way to run an insurance business. As a means of providing equitable and functional remedy for accidents, illness or injury, it is horrific. It unquestionably results in unnecessary and avoidable human death and misery, overwhelmingly to the poor and weak, simply out of the fear of economic penalty.

Some organizations offer standard “sick days” each year that you get as extra vacation days (or as a monetary bonus) if you’re not sick. The consequence of this is to treat sickness as a kind of crime that you get rewarded for not committing. It assumes what Malcolm Gladwell has called “the Moral Hazard Myth” — that whenever you offer insurance for something, it automatically leads to rampant abuse. In other words, that people — especially the poor, weak, and unemployed — are lazy exploiters of public largesse. Organizations I know that have tried “sick day” policies ended up with sick people coming to work, spreading their illness and doing poor quality work because of it, so they could “save up” their sick days for extended vacation.

Insurance companies have also tried, in a superficial and sloppy way, to reward people for avoiding behaviours that cause illness (like having premiums for smokers that are twice those for non-smokers). The general consequence of such policies is (a) it encourages addicts to lie, and (b) it encourages insurance companies to spy on people so they can catch people lying so they can keep the premiums but not have to pay any claims. Great system, huh.

The problem with all such schemes is that it is impossible to say when an illness is the result of hereditary factors (genetic predisposition), when it is the result of environmental exposures (in the home and workplace and society at large), and when it is the result of behaviours over which the patient has (according to some philosophies, anyway) some degree of control. Or, to put it another way, it’s impossible to say when and to what degree it’s the patient’s fault they were sick or injured.

So while the idea of paying people to stay healthy appeals to me in a wry kind of way, I think it is basically an unworkable idea. So what might work better? Are there other ways, other than financial bribes and penalties, that can actually change behaviour in a way that will make people healthier?

There’s a company in our community that provides a free, supervised exercise facility to all its employees, and a subsidized cafeteria that offers only healthy foods. I think they’re on the right track — they’re rewarding behaviours that repay them as an employer (through healthier, more resilient workers), without getting specific about who’s to blame when an individual becomes sick or injured. It’s a ‘no fault’ system.

What is needed to supplement this is more honesty in our society and our economy about many of the things that are bad for our health, but which are very profitable, and which therefore are rarely recognized or addressed as the social evils they really are. Alcohol, for all its benefits, sucks billions out of the economy in death and violence and injury and illness every year, yet we still tolerate advertisements that show its consumption as an essential ingredient of personal happiness. The meats, and many other foods we eat that are advertised to the hilt (especially the fat, salt and sugar-laden “fast-food” varieties) are chemical cesspools that unquestionably add billions of dollars to annual health care costs.

The real answer, I would argue, is not rewarding people for staying healthy (because we can never determine when their health or lack of it is due to their behaviour or factors beyond their control), but rather health care innovations that address the real, preventable causes of illness and injury:

  1. Discovery and provision free of charge of safe substitutes for the substances to which we are addicted, including salt, refined sugars, starches, nicotine, alcohol, and opiates (and perhaps even some hormones and chemicals produced by our own bodies during addictive behaviours like gambling, pyromania and violent abuse of others). I think the record shows that it’s futile to get us “unaddicted” by the use of will power, counseling, therapy and various reward and coercive programs. Such programs only work for a few people, and they are temporary and fragile. Let’s acknowledge the power of the monkey, that he has us all in his grasp, and that the best we can do is find substitutes for our addictions that don’t cause the social, physical and psychological damage that the toxins we’re now hooked on do. That means we need to stop rewarding the companies that profit, outrageously, from our addictions, and make them responsible, if they want to stay in business, for helping us find (and fund) the ‘cures’ for these addictions. 
  2. Development of easy exercises that can be done while doing other “productive” work. For example, perhaps PCs powered by silent hand-cranks or foot-pedals could not only give the sedentary some much needed exercise, but also help conserve non-renewable energy resources at the same time. Our bodies are meant to be moving, and natural physical activity is essential to resilience, to keep us free from illness and injury. As long as it’s more fun and more profitable to be physically inactive than active, that’s what we will be. We need to make it easy to be fit, so we don’t need to “make time” for it, but instead become fit in the normal course of doing everything we do. This will require some great ingenuity, but we’ve solved much greater problems.
  3. Making prevention, self-diagnosis and self-treatment of illnesses and accidents free and easy. Today we’re discouraged by lawyers, by corporations, and by governments trying to justify their expensive centralized infrastructure, from taking responsibility for and care of our own bodies. Take away those barriers, and make it easy for us to track our own health and fitness, and look after ourselves, and we’ll tap into the collective wisdom of six billion instead of relying helplessly on the spotty and overstressed knowledge of ‘professionals’. But it has to be free, and accessible to all. And it would come with a catch: We would have to legally accept responsibility for our own health, and not look for people to sue for billions of dollars when (as will inevitably happen to some of us) the collective wisdom is inadequate, or just plain wrong. We have to learn from our mistakes, and to do so we have to have permission to make them. 

We cannot expect those with vested interests in the current health care system to reform it. We need to create our own organizations to develop, in Open Source form, these three types of health care innovation. We will have to do battle with the lawyers, corporations, politicians and preachers and some medical practitioners, who will not yield power of the current massive, extravagant and dysfunctional system easily. But like all disruptive innovation, our work in these three areas will be subversive. The regular health-care system won’t know it’s been rendered obsolete until it’s too late. And there are many in the existing health-care system who recognize the need for these innovations and the distress of the current system, who will be more than willing to join us in making the new, responsible, patient-centred system work.

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6 Responses to Reforming Health Care

  1. I read somewhere about a researcher who is trying a “walking office”, that’s modified so that the desk is above a slow-moving treadmill. Apparently after a day or two it becomes second nature to walk while working. Neat.

  2. I don’t think that “exercising while you work” really addresses the problem. The problem with exercise is that it requires discipline. Why don’t we play instead? What if we just keep on playing after childhood ends? It’s very important to meet the people in your neighborhood for a ball game. It would, of course, require a culture change, where we don’t “work” so much.

  3. Good column.I’ve been thinking of some of those things. The ‘office treadmill’ or some such thing, in particular.That said, I think the initial premise considered in the article can be refuted with a simple proposition: it is absurd to have sick people subsidize healthy people.Moreover, I think there should be more explicit recognition that it is actually *more expensive* to live healthy – the marketplace being what it is, providers know that people who ‘buy healthy’ are more motivated, and hence, will pay more.We need to address the hidden costs of unhealthy products. They are, indeed, very similar to products that create pollutants when they are produced. Just as it is reasonable to incorporate the cost of pollution into, say, plastics, it is reasonjable to incorporate the cost of health care into, say, fatty foods.In a similar manner, while exercise is a lot of work, there is little or no productive payoff. It seems to me, for example, that the effort I put into my stationary bicycle should be repaid in the form of electricity. But there is no means for me to micro-produce electricity and plug it back into the grid – or even into my home supply.The question of fitness and health isn’t a simple problem we can address with simple measures. It is, as your column seems to suggest, a structural problem, and one we need to address by rethinking basic assumptions.

  4. Doug Alder says:

    Ther’s also the old asian way which is you pay (or in this case the government pays)the medical practitioner only while you are healthy

  5. lugon says:

    care about each other would possibly be the only way forward in a flu pandemic where people are better of if they stay at home – people would do shopping for the entire family and so on – so you need to have a family or neighbours that know you etcif people stay at home when ill there’s much less transmission, which is good for everyone as it slows down the

  6. lugon says:

    (sorry about the formatting)Care about each other would possibly be the only way forward in a flu pandemic where people are better of if they stay at home – people would do shopping for the entire family and so on – so you need to have a family or neighbours that know you etcIf people stay at home when ill there’s much less transmission, which is good for everyone as it slows down the and

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